Introduction
A biceps tendon tear in the shoulder primarily involves the long head of the biceps muscle. The biceps brachii has two origins:
• The long head (caput longum)
• The short head (caput breve)
While tears of the short head are extremely rare, injuries to the long head tendon are much more common. These tears can result from degeneration, overuse, or trauma such as falls. The reason lies in the unique anatomy of the long head, which has evolved over time with the upright posture of humans.
In four-legged animals like dogs and cats, the long head tendon runs straight. However, in humans, this tendon is bent at a 90-degree angle as it crosses the humeral head and attaches to the rim of the glenoid (the joint socket) and the labrum (the cartilage that lines the socket).
This anatomy creates several weak points:
1. The 90-degree bend in the tendon.
2. Narrowing in the bicipital groove (a channel in the humeral head).
3. The attachment to the glenoid labrum, particularly the superior labrum (superior labrum anterior to posterior, or SLAP lesion).
Tears most commonly occur at the attachment point of the tendon to the labrum, or along the bicipital groove, where the tendon may split longitudinally.
Does a Complete Tear of the Biceps Tendon Require Surgery?
In most cases, surgery is not necessary for a complete tear of the long head of the biceps tendon. Functionally, the long head contributes very little to the overall strength of the biceps muscle. The majority of the strength comes from the short head, which is rarely affected by degenerative changes or injuries.
Following a complete tear of the long head:
• Severe pain typically lasts for about two weeks.
• Pain usually subsides, and patients often report less discomfort compared to the pre-tear state.
A complete tear may lead to a noticeable change in the shape of the biceps muscle, known as the Popeye deformity, named after the cartoon character with a prominent biceps. However, this change is purely cosmetic and does not impact function.
In cases of overhead athletes or professional sports players, the 1–2% contribution of the long head to biceps strength may warrant surgical repair to optimize performance.
How Is a Biceps Tendon Tear Treated?
Conservative Treatment
Most biceps tendon tears are partial tears and can be managed without surgery. The standard treatment includes:
1. Activation therapy:
• Specific exercises stimulate stem cells in the torn area, promoting the formation of parallel collagen fibers and creating a stable scar tissue.
2. Corticosteroid injections:
• These can reduce pain, allowing patients to continue with rehabilitation exercises.
Important: Many patients mistakenly believe they should avoid using the tendon after a tear. However, in cases of degenerative tears, loading the tendon is essential for healing. Immobilization is counterproductive, and regular exercise is vital for recovery.
About 70% of cases respond well to conservative treatment. In the remaining 30% of cases, patients may continue to experience pain despite therapy, and surgery becomes necessary.
What Does Surgery for a Biceps Tendon Tear Involve?
The preferred surgical technique for a complete tear is the subpectoral biceps tenodesis. This involves securing the tendon below the pectoralis major muscle before it reaches the 90-degree bend.
Advantages of subpectoral biceps tenodesis:
• Restores full biceps strength.
• Prevents the Popeye deformity.
The procedure involves the placement of a small metal button or anchor in the humeral bone. This anchor is loaded with sutures, which are used to secure the tendon to the bone.
What Is the Recovery Time After Biceps Tenodesis?
1. Immobilization: Required only during the skin healing phase (about 14 days).
2. Free movement exercises: Allowed starting on day 15.
3. Light strengthening exercises: Up to 3 kg can be lifted beginning in the 6th week post-surgery.
4. Full load training: Permitted after 12 weeks.
5. Overhead sports: Can gradually resume starting in the 6th week.
What Are the Risks of Surgery?
The risks associated with biceps tenodesis are minimal due to the short duration of the procedure (10–12 minutes). Potential risks include:
• Re-tear of the tendon if excessive stress is applied too early.
• Typical surgical risks such as wound healing issues, infection, or hematoma, although these are rare.