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Biceps Tendon Injuries at the Shoulder

The biceps muscle has two tendons that attach it to the bones of the shoulder and one tendon that attaches to the radius bone at the elbow. Injuries to the muscle include tendonitis and tendon tears. The biceps muscle is located at the front of your upper arm. The muscle has two tendons that attach it to the blade bone of the shoulder and one tendon that attaches to the radius bone at the elbow. The tendons are rigid strips of tissue that connect muscles to bones and move our limbs. Injuries to the biceps tendons include:

• Proximal biceps tendonitis at shoulder
• Proximal biceps tendon tear at the shoulder
• Distal biceps tendonitis and tear at the elbow

The biceps tendons attach the biceps muscle to bones in the shoulder and the elbow. If you tear the biceps tendon at the shoulder, you may lose some strength in your arm and have pain when you forcefully turn your arm from palm down to palm up. Many people can still function with a biceps tendon tear and only need simple treatments to relieve symptoms. If nonsurgical treatments cannot reduce symptoms or require complete strength recovery, repair of the torn tendon is necessary.

Anatomy

There are two attachments of the biceps tendon at the shoulder joint. The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centred in your shoulder socket. These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.

Biceps tendonitis

What is biceps tendonitis?

Even though tendons are tough, if you overuse them, they can become sore and painful. Micro-tears cause this in the tendon, called tendonitis(sometimes spelt “tendinitis”). Tendonitis can occur because of repetitive motion. For instance, professional baseball players, swimmers, tennis players and golfers are at risk for tendonitis in their shoulders, arms and elbows. Tendonitis can also occur because of a sudden, serious load to the tendon. You can get biceps tendonitis in the shoulder or at the elbow. It is unusual to have tendonitis in both places at the same time. Biceps tendonitis can co-occur in the shoulder as rotator cuff tendonitis as it is part of the rotator cuff complex.

How is biceps tendonitis treated?

Non-operative treatment

 • Cold packs or ice will reduce swelling and pain caused by tendonitis.
• Nonsteroidal anti-inflammatory medications such as naproxen or ibuprofen will help relieve swelling and pain.
• Prof Imam may also recommend rest. It will be essential to avoid any heavy lifting, flexing at the elbow and over your head.
• Your doctor may refer you for physical therapy to help your shoulder or elbow recover in some cases.
• In severe cases of tendonitis without a tear, corticosteroid injections, platelet-rich plasma or stem cells may offer relief of pain, halt the inflammatory process, and get the tendon back on a path of healing.

Most patients who have had surgery for tendonitis can move their arms without pain and regain a full range of motion.

• Because most cases of tendonitis are caused by overuse, the best treatment is prevention.
• It is essential to avoid or alter the activities that cause the problem. When doing physical activities, take it slowly and gradually build up your activity level, limit the number of repetitions you do and the amount of force you use, and stop if you feel any unusual pain. Be careful to avoid and correct underlying conditions such as improper posture or poor technique in sports or work.

Biceps tendon Tears

What are biceps tendon tears?

In cases of serious or constant overuse, a tendon may fray and eventually tear. A tendon can also tear as part of an injury, such as moving or awkwardly twisting your elbow or shoulder or falling with your arm outstretched. At the elbow, the bicep tendon most often tears during the act of lifting a heavy object (for example, a couch or a refrigerator). A biceps tendon tear can happen at either the shoulder or the elbow. A tear can also be complete or partial. A complete tear means the tendon has torn away from the bone.

Biceps tendon tears can be either partial or complete.

• Partial tears. Many tears do not completely sever the tendon.
Complete tears. A complete tear will split the tendon into two pieces.

In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes when lifting a heavy object.

The long head of the biceps tendon is more likely to be injured. This is because it is vulnerable as it travels through the shoulder joint to its attachment point in the socket. Fortunately, the biceps has two attachments at the shoulder. The short head of the biceps rarely tears. Because of this second attachment, many people can still use their biceps even after a complete tear of the long head. When you tear your biceps tendon, you can also damage other parts of your shoulder, such as the rotator cuff tendons.

What are the causes of the long head of biceps tears?

There are two main causes of biceps tendon tears: injury and overuse.

• Injury If you fall hard on an outstretched arm or lift something too heavy, you can tear your biceps tendon.
• Overuse Many tears result from wearing down and fraying of the tendon that occurs slowly over time. This naturally occurs as we age. It can be worsened by overuse – repeating the same shoulder motions again and again.

Overuse can cause a range of shoulder problems, including tendonitis, shoulder impingement, and rotator cuff injuries. Having any of these conditions puts more stress on the biceps tendon, making it more likely to weaken or tear.

Risk Factors

Your risk for a tendon tear increases with:

• Old Age
• Heavy overhead activities
• Shoulder overuse. Repetitive overhead sports, such as swimming or tennis, can cause more tendon wear and tear.
• Smoking. Nicotine use can affect nutrition in the tendon.
• Corticosteroid medications. Using corticosteroids has been linked to increased muscle and tendon weakness.

What are the symptoms of a biceps tendon tear?

The most obvious symptom will be a sudden, severe pain in the upper part of your arm or at the elbow, depending on where the tendon is injured. You may hear or feel a “pop” when a tendon tears. Other signs that you may have torn a biceps tendon can include:

• Cramping of the biceps muscle with strenuous use of the arm
• Bruising from the middle of the upper arm down toward the elbow
• Pain or tenderness at the shoulder and the elbow
• Weakness in the shoulder and the elbow
• Difficulty turning the arm palm up or palm down
• Because a torn tendon can no longer keep the biceps muscle tight, a bulge in the upper arm above the elbow (“Popeye Muscle”) may appear, with a dent closer to the shoulder.

Imaging Tests

 • X-rays. Although x-rays cannot show soft tissues like the biceps tendon, they can be helpful in ruling out other problems that can cause shoulder and elbow pain.
Magnetic resonance imaging (MRI). These scans create better images of soft tissues. They can show both partial and complete tears.

How are shoulder biceps tears treated?

Surgery may be a choice for those who continue to experience symptoms after non-surgical treatments and have a cosmetic “Popeye” bicep muscle. Surgery to reattach a long head tendon is quite safe, with few complications. It can return nearly all of your arm strength and function, and a re-tearing of the repaired tendon is uncommon. If you decide to have surgery, you will need to do flexibility and strengthening exercises to rehabilitate your shoulder. This can last for several months.

Nonsurgical Treatment

For many people, pain from a long head of biceps tendon tear resolves over time. Mild arm weakness or arm deformity may not bother some patients, such as older and less active people.

In addition, if you have not damaged a more critical structure, such as the rotator cuff, nonsurgical treatment is a reasonable option. This can include:

• Ice. Apply cold packs for 20 minutes at a time, several times a day, to keep down swelling. Do not apply ice directly to the skin.
• Nonsteroidal anti-inflammatory medications. Drugs like ibuprofen, aspirin, or naproxen reduce pain and swelling.
• Rest. Avoid heavy lifting and overhead activities to relieve pain and limit swelling. Your doctor may recommend using a sling for a brief time.
• Physiotherapy. Flexibility and strengthening exercises will restore movement and strengthen your shoulder.

Surgical Treatment

Surgical treatment for a long head of the biceps tendon tear is rarely needed. However, some patients who develop cramping of the muscle or pain, or who require complete recovery of strength, such as athletes or manual laborers, may require surgery. Surgery may also be the right option for those with partial tears whose symptoms are not relieved with nonsurgical treatment.

Procedure. Several new procedures have been developed that repair the tendon with minimal incisions. All of them share a single goal; the goal of the surgery is to re-anchor the torn tendon back to the bone. Your doctor will discuss with you the options that are best for your specific case.

Rehabilitation. After surgery, your shoulder may be immobilized temporarily with a sling. One of the team will soon start you on therapeutic exercises. Flexibility exercises will improve the range of motion in your shoulder. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.

Surgical Outcome. Successful surgery can correct muscle deformity and return your arm’s strength and function to nearly normal in more than 90% of the time.

Biceps Transfer (Subpectoral tenodesis)

Biceps Tenodesis

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