Long head bicep tendon

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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The glenoid fossa is the part of the scapula that articulates with the head of the humerus (upper arm bone).

The long head of the biceps originates from an area at the top of the glenoid fossa.

The tendon then runs through the bicipital groove of the humerus. The tendon glides over the humeral head, stabilizing it in the glenoid fossa by preventing the humerus from riding up in the fossa when the arm is raised.

The distal tendon insertion of the biceps tendon is on the radial tuberosity. This allows the biceps muscle to function mainly as an elbow flexor (bender)and forearm supinator ( forearm rotation).

The long head of the biceps is at risk of injury and degenerative changes because of its mechanical function and proximity to the rotator cuff, bicipital groove, and acromion a bony projection at the top of the scapula).

In fact, ruptures of the long head account for 96% of all biceps brachii injuries, while distal tendon and short head (the short head of the biceps originates from the coracoid process of the scapula but bypasses the bicipital groove. It also inserts distally at the radial tuberosity) ruptures account for 3% and 1%, respectively.

The conditions that are most frequently associated with--and probably contribute to--ruptures of the long head of the biceps are rotator cuff pathology, spurs involving the bicipital groove, and shoulder instability.

When the long-head tendon ruptures, patients may feel a pop. They may report pain in the front of the shoulder that radiates to the biceps muscle belly or distal humerus. Repetitive overhead activities and lifting may make the pain worse, while rest usually brings relief. The pain may also be worse at night. Patients commonly have a history of injury to the shoulder or of chronic shoulder pain that improves after the rupture. When the patient's only symptom is a chronic ache in the front of the shoulder, it may be difficult to make a diagnosis.

Most patients present with unusual bulging of the biceps muscle on the affected arm (“Popeye bicep”).

Testing for biceps tendinitis is also important, since a positive finding may rule out a torn tendon. With the patient's arm at their side rotated slightly inward (internal rotation) and the elbow flexed to 90°, palpation of the biceps tendon may reveal tenderness in the bicipital groove, indicating probable biceps tendinitis.

Strength testing may reveal weakness which can be a sign of tendinitis or of tendon rupture. Biceps strength may be tested more specifically by having the patient bring the arm to the side, holding the elbow at 90° flexion with the forearm supinated (forearm turned so that the palm is facing up), and then flexing the elbow against resistance.

Since biceps problems are often associated with impingement syndromes (rotator cuff pinched between the roof of the scapula and the head of the humerus), the assessment should include a complete exam of the patient's shoulder. Most patients who have a ruptured biceps tendon will have full range of motion in both shoulders and elbows.

Diagnosis can usually be made on the basis of the history and physical exam.

MRI may be useful in assessing biceps tendon anatomy and associated rotator cuff and shoulder joint pathology. MRI should be considered in patients who have clinical evidence of an associated rotator cuff tear and in those who want to have their biceps surgically repaired. Diagnostic ultrasound is actually faster and just as accurate at assessing biceps tendon pathology.

Ruptures of the distal insertion of the biceps tendon, though less common than those of the long head, are associated with more long-term problems.

Treatment of a ruptured long head is usually conservative. The immediate goals of treatment are the maintenance of shoulder range of motion and the reduction of inflammation and pain with the use of anti inflammatory drugs, rest, and ice. This is followed by strengthening exercises for the shoulder and elbow.

Some younger athletes choose to have a ruptured long head surgically repaired in order to restore symmetry to the biceps muscle. The best surgical results are achieved when the repair is performed within 3 to 4 weeks of the injury. The procedure is called a tenodesis. This involves attaching the proximal tendon to the proximal humerus to restore a normal contour to the biceps belly and symmetry with the other biceps muscle.

Ruptures of the biceps tendon are most common in middle-aged patients. Conservative therapy usually allows patients to resume their activities without significant deficits.

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