Each year, about 10 million people seek medical attention for shoulder injuries, and another 4 million present to physicians with arm injuries. Tendinitis of the long head of the biceps (LHB) is a common inflammatory tenosynovitis, which occurs as the tendon courses along its constrained path within the bicipital groove of the humerus. It typically presents with anterior shoulder pain and is often exacerbated by overuse. In many cases, LHB tendinopathy occurs in combination with other shoulder problems, particularly rotator cuff tendon injuries.
“The goal in treating any LHB tendinopathy should be to address the pain in a way that also respects the patient’s lifestyle.”
Despite plenty of research into the anatomy of the LHB tendon and conditions that affect it, there is still some controversy on the most appropriate management strategies for patients with these injuries. It’s known that tendinopathy of the LHB has inflammatory, degenerative, overuse-related, and traumatic causes, but the medical literature doesn’t provide evidence to support one specific treatment approach over another; there are advantages and disadvantages to consider for each procedure. In the November 2010 Journal of the American Academy of Orthopaedic Surgeons, my colleagues and I published a review on the diagnosis and treatment of LHB tendinitis to assist physicians who manage these injuries.
Determining Treatment Approaches
LHB tendinitis is associated with a variety of causes and a wide range of severity. As such, patients must receive a thorough patient history and physical examination, including radiographic imaging, to determine the appropriate diagnosis and treatment for their injury. Once a diagnosis has been established, patients will require non-surgical therapies—rest, ice, NSAIDs, activity modification, and physical therapy—as first-line treatment. Selective cortisone injections may also be useful, but only if other strategies are ineffective. More research is needed in the role of these injections in treatment.
The goal in treating any LHB tendinopathy should be to address the pain in a way that also respects the patient’s lifestyle. A variety of both surgical and non-surgical options can be effective for patients. Non-surgical treatment is the first—and in many cases may be the only—treatment that’s necessary. The decision to have surgery should be based on severity and duration of uncontrolled pain and if other shoulder problems (eg, rotator cuff injuries) are also present.
Surgical Management Strategies
Patients with symptoms that are refractory to non-surgical management strategies are indicated for biceps tenotomy or tenodesis. Tenodesis should be reserved for younger, physically active patients because it allows for preservation of the length-tension relationship of the biceps muscle and helps maintain normal contour of the biceps muscle. Biceps tenotomy is more appropriate for older, less active patients. This option is the least invasive but may result in a “Popeye bulge” in the arm. Recent studies have reported no significant difference in function or patient satisfaction between these primary surgical options. Both procedures have a complication rate of less than 1%, and both can be performed via arthroscopy, which is less invasive for patients.
One particular procedure that has been shown to be especially effective is the mini-open subpectoral biceps tenodesis using interference screw fixation. This procedure provides the strongest fixation construct with a technique that removes the intertubercular portion of the LHB tendon and provides fixation at the appropriate resting position of the biceps tendon. While this treatment is currently our preferred approach, there is still a need for comparative research data on surgical versus non-surgical treatment outcomes for LHB tendinopathy so that we can further enhance patient outcomes.
Readings & Resources (click to view)
Nho SJ, Strauss EJ, Lenart BA, et al. Long head of the biceps tendinopathy: diagnosis and management. J Am Acad Orthop Surg. 2010;18:645-656. Available at:http://www.jaaos.org/cgi/content/abstract/18/11/645.
Ryu JH, Pedowitz RA. Rehabilitation of biceps tendon disorders in athletes. Clin Sports Med. 2010;29:229-246.
Buck FM, Grehn H, Hilbe M, Pfirrmann CW, Manzanell S, Hodler J. Degeneration of the long biceps tendon: comparison of MRI with gross anatomy and histology. AJR Am J Roentgenol. 2009;193:1367-1375.
Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. 2009;80:470-476.