Biceps Tendonitis

Mike Walton & Len Funk

Biceps tendonitis is an inflammation of the Long Head of Biceps tendon (also known as LHB).

Sometimes the tendon becomes inflamed after a fall or injury eg lifting heavy weights, but can sometimes develop on its own. In middle aged and older people biceps tendonitis is usually found with other shoulder pathologies such as impingement or rotator cuff tears.

Biceps tendonitis can be very painful. In slim people tendon can often be felt at the front of the shoulder and can be very tender. The pain can then extend down into the biceps muscle in the arm.Pain develops at the front of the shoulder, worse when lifting weights in front of the body and lifting overhead. This may be caused by an injury, such as a fall or lifting heavy weights, but sometimes may develop without any injury.
Biceps tendonitis may be due to rubbing of bone spurs on the biceps tendon, instability of the tendon and often occurs with a rotator cuff tear (complete or partial tear). 

Normal and inflamed LHB (Tendonitis):

The pain is typically at the front of the shoulder and extends down the biceps muscle.

An ultrasound scan is useful to help diagnose biceps tendonitis and a rotator cuff tear. The scans below show a normal LHB tendon on the left and a swollen, inflamed LHB on the right (tendonitis):


Biceps tendonitis can usually be managed without surgery. Treatment usually consists of a period of rest from lifting accompanied with anti-inflammatories and physiotherapy. The physiotherapist will optimise the movement of the shoulder and rotator cuff to place less strain on the biceps tendon.

Sometimes injections can be used both to help with the diagnosis and also to help reduce pain and inflammation. The injections can be with local anaesthetic and steroid but this has a small risk of leading to tendon rupture and a safer option is with hyaluronan. The LHB is under a lot of muscle and, if cannot be felt, the injections are best performed under ultrasound guidance  

Ultrasound guided biceps sheath injection:
Video of an ultrasound guided injection of Ostenil hyaluronan:

If pain still persists despite non-operative treatment then surgery can be considered. Surgery can be either with a 'Tenotomy' or 'Tenodesis'. If a rotator cuff tear is confirmed an arthroscopic rotator cuff repair is often required. This will include treatment of the LHB tendon, which is often partially torn, inflamed, swollen, unstable or dislocated.

Tenotomy vs. Tenodesis

Several studies and meta-analyses have been published, which show that >75% of patients are very satisfied with either operation. None of the studies have been able to show any difference between the operations on any of the outcome measures that we commonly use. 

There is very little functional loss after biceps surgery. Duff et al , 2012 looked at biceps strength after tenotomy. They found that, although 16% of patients felt a little weaker on their operated arm, when it was measured they were almost exactly the same as their other arm. Approximately 19% of patient may develope cramping of the biceps muscle after a tenotomy (Duff, 2012). However, Slenker (2012) showed that there is no difference in cramping between tenotomy and tenodesis (19% vs. 24% repsectively).  
The main difference between the operations is the risk of developing a cosmetic popeye deformity of the biceps tendon. A review article by Hsu (2011) found a rate of popeye sign to be 41% after tenotomy and 25% following tenodesis. A similar study by Slenker (2012) found a similar rate of 43% after tenotomy but only 8% after tendoesis. Whilst this deformity may be apparent both Duff (2012) and Boileau (2007) found that patients, if they noticed (which they often didn’t), were seldom concerned by it.

The rehabilitation after the procedures is very similar but patients after tenodesis have to avoid straining their biceps muscle for a little longer to allow the tendon to heal.

Should you have a Tenotomy or Tenodesis?
This is an individual decision made between each patient and surgeon. Most patients can expect an excellent outcome following a simple tenotomy however many surgeons would advocate a tenodesis is young, active patients. Please discuss these options with your surgeon.

Also See:

  1. Karataglis D, Papadopoulos P, Boutsiadis A, Fotiadou A, Ditsios K, Hatzokos I, Christodoulou A. Ultrasound evaluation of the distal migration of the long head of biceps tendon following tenotomy in patients undergoing arthroscopic repair of tears of the rotator cuff. J Bone Joint Surg Br. 2012 Nov;94(11):1534-9. doi: 10.1302/0301-620X.94B11.29499.
  2. Slenker NR, Lawson K, Ciccotti MG, Dodson CC, Cohen SB. Biceps tenotomy versus tenodesis: clinical outcomes. Arthroscopy. 2012 Apr;28(4):576-82. doi: 10.1016/j.arthro.2011.10.017. Epub 2012 Jan 28.
  3. Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Bach BR. Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results. J Shoulder Elbow Surg. 2011 Mar;20(2):326-32. doi: 10.1016/j.jse.2010.08.019. Epub 2010 Nov 4.
  4. Boileau P, Baqué F, Valerio L, Ahrens P, Chuinard C, Trojani C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007 Apr;89(4):747-57.
  5. Duff SJ, Campbell PT. Patient acceptance of long head of biceps brachii tenotomy. J Shoulder Elbow Surg. 2012 Jan;21(1):61-5. doi: 10.1016/j.jse.2011.01.014.

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