Long Head of Biceps Tendinopathy

Overuse or degenerative disease of the long head of biceps tendon as it runs through the bicipital groove and over the humeral head into the glenoid labrum. The process is mainly tendinopathy (collagen disorganisation, sheath thickening) with synovitis of the tendon sheath, not a purely inflammatory condition.

• Isolated primary tendinopathy is uncommon (about 5 to 10%). In most patients it is secondary to rotator cuff disease, subacromial impingement, labral (SLAP) lesions, subscapularis tears, or glenohumeral instability.
• Causes and risk factors: repetitive overhead and lifting activity (swimmers, throwers, weightlifters, racquet sports, painters), age above 40 (degeneration), a shallow or spurred groove, diabetes, hypercholesterolaemia, smoking, fluoroquinolone and corticosteroid exposure.
• Natural history: most patients improve with load modification and rehabilitation over 6 to 12 weeks. Chronic tendinopathy can progress to partial tear, subluxation or dislocation from the groove (with subscapularis tear), and rupture.
• Rupture of the long head affects about 3 per 100,000 per year, usually in people over 50, and causes little functional loss.

• Anterior shoulder pain localised to the bicipital groove (about 7 cm distal to the anterior edge of the acromion), radiating down the anterior arm and sometimes to the elbow, worse with lifting, overhead reaching, pulling and carrying, and often a night ache.
• Tenderness over the groove, which moves with arm rotation (the tendon is felt at about 10 degrees of internal rotation). Painful resisted forearm supination with the elbow flexed to 90 degrees. Pain on resisted shoulder flexion with the elbow extended and the forearm supinated. Painful snapping or clicking with rotation suggests instability of the tendon in the groove.
• Rupture: a sudden pop, bruising on the anterior arm, and a distal bulge of the muscle belly on elbow flexion ("Popeye" deformity), with mild loss of supination and flexion strength (about 10 to 20%).
• Differential diagnosis: rotator cuff tendinopathy or tear, subacromial pain, SLAP lesion, acromioclavicular arthritis, glenohumeral arthritis, adhesive capsulitis, cervical radiculopathy (C5 and C6), distal biceps tendinopathy, referred cardiac, gallbladder or diaphragmatic pain, and septic arthritis.
• Red flags: trauma with sudden weakness, fever and hot swollen joint, severe constant night pain, neurological deficit, weight loss or a history of cancer, and chest pain or breathlessness with arm pain.
• Complications: chronic pain, tendon subluxation, partial tear and rupture, adhesive capsulitis, and sleep and work disability.

• Clinical, with examination of the neck, the whole shoulder, cuff strength, and the specific groove and resisted supination tests.
• X-ray of the shoulder (anteroposterior, scapular Y and axillary views, with a groove view) for spurs, calcification, arthritis and fracture.
• Ultrasound (dynamic) shows tendon thickening, fluid in the sheath (a halo), tears, and subluxation in the groove, and guides injection. MRI (or MR arthrography) shows labral lesions, subscapularis and cuff tears, and tendon pathology, and is used when diagnosis is uncertain or surgery is planned.
• A positive response to an ultrasound guided sheath injection of local anaesthetic (lidocaine 1% 2 to 3 mL) with pain relief confirms the source. Blood tests (CRP, ESR, HbA1c) if inflammatory arthritis, infection or diabetes is suspected.

• Relative rest from aggravating overhead lifting and pulling for 2 to 6 weeks, with maintained pain free movement. Avoid a sling beyond 1 to 2 days.
• Analgesia: paracetamol 1 g orally 6 hourly. Ibuprofen 400 mg orally 8 hourly with food (or naproxen 500 mg 12 hourly, or diclofenac 50 mg 8 hourly) for 1 to 2 weeks with gastroprotection in at risk patients. Topical diclofenac 1% gel 2 to 4 g 3 to 4 times daily. Ice for 10 to 15 minutes after activity.
• Physiotherapy for 8 to 12 weeks: scapular stabilisation, rotator cuff strengthening, posterior capsule stretching, then progressive isometric and eccentric loading of the biceps (3 sets of 10 to 15), and graded return to lifting.
• Corticosteroid injection into the tendon sheath (not into the tendon) for pain persisting after 4 to 6 weeks: triamcinolone acetonide 20 to 40 mg (or methylprednisolone acetate 20 to 40 mg) with lidocaine 1% 2 to 3 mL, under ultrasound guidance. Relief lasts 2 to 12 weeks. Limit to 1 to 2 injections. Risks: tendon weakening and rupture, skin atrophy and depigmentation, infection, and a rise in glucose for 3 to 5 days in diabetes.
• Treat associated cuff, labral or impingement disease at the same time.
• Surgery for failure after 3 to 6 months of conservative care, or for painful instability or a symptomatic partial tear involving more than 25 to 50% of the tendon: arthroscopic biceps tenotomy (quick, with a cosmetic bulge and occasional cramping) or tenodesis (fixing the tendon in the groove or humerus, preferred in active patients under 60 to keep contour and strength), with a sling for 2 to 4 weeks (tenodesis 4 to 6 weeks) and return to activity at 3 to 4 months.
• Proximal rupture: most are treated without surgery with analgesia and early rehabilitation, and the pain settles in 2 to 6 weeks. Consider repair for young manual workers and athletes needing full supination strength.
• Special groups:
  • Diabetes: monitor glucose after injection, with a higher risk of stiffness.
  • Elderly: prefer exercise, topical agents, and tenotomy if surgery is needed.
  • Fluoroquinolone and statin users: review the drug if tendon pain occurs.
  • Pregnancy: physiotherapy, ice and paracetamol. Avoid NSAIDs after 20 weeks.
  • Anticoagulation: use ultrasound guidance and a fine needle, with pressure for 5 to 10 minutes.
  • Renal impairment and gastrointestinal disease: avoid oral NSAIDs.
• Follow up: review at 4 to 6 weeks and at 3 months. Refer to orthopaedics or sports medicine for suspected cuff or labral tear, tendon subluxation, failure after 3 to 6 months, or rupture in a high demand patient.