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Biceps Tendon Pain: A Popular Diagnosis Loaded with Decades of Controversy

Biceps tendon pain treatment

Biceps tendon pain, particularly the long head of the biceps at the shoulder, is a very popular diagnosis these days. This diagnosis is also followed by an increasingly common recommendation to perform a surgical procedure called a biceps tenodesis, where the portion of the biceps tendon inside the shoulder joint is removed while stabilizing the origin of the biceps tendon elsewhere, along its anatomic course in the bicipital groove (proximal or distal) or moving it to another location like the coracoid process adjacent to the short head biceps origin. Although we have treated thousands of patients with biceps tendon pain (pathology), the incidence of patients with isolated pathology of the biceps tendon in my practice is exceedingly rare. In this article, we hope to help sort through the controversy of not only the diagnosis of isolated biceps pathology, but also the best method of treatment, finally reviewing our preferred technique for addressing biceps tendon pathology. 

Click here to watch a video about Biceps Tendon Injury Surgery.


Often the diagnosis of biceps tendon pain is made based on tenderness to palpation at the anterior shoulder or at the bicipital groove. As we reported previously, palpation can be highly accurate for rotator cuff tears, but while the RENT test has been independently cited as having a high quality of diagnostic accuracy for rotator cuff tears (Br J Sports Med 2008; 42:80–92.), no such physical examination maneuver or test has been supported for the diagnosis of biceps tendon pathology. In Physical Examination for Partial Biceps Tendon Tears, AJSM. Vol. 35, No. 8, 2007, Gill et al. evaluated 847 patients with a variety of shoulder pathologies who underwent arthroscopy for the accuracy of physical examination techniques to predict the presence of biceps tendon pathology. Overall, tenderness on palpation in the region of the biceps had a sensitivity of 53%, a specificity of 54%, and an accuracy of 54%. The authors concluded, “Our study shows that no single physical examination test can accurately predict the presence of a partial tear of the long head of the biceps tendon and highlights the difficulty of assessing the role of the biceps tendon in pain syndromes of the shoulder. One confounding factor is that there is no known pain pattern specific for the biceps tendon. Although biceps tendon pain can radiate down the front of the shoulder, pain into the front of the shoulder can be secondary to a variety of causes, including rotator cuff injury.” Of further interest, as in our own experience, all patients with partial biceps tendon tears also had other lesions.

Anatomy, Pathology, and Biceps Function

The biceps tendon long head has several unique features.  Along with being part of a two joint muscle (the biceps spans the shoulder and elbow joints), the biceps long head tendon is intra-articular (within the joint) but extrasynovial, meaning it is contained within a sheath formed by the continuation of the synovial lining of the joint capsule.  This means that the segment of the tendon within the joint from approximately 1-3cm distal to its origin is a relatively hypovascular region.

Biceps Tendon

As with other tendons that are part of two joint muscles (Achilles tendon, Iliotibial band, quadriceps tendon, etc.) the biceps tendon is subject to potentially greater stresses.  The elastic range of strain for tendons is less than 4% and microscopic failure occurs beyond 4% strain.  Beyond 8-10% strain, macroscopic failure occurs and complete failure can occur rapidly thereafter.  Both the amount and rate of loading can play a role in tendon injury.  The highest risk of rupture occurs when tension is applied quickly and obliquely, and the highest forces are seen during eccentric muscle contraction.

Tendon Sheath

The biceps tendon itself, like other tendons, does not have many nerve fibers within the main body of the tendon. The majority of the nerve supply forms a sheath around the tendon as well as supplying specialized mechanoreceptors (Golgi Tendon Organs) to the muscle tendon junction.  Along with helping coordinated muscle activity, position sense, protective inhibition and stress relaxation, these fibers also help transmit biceps tendon pain (glutamate, substance P, etc.).

The oxygen consumption of tendons and ligaments is also 7.5 times lower than that of skeletal muscles.  Although these adaptations are essential to carry loads and maintain tension for long periods without ischemia and necrosis, the low metabolic rate also means a very slow rate of healing after injury.

Biceps Tendonitis

All of these factors help us better understand that the biceps tendon, along with other tendons as well, can be injured by multiple mechanisms-acute, chronic, intrinsic, extrinsic, micro trauma, and macro trauma-and commonly a combination of mechanisms, acute on chronic for example.   With any injury, the intrinsic ability of the tendon to heal is tested.  Although the term biceps “tendonitis” and “tendinitis” are often used, inflammation of the biceps tendon itself is rarely seen, as the inflammatory changes typically occur at the biceps tendon sheath.  As with other tendons, the more correct term for biceps tendon injury should be biceps tendinopathy, meaning pathologic change of the biceps tendon.  The exact mechanism and process for biceps tendinopathy still remains unclear, with many possible-contributing factors.  Often, degenerative changes of the rotator cuff also accompany biceps tendon degeneration with mucoid degeneration, fibrocartilaginous metaplasia accompanied by calcium deposition, and amyloid degeneration all observed.

Tendon Long Head

Unfortunately, the degenerative tissue that forms in response to injury does not have the same biomechanical profile of normal tendons, and more than likely a downward spiral of increasing stress and strain on the remaining normal tendon fibers results in propagation of injury with progressive deterioration leading to tendon failure.

The function of the biceps tendon long head is still highly debated and not entirely understood.  Shoulder function and movement requires a highly complex and coordinated chain of events, which also means that with so many steps involved in the process, the causes for injury and pain can be many and varied.  For instance, one study, comparing professional to amateur pitchers, found that amateurs required considerably more biceps activity to accelerate and decelerate the arm, while professionals were able to selectively recruit the subscapularis portion of the rotator cuff for this purpose.  Possibly, those with the greatest inherent skill or control in the throwing motion are able to lessen the demands on the biceps tendon (AJSM 1987 Nov-Dec;15(6):586-90).

Biceps Pain

Along with biceps tendon pain and tendinopathy, a lot of work has also been done on the origin of the biceps tendon long head. There is considerable variability in the origin of the biceps tendon long head, with reported origins from the supraglenoid tubercle, superior labrumposterior labrum, and rotator cuff, have been reported. Combinations of these have also been reported. More information here about superior labrum anterior posterior SLAP lesions.

Consistent with the “circle concept” of the shoulder, we find biceps tendon long head pathology to often coexist with all the other maladies and diagnoses that afflict the shoulder.

Biceps Pain Treatment Options

Treatment of biceps tendinopathy is also controversial. For the biceps tendon long head, itself, recommendations include biceps tenotomy and biceps tenodesis. There is also considerable controversy regarding the need to evaluate and address concurrent shoulder pathology at the same time. This recent article from USA Today helps highlight the debate at this shoulder surgery article at USA Today. Based on our belief that the shoulder function is indeed complex and not entirely understood, we focus on anatomic restoration and repair of all concurrent pathology. To provide some historical basis and support for the anatomic approach, a long-term review performed at the Mayo Clinic (Becker et al. JBJS. 1989; 71: 376-381) found that isolated biceps tenodesis although advocated for more than fifty years, resulted in disappointing results with longer follow-up.

A biceps tenotomy involves releasing the biceps tendon long head from its origin inside the shoulder joint. The tendon then retracts for a variable distance and heals at this variable distal location.

Biceps Tenodesis

A biceps tenodesis involves releasing the biceps tendon long head from its origin inside the shoulder joint, followed by fixation of the tendon. The fixation method and location can be highly variable and are of significant debate. Several popular options include-soft tissue tenodesis (suturing the biceps tendon long head to the rotator cuff or biceps pulley), suture anchor fixation and interference screw fixation. Biceps tenodesis has also been promoted proximally within the bicipital groove, distally at the exit of the bicipital groove, more distally at the pectoralis major insertion, and at the coracoid process next to the biceps short head origin.

A recent study by Wittstein et al. (AJSM. 2010) compared biceps tenotomy with biceps tenodesis, and found that the patients with a biceps tenotomy had a higher incidence of a “Popeye deformity” and reduced supination strength with all other parameters including patient satisfaction similar between the two groups.

Our Approach

The “Popeye deformity” has been reported with both biceps tenodesis and tenotomy and most agree that this is likely more reflective of the level of core degeneration and fraying of the biceps tendon long head rather than the strength of fixation. It is important to honor the biologic time required for tendon healing before initiating stressful activities. With this in mind, we attempt to preserve the anatomic course of the biceps tendon long head in the hopes of helping to preserve as much of the neuromuscular and proprioceptive feedback role of the biceps tendon long head while removing the diseased and hypovascular portion of the tendon from within the shoulder joint. For highly diseased and frayed tendons with little remaining structural capacity, we perform a biceps tenotomy at its origin, which typically results in the migration of the tendon to the level of the bicipital groove.

For tendons with residual structural capacity, we perform a soft tissue biceps tenodesis. Our technique for soft tissue biceps tenodesis is termed the arthroscopic locking lasso rack hitch biceps tenodesis technique. The biceps tendon is sutured to the rotator cuff (subscapularissupraspinatus) and/or the biceps reflection pulley based on the unique circumstances involved in each case.

Biceps Tendon Pathology

As noted at the beginning of our discussion, in our hands, biceps tendon pathology is most often incidental to other treatable pathology within the shoulder so it is important to have a reliable, minimally invasive, and anatomic technique that does not require a considerable amount of operative time and additional implants. Our technique also avoids the possible complications related to open surgery, avoids the cost of additional implants, and does not interfere with MRI or CT scans.

In summary, biceps tendon pain is often the harbinger of additional pathology and we recommend a thoughtful, detailed, and comprehensive approach to the evaluation of patients with anterior shoulder pain and biceps tendon pain.

Vivek Agrawal, MD

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