WHAT IS AND SYMPTOMS
WHAT IS BRACHIAL BICEPS TENDINITIS IT AND WHAT ARE ITS SYMPTOMS?
The biceps tendon can be damaged from different causes but it is not usually inflamed, so it’s more accurate to describe injuries that occur here as tendinosis and not tendinitis. Importantly, and as mentioned before, the biceps is usually the perpetrator of other shoulder injuries and is known as a “pain generator” in the shoulder. A detailed history and a good physical examination are very important in order to know the real cause of the problem.
The main causes of a brachial biceps injury are explained below:
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Breaks: The biceps can be broken both at the elbow and at the shoulder level with falls or sudden movements (i.e. carrying excessive weight). Normally these tears occur in previously damaged tendons. It is typical to feel a “snap” and the “Popeye deformity” may appear in the arm, called so because the biceps will bulge unnaturally, similar to the exaggerated muscle shape of the famous cartoon character.
Instability: Caused by injuries to the biceps pulley, typically damaged by repetitive throwing motions and, in some patients, is associated with rotator cuff injuries to the point of impingement. This is because, in the absence of the “cover” that keeps the biceps in its correct position, it becomes unstable and can damage the tendons around it, such as the subscapularis and the supraspinatus.
Tendinopathy: The biceps tendon, like the other tendons of the shoulder, can undergo degenerative changes with age and use. In the case of the biceps, around 80% of its degenerative changes are associated with rotator cuff injuries. Tendenopathy injuries are more frequently found in patients who smoke or who use their shoulder in repetitive throwing motions at work or during sport. When talking about the shoulder, it is also important to remember and consider the scapula, which has a very important role in its biomechanics. Due to muscular imbalances caused by shoulder tendinopathy, scapular dyskinesia (alteration in the movement of the scapula) is an extremely common secondary injury that can cause pain in the brachial biceps. In patients who practice racquet sports, it’s common to find these mechanical imbalances of the scapula that lead to pain in the shoulder.
The diagnosis of this pathology is based on:
- The patient’s symptoms and the examination carried out by the traumatologist
- Additional ultrasound tests or MRI scans, as required, to rule out associated injuries.
Other related shoulder injuries:
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WHAT ARE ITS SYMPTOMS AND HOW IS BICEPS TENDINITIS DIAGNOSED?
The most common symptoms of this injury are:
Pain in the front of the shoulder- Decreased strength and functional weakness in the shoulder.
- Pain when the elbow is flexed with resistance (or free from resistance, in severe tendonitis cases)
- Pain that increases at night and with activities performed overhead.
Pain in the front of the shoulderIF THE INJURY IS NOT TREATED IN TIME
If a treatment is not carried out to treat biceps tendonitis, it can lead to serious consequences:
Work
If biceps tendonitis is not treated, it can lead to a functional loss of the muscle, which will cause problems to adequately perform work-related activities.
Sport
This injury will make it impossible to perform exercises requiring shoulder muscle strength and the shoulder will only be damaged further if you train while in pain, so a shoulder trauma specialists should always be consulted.
Tendon Rupture
If you think your brachial biceps injury doesn’t require treatment, remember that even a minor form of this injury can lead to a rupture of itself or other tendons, which may result in the need for surgery.
WHAT IS THE TREATMENT FOR A BICEPS TENDINITIS?
CONSERVATIVE TREATMENT OF BRACHIAL BICEPS INJURIES
There are two types of treatment for brachial biceps injuries: surgical treatment or conservative treatment. It is very important to recognize the cause of the pain when choosing between them.
Conservative treatment of bicep tendinosis is fundamentally based on three phases: initial (or acute) phase, intermediate (or rehabilitation) phase, and advanced (or strengthening) phase.
In the initial phase, the fundamental objectives are to reduce pain and inflammation and to identify and correct muscle imbalances and postural adaptations.
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For this, therapies such as laser, iontophoresis and dry needling are used. Injections or similar treatments are used if the pain persists. In most cases, corticosteroids with local anesthetic are injected with ultrasound guidance. Once the pain is controlled, isometric scapular work and proprioception exercises are essential.
The intermediate phase of recovery focuses on gaining flexibility, mobility, and improving neuromuscular control. Isotonic exercises are started, focusing especially on shoulder girdle work.
The advanced phase is characterized by muscle strengthening and specific rehabilitation exercises depending on the sport.
SURGICAL TREATMENT OF BRACHIAL BICEPS INJURIES
When the patient has undergone conservative treatment but the pain persists, we opt for surgical treatment, specific to biceps injuries. This can be either tenotomy or tenodesis.
Tenotomy consists of cutting the tendon. It is performed arthroscopically (see shoulder arthroscopy section) and is a technically simple and fast procedure. There are no risks of material intolerance, it allows for early rehabilitation, and it eliminates pain. The only downside is the aesthetic “Popeye” effect in which, in some patients, the muscle mass of the biceps “drops” at the elbow.
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Tenodesis consists of cutting the damaged tendon and reaffixing it to the bone in a number of ways (for example screws or harpoons). It can be done arthroscopically or in open surgery (with an incision of about 2 cm). This procedure is a more expensive and time-consuming technique compared to tenotomy and is not without complications such as residual pain in the anterior aspect of the shoulder. There is much controversy about the treatment of choice, but in general terms tenotomy (tendon removal) is preferred as the first choice, and tenodesis (tendon reattachment) is opted for young patients, in athletes, or those who work in manual labor requiring greater strength.
Biceps tears are most often treated conservatively, since the impact on the function of the arm is minimal (the patient may lose some strength, about 30%, in supination, or movements when the palm is facing upwards. Surgical treatment is usually only performed in high-level athletes, manual labor workers, or in patients who, despite conservative treatment, feel cramps in their arm. In these cases, the treatment carried out is a tenodesis (tendon reattachment)
Click here to see to an open tenodesis surgery animation:
Click here to see an arthroscopic tenodesis surgery animation:
https://www.arthrex.com/es/recursos/animacion/VaLRfBovVES7MgFnf44H4Q/loop-n-tack-biceps-tenodesis
FREQUENTLY ASKED QUESTIONS
What is the brachial biceps?
The brachial biceps is a muscle located in the shoulder and connected to the elbow. It has two ‘heads’: the short head and the long head with the long head usually causing the biggest problems. Its function at the elbow is to supinate (turn the palm of the hand upwards) and flex the elbow, but its function at the shoulder is more disputed.
How long does it take to perform an arthroscopic surgery for brachial biceps tendonitis?
The duration of this type of intervention varies depending on the chosen technique and the characteristics of the patient, with an average time of 15-30 minutes.
What is the recuperation like after an arthroscopic brachial biceps surgery?
- Immobilization in a shoulder sling will be needed for 1 week (in the case of a tenotomy surgery) or for 4 weeks (in the case of a tenodesis surgery)
- Specialized shoulder rehabilitation therapy should begin immediately after surgery.
- After tentomy surgery, daily activities will resume after 2 or 3 weeks and activities requiring more strength after 2 to 3 months. In case of tenodesis surgery, daily activities can resume in about 6 weeks and strength activities in 3 to 4 months
What are the possible complications from an arthroscopic brachial biceps surgery?
- If a tenotomy is performed, there is a risk of an aesthetic “Popeye” effect and the slight loss of supination force (movement to face the palm of the hand upward)
- If a tenodesis is performed, there exists the risk of residual anterior shoulder pain (pain in the front of the shoulder).
REFERENCES
Chang KV, Mezian K, Naňka O, Wu WT, Lin CP, Özçakar L. Ultrasound-guided interventions for painful shoulder: from anatomy to evidence. J Pain Res. 2018 Oct 11;11:2311-2322. doi: 10.2147/JPR.S169434. eCollection 2018.PMID: 30349357
Biceps Tenotomy Versus Tenodesis. Patel KV, Bravman J, Vidal A, Chrisman A, McCarty E2.Clin Sports Med. 2016 Jan;35(1):93-111. doi: 10.1016/j.csm.2015.08.008.
Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results.Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Bach BR.J Shoulder Elbow Surg. 2011 Mar;20(2):326-32. doi: 10.1016/j.jse.2010.08.019.
Bradbury T, Dunn WR, Kuhn JE.Preventing the popeye deformity after release of the long head of the biceps tendon: an alternative technique and biomechanical evaluation. Arthroscopy. 2008 Oct;24(10):1099-102. doi: 10.1016/j.arthro.2008.06.002. Epub 2008 Jul 24.
Wilk KE, Hooks TR The Painful Long Head of the Biceps Brachii: Nonoperative Treatment Approaches.Clin Sports Med. 2016 Jan;35(1):75-92. doi: 10.1016/j.csm.2015.08.012. Epub 2015 Oct 17.PMID: 26614470
Bradbury T, Dunn WR, Kuhn JE.Preventing the popeye deformity after release of the long head of the biceps tendon: an alternative technique and biomechanical evaluation. Arthroscopy. 2008 Oct;24(10):1099-102. doi: 10.1016/j.arthro.2008.06.002. Epub 2008 Jul 24.
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