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Biceps Tendon Anatomy

The biceps tendon in the shoulder is intimately related to the rotator cuff, and it is impossible to evaluate one without considering the role of the other. Most people are familiar with the biceps muscle, and the reason it is called the biceps is because it has two heads: 1) a broad, flat part that attaches to the coracoid on the outside part of the shoulder, 2) a slender rope-like part that slips in between the rotator cuff tendon attachments into the ball and socket joint to attach to the top of the glenoid labrum. It is important to identify exactly where the pain is coming from, so that the treatment can properly address the underlying problem.

Biceps Tendonitis

When the shoulder is functioning normally, the biceps tendon slides smoothly inside of its groove on the front part of the shoulder. If the shoulder is moving in a way that affects the gliding of the biceps tendon it can become inflamed or even torn, causing significant pain that is felt in the front of the shoulder. If you are able to take NSAIDs, going on a course of a long acting NSAID like Naproxen or Meloxicam can be helpful to settle down the inflammation before going to Physical Therapy to work on a shoulder blade and rotator cuff program that improves the mechanics of the shoulder and helps the biceps to glide more smoothly through its grove and into the shoulder joint.

If the NSAIDs are not working or if you are not allowed to take them, then it may be worthwhile to discuss an ultrasound guided biceps injection of cortisone. In addition to treating the inflammation, this will help to confirm the diagnosis, since in addition to the cortisone we also inject a numbing medicine into the space around the biceps - if the pain goes away completely, that means that the pain was coming from the biceps tendon. This way, if we decide to do surgery down the road, we can do so with the confidence that you should get the same pain relief from the operation as you did from the numbing component of the cortisone injection.

Surprisingly, if the biceps tendon does rupture completely on its own, as long as the rotator cuff is not significantly torn, the result is usually very acceptable with most patients being able to deal with the Popeye deformity in their upper arm without the need for surgery. If a biceps problem does fail conservative management, the two types of surgery to address inflammation and damage to the biceps are a tenotomy (simply cutting the biceps to allow for early rehabilitation, an operation made famous by John Elway and Brett Favre) or a tenodesis (see picture showing the anchoring of the biceps into its groove to avoid the deformity and potential cramping associated with a Popeye deformity).  The decision between these two operations, just like the decision to go ahead with surgery at all, is always made on a case by case basis. 

Click here to get an idea of how to prepare for your shoulder surgery and see the instructions you will be given on the day of surgery. 

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Biceps Tenodesis - you see the anchor holding down the biceps at the bottom of the groove and the painful part of the biceps is removed (white section).

SLAP Tears

After the biceps slips into the shoulder joint, it attaches to the top of the labrum, which is the ring of fibrous tissue that encircles the glenoid socket. This attachment point is called the "superior labrum" and if the biceps anchor is detached the tear usually propagates forwards (anterior) and backwards (posterior) along the labral attachment to the glenoid. That is why it is called a superior labrum anterior and posterior (SLAP) tear. The way to approach these tears is very similar to biceps tendonitis, with the main difference being that an ultrasound guided injection for a SLAP tear should be injected into the ball and socket joint instead of the groove of the biceps. In both cases, the injection is therapeutic (it treats the inflammation) and diagnostic (it helps us to confirm that we know where the pain is coming from. Either way, we do our best to help settle down the inflammation with NSAIDs or cortisone, then try to improve shoulder mechanics with physical therapy, and if all else fails we discuss the risks and benefits of a tenotomy or tenodesis of the biceps. The preparation for and recovery from surgery is the same as if the procedure is done for biceps tendonitis, above.