BICIPITAL TENDINITIS (LONG HEAD BICEPS)/ TEAR

The biceps muscle is located in front of your upper arm. It helps in bending your elbow, rotational movements of your forearm and in maintaining stability in the shoulder joint. The biceps muscle has three tendons, two of which attach it to the bone in the shoulder and the other attaches at the elbow. Of the two that attach it to the shoulder blade, one is long and attaches it to the upper margin of the shoulder socket. The shorter one attaches it to the coracoid process of the shoulder blade to form the conjoint tendon. The biceps tendon at the elbow is called the distal biceps tendon. The long head of biceps (LHB) is often a prime pain generator of the shoulder when it becomes inflamed. A tear in this tendon will make it painful and difficult for you to move your shoulder and weaken your biceps power at the arm. Once the long head biceps tendon is torn, it cannot regrow back to the bone and heal by itself. Permanent weakness during movements of the shoulder may occur, if the tendon is not repaired surgically.

Long head biceps tendon tears can be complete or partial. In partial LHB tendon tear, the tendon does not tear completely but is often painful. A complete tendon tear means it ruptures completely off the shoulder blade.

Causes

LHB tendon ruptures most often result from a sudden injury or lifting a heavy object. Additional risk factors, such as advancing age, smoking and use of corticosteroid medications, can also result in increased muscle and tendon inflammation and weakness, which can lead to the tendon rupture. It may also be predisposed by a LHB tendon that dislocates from the groove in the upper arm bone repeatedly leading to wear.

Signs and symptoms

The most common symptom is a sudden, severe pain in the upper arm or shoulder.¬† You may feel a “pop” at the shoulder when the tendon tears. Other symptoms include swelling, visible bruising, weakness in the shoulder and arm, trouble turning your arm from a palm down to a palm up position, and a gap in the front of the shoulder, caused by the absence of the tendon.¬† A bulge may also appear in your arm caused by the recoiled, shortened biceps muscle.

Diagnosis

Long head biceps tendon rupture is usually diagnosed based on your symptoms, medical history, and physical examination. During the physical examination, Dr Bala will look for a gap in the tendon by palpating the front part of your shoulder. He will also look for weakness of movement of the forearm from palm down to palm up position. Dr Bala will diagnose a partial tear by asking you to bend your arm and tighten the biceps muscle, and identify weakness and pain if there is a partial tear. Rarely x-rays can show a fleck of calcium deposition at the upper end of the socket. Using an Ultrasound or MRI scan, Dr Bala can determine whether the tear is partial or complete.

Non operative treatment 

Tendinitis of the Long head of biceps tendon without tears or partial tears of the distal biceps can be managed conservatively with rest, painkillers and graded physiotherapy to strengthen the tendon. If this has failed to relieve your symptoms Dr Bala may inject the shoulder joint and the front of the shoulder (where the tendon lies outside the joint) with steroids.

 

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In rare instances Dr Bala may opt to use cells from your own blood that are rich in undifferentiated cells. This preparation is called Platelet Rich Plasma or PRP. This injection may aid healing of minor tears of the long head biceps tendon.

Treatment

If you have failed 2 steroid injections or if the first one did not work for long enough, Dr Bala may suggest surgery. During surgery Dr Bala will introduce a camera to visualize the shoulder joint through small keyhole incisions. The portion of the long head of biceps within the joint may need to be cleaned and sometimes cut if damaged beyond repair. If it is your non-dominant shoulder that is involved and your age and activity level does not require strength, this procedure alone (Biceps tenotomy) may solve the problem.

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If you are younger or this problem involves your dominant shoulder and your work demands shoulder strength Dr Bala may decide to fix the cut end of the tendon to the arm bone (Biceps tenodesis). This may be done entirely through keyhole incisions or through small cuts in the upper (Suprapectoral) or upper mid arm (Subpectoral) depending on how much of the tendon is involved with disease. The torn or cut long head biceps tendon is brought up through the incision. The humerus bone is then prepared for tendon reattachment and to promote healing. The sutures are passed through the tendon in a particular interlocking manner so as to ensure a strong tendon repair. Dr Bala prefers to fix the tendon to the humerus using a device called a Pec button and uses a single incision for this procedure.

As this procedure is performed near important nerves that supply the shoulder Dr Bala will explain in more detail the risks involved with this surgery and what precautions he takes to prevent them from happening. Dr Bala takes special precautions while performing this surgery to protect important structures near the shoulder to prevent complications. In the event you may have a tattoo on the shoulder Dr Bala is well versed in suturing tattoos back accurately with absorbable sutures. 2 weeks after the surgery gentle exercises are instituted to regain range of movement and strength to the shoulder.