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Long Head Biceps Muscle Disorders (LHB): From Conservative Treatment to Surgery

From conservative treatment to surgery: solutions for long head of biceps tendon (CLBO) disorders. Practical advice for injury diagnosis, treatment, and physiotherapy.

Dr. Gabriele Vasario, MD

18 min. Dec 18, 2024

PATHOLOGIES OF THE LONG HEAD OF THE BICEPS (CLBO)

Pathology of the Long Head of the Biceps

The pathology affecting the tendon of the long head of the biceps brachii muscle (CLB or CLBO), located within the shoulder joint, is a medical condition that not only severely challenges joint function but also manifests itself through a range of symptoms that can significantly impact patients' quality of life. Understanding the origins and characteristic signs of this condition is therefore crucial for tailoring targeted therapeutic interventions and restoring some of their lost peace of mind.

Importance and Impact on Shoulder Function

The long head of the biceps tendon is a cornerstone of the shoulder's movement mechanics, acting as a bulwark for stability and efficient function during everyday life and athletic exertion. Its health is essential to ensure the shoulder maintains full functionality, allowing a wide range of actions without discomfort, weakness, or restriction of motor skills.

Compromised tendon function can severely impact upper limb performance, hindering flexibility and causing symptoms such as pain and limited range of motion. These issues not only impact sports activities but also more mundane, everyday activities, making a proactive approach to tendon care and maintenance imperative.

Common Causes and Symptoms of Long Head Biceps Disorders

Among the most common causes of this syndrome are a number of factors, ranging from repetitive movements—especially overhead ones—that can overstress the tendon, to direct trauma, such as falls on an outstretched arm or sudden, unexpected loads that strain the tendon's integrity. Advancing age also plays a significant role, contributing to tendon wear.

The most common symptoms associated with long head biceps disease are varied and multifaceted: anterior shoulder pain that may radiate down the arm, a feeling of weakness when lifting objects or rotating the joint, and crackling or popping sounds when moving the shoulder. In some cases, a noticeable biceps deformity, known as the "Popeye sign," may also occur due to contracture of the biceps muscle.

Treatment for this condition depends on the specific needs of the patient and the severity of the condition. Treatment options range from conservative approaches, such as physical therapy aimed at strengthening the surrounding muscles and improving joint flexibility, to the use of anti-inflammatory medications to relieve pain. In more severe cases, surgery may be necessary to repair or reattach the injured tendon.

Anatomy and Function of the Long Head of the Biceps

The long head of the biceps tendon is a complex anatomical structure that plays a crucial role in supporting and facilitating shoulder movement. Understanding its detailed structure and its impact on shoulder function is important to fully evaluate long head of the biceps pathology.

The biceps brachii muscle, located in the front of the upper arm, plays a crucial role in forearm flexion and hand rotation. This bipennate muscle, known for its characteristic shape resembling two heads or "biceps," extends from the humerus to the forearm. When we lift objects or perform activities that require elbow flexion, such as push-ups or picking up groceries, the biceps brachii springs into action, demonstrating its essential function in daily life. Its abundant presence in targeted training routines is not only for aesthetics but also reflects its importance in arm strength and mobility.

The tendon of the long head of the biceps is composed of tendinous fibers originating from the glenoid cavity of the scapula. From there, the tendon, traversing from intra-articular to extra-articular through a complex tunnel characterized by various and extremely fragile structures such as the pulley, the superior glenohumeral ligament, and the bicipital groove of the humerus, exits the joint along the anterior portion of the arm, where it joins the short head of the biceps and continues its insertion at the level of the radius in the forearm. This anatomical structure allows the biceps muscle to play a significant role in elbow flexion and forearm supination. Furthermore, the tendon of the long head of the biceps also participates in the dynamic stabilization of the shoulder during complex movements.

The function of the long head of the biceps tendon is to contribute to the stability and mobility of the shoulder during daily and sporting activities. For a long time, it was considered one of the main depressors of the humeral head, although more recent anatomical studies have cast doubt on this function.

Throughout evolution, ancient mammals exhibited anatomical features suited to their quadrupedal lifestyle, such as the biceps tendon, which contributed to passive shoulder stability. This mechanism was essential for supporting the movement and strength required for four-legged locomotion. However, with the transition to bipedalism in humans and primates, a significant anatomical adaptation occurred: increased mobility of the upper limb made passive stability less crucial. This evolution allowed for a wide range of movements, such as adduction, abduction, and elevation, essential for daily activities and object manipulation. For example, the ability to raise arms and hands overhead or reach laterally are functions directly linked to these evolutionary changes. The transformation of force vectors and the modification of the curvature of the biceps tendon reflect adaptation to upright posture, but they also increased the vulnerability and wear of the shoulder, highlighting an evolutionary trade-off between mobility and stability.

However, it is important to note that the role of the long head of the biceps may be overestimated compared to the short head of the biceps, which contributes more to shoulder strength and stability.

Additionally, the intraarticular portion of the long head of the biceps tendon can cause significant problems, including injury, inflammation, and pain. These problems can significantly impact shoulder function and require careful evaluation and management.

Possible Causes of CLB Disorders

Risk factors for CLB pathologies

Understanding the risk factors associated with long head of the biceps (LHB) disorders is crucial to preventing and managing these conditions. Age plays a significant role, as wear and tear over time can increase the tendon's vulnerability to inflammation or injury. Specific sports activities—such as baseball, tennis, swimming, or weightlifting—can jeopardize the health of the LHB due to repetitive motions or overuse, especially if they involve overhead movements (holding the arms above the head). Previous injuries can also be a warning sign, as they may have weakened the tendon or altered its joint stability.

Anatomical variations in the groove where the biceps tendon is located can promote tendon instability. A narrow or shallow bicipital groove can cause tendon problems, while a prominent synovial fold or abnormal inclination can increase the risk of injury. These conditions affect the stability of the biceps tendon and can lead to conditions such as tendinitis or tendon rupture.

From overuse to sports injuries: the etiology of long head biceps (LHB) disorders.

Isolated "diseases" affecting the CLB frequently arise from overuse or sports-related trauma. The origin of these disorders ranges from repetitive movements that stress and irritate the tendon, to direct blows such as a fall on an open hand, potentially causing a tear. For example, a baseball pitcher may develop CLB tendinitis due to the monotony and intensity of his pitches, while a bodybuilder may experience a tendon rupture due to overload during exceptionally strenuous weight lifting.

In this intricate ballet of cause and effect, every athletic gesture becomes a potential catalyst for injury, where the line between optimal performance and physical damage becomes blurred. Conventional wisdom suggests that "it's the straw that breaks the camel's back," but in the context of CLB pathologies, it's rather the accumulation of microtraumas that weaves the web of pathology and inflammation. Like a sailor navigating stormy waters, the athlete must constantly balance the desire for excellence with the risk of being shipwrecked in the sea of microinjuries and inflammation.

The long head of the biceps is a peculiar tendon due to its anatomical position, wedged between the subscapularis and supraspinatus tendons as they exit the shoulder joint. This position makes it vulnerable to secondary pathologies resulting from problems with adjacent tendons. For example, inflammation or degeneration of the subscapularis or supraspinatus tendons can directly affect the health of the long head of the biceps, causing pain and limited range of motion. In practice, if one of these adjacent tendons is damaged or inflamed, the long head of the biceps can be affected, manifesting not primary but secondary symptoms, which require careful evaluation by a surgeon specializing in shoulder disorders.

The biceps canal serves as a critical connection between the inside and outside of the shoulder joint. When a condition, such as osteoarthritis or a rotator cuff tear, affects the joint capsule, it can cause excess inflammatory synovial fluid. This fluid must be drained, and the only possible route is through the biceps canal. Therefore, problems within the shoulder can lead to inflammation of the biceps tendon, a condition known as biceps tenosynovitis.

SLAP (Superior Labrum from Anterior to Posterior) tears are damage to the upper labrum of the glenoid cavity, the portion of the scapular bone that forms the glenoid cavity, around which the head of the humerus rotates. This type of injury specifically involves the glenoid labrum, a type of fibrocartilaginous ring that helps stabilize the shoulder joint, and the bicipital anchor, the point where the tendon of the long head of the biceps attaches to the upper labrum of the glenoid cavity. A classic example of a SLAP tear occurs in baseball pitchers, where repetitive, high-speed movements can lead to a separation of the upper labrum. Another example is direct trauma to the shoulder, such as a fall on an outstretched hand, which can cause a similar type of injury.

Identifying CLB Disease Symptoms and Warning Signs

Main symptoms associated with pathologies of the long head of the biceps (CLBO)

When the long head of the biceps (CLBO) becomes inflamed or damaged, symptoms such as anterior shoulder pain, swelling, and a clicking or locking sensation when moving the arm may occur. For example, lifting heavy objects or performing repetitive movements can trigger a flare-up of pain, a possible sign of CLBO tendinitis.

Among the many specialized clinical tests to assess its integrity are the Speed Test and the Yergason Test. The Speed Test is performed by asking the patient to flex the forearm against resistance, assessing the presence of pain in the anterior shoulder. The Yergason Test, on the other hand, involves asking the patient to rotate the forearm outward against resistance, with the elbow flexed at 90 degrees, to identify pain or clicking along the course of the biceps tendon.

In sports medicine, there is a wide array of tests designed to assess the health and strength of the biceps anchor, an important tendon complex located in the shoulder. Among these, the O'Brien test stands out for its specificity in diagnosing problems related to the anteroposterior superior labrum of the shoulder. This is just one example of the many tests available, each designed to investigate specific issues and ensure an accurate and targeted diagnosis.

Popeye's sign occurs when the tendon of the long head of the biceps ruptures, resulting in a characteristic ball-shaped deformity in the upper arm. The name comes from the comic book character Popeye, known for his unusually large forearms. A common example of how Popeye's sign can manifest is following trauma or overload during activities involving heavy lifting. In affected patients, observing the affected arm while it is flexed, a prominent bulge may be noted in the upper arm, precisely where the biceps muscle becomes most visible.

The key symptom remains pain when directly pressing on the tendon in the anterior part of the shoulder, which can usually be self-induced by the patient, provided they have a basic knowledge of anatomy.

Diagnostic Imaging in Long Head of Biceps Muscle (CLBO) Disorders

Role of ultrasound and magnetic resonance imaging

Ultrasound and magnetic resonance imaging (MRI) are crucial for diagnosing disorders of the long head of the biceps (CLBO), providing detailed information on the tendon's health. Ultrasound allows for a real-time dynamic assessment, identifying any partial tears, while MRI provides a detailed view, detecting even the smallest alterations. Both techniques are essential for confirming and detailing the diagnosis of CLBO tendinopathy.

Conservative and Surgical Treatments for Long Head of the Biceps (LHB) Disorders

Nonsurgical approaches to the treatment of CLB

In the non-surgical treatment of the long head of the biceps (CLBO), tecar therapy and laser therapy represent two prominent conservative instrumental options that utilize advanced technologies to accelerate the healing process. Tecar therapy uses heat generated by high-frequency currents to stimulate circulation and cellular metabolism, while laser therapy uses concentrated light beams to reduce inflammation and promote tissue regeneration. Regarding infiltrative treatments, in addition to cortisone injections, growth factor injections are also recommended, which can be particularly effective in promoting cell renewal and tissue healing. Accuracy in administering infiltrations (which tends to be much greater if performed with the aid of ultrasound) is crucial to optimizing results, significantly improving treatment efficacy and often allowing patients to achieve significant pain relief and faster functional recovery.

Tenodesis vs. tenotomy: surgical interventions for CLB

Long head biceps tendon disorders (LHBD) can significantly compromise the function and comfort of the upper limb, in some cases requiring surgery. Among the surgical options, tenotomy and tenodesis represent two main procedures. Tenotomy involves cutting the diseased tendon, freeing it from its insertion, offering rapid pain relief but potentially causing reduced strength (this is actually denied by most literature, although a phenomenon called camping, an involuntary muscle contracture lasting a few milliseconds or mild cramps, may occur) and a cosmetic deformity known as the "Popeye sign" (more evident in very thin individuals). Tenodesis, on the other hand, aims to first perform a tenotomy as in the previous procedure, but then reattach the tendon to a new position, attempting to preserve the length and tension of the tendon, thus minimizing the cosmetic impact and maintaining greater muscle strength. Both methods have their specific advantages and the choice between them depends on the patient's individual needs, daily activities and post-operative expectations.

At specialized shoulder surgery conferences, both the two treatments and the various available techniques are discussed. For further information, we recommend consulting the specific articles on the pathology in the news and research section of the website.

Often, in the repair of the subscapularis and supraspinatus tendons in their most anterior portion, a tenotomy or tenodesis of the long head of the biceps is necessary as an accessory procedure to improve the repair of the tendon itself and to avoid its compromise over time, given the close anatomical correlation of these structures.

In the case of biceps long head insertion injuries that also involve the glenoid labrum (SLAP), surgical or conservative treatment is decided primarily based on the patient's age and sport. Generally, the younger and more athletic the patient, the more likely an anatomical repair is to be sought, although it is not always easy to achieve the correct tension to apply to the tendon during intra-articular repair.

Rehabilitation after surgery for CLB pathologies

Postoperative rehabilitation and recovery play a crucial role for patients who have undergone surgery for a biceps long head disorder. This rehabilitation process is essential for restoring strength, flexibility, and function to the affected limb, significantly reducing the risk of complications or recurrence.

Generally, functional recovery after tenotomies is faster than recovery after tenodesis. However, it all depends on the technique used and the specific pathology. Both procedures do not require extensive physiotherapy, but often simply require respecting the natural biological timing and normal post-operative rehabilitation phases.

Regarding specific exercises and strategies for regaining functionality, they will depend on the type of surgery, considering that flexion against resistance will only be permitted after an appropriate amount of time in the case of tenodesis or repair of the biceps anchor.

Research and Progress

Recent research on the management of long head of the biceps tendon (LHB) pathology has contributed to significant advances in treatment modalities and provided valuable insights into future treatment options. Understanding LHB pathology and the development of innovative therapeutic approaches have been informed by a wide range of studies and clinical investigations.

Recent search results

Recent studies have focused on various aspects of CLB pathology, including the incidence of pathological changes, the diagnostic accuracy of imaging modalities, and the relationship between CLB pathology and comorbid shoulder disorders. For example, a systematic review and meta-analysis evaluated the diagnostic accuracy of MRI for detecting tears and instability of the proximal long head of the biceps tendon, providing valuable insights into the role of diagnostic imaging in the evaluation of CLB pathology. Furthermore, one study analyzed the contribution of MRI and CT arthrography to the diagnosis of intra-articular tendinopathy of the long head of the biceps, shedding light on the diagnostic capabilities of these imaging modalities.

Advances in treatment modalities

Advances in treatment modalities for CLB pathology have been the subject of extensive research, with a focus on both conservative and surgical interventions. A scoping review highlighted the clinical utility of traditional and new tests in diagnosing injuries of the biceps tendon and the anterior and posterior superior labrum of the shoulder, emphasizing the importance of accurate diagnostic methods to guide treatment decisions. Furthermore, a systematic review and meta-analysis compared the outcomes of biceps tenotomy and tenodesis, providing valuable insights into the postoperative outcomes of these surgical procedures.

Emerging trends in management

Emerging trends in the management of CLB pathology have been characterized by the development of new surgical techniques and rehabilitation protocols. For example, one study analyzed the effect of bicipital groove morphology on the stability of the long head of the biceps tendon, contributing to the understanding of the anatomical factors that influence tendon stability and function. Furthermore, a systematic review and meta-analysis compared suprapectoral with subpectoral tenodesis for long head of the biceps brachii tendinopathy, providing guidance on the optimal surgical approach for this condition.

The future of therapeutic options

The future of treatment options for CLB pathology will likely be shaped by ongoing research efforts aimed at refining diagnostic methods, optimizing surgical techniques, and improving rehabilitation strategies. Prospective studies and clinical trials will further clarify the comparative effectiveness of conservative and surgical interventions, leading to the development of evidence-based treatment guidelines. Furthermore, advances in imaging technology and biomechanical research may contribute to the development of personalized treatment approaches, tailored to the specific characteristics of CLB pathology in individual patients.

Recent research findings and advances in treatment modalities have significantly contributed to the management of biceps tendon disease. The future of treatment options is expected to be characterized by ongoing research efforts aimed at refining diagnostic methods, optimizing surgical techniques, and improving rehabilitation strategies to improve patient outcomes.

Learn more in the section News and Research

References and Further Information

  1. Murthi AM, Vosburgh CL, Neviaser TJ. The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg. 2000;9(5):382-385. PubMed
  2. Mead MP, Gumucio JP, Awan TM, Mendias CL, Sugg KB. Pathogenesis and management of tendinopathies in sports medicine. Transl Sports Med. 2018;1(1):5-13. PMC free article
  3. Boileau P, Maynou C, Balestro JC, et al. Le long biceps [Long head of the biceps pathology]. Rev Chir Orthop Reparatrice Appar Mot. 2007;93(8):19. PubMed
  4. Becker DA, Cofield RH. Tenodesis of the long head of the biceps brachii for chronic bicipital tendinitis. Long-term results J Bone Joint Surg Am. 1989;71(3):376-381. PubMed
  5. Oh JH, et al. Comparison of Treatments for Superior Labrum-Biceps Complex Lesions With Concomitant Rotator Cuff Repair: A Prospective, Randomized, Comparative Analysis of Debridement, Biceps Tenotomy, and Biceps Tenodesis. Arthroscopy. 2016.
  6. Osbahr DC, et al. The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy. 2002.
  7. Patel KV, et al. Biceps tenotomy versus tenodesis. Clin Sports Med. 2016.
  8. Shank JR, et al. A comparison of forearm supination and elbow flexion strength in patients with long head of the biceps tenotomy or tenodesis. Arthroscopy. 2011.
  9. Becker DA, et al. Tenodesis of the long head of the biceps brachii for chronic bicipital tendinitis. Long-term results J Bone Joint Surg Am. 1989.
  10. MacDonald P, et al. Biceps Tenodesis Versus Tenotomy in the Treatment of Lesions of the Long Head of the Biceps Tendon in Patients Undergoing Arthroscopic Shoulder Surgery: A Prospective Double-Blinded Randomized Controlled Trial. Am J Sports Med. 2020;48:1439-1449. PubMed
  11. Oh JH, et al. Comparison of Treatments for Superior Labrum-Biceps Complex Lesions With Concomitant Rotator Cuff Repair: A Prospective, Randomized, Comparative Analysis of Debridement, Biceps Tenotomy, and Biceps Tenodesis. Arthroscopy. 2016.
  12. Osbahr DC, et al. The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy. 2002.
  13. Patel KV, et al. Biceps tenotomy versus tenodesis. Clin Sports Med. 2016.
  14. Shank JR, et al. A comparison of forearm supination and elbow flexion strength in patients with long head of the biceps tenotomy or tenodesis. Arthroscopy. 2011.