Biceps tendon tear treatment

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

As with many of the conditions we treat at Caring Medical, a biceps tendon tear or a chronic condition of biceps tendinopathy is not a problem that we see as an isolated problem. The problem of the biceps tendon in the shoulder is usually one problem existing among many shoulder problems.

Here are the typical stories we hear at our center when someone with shoulder problems contacts us:

Rotator cuff, damage to the biceps tendon, and the shoulder labrum

I have a torn rotator cuff, damage to the biceps tendon, and the shoulder labrum. I am being told that I need shoulder surgery to go in and clean up all this mess. I haven’t been able to lift my arm over my head for years.

Supraspinatus and biceps tendon

I have a partial tear of the supraspinatus and biceps tendon. I play slow-pitch softball and I pitch. I can still pitch but it comes with some or a lot of pain depending on the day.

Nerve impingment after surgery

I had a successful rotator cuff and bicep tear surgery in early 2022. I completed the physical therapy and was able to return to work. I was also able to return to the gym with light workouts. I then started having sharp pain which increased in severity. I went back to my surgeon who saw nothing. I went to a sports medicine doctor who did an MRI and saw nothing. I have muscle weakness, range of motion issues and sudden, severe, sharp pains like a knife being stuck into my shoulder, all motion related. I am unable to sleep.

More MRIs come in than stories

Bicep tendon problems are one of the problems that we see that when people contact us, they will send us a cut and paste of their MRI impression and ask, “can you fix this.” Unfortunately, many of these people do not tell us about their shoulder pain, their daily quality of life, or their limitations. Just an MRI report and “can you fix this.” Our treatments are based on physical examination and the functional capabilities of the shoulder. An MRI can be helpful but it may not be the “tell-all,” that some people think an MRI is. Usually, when they send in a cut and paste MRI report it is because they were told to have surgery. As we will see below, sometimes, in cases of complete tear or rupture, surgery may be the only answer. In cases of partial tears, surgery, for many people, can be avoided.

“Tendinopathy of the long head of the biceps tendon is a difficult medical issue.”

Here is a recent research examination (1) of the problems in understanding biceps tendinopathy. It comes from a team of pathologists whose job it is to understand, as best they can, biceps tendinopathy. Here are the learning points and our interpretation.

“Tendinopathy of the long head of the biceps tendon is a difficult medical issue. Its pathogenesis and etiology are multifactorial and unclear. Tendinopathy is thought to be primarily degenerative in nature, as tendons are characterized by impaired regeneration and healing.”

Simply, it is a wear and tear disease that inflammation gives up on. What does this mean? The body thinks the tendon cannot heal.

Simply, it is a wear and tear disease and at some point tendinitis, that is inflammation and the natural healing response shuts down because either the tendon is healed, or the body thinks the tendon cannot heal. So tendinitis turns into tendinosis. Pain without inflammation. It is at this point that anti-inflammatories and cortisone become ineffective.

What this study points out is that non-healing biceps tendinopathy is not a problem of too much inflammation, but rather not enough inflammation. How can this be? Let’s let the pathologists describe this.

Repetitive overloading and wear and tear lead to degeneration of the tendon. This process is called tendinopathy, and as demonstrated by several studies seems to be predominantly a result of mechanical damage associated with a very limited inflammatory response.
The long head of the biceps tendon has a unique anatomy. It is divided into two portions: extraarticular (outside the shoulder joint) and intra-articular (inside the shoulder joint). The intra-articular part of the long head of the biceps tendon is prone to degeneration due to its exposition to tear, compression, and friction forces.
Although damage to tendinous tissue related to mechanical overload is typically referred to as tendinosis, this term may be misleading, since the inflammatory process implied by the name is usually mildly marked, and the degenerative process seems to play the main role. So far in most cases of long head of the biceps tendon tendinopathies, anti-inflammatory methods of treatment have been used as a first choice.
Given the fact that most studies did not demonstrate the presence of an inflammatory process, this is becoming controversial, particularly corticosteroids injections, especially since a high percentage of unsuccessful cases have been reported. Similarly, this can explain why the use of non-steroid anti-inflammatory drugs (NSAID) may be ineffective in the long head of the biceps tendon pathologies.

Bicep tendon degeneration usually is not a limited or isolated problem. It is one condition among many in a problem shoulder.

In the above study, the pathologists noted what we see clinically and empirically. That bicep tendon degeneration usually is not a limited or isolated problem. It is one condition among many in a problem shoulder.

The research above was conducted among 35 patients who had a shoulder arthroscopy: This was their general description:

Of the 35 patients:
- 11 had a duration of symptoms less than 1 year
- more than one year and less than two years among 10 patients
- and longer than 2 years in a group of 14 patients.
All patients admitted, that they occasionally took NSAID (non-steroidal anti-inflammatory drugs) because of their shoulder pain.
Of the 35 patients:
- Only three had an isolated long head of the biceps tendon tear.
- 24 patients – two of three had rotator cuff tears.
- More than half, 18 patients, had subacromial impingements.
- Two had shoulder labral tears.
- During shoulder arthroscopy 7 patients underwent the tenotomy procedure and 27 patients underwent the tenodesis procedure, there was one stub resection due to previous the head of the biceps tendon complete rupture.

What are we seeing in this image?

In the image below we note that the Biceps pulley is a complex shoulder ligament complex that keeps the long head of the biceps tendon in the bicipital groove (the notch of the humerus bone.)

As noted in a paper published in the journal Radiographics. (2)

The pulley complex is composed of the superior glenohumeral ligament, the coracohumeral ligament, and the distal attachment of the subscapularis tendon. Pathologic conditions associated with pulley lesions include anterosuperior impingement, instability of the biceps tendon, biceps tendinopathy or tendinosis, superior labrum anterior and posterior lesions, and adhesive capsulitis.”

Biceps Tendon Tear Treatment

Prolotherapy specialist Danielle Matias, MMS, PA-C discusses biceps tendon tears and when we would see a patient with a biceps tendon injury in our office for Comprehensive Prolotherapy injections vs. when it is a surgical case. She also explains how ultrasound is used during the Prolotherapy series to look for objective improvement of tissue integrity.

Prolotherapy injections. This is the injections of dextrose, a simple sugar that provokes a healing response in damaged soft tissue. This will be explained below.

While the biceps tendon originates at the shoulder and goes down to attach at the elbow. In this video, we will focus on injuries at the shoulder.

It is a surgical problem when:

People can tear their biceps tendon to the point where it’s torn in two. That is a complete tear of the bicep tendon. The typical signs are heavy bruising and the biceps muscle has contracted or rolled itself up into a ball. Some of you researching this problem may recognize this as a “Popeye” sign. An obvious distortion of the bicep anatomy and muscle. The treatment for this is surgical.

Non-surgical options can help when:

In cases where the tendon is still intact but has been partially torn or degenerated, these problems can usually be treated non-surgically. Even if the patient has significant pain.
In cases where someone has a lot of pain on function, we usually find that the patient has more issues than a biceps tendon tear. They usually suffer from many problems in the shoulder such as a rotator cuff tear a labral tear or even a laxity or looseness and stretching and spraining of the shoulder ligaments within the shoulder capsule. This is typical of degenerative wear and tear.
Here are ultrasound images that look at the biceps tendon. This view is a long axis view so we’re looking at the tendon that goes down the arm. A normal healthy tendon on ultrasound should be ultra white in appearance. So as in this image, when we see areas of black or even a darker gray that’s a sign of tendinosis, tendinopathy, tendon degeneration, or can even be a sign of tearing and fraying in the fibers. This change in color is in part because of an immune response to injury.

What are we seeing in this image?

The pools of black and dark grey fluid permeating throughout the tendon revealed on ultrasound.

Before and after Prolotherapy treatment

What are we seeing in this image?

The significant fluid is seen in the before picture. This is a sign of tendon damage.
Three months later in the bottom image, there is a significant reduction in the fluid that surrounds the tendon. A signal that healing is occurring.

This patient also had ligament laxity in his shoulder and some rotator cuff degeneration. This is why we treat the whole shoulder. As mentioned above, bicep tenons problems are usually not isolated injury.

In this video, a general demonstration of Prolotherapy and PRP treatment is given.

Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:

PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
In the shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
The patient in this video is not sedated in any way. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
This patient, in particular, came to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule, and the glenohumeral ligaments are treated.
PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrated cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments, in this case, it was in his anterior shoulder attachments to address the chronic dislocations.

Questions about our treatments?

If you have questions about Biceps tendon tear treatment and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

References

1 ZabrZyński J, Paczesny Ł, ŁaPaJ Ł, Grzanka D, Szukalski J. Is the inflammation process absolutely absent in tendinopathy of the long head of the biceps tendon? Histopathologic study of the long head of the biceps tendon after arthroscopic treatment. Polish Journal of Pathology. 2017 Jan 1;68(4):318-25. [Google Scholar]
2 Nakata W, Katou S, Fujita A, Nakata M, Lefor AT, Sugimoto H. Biceps pulley: normal anatomy and associated lesions at MR arthrography. Radiographics. 2011 May;31(3):791-810. [Google Scholar]

2021