Tendinosis / Rupture / Subluxation / Hypertrophy

FunctionNormal Biceps


LHB primary function is humeral head depressor


Also accelerate / decelerate arm in overhead sports




Biceps problems usually occur with other pathology 

- rotator cuff / instability


3 main problems


1.  Degeneration

- "Tendinosis"

- usually associated with impingement

- can lead to rupture



- rarely associated with weakness

- 80% flexion strength from brachialis and short head biceps


2.  Instability


Stability contributed by

- transverse humeral ligament

- coracohumeral ligament

- superior GH ligament


Almost always associated with cuff tears

- SS tears

- medial subluxation with SSC tear


Lafosse et al Arthroscopy 2007

- biceps can be unstable anteriorly or posteriorly

- anterior with SSC tears

- posterior with SS tears


3.  Disorders of the origin (SLAP)


4.  Hourglass Biceps


Wiley etal J Shoulder Hand Surg 2004

- thickened intra-articular portion biceps

- unable to travel in groove

- with forward flexion of arm, arthroscopically see bunching of biceps

- requires double release  / tenotomy / tenodesis





- from postero-superior labrum and supraglenoid tubercule


Tendon is intra-articular

- passes deep to CH ligament, through rotator interval

- enters bicipital groove, beneath transverse humeral ligament




Tenderness over biceps tendon crucial



- Popeye appearance


Popeye Sign BicepsPopeye Biceps



- forward flexed shoulder against resistance

- elbow kept extended and supinated

- feel pain or palpate tenderness



- elbow flexed and pronated

- resist supination

- pain over LHB


O'Brien's / SLAP

- arm forward flexed and adducted in plane of scapula

- point thumb down and resist downwards force

- this generates pain

- no / less pain with thumb up






MRI Enlocated Biceps Tendon




Biceps Tendonitis MRI


Tendonosis / thickening


Biceps Tendinosis MRI


Medial Subluxation


Biceps Tendon Medially DislocatedMedially Dislocated Biceps Tendon with Torn SubscapularisBiceps Medially Dislocated and Torn SSC






Arthroscopy Normal Biceps Tendon Arthroscopy Normal Biceps Exit


Mild Tendonopathy


Biceps Tendonopathy Grade 2 Arthroscopy


Moderate Tendonopathy


Shoulder Biceps Moderate Tendonopathy


Severe Tendonopathy


Biceps Tendonopathy ArhroscopyBiceps Tear near complete


Dislocated Biceps in Presence of complete SSC Rupture


Shoulder Scope Dislocated Biceps TendonMedially Subluxed Biceps Tendon




1.  Tendonitis


Non Operative


As per rotator cuff / impingement


- physio


Surgical Options


1.  SAD

2.  Manage rotator cuff pathology

3.  Consider for inflamed but intact LHB

- release THL

- spare CH ligament


2.  Tendon Fraying / Tendinosis / Rupture


Grade tendon integrity


I     Minor fraying <25%

II    Fraying 25-50%

III   Fraying >50%

IV   Complete rupture


Management Strategy


I & II

- SAD & debride tendon 



- SAD & biceps tenodesis / tenotomy


Tenotomy v Tenodesis


Frost et al Am J Sports Medicine April 2009

- reviewed all articles on tenotomy / tenodesis

- concluded that there is no evidence for superiority of one over another


Koh et al Am J Sports Med 2010

- tenotomy v tenodesis in setting RC tears

- 9% popeye in tenodesis (suture anchor) and 27% in tenotomy

- no other difference in terms elbow flexion power / shoulder scores




Popeye deformity


Lim et al Am J Sports Med 2011

- incidence of pop-eye of 45% post tenotomy

- more common in men


Cosmetic deformity acceptable in elderly

- not in young

- avoided by tenodesis




Shank et al Arthroscopy 2011

- no evidence of decreased elbow flexion or supination strength





- young patient grade II, III, IV

- slim arm (where popeye would cause significant cosmetic problem)



- screw prominence / pain

- failure of fixation



- arthroscopic

- open

- see techniques




Soft tissue or bony fixation

- in inter-tubercular groove

- suprapectoral


Sheibel Am J Sports Med 2011

- soft tissue v bony anchor fixation

- superior cosmetic and functional outcome with bony




Suprapectoral or subpectoral


Nho et al J Should Elbow Surgery 2010

- 353 patients treated with subpectoral bioabsorbable tenodesis screw

- 2% complication rate

- 2 patients with popeye

- 2 with tenderness over screw

- 1 deep infection

- 1 MCN injury


3.  Subluxation




Usually medial from SSC tear

- must manage LHB or SSC repair will fail




1.  Tenodesis / Tenotomy + SSC repair


2.  Stabilisation + SSC repair



- can get stenosed painful tendon  


Maler et al JBJS Am 2007

- 21 patients with traumatic tear of SSC treated within 6 weeks

- open SSC repair and LHB stabilisation

- 7 had symptoms of mild tenodinopathy

- 2 recurrent instability and 1 rupture on US