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What is it?
As the word “bi” indicates, this muscle has two attachments (one called long and the other short ‘head’) at the top of the arm. By convention when one talks about biceps tendon, they are referring to the long head of the biceps muscle. Part of the long head of the biceps is inside the shoulder joint where it blend with the cartilage rim of the shoulder socket.
The role of the long head of biceps is still under much debate. Does it depress the humeral head during various movements? Does it guide the humeral head in the correct direction due to its ‘mono-rail’ system of pulley and groove? Is it a vestigial structure inside the joint like appendix inside the abdomen?
What ever it is we know that it has numerous nerve endings and when it is irritated, it can be very painful.
The symptoms depends on the site of the damage. It can be damaged inside, or at the exit from the joint or outside the joint. Typical damages occurs at
A) Damage outside the joint = Tendinitis
B) Damage at the exit of the joint = Biceps tendon dislocation
C) Damage inside the joint = SLAP Lesion (SLAP = Superior Labrum Anterior to posterior). Damage at its attachment to the shoulder socket.
Inflammation of the biceps tendon is relatively common and usually occurs as a part of impingement syndrome when the tendon is plucked like a guitar string by the ligament-bone complex of the acromial arch. One points to the front of the shoulder as the painful spot.
Biceps tendon dislocation is invariably painful experience. One will never forget this event. It usually occurs as a late consequence of rotator cuff tear. The episode is characterised by severe pain on attempted forward elevation of the arm when the tendon gets jammed in the front of the joint. On rare occasions, the biceps can relocate back; but this is often temporary.
SLAP lesion occurs when the biceps muscle contracts forcibly against resistance resulting in tugging of the insertion of the long head which then gets detached or torn from the shoulder socket. Typical instances leading to such injuries are when the arm is pulled away when holding on to someone/something (sports) or when one looses grip while holding a heavy object and tries to regain the hold in vain. This condition gives raise to ‘clicks’ coming from the inside of the joint, quickly tiring biceps on activity and momentary sensation of joint ‘popping-out’.
In majority of cases, simple measures will ease the pain for tendinitis. A well-directed physiotherapy may give good pain relief. In some instances, one may need injection of cortisone (steroid) and local anaesthetic mixture usually in the subacromial space. Overall, about 50% get better with activity modification, tablets and physiotherapy and targeted injection.
However, dislocation and SLAP lesions will not heal on their own and will require further surgical attention. Those who do not get better may require surgical intervention especially when the quality of life is affected. A very good option for biceps dislocation in the presence of a large to massive rotator cuff tear is biceps tenotomy - dividing biceps tendon from inside the joint and releasing it. SLAP lesion requires re-attachment of the tendon using anchors and the approach is similar to repairing labrum (see arthroscopic stabilisation)