Problems affecting the upper biceps tendon (long head of biceps) are a common source of pain at the front of the shoulder, particularly in people who perform repetitive lifting, overhead activity, or sports involving throwing. Biceps tendon conditions frequently occur alongside other shoulder problems, including rotator cuff disease, shoulder impingement, and labral injury. Problems with the lower (distal) biceps tendon include tearing from the bone at the elbow or pain in the same area from repetitive overload. This is explained in more detail on the distal biceps tendon rupture and the biceps tendon repair pages.
The biceps muscle in the arm has two distinct connections at the shoulder, giving rise to the ‘long head’ and the ‘short head’ of biceps.
It is the long head of biceps which is discussed here.
The short head of biceps arises from the coracoid process, a bony prominence at the front of the shoulder, and lies outside the shoulder joint. This portion of the tendon is almost never a cause of shoulder pain and is rarely injured.
The long head of biceps tendon is one of the few tendons in the human body that travels inside a joint. It attaches to the top of the shoulder socket (at the upper glenoid labrum), passes through the shoulder joint and then runs down the front of the shoulder within a narrow channel known as the bicipital groove.
This unique pathway makes the long head of biceps tendon particularly vulnerable to irritation, instability, and injury.
Biceps tendinitis and tendinopathy: Degeneration or inflammation of the biceps tendon may develop gradually over time. This is often associated with rotator cuff disease or shoulder impingement and typically causes pain at the front of the shoulder, particularly with lifting or overhead use.
Biceps tendon instability: When the small ligaments holding the biceps tendon in place are compromised, particularly when there is a subscapularis tendon tear, the biceps tendon may intermittently slip out of its groove. This can cause pain, clicking, or snapping sensations at the front of the shoulder.
SLAP tears: The long head of the biceps attaches to the labral cartilage at the top of the socket of the shoulder. Injury at this attachment point is known as a SLAP tear and is commonly seen in throwing athletes or following repetitive overhead activity. Symptoms may include deep shoulder pain, catching, or weakness.
Biceps tendon rupture: A rupture of the long head of the biceps tendon may occur suddenly or following long-standing weakness from degeneration. It does not usually require a major injury or accident. Patients may notice a sudden “pop,” bruising, and a more visible bulge in the bicep muscle, sometimes referred to as a Popeye deformity. Pain predictably improves, but fatigue or cramping in the bicep muscle may persist in some individuals.
Identifying whether the biceps tendon is the primary pain generator or part of a broader shoulder problem is essential when planning treatment.
Even full ruptures of the tendon are almost always treated without surgery, accepting a change in shape of the bicep muscle (the ‘popeye’ or dropped biceps deformity). Often pre-existing pain from a frayed and inflamed bicep tendon will resolve after it ruptures. Discomfort and bruising around the shoulder and upper arm will persist for 3 to 4 weeks and can be managed with analgesics and a gentle movement exercise plan to ensure recovery of full movement range at the shoulder.
Full strength around the shoulder and the bicep muscle itself will return since the bicep muscle remains fully connected via the short head of bicep tendon which is always unaffected. It is only the long head component which ruptures.
If shoulder stiffness or pain persists for a more prolonged period, then further treatment may be required.
Surgery may be considered if bicep symptoms persist despite appropriate non-operative management or if biceps pathology is contributing significantly to shoulder dysfunction. Given the close relationship between the biceps tendon and other shoulder structures, surgery often addresses multiple issues simultaneously.
Regarding surgical options specifically for the biceps tendon itself, there are two approaches:
Biceps tenotomy: Biceps tenotomy involves releasing the long head of the biceps tendon from its attachment. This option may be appropriate for some patients and is associated with a simpler recovery. A cosmetic Popeye deformity may occur, though this does not usually affect function.
Releasing the tendon does not reduce bicep muscle strength since the muscle remains fully connected through the more important short head of biceps.
Biceps tenodesis: Biceps tenodesis involves removing the diseased portion of the tendon from within the joint and reattaching it to the humerus. This approach maintains the contour of the biceps muscle and reduces the risk of cosmetic deformity. Because the tendon must heal to bone, rehabilitation is more structured and protective in the early phase.
This can be performed through a 2cm incision with a small plastic screw, or more commonly with threads alone from the bicep tendon to the nearby bone
Shoulder strength and function remain unchanged regardless of which surgical approach to the tendon is taken.
The biceps very commonly requires treatment at the time of rotator cuff repair surgery.
Individualised treatment planning
Management of biceps tendon problems depends on:
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