The Clinical Syndrome

The tendons of the long and short heads of the biceps are particularly susceptible to the development of tendinitis. Biceps tendon tear is usually caused at least partially by impingement on the tendons of the biceps at the coracoacromial arch. The onset of pain and functional disability associated biceps tendon tear is generally acute, occurring after overuse or misuse of the shoulder joint, such as trying to start a recalcitrant lawn mower, practicing an overhead tennis serve, or performing an overaggressive follow-through when driving golf balls ( Fig. 31.1 ). More common in men, proximal rupture of the tendon of the long head of the biceps tendon accounts for more than 97% of biceps tendon ruptures; ruptures of the distal portion of the biceps tendon occur less than 3% of the time. Rupture of the long head of the biceps tendon generally occurs in the fourth to sixth decades, but it can occur in younger age groups involved in high-risk activities such as snowboarding.

The onset of pain and functional disability associated with biceps tendon tear is generally acute, occurring after overuse or misuse of the shoulder joint, such as trying to start a recalcitrant lawn mower.

The biceps muscle and tendons are intimately involved in shoulder and upper extremity function and are susceptible to trauma and to wear and tear ( Fig. 31.2 ). If the damage is severe enough, the tendon of the long head of the biceps can rupture, leaving the patient with a telltale “Popeye” biceps (named after the cartoon character) ( Fig. 31.3 ). This deformity can be accentuated by having the patient perform Ludington’s maneuver: placing his or her hands behind the head and flexing the biceps muscle ( Fig. 31.4 ).

Arthroscopic images of the long head of the biceps tendon as seen from the posterior portal showing synovitis ( A ), partial tear ( B ), and delamination ( C ) of the long head of the biceps, concomitant with rotator cuff tear.

(From Virk MS, Cole BJ. Proximal biceps tendon and rotator cuff tears. Clin Sports Med. 2016;35(1):153–161.)

Typical Popeye deformity seen with rupture of the long head of the biceps tendon.

(From Virk MS, Cole BJ. Proximal biceps tendon and rotator cuff tears. Clin Sports Med. 2016;35(1):153–161.)

The Ludington’s maneuver for ruptured long tendon of the biceps. C, contraction of biceps; P, pressure applied.

(From Waldman SD. Physical diagnosis of pain: an atlas of signs and symptoms . 2nd ed. Philadelphia: Saunders; 2010:78.)

Signs and Symptoms

In most patients, the pain of biceps tendon tear occurs acutely and is accompanied by a pop or snapping sound. The pain is constant and severe and is localized in the anterior shoulder over the bicipital groove. Ecchymosis may be present if the trauma is acute and severe . Significant sleep disturbance is often reported. Patients with a partial tendon tear and significant tendinitis may attempt to splint the affected shoulder by internal rotation of the humerus, which moves the biceps tendon from beneath the coracoacromial arch. Patients with biceps tendon tear have a positive Ludington’s test result, as described earlier. Bursitis and tendinitis often accompany biceps tendon tear. Occasionally, patients with acute tear of the long tendon of the biceps may experience only vague discomfort and seek medical attention only because of the cosmetic abnormality of retracted biceps tendon and muscle . Occasionally, without treatment, frozen shoulder may develop.