What You Should Know About Torn Bicep Tendon Injuries

A biceps tendon injury is a tear or rupture of connective tissue that connects the biceps muscle of the upper arm to bones at either the shoulder (proximal tendon) or elbow (distal tendon). Proximal tears are more common than distal tears and usually are the the result of chronic overuse or an acute injury, such as a direct blow to the shoulder or falling onto an outstretched arm.

Man holding his shoulder in pain
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Injury to a biceps tendon typically cause symptoms such as pain, swelling, and weakness. People who sustain a complete rupture of the proximal biceps tendon sometimes develop a bulge in the upper arm due to a clumping of the disconnected muscle that's often referred to as a "Popeye deformity." Treatment of a biceps tendon injury will depend on the extent of the tear: Some can be managed with rest and physical therapy, while others may require surgery and extensive rehab.

Symptoms of a Biceps Tendon Injury

The distal biceps tendon has one attachment to the radius bone at the elbow. The proximal biceps tendon has two attachments to the bones of the scapula of the shoulder. The two shoulder attachments are known as the long head and the short head. This long head tendon attaches to the rim of cartilage that surrounds the shoulder socket called the labrum, while the short head attaches to a hook-shaped part of the scapula called the coracoid process.

The majority of biceps injuries affect the long head of the proximal tendon. Since the short head of the tendon will remain attached, there usually is little loss of function, if any, especially in the case of a partial tear. If a proximal biceps tendon ruptures (tears completely away from its attachment), it's often associated with a rotator cuff tear.

In the case of a distal tear, loss of function usually occurs and surgery will likely be needed.

Typically people with proximal biceps tendon tears have pain along the front of their shoulder. If this occurs as the result of an acute injury, they may feel or hear a snap in that area at the time. There may also be a clicking or catching sensation with movement.

Other symptoms of partial or complete proximal biceps tendon tears include:

  • Shoulder swelling
  • Bruising
  • Weakness and/or loss of function
  • Pain that worsens with movement of the arm

A complete biceps tendon rupture at the shoulder also may result in a bulge in the upper arm between the elbow and shoulder—what is commonly referred to as a "Popeye muscle" or "Popeye deformity." This happens because after the ruptured tendon retracts the muscle shortens and it bunches up in the arm.

Causes

Biceps tendon tears can result from chronic overuse during sports and daily habitual movements or from any injury that causes sudden strain on the tissues, such as falling on a straightened arm or an arm that gets twisted in an awkward way. They also can occur after lifting something that's too heavy.

Bicep tendon tears and ruptures may begin as micro tears in the tendon from irritation and inflammation called tendonitis, which is common in sports that require repetitive movement of the bicep, elbow, and shoulder, such as baseball, swimming, and tennis. Those with biceps tendonitis may also have rotator cuff tendonitis. A torn tendon may begin to fray and eventually lead to a complete rupture.

Risk Factors

In older people, rupture of the proximal head of the biceps tendon occurs most often due to degenerative changes. Many patients have preceding shoulder pain consistent with impingement syndrome, or inflammation of the rotator cuff tendons and bursa, or a rotator cuff tear.

In younger patients, tears of the biceps tendon typically occur where the long head of the biceps attaches to the labrum. These injuries are called "SLAP tears" (superior labrum from anterior to posterior tears), a description of the location of the tear at the junction of the tendon and the labrum of the shoulder.

Diagnosis

If you injure your shoulder or elbow or begin to have chronic pain in these areas, your doctor will examine your shoulder for signs of a tear or rupture, such as a Popeye deformity, ask questions about your recent activity, and take a medical history.

They will likely take you through a series of movement exercises to see if you've lost strength, range of motion, or ability to fully rotate your arm as well as manipulate your arm in various ways.

Imaging tests can help a doctor refine the diagnosis of a biceps tendon injury. An X-ray, which provides a detailed look at skeletal tissue, can determine if there are any injuries to the bones. In order to determine the extent of damage to soft tissue, magnetic resonance imaging (MRI) is required. An MRI scan can, for example, reveal if a tear is partial or full. This information is vital for creating an effective treatment plan.

Treatment

Treatment of a biceps tendon tear will depend on the extent of the injury, the degree of pain and loss of function involved, and for some people who develop a pronounced Popeye deformity, aesthetics. Surgery is almost always necessary to repair a distal biceps tear.

Nonsurgical

Your doctor may recommend any or all the following ways to manage a tendonitis or tears: 

  • Apply ice packs several times a day to reduce swelling.
  • Take nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin, or naproxen for relief of pain and inflammation.
  • Rest the affect arm: Don't lift anything heavy or engage in activities that require you to reach overhead. Wear a sling if necessary.
  • Physical therapy to improve strength and flexibility or electrical stimulation, such as transcutaneus electic neuromuscular stimulation (TENS), to manage pain.
  • For severe or persistent inflammation around the tendon, an injection of cortisone.

Surgery

If there isn't improvement within three months or if the damage is severe, surgery will be recommended. Common surgeries for biceps tendon tears include a biceps tenotomy and a biceps tenodesis. A tenotomy is a procedure to cut the tendon of the long head of the biceps so that the tendon retracts back into the arm and away from the shoulder. This procedure is effective for pain relief but leads to the bulging Popeye issue. A biceps tenodesis re-attaches the tendon to bone on the outside of the shoulder. If only a small portion of the tendon was damaged, an arthroscopic debridement, or shaving of the torn fibers, is an alternate surgical option.

Additional surgeries may be required if the biceps rupture occurs in conjunction with other tendon injuries of the shoulder, specifically a rotator cuff tear.

Rehabilitation

In the first couple of days after surgery you will likely have some swelling and sensitivity. Your shoulder will be bandaged and you'll need to wear a sling to minimize arm movements. After a week or two, you will be referred to a physical therapist for exercises to help you improve strength and flexibility in your biceps and surrounding muscles and to improve range of motion slowly. You will likely need to avoid any moderate or heavy lifting for the first month but the physical therapist will evaluate you and set you up with exercises, such as curls and rotations, gently building over time.

A Word From Verywell

The recovery period for a biceps tendon tear can take months or even a whole year. The rest time and physical therapy can seem tedious, but it's important to take it slow so that you can restore full function and avoid additional injuries.

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