How Biceps Tendon Problems Can Cause Shoulder Pain

The biceps muscle is a large muscle in the front of the arm that gives you strength when bending the elbow, and it also plays an important role in shoulder function. There are several problems that can occur with the biceps tendon that may lead to the development of shoulder pain.

Many people think of the biceps only further down the arm and into the elbow joint, but in fact, the muscle, and more specifically the biceps tendon, also have important roles in the function of the shoulder joint. Biceps tendon problems can be seen in isolation, or as part of problems with the rotator cuff in the shoulder.

The Biceps Tendon

A tendon is a structure that connects muscle to bone, and the biceps are connected by tendons at both the elbow and shoulder joints. At the shoulder joint, there are actually two tendons that connect the biceps to the bone, which is why the muscle is called the biceps: bi, meaning "two," attachments at the shoulder.

These attachments are called the "long head" of the biceps and the "short head" of the biceps. The long head of the biceps is almost always the culprit of biceps-related pain in the shoulder. Together, these two tendons are referred to as the "proximal biceps" tendons.

There can also be biceps tendon problems with the attachment of the muscle at the elbow, known as the "distal biceps" tendon. In the elbow, there's only one tendon; it passes under the crease of the elbow joint. The most common biceps tendon problem of the distal biceps tendon is ruptured distal biceps.

Proximal Biceps Tendon Problems

Most proximal biceps tendon problems occur on the long head of the biceps. The short head of the biceps is farther away from the shoulder joint and has a solid attachment to the bone.

The long head of the biceps courses through a groove in the arm bone, then through the rotator cuff and attaches to the bone near the labrum of the shoulder. The long head of the biceps can have problems at any of these locations.

Most problems of the long head of the biceps cause pain over the front of the shoulder; often people feel a snapping or clicking sensation. In addition, biceps tendon problems are commonly associated with rotator cuff problems, so in many cases, both of these problems need to be treated together.

Common long head of the biceps tendon problems include:

Biceps Tendonitis and Tears

The most common cause of biceps pain is inflammation of the tendon. Inflammation may cause swelling and pain around the biceps tendon, and over time it can lead to the development of damage to the tendon, including tears. Tears within the biceps tendon can lead to persistent pain that sometimes requires surgical treatment.

Biceps Tendon Ruptures

When damaged significantly, the biceps tendon may tear off completely from its attachment. This injury is often associated with a rotator cuff tear, and anyone with a ruptured long head of the biceps should be suspected to have a rotator cuff tear.

The tendon snaps into the arm, and part of the biceps muscle retracts, causing a bulge within the biceps. When flexing their biceps, people with a ruptured tendon often look like they have a "Popeye" muscle from the balled up, retracted muscle and tendon.

SLAP Tears

Where the biceps tendon enters the shoulder, it attaches to the bone through a cuff of cartilage that surrounds the shoulder joint called the labrum. The biceps tendon can pull the labrum away from the bone causing a condition called a SLAP tear — a type of labral tear in the shoulder joint.

Biceps Tendon Subluxation/Dislocation

The biceps tendon comes up the front of the arm into the shoulder. On the front of the arm, there's a groove for the tendon called the bicipital groove—a trough in the bone that stabilizes the biceps tendon. On the top of the groove, the rotator cuff holds the tendon in the groove when the arm rotates.

In people with specific types of rotator cuff tears, the biceps tendon may not be tightly held in the groove—and may even snap out of the groove—causing a painful snapping sensation. When the tendon is unstable, it is called subluxation; when the tendon completely comes out of the groove, it is called a dislocation.

Treatment

Not all biceps tendon problems are treated the same way. Depending on the cause of the condition, your treatment plan may vary.

Simple treatments for biceps tendon problems include rest, ice, anti-inflammatory medications, physical therapy, and shoulder exercises. If there's inflammation around the tendon, an injection of cortisone around the tendon may be considered.

Surgical treatments of the biceps tendon may be considered. The most common treatments for biceps tendon problems include a biceps tenotomy and a biceps tenodesis.

A tenotomy means 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 where it can cause pain. The surgery is quick, simple, and has reliable results. Some patients don't like the appearance of their biceps after surgery, and some people complain of cramping in the arm after surgery.​

The alternative to tenotomy is called a biceps tenodesis. This surgery is performed to move the attachment of the long head of the biceps outside of the shoulder, but it re-attaches the tendon to the bone. Therefore, the muscle retains its function, and the shoulder problems that occur with many biceps conditions are usually resolved.

Biceps tenodesis has a longer recovery period but often has excellent results.