Long Head of Biceps (LHB) Tendon ProblemsNick Ferran2022-01-26T03:33:33+00:00
LONG HEAD OF BICEPS (LHB) TENDON PROBLEMS
What is the Long Head of Biceps (LHB) Tendon?
Normal anatomy of the Long Head of Biceps (LHB) Tendon. (click to enlarge)
The biceps muscle has two tendons at its top end, the short head of biceps tendon and the Long Head of Biceps (LHB) tendon. Because of its make up and location, Long Head of Biceps tendon problems are common. The short head of biceps tendon is the main biceps tendon at its top end, it lies outside the shoulder joint and provides approximately 90% of muscle strength. The Long Head of Biceps (LHB) tendon is a much smaller tendon that contributes around 10% of muscle strength. The LHB is unusual in that it goes up a groove (the bicipital groove) enters the shoulder joint over the humeral head (ball of the shoulder) and attaches to the top of the glenoid (shoulder socket). The LHB tendon is the only tendon that runs inside a joint. Because the Long Head of Biceps attaches to the shoulder socket (a fixed point) inside the shoulder joint but runs in a groove in the ball of the shoulder, it moves with the ball as the arm moves through its wide range of movement. This puts a lot of stress on the tendon and its attachment on the socket and over time can lead to Long Head of Biceps tendon problems.
Some common LHB problems include LHB tenosynovitis, LHB tendinopathy, LHB rupture, LHB subluxation, and SLAP tears. We discuss these conditions below.
What are the symptoms of LHB problems?
Problems with the Long Head of Biceps tendon can sometimes be tricky to diagnose. The LHB is located at the front of the shoulder and while most of the time problems associated with it can cause pain at the front of the shoulder, it isn’t the only thing that can cause pain in this region, and it doesn’t always cause pain at at this location. Location of pain on its own is therefore not always helpful in diagnosing the problem.
Several LHB problems can cause pain with pitching or throwing sports such as baseball and bowling in cricket but can also cause pain with overhead sports such as tennis or badminton.
Subluxation of the long head of biceps tendon out of the bicipital groove can cause clicking or a snapping sensation in the shoulder.
Spontaneous rupture of the long head of biceps can cause bruising above the biceps muscle and a change in the shape of the biceps muscle.
What is LHB Tenosynovitis?
The normal LHB Tendon Sheath. (Click to enlarge)
Outside the shoulder joint the Long Head of Biceps tendon is covered by a tendon sheath (tenosynovium). The tendon sheath provides lubrication and nutrition to the tendon. In some patients the tendon sheath becomes inflamed causing pain at the front of the shoulder.
LHB tenosynovitis is usually diagnosed by ultrasound or MRI scan and excess fluid can be seen around the tendon as it runs in its groove.
Self-management options include rest, icing, anti-inflammatories. Occasionally an injection of steroid into the tendon sheath under ultrasound guidance may be needed to settle symptoms.
If non-operative management fails sometimes surgery may be needed.
LHB Tenosynovitis. (Click to enlarge)
We discuss surgical options for the Long Head of Biceps below.
As we age our tendons age. Tendons do not repair fully in the way our skin and bones do. Over time age-related changes are seen in our tendons as micro damage from wear and tear affects the tendons. This age-related degeneration is often referred to as tendinopathy. The Long Head of Biceps tendon can undergo these age-related changes especially in the portion of the tendon inside the joint which twists and slides over the ball of the shoulder as it rotates with movement throughout life.
The degenerative changes that occur in the tendon can be seen on an MRI scan or be directly visualised during key-hole surgery. The LHB tendon becomes thickened, flattened, frayed, and inflamed. Often LHB tendinopathy can lead to shoulder pain.
Physiotherapy to keep the biceps muscle strong and work on posture and strengthening of the rotator cuff muscles can often help patients with LHB tendinopathy, however in severe cases surgery is often needed. We discuss the surgical options for the Long Head of Biceps below.
What is an LHB Rupture?
In extreme cases of longstanding LHB tendinopathy the tendon can become so frayed that it spontaneously ruptures. This often results in a popping sensation and patients notice bruising above the biceps muscle and a change in biceps muscle shape also known as a Popeye sign. Patients who have spontaneous ruptures often note that the pain they had at the front of the shoulder suddenly settles as the tendon ruptures.
We don’t need to treat spontaneous ruptures of the LHB as pain from tendinopathy often settles immediately and there is no significant loss of strength. The 10% of strength contributed by the Long Head of Biceps Tendon can only be measured by machines and is not noticeable to patients. Reassurance is often all that is needed.
LHB subluxation where the LHB is dislocated from its groove. (Click to enlarge)
The Long Head of Biceps tendon is meant to run in the bicipital groove no matter what position the shoulder is in. Soft tissue structures hold the LHB tendon in its groove as the shoulder rotates. After prolonged wear and tear or occasionally suddenly due to a severe injury, the structures that keep the LHB in its groove fail and the Long Head of Biceps tendon can sublux or slip in and out of its groove.
Subluxation of the LHB can often cause a clicking or clunking sensation at the front of the shoulder which may or may not be painful. The LHB often subluxes forward out of its groove on to the subscapularis tendon (rotator cuff tendon at the front of the shoulder). If this is left for a long time it can damage the subscapularis tendon attachment.
LHB subluxation is due to structural damage in the shoulder so there is little non-operative management that can be done and often shoulder surgery is needed. We discuss the surgical options for LHB problems below.
What is a SLAP tear?
Shoulder socket side view with rotator cuff muscles. (Click to enlarge)
The Long Head of Biceps Tendon attaches to the top of the shoulder socket to a structure called the glenoid labrum. The labrum is a fibrous ring that is attached to the rim of the shoulder socket. Due to the constant twisting of the LHB tendon as the shoulder rotates damage can occur to the LHB anchor on the labrum. Damage to the biceps anchor can occasionally be acute and traumatic but in most cases, it is chronic due to degeneration. The LHB anchor at the labrum becomes detached from the socket in what is referred to as a Superior Labrum Anterior to Posterior tear or SLAP Tear. SLAP tears are common in pitching or throwing sports and overhead sports such a badminton.
In almost all cases SLAP tears can be managed with rehabilitation through physiotherapy with focus on posterior rotator cuff strengthening and alteration of sporting technique. In very rare cases surgery is needed.
Historically, surgery for SLAP tears consisted of a SLAP repair where the LHB anchor of the labrum was reattached to the labrum using sutures and plastic anchors in the bone but this procedure was associated with several post-operative complications and is now seldom performed.
SLAP Tear. (CLick to enlarge)
More recently, if SLAP tears do not settle with physiotherapy, we perform either an LHB Tenodesis or and LHB Tenotomy and we describe these procedures below.
What is an LHB Tenodesis?
An LHB Tenodesis is a key-hole procedure during which we cut the LHB tendon in the shoulder joint and anchor it to its groove at the top of the humeral head (ball of the shoulder). This reliably sorts pain caused by LHB problems. The operation is carried out as a day-case procedure usually with patients awake under regional anaesthesia.
After surgery patients are usually in a sling for 4-6 weeks to protect the tenodesis. Following this physiotherapy is usually needed for 3-6 months.
The risks of a LHB tenodesis include change in biceps muscle shape, cramping of the biceps muscle which usually settles, failure of the repair, and shoulder stiffness along with the other risks of key-hole shoulder surgery.
What is an LHB Tenotomy?
In some cases, the LHB tendon is too damaged to be anchored to its groove or patients may want a quicker recovery than an LHB Tenodesis. In these cases, an LHB Tenotomy is performed. During an LHB Tenotomy the LHB tendon is cut inside the joint without anchoring it to the bone. This procedure is key-hole, day-case, and often done with the patient awake under regional anaesthesia.
As there is no anchoring of the tendon to the bone to protect, after an LHB Tenotomy, the patient is only in a temporary sling for 24 hours and can get back to activity quicker with only 3 months of physiotherapy required.
An LHB Tenotomy has a higher risk of change in shape of the biceps muscle and cramping of the biceps muscle than a Tenodesis, but there is a quicker recovery and lower risk of stiffness as a result.