Nonoperative treatment of disorders of the long head of the biceps is usually directed by the treatment for concomitant rotator cuff disease. Initially ice, rest, and anti-inflammatory medications in conjunction with a well-supervised physical therapy program should be prescribed. Athletic activity that incites shoulder pain should be temporarily curtailed. Patients who fail a trial of rest and physical therapy may require a sub-acromial steroid injection to help control the inflammation. Injections can also be given in the glenohumeral joint or directly into the tendon sheath. During the acute phase of inflammation, physical therapy begins with range-of-motion exercises of the shoulder before moving on to strengthening of periscapular musculature. The serratus anterior and trapezius muscles help create a stable platform for the scapula. Strengthening exercises can gradually progress to repetitive eccentric loading of the biceps to build endurance in preparation for strenuous activities. Overhead athletic activity is allowed once the strength is fully restored. In many cases, conservative management will be curative, but occasionally biceps tendonitis may persist or even worsen. Nonoperative management of biceps instability is usually unsuccessful as there is almost always an associated tear of the rotator cuff. Symptomatic biceps tendonopathy that is resistant to well-supervised nonoperative measures is an indication for surgical management.
Isolated spontaneous ruptures of the biceps can occur and the mode of treatment should be dependent on the physical activity level of the patient. It has been reported that high-demand athletes with biceps degeneration perform better, with much less pain after either spontaneous rupture or surgical removal.24 Biceps tenodesis, however, has potential advantages over biceps tenotomy. Tenodesis of the biceps helps to maintain the length-tension relationship of the tendon, which can prevent loss of flexion and supination power. Tenodesis may also prevent cramping in the muscle belly and avoid the cosmetically unpleas-ing Popeye deformity. Mariani et al25 compared the results of surgical repair in patients with an acute rupture of the long head of the biceps and nonoperative treatment. Residual arm pain was infrequent in both groups, and the group treated without surgery was able to return to work earlier. On biomechanical testing, the nonsurgically treated group demonstrated a 21% loss in supination power and an 8% loss in flexion power. There was no loss of strength in either supination or flexion in the group treated with surgical repair.
The treatment algorithm of the biceps is not always straightforward. The majority of biceps tendon ruptures are associated with rotator cuff tears, and treatment should be directed toward the rotator cuff pathology before addressing the biceps tendon. On the rare occasion that an athlete's symptoms are localized to the biceps alone, a tenodesis or tenotomy is recommended. In athletes with bicipital degeneration associated with impingement, appropriate treatment includes a complete subacromial decompression and evaluation of the rotator cuff. Surgical options vary from benign neglect to synovectomy and partial tendon débridement to tenodesis or tenotomy. In the senior author's experience, the final decision to perform a biceps tenodesis is made after arthroscopic evaluation. In an athlete with anterior shoulder pain, associated tenderness in the bicipital groove, and arthroscopic evidence of greater than 50% involvement of the biceps tendon, an arthroscopic tenodesis is indicated.
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