What is the treatment for a tear and retraction of the long head of the biceps tendon?

Treatment of Long Head of Biceps Tendon Tear and Retraction

For a tear and retraction of the long head of the biceps tendon, surgical management with either tenotomy or tenodesis is recommended when symptoms are refractory to conservative treatment, with both procedures showing similar patient satisfaction outcomes despite cosmetic differences. 1

Initial Assessment and Diagnosis

• MRI is the preferred imaging modality for biceps tendon tears, with high sensitivity for detecting both partial and complete tears 2
• MRI findings typically show:
  • Retraction of the tendon
  • Possible associated injuries (rotator cuff tears are common concomitant injuries)
  • Partial ruptures of the long head with an intact short head are the most common injury pattern 2

Treatment Algorithm

1. Conservative Management (First-Line)

• Rest and activity modification
• NSAIDs for pain control
• Physical therapy focusing on progressive loading protocol
• Corticosteroid injections (limited to 2-3 injections with 4-6 weeks between injections) 3

2. Surgical Management

When conservative treatment fails after 3-6 months, surgical options include:

A. Tenotomy

• Simple cutting of the tendon without reattachment
• Advantages:
  • Shorter surgical time
  • Faster recovery
  • Less postoperative restrictions
• Disadvantages:
  • Higher incidence of "Popeye" deformity (cosmetic concern)
  • Potential for muscle cramping
  • Possible bicipital groove pain 1

B. Tenodesis

• Reattachment of the tendon to bone
• Can be performed proximally or distally (subpectoral)
• Advantages:
  • Better cosmetic outcome (prevents "Popeye" deformity)
  • Maintains length-tension relationship of the biceps
  • Subpectoral tenodesis may have lower recurrence rates than proximal techniques 4
• Disadvantages:
  • More technically demanding
  • Longer recovery time
  • More postoperative restrictions

Decision-Making Factors

• Patient age and activity level: Younger, more active patients may benefit more from tenodesis
• Cosmetic concerns: Patients concerned about appearance may prefer tenodesis
• Comorbidities: Tenotomy may be preferred in elderly or less active patients
• Associated pathologies: Presence of concomitant rotator cuff tears may influence surgical approach

Rehabilitation Protocol

1. Initial phase (0-4 weeks):

   • Pain control
   • Protected range of motion
   • Avoidance of heavy lifting

2. Intermediate phase (4-8 weeks):

   • Progressive strengthening exercises
   • Gradual return to activities

3. Advanced phase (8-12 weeks):

   • Sport-specific or occupation-specific training
   • Return to full activities when strength is >90% compared to uninjured side 3

Important Considerations

• Despite the cosmetic differences and potential for "Popeye" deformity with tenotomy, both tenotomy and tenodesis show similar functional outcomes and patient satisfaction 1
• In cases of chronic or severely retracted tears, treatment becomes more challenging and may require specialized approaches 5
• For massive, irreparable rotator cuff tears with biceps involvement, the long head of biceps tendon can sometimes be used for augmentation or reconstruction 6

Common Pitfalls

• Delaying surgical intervention when conservative management fails can lead to further retraction and more difficult repair
• Overlooking associated pathologies (especially rotator cuff tears)
• Inadequate rehabilitation following surgical intervention
• Choosing tenodesis solely for cosmetic reasons in elderly, low-demand patients where tenotomy might provide faster recovery