What is the treatment for a partial biceps tendon tear?

Treatment for Partial Biceps Tendon Tear

For partial biceps tendon tears involving <50% of the tendon, initial conservative management with rest, NSAIDs, and physical therapy is recommended for 3-6 months; tears involving >50% of the tendon should proceed directly to surgical repair due to high failure rates with conservative treatment. 1, 2

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis and extent of tearing:

• MRI without contrast is the gold standard imaging modality, with 86.4% accuracy for biceps tendon tears and superior ability to distinguish partial from complete tears (sensitivity 76%, specificity 50%). 3
• The FABS position (flexion-abduction-supination) on MRI provides optimal visualization of the distal biceps tendon. 3, 1
• Ultrasound is less accurate (45.5% for complete tears) and should only be used when MRI is contraindicated. 3

Treatment Algorithm Based on Tear Severity

For Tears <50% of Tendon Thickness

Conservative management is the first-line approach and succeeds in approximately 76% of cases (16 of 21 patients). 4

Phase 1 (Weeks 0-4): Initial Conservative Management

• Relative rest: Reduce activities that reproduce pain but avoid complete immobilization to prevent muscle atrophy. 5, 6
• Cryotherapy: Apply ice through a wet towel for 10-minute periods after activity to reduce pain and swelling. 5, 6
• NSAIDs: Use oral NSAIDs for short-term pain relief (topical NSAIDs eliminate GI hemorrhage risk). 5, 6
• Splint immobilization: Intermittent splinting for symptom control in mild cases. 4

Phase 2 (Weeks 4-12): Physical Therapy

• Eccentric strengthening exercises: These have proven beneficial for tendinopathies and stimulate proper collagen alignment. 5, 6
• Progressive range of motion exercises: Advance from gentle stretching to strengthening as tolerated. 6
• Tensile loading: Controlled loading stimulates collagen production and guides normal fiber alignment. 5

Phase 3 (Weeks 12-24): Advanced Conservative Options

• Ultrasound-guided corticosteroid injection: Consider if pain limits therapy participation; showed improvement in 12 of 12 cases in one series. 4, 6
• Continue therapy for minimum 3-6 months before declaring conservative failure. 4, 2

For Tears >50% of Tendon Thickness

Surgical repair is recommended as primary treatment due to high failure rates with conservative management. 1, 2

Surgical technique involves:

• Division of the remaining intact tendon fibers and repair of the entire tendon as a single unit to the radial tuberosity. 2
• Surgical debridement of surrounding synovitis if present. 2
• Arthroscopic evaluation can quantify tear extent and allow debridement, though should only be performed by experienced surgeons. 2

Surgical Indications for Any Partial Tear

Proceed to surgery if:

• Conservative treatment fails after 3-6 months with persistent debilitating symptoms. 7, 4, 6
• Tear involves >50% of tendon thickness on initial presentation. 1, 2
• Progressive weakness or functional limitation despite conservative care. 7

Expected Outcomes

Conservative management:

• Success rate of 76% for tears <50% with symptom improvement at mean 4.9 months. 4
• Mild cases may respond to NSAIDs and splinting alone within 4 weeks. 4

Surgical repair:

• Uniformly good results with all patients satisfied at mean 30.6 months follow-up. 7
• Maintenance of preoperative range of motion with no significant postoperative pain. 7
• Main complication is transient lateral antebrachial cutaneous nerve neurapraxia (2 of 7 cases). 7
• Total functional recovery achieved in surgical cases. 8

Critical Pitfalls to Avoid

• Do not rely solely on clinical examination: The tendon remains palpable in partial tears, making diagnosis challenging without imaging. 1, 2
• Do not use ultrasound as primary imaging: Its 45.5% accuracy for complete tears and limited ability to detect partial tears makes it inadequate. 3
• Do not delay surgery for >50% tears: These have high conservative failure rates and benefit from early surgical intervention. 1, 2
• Do not completely immobilize: This causes muscle atrophy and deconditioning; maintain some controlled movement. 5