What is the next step for a patient with a complete tear of the long head of the biceps tendon in the right shoulder?

Management of Complete Long Head Biceps Tendon Tear

For a patient with MRI-confirmed complete tear of the long head of the biceps tendon, the next step is conservative management with rest, activity modification, NSAIDs, and physical therapy, as this is not an emergent condition and does not require immediate surgical intervention. 1

Initial Management Approach

Conservative Treatment (First-Line)

• Begin with non-operative management consisting of rest, ice, oral analgesics (NSAIDs), and physical therapy. 2, 3
• This conservative approach should be attempted for at least 3 months before considering surgical options. 2
• The tear does not pose an immediate threat to life, limb, or long-term function when properly managed in a timely manner. 1

Clinical Monitoring

• Assess for the presence of "Popeye" deformity (cosmetic bulging of the distal biceps muscle), which commonly occurs with complete proximal biceps tears. 4, 5
• Monitor for muscle cramping and anterior shoulder pain during the conservative treatment period. 4
• Evaluate functional outcomes and patient satisfaction with activities of daily living. 4

Surgical Considerations (If Conservative Management Fails)

Indications for Surgery

• Surgery should be considered if conservative measures fail after 3 months, or if there is severe damage to the biceps tendon causing persistent symptoms. 2
• Patients with symptoms refractory to non-surgical management are candidates for either biceps tenotomy or tenodesis procedures. 4, 3

Surgical Options

• Both tenotomy and tenodesis are effective options with no substantial differences in functional scores or patient satisfaction between the two techniques. 4
• Tenotomy has a higher incidence of "Popeye" deformity, muscle cramping, and bicipital groove pain compared to tenodesis. 4
• Tenodesis may provide superior cosmetic results and avoid chronic discomfort from spasms, particularly important in younger, active patients. 6
• Arthroscopic techniques have shown promising results and are increasingly preferred over open procedures. 3

Important Clinical Pitfalls to Avoid

• Do not treat this as an emergency requiring immediate surgical intervention – the condition allows time for proper conservative management and shared decision-making. 1
• Evaluate for associated shoulder pathology – complete biceps tears commonly occur with rotator cuff tears or SLAP lesions, which may influence treatment decisions. 2, 3
• Consider patient age and activity level – younger, active patients may benefit more from tenodesis to preserve cosmetic appearance and avoid cramping, while older, less active patients may do well with tenotomy or even conservative management alone. 4, 6