What is the treatment for an injury of the tendon of the biceps, coded as S46.209A (biceps tendon injury)?

Treatment of Biceps Tendon Injury (S46.209A)

For biceps tendon injuries, begin with conservative management including relative rest and NSAIDs as first-line treatment, but surgical repair is indicated for complete tears and significant partial tears, particularly in active patients who require restoration of supination strength and endurance. 1, 2, 3

Initial Diagnostic Workup

Imaging Algorithm

• Obtain plain radiographs first to rule out associated fractures or other bony abnormalities 1, 4
• MRI without contrast is the preferred next imaging study with superior accuracy (86.4%) compared to ultrasound (45.5%) for biceps tendon pathology 1, 4
• Request the FABS (flexion-abduction-supination) view on MRI for optimal visualization of the distal biceps tendon—patient positioned prone with elbow flexed at 90°, shoulder abducted, and forearm supinated 5, 1, 4
• Ultrasound may be considered only when MRI is contraindicated, but recognize its significant limitations in detecting partial tears and tendinopathy 1, 4, 6

Clinical Examination Findings

• Look for localized pain in the antecubital fossa that is load-related and worsens with repetitive overhead motion 1
• Palpate for well-localized tenderness in the bicipital groove (with arm in 10 degrees of internal rotation for proximal injuries) that reproduces the patient's pain 1, 7
• Inspect for unusual bulging of the biceps muscle (the "Popeye sign") which indicates complete rupture 8
• Perform physical maneuvers that simulate tendon loading to reproduce symptoms 1

Treatment Algorithm

Conservative Management (First-Line for Partial Tears and Proximal Ruptures)

• Relative rest to decrease repetitive loading of the damaged tendon 1
• Oral NSAIDs for pain and inflammation control 1, 7
• Physical therapy after initial rest period 7
• Consider corticosteroid injections into the biceps tendon sheath for persistent symptoms (particularly for tendinitis/tendinosis) 7
• Continue conservative treatment for 3 months before considering surgical intervention 7

Conservative treatment is appropriate for:

• Proximal (long head) biceps tendon ruptures, which typically regain normal strength with non-operative management 8, 3
• Elderly patients with low physical activity levels 2
• Mild partial tendon tears 2
• Patients with contraindications to surgery 2

Surgical Management (Indicated for Specific Scenarios)

Proceed to surgery for:

• Complete distal biceps tendon tears requiring restoration of supination strength and flexion endurance 2, 3
• Significant partial distal biceps tears in active patients 2
• Failed conservative management after 3 months 7
• Severe tendon damage identified on imaging 7

Surgical approach considerations:

• Anatomical reinsertion of the tendon at the radial tuberosity is the standard for acute complete tears 2
• Chronic injuries typically require tendon reconstruction using autografts or allografts 2
• Overall complication rate is 25%, with major complications occurring in 4.6% of cases 9
• The most common major complication is posterior interosseous nerve injury (1.6%), which typically resolves with expectant management 9

Critical Pitfalls to Avoid

• Do not rely solely on ultrasound for diagnosis—it has significantly lower accuracy (45.5%) compared to MRI (86.4%) and poor sensitivity (62.5%) and specificity (20%) for detecting tears 5, 1, 4, 6
• Distinguish between partial and complete tears using MRI—this differentiation is crucial for treatment planning as it determines surgical versus conservative management 1, 4, 6
• Perform a complete shoulder examination when evaluating biceps tendon injuries, as they are commonly accompanied by rotator cuff tears or SLAP lesions 7, 8
• Recognize that distal biceps injuries occur most commonly in the dominant arm of men in their fourth decade following traumatic events 3, 9
• Understand that proximal (long head) ruptures have different treatment implications than distal ruptures—proximal injuries are primarily treated non-operatively with adequate results, while distal ruptures typically require surgical repair in active patients 3