Treatment of Complete Long Head Biceps Tendon Tear
For a complete tear and retraction of the long head biceps tendon with shoulder pain, initial conservative management with rest, NSAIDs, and physical therapy should be attempted first, with surgical intervention (tenodesis or tenotomy) reserved for patients who fail conservative treatment after an adequate trial. 1, 2, 3
Initial Management Approach
Conservative Treatment (First-Line)
- Begin with nonsurgical management consisting of rest, activity modification, NSAIDs, physical therapy, and potentially corticosteroid injections. 1, 2, 3
- This approach is the accepted first-line treatment even for complete tears, as the condition is not emergent and does not pose immediate threat to limb or long-term function when managed appropriately. 4
- Conservative management should be given an adequate trial before proceeding to surgical options. 2, 3
Surgical Indications
When to Proceed with Surgery
- Surgical management is indicated when symptoms remain refractory to conservative treatment. 1, 3
- The two primary surgical options are biceps tenotomy (simple release) or tenodesis (reattachment). 1, 2, 3
Surgical Decision-Making: Tenotomy vs. Tenodesis
Key Considerations
- Both tenotomy and tenodesis show no substantial differences in functional scores or patient satisfaction. 1, 2
- Tenotomy has a higher incidence of "Popeye" deformity (cosmetic bulging of biceps muscle), muscle cramping, and residual bicipital groove pain compared to tenodesis. 1
- Tenodesis avoids these cosmetic and symptomatic issues but is technically more complex. 1
Patient-Specific Factors
- For younger, active patients or those concerned about cosmesis, tenodesis is generally preferred to avoid Popeye deformity. 1
- For older, less active patients where cosmesis is less concerning, simple tenotomy may be sufficient and involves less surgical complexity. 1, 2
- Both arthroscopic and open tenodesis techniques have shown promising results, with arthroscopic approaches gaining favor. 3
Common Pitfalls to Avoid
- Do not assume all complete tears require immediate surgery—the majority of patients can be managed conservatively initially, as complete tears do not represent surgical emergencies. 4, 1, 2
- Do not overlook associated pathology—long head biceps tears frequently occur with rotator cuff pathology, SLAP lesions, or pulley tears, which your MRI has already helped identify. 5, 2
- Do not rely solely on the Popeye deformity for diagnosis—while this clinical sign is characteristic of proximal tears, MRI confirmation (as already obtained) is essential for surgical planning. 6, 4