What is the recommended treatment for an adult patient with a history of physical activity or trauma, presenting with arm pain and an MRI-confirmed complete tear of the proximal long head of the biceps tendon?

Treatment Recommendation for Complete Proximal Long Head Biceps Tendon Tear

For an adult with a complete tear of the proximal long head of the biceps tendon (LHBT), conservative management with physical therapy and anti-inflammatory medications should be the initial treatment approach, as this injury does not pose an immediate threat to life, limb, or long-term function and typically results in good outcomes without surgery. 1, 2

Initial Management Strategy

• Begin with conservative treatment including anti-inflammatory medications, physical therapy, and potentially ultrasound-guided corticosteroid injections before considering surgical intervention 2
• The diagnosis has been appropriately confirmed with MRI, which is the gold standard imaging modality with 86.4% accuracy for biceps tendon tears 3, 1
• This is not an emergent condition requiring immediate surgical intervention 1

Understanding the Injury Pattern

Your patient has a complete tear of the proximal LHBT with retraction to the mid-humeral diaphysis, which represents a relatively uncommon injury pattern:

• Isolated complete ruptures of the long head are the least common biceps injury pattern 1
• The intact short head of the biceps maintains significant functional capacity 4
• The small hematoma noted on MRI is expected and does not alter management 4

When to Consider Surgical Intervention

If conservative management fails after an appropriate trial (typically 3-6 months), surgical options include:

• Biceps tenotomy (simple release)
• Biceps tenodesis (reattachment to humerus)
• Choice depends on patient age, activity level, and cosmetic concerns 2

Surgical Approach Considerations (if needed):

• Younger, active patients or those concerned about cosmetic deformity (Popeye sign) may benefit from tenodesis 2
• Older, less active patients typically do well with tenotomy or continued conservative management 2
• Multiple tenodesis techniques exist (suprapectoral, subpectoral, intra-articular) with generally good outcomes 2

Critical Pitfalls to Avoid

• Do not rush to surgery - most proximal LHBT tears have excellent outcomes with conservative management 2
• Assess for associated rotator cuff pathology - proximal biceps tears are often part of a broader degenerative process involving the rotator cuff and subacromial space 5
• Monitor for progression - while rare in isolated LHBT tears, follow the patient for potential rotator cuff degeneration 5
• Avoid serial surgical revisions if initial surgery fails, as repeated procedures lead to deteriorating outcomes with increased morbidity 6

Expected Outcomes

• Patients treated conservatively or surgically typically achieve good to excellent clinical outcomes with low complication rates 2
• The intact short head of the biceps provides adequate elbow flexion and supination strength 4
• Some cosmetic deformity (Popeye sign) may persist but rarely affects function 2