Hand surgeon Benjamin R. Graves MD discusses the biceps brachii and the impact it has on the shoulders and elbows of athletes.
As an upper extremity surgeon, I see patients of all ages, sports, and skill levels for shoulder and elbow injuries on a daily basis. These problems can be acute or chronic and vary from mild to severe. Mild cases can often be treated with non-surgical measures, whereas more severe injuries may require surgery.
One muscle in particular, the biceps brachii (pronounced bray-key-eye), is frequently injured during sports activity, and is one of the more common reasons a patient may come to see me for evaluation. What makes this muscle unique is that it spans two joints, the shoulder and the elbow. This means that an injury to the “biceps” can involve the elbow, the shoulder, or both.
The biceps brachii muscle is in the front of the arm. The muscle gets more prominent and can bulge out in some people when the elbow is flexed. Just past the elbow, the biceps brachii muscle inserts onto the radius bone of the forearm and has two functions: flexing the elbow and rotating the forearm so the palm faces up (this motion is called supination).
At the shoulder, the biceps brachii muscle has two tendons. The first, called the short head, attaches outside of the shoulder joint and rarely causes problems for athletes. The second is termed the long head of the biceps tendon (LHBT) and is commonly injured during sporting activity.
The long head of the biceps is found in the front of the shoulder. It is stabilized by strong ligaments between the insertions of two rotator cuff tendons as it makes a sharp turn around the humeral head, or “ball” of the shoulder joint. Here, it enters the shoulder joint and inserts at the top of the glenoid, or “socket,” where it is closely associated with the superior labrum that surrounds the glenoid.
Prevention and Treatment
At the elbow, more mild injuries to the biceps brachii can range from mild distal biceps tendinitis to partial tears of the distal biceps. These injuries can be painful and activity-limiting, but usually resolve on their own.
Distal biceps tendinitis usually presents with pain in the front of the elbow when the elbow is flexed. There may be no specific injury. This can happen with repetitive tasks such as weight lifting, or with physically-demanding jobs. The best way to prevent this from becoming a bigger issue is to “listen to your elbow.” If it hurts to do a certain activity, think about ways to perform that activity without causing the pain. This may be as simple as changing the position of the arm or elbow, or changing hands to perform certain tasks. Mild tendinitis will usually resolve in a few weeks if a conscious attempt is made to prevent the pain from becoming a more chronic issue. Anti-inflammatory medications can also help decrease the pain.
More severe injuries include larger partial ruptures and complete ruptures of the distal biceps tendon. Patients that experience a distal biceps rupture often describe:
- Loud, painful “pop”
- Bruising in the front of the elbow
- Loss of strength
Sometimes, with enough force, a distal biceps rupture can be unavoidable. These injuries can occur even in healthy, younger people. There may be no warning signs, and an activity that used to be performed easily can cause a rupture. If you think you may have ruptured your distal biceps tendon, it is worthwhile to discuss the injury and treatment options with an orthopedic surgeon sooner rather than later, preferably within the first few weeks after the injury.
Complete distal biceps tendon ruptures can become more difficult to treat as more time passes because the tendon retracts and scar tissue forms. With enough time after the injury, the muscle can undergo irreversible changes. Primary repair, which means the tendon is repaired without tissue grafts, can usually be performed predictably within the first six to eight weeks after the injury. Outside this time window, a primary repair becomes less predictable, and tendon grafts may be required.
In the shoulder, the LHBT is vulnerable to injury along its course at three points:
- Before it enters the joint
- At the point that it enters the joint
- Where it attaches to the “socket”
Before it enters the shoulder joint the LHBT can become inflamed and irritated, which can become painful and activity-limiting. Symptoms of biceps tendinitis include:
- Pain with reaching forward or rotating the shoulder to reach behind
- Sharp, stabbing pain while tucking in a shirt, fastening a bra, or reaching for a seatbelt
The best way to prevent this from turning into a chronic issue is to avoid activities that make this pain worse for a few weeks. Anti-inflammatory medications can help decrease symptoms during these episodes. If the pain persists, your musculoskeletal provider may offer a steroid injection into the biceps tendon region in the front of the shoulder. Sometimes, this can help relieve the pain completely. Other times, the pain will temporarily resolve but will return within a few months. Ultimately, if non-operative treatments fail to resolve the issue, surgery can be performed that may help you return to your sport or activity of choice with less pain.
Partial tears of the LHBT can occur as the tendon enters the shoulder joint. Ironically, if a partial tear ruptures and becomes a complete tear, the pain may resolve. This may cause a “lump” in the front of the arm near the elbow, which is called a “Popeye” deformity. Surgery to fix this is not required but is considered for patients that do not like how their Popeye deformity looks, or for people that experience significant weakness.
Tears of the biceps tendon as it attaches to the “socket” and labrum are common injuries in athletes as well. Sports and activities that place the arm in extreme rotation at high speeds can tear the LHBT from this insertion, causing pain and loss of strength. Throwing athletes will lose throwing velocity and accuracy. These injuries are called “SLAP” tears, which describes the location and which direction the tear has occurred (Superior Labrum, Anterior to Posterior). In younger, higher-demand athletes these tears can often be repaired arthroscopically. As patients age past their mid-30s, this repair may fail to heal, and recovery becomes less predictable. For this reason, a biceps tenodesis may be recommended instead of SLAP repair. Biceps tenodesis is a procedure during which the biceps tendon is released from its attachment at the top of the glenoid and it is relocated to a position that will help eliminate the pain associated with the SLAP tear while preventing a Popeye deformity and maintaining strength. Activities and sports can be resumed after healing has occurred, and in general, people do very well after this procedure.
Individuals who have lower demands on their arm may do well without surgery for their SLAP tear. If certain activities can be avoided, such as throwing at high speeds, patients may have very little pain or limitation with a SLAP tear during their normal daily lives. In these cases, the injury is successfully treated non-surgically. Just as with tendinitis of the biceps at the elbow, tendinitis and partial tears of the biceps at the shoulder can be treated with “listening to your shoulder.” Avoiding activities that make the pain worse for a few weeks, while taking anti-inflammatory medications, can help prevent the pain from becoming a bigger issue.
In summary, the biceps brachii is frequently involved in sports injuries of the shoulder and the elbow. Most of the time these injuries can be prevented from becoming a chronic issue through rest, avoidance of activity that worsens the pain, and anti-inflammatory medications. If these measures do not help relieve the pain, a consultation with an orthopedic surgeon may help get you back in the game with a targeted treatment regimen, or with surgery if necessary.
Learn more about injuries and conditions of the upper extremity, and browse orthopaedic surgeons near you at www.HandCare.org.
Benjamin R. Graves MD is a Board Certified Orthopaedic Surgeon that specializes in treatment of conditions of the Hand, Elbow, and Shoulder. He is on faculty at Wake Forest University School of Medicine in Winston-Salem, NC, where he holds the academic rank of Assistant Professor. He serves on the American Society for Surgery of the Hand (ASSH) Diversity and Public Education Committees.