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The long head of the biceps (LHB) tendon is a common source of shoulder pain. The LHB is located at the front of the shoulder and is the only tendon that runs inside a joint. Due to its location, LHB problems can cause pain with pitching or throwing sports such as baseball and bowling in cricket, as well as overhead sports such as tennis or badminton. A spontaneous rupture of the LHB tendon is more common in older individuals and can result in a popping sensation, bruising above the biceps muscle, and a change in muscle shape, also known as a Popeye deformity. While surgery is rarely needed for an LHB tendon rupture, it may be considered for younger, more active individuals or those who find the cosmetic appearance of the Popeye deformity unacceptable.
| Characteristics | Values |
|---|---|
| Location | The LHB tendon is located at the front of the shoulder |
| Structure | The biceps muscle has two tendons at its top end: the short head of the biceps tendon and the LHB tendon. The LHB tendon is much smaller and contributes around 10% of muscle strength. |
| Function | The LHB tendon is the only tendon that runs inside a joint. It moves with the ball of the shoulder as the arm moves. |
| Problems | LHB tendinopathy, rupture, dislocation from its groove (subluxation) |
| Symptoms | Pain, snapping sensation, bruising, change in biceps muscle shape (Popeye sign), muscle cramping, decreased supination strength |
| Diagnosis | Patient history, physical examination, musculoskeletal ultrasound (MSK US), MRI, arthroscopic examination |
| Treatment | Physiotherapy, anti-inflammatory medications, surgery (biceps tenotomy or tenodesis) |
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LHB tendon rupture
The long head of the biceps (LHB) tendon is a small tendon that contributes around 10% of muscle strength. It is the only tendon that runs inside a joint. The LHB tendon becomes thickened, flattened, frayed, and inflamed over time due to age-related degeneration or "tendinopathy". This degeneration can be identified through an MRI scan or during keyhole surgery.
A spontaneous rupture of the LHB tendon is more common in older individuals and is caused by the degeneration of the tendon. Patients may experience chronic anterior shoulder pain before the rupture occurs. The rupture itself is acutely painful and often accompanied by bruising and the distinctive "Popeye deformity", where the biceps muscle appears more prominent due to the tendon's detachment.
In older patients, a spontaneous rupture of the LHB is usually well tolerated once the acute pain has resolved. Non-operative treatment is typically recommended for this group, including pain management and physical therapy. However, younger, more active patients may be less tolerant of the rupture due to muscle cramping, perceived decreased supination strength, and cosmetic concerns. For these patients, surgical intervention may be considered, involving cutting and reattaching the tendon.
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LHB tendinopathy
The biceps muscle has two tendons at its top end: the short head of the biceps tendon and the long head of the biceps (LHB) tendon. The LHB is located at the front of the shoulder and is the only tendon that runs inside a joint. It goes up a groove (the bicipital groove), enters the shoulder joint over the humeral head (the ball of the shoulder), and attaches to the top of the glenoid (shoulder socket).
The initial management of LHB tendinopathy is non-surgical. A period of rest and activity modification is beneficial in the acute setting, coupled with non-steroidal anti-inflammatory drugs (NSAIDs). Successful physical therapy regimens target the underlying source(s) contributing to the LHB tendon pathology. Potential factors predisposing to biceps-related shoulder injuries include glenohumeral internal rotation deficit (GIRD) in overhead-throwing athletes/baseball pitchers, poor trunk control, scapular dyskinesia, and internal impingement. Strengthening protocols should focus on restoring muscle balance across the shoulder girdle, including rotator cuff and periscapular muscle strengthening programs. Focused stretching on the anterior shoulder structures, including pectoralis minor, should also be considered.
In severe cases of LHB tendinopathy, surgery may be required. When surgery is necessary, the surgeon must understand the advantages and disadvantages of biceps tenotomy or tenodesis. When tenodesis is chosen, the location and fixation technique must be carefully considered to optimise pain relief and restore function.
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LHB spontaneous rupture
The Long Head of Biceps (LHB) tendon is a small tendon that contributes around 10% of muscle strength. It is located at the front of the shoulder and runs inside a groove (the bicipital groove) before entering the shoulder joint and attaching to the top of the glenoid (shoulder socket).
LHB tendinopathy is a common issue that can cause shoulder pain and decreased shoulder function, particularly with activity. It is often associated with tears of the subscapularis tendon and pathology of the rotator cuff. In extreme cases of longstanding LHB tendinopathy, the tendon can spontaneously rupture. This is more common in older individuals and is caused by degeneration of the tendon. Patients may experience prodromal symptoms of chronic anterior shoulder pain before the rupture occurs.
A spontaneous LHB rupture is acutely painful and often accompanied by bruising above the biceps muscle and a change in the shape of the muscle, known as a "Popeye sign" or "Popeye deformity". This change in muscle shape is due to the tendon's detachment and can be more noticeable in leaner people. Patients who experience a spontaneous rupture often report that the pain they felt before the rupture suddenly disappears as the tendon ruptures.
Non-operative treatment is usually indicated for a spontaneous LHB rupture, especially in older patients, as the pain often resolves on its own and there is no significant loss of strength. However, younger, more active patients may experience muscle cramping and decreased supination strength, and may find the cosmetic appearance of the "Popeye deformity" unacceptable. In these cases, surgical intervention may be considered.
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LHB subluxation
The LHB muscle, or lateral humeral condyle and brachialis muscle, is a small muscle located on the lateral side of the elbow. It originates from the common extensor origin and inserts onto the lateral condyle of the humerus. This muscle is important for stabilizing the elbow joint and assisting with forearm supination and pronation.
An LHB subluxation refers to a partial or incomplete dislocation of the LHB muscle at the elbow. This can occur when the elbow is forced beyond its normal range of motion, often due to a traumatic incident or repetitive strain. During an LHB subluxation, the muscle and its tendon slip out of place, moving over the lateral humeral condyle. This can cause pain, swelling, and instability in the elbow joint. Individuals may also experience a popping sensation and reduced range of motion.
Treatment for an LHB subluxation typically involves reducing the dislocation, which means gently manipulating the elbow to return the LHB muscle and tendon to their correct positions. This procedure is usually performed in a medical setting and may require local anesthesia or sedation. After reduction, immobilization of the elbow with a splint or cast is often necessary to allow the tissues to heal and stabilize the joint.
Following the reduction and immobilization period, rehabilitation is crucial to restore elbow function and strength. Physical therapy exercises focus on gradually improving range of motion, flexibility, and strength in the elbow and surrounding muscles. It is important to work with a qualified healthcare professional to ensure safe and effective rehabilitation. The recovery time can vary depending on the severity of the injury and the individual's response to treatment.
To prevent LHB subluxation, it is important to maintain proper strength and flexibility in the elbow and surrounding muscles. This includes performing appropriate warm-up and cooling-down routines before and after physical activities, as well as incorporating exercises that target the elbow joint and LHB muscle specifically. Additionally, avoiding excessive or repetitive strain on the elbow can help reduce the risk of LHB subluxation.
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LHB pain
The Long Head of Biceps (LHB) tendon is a small tendon that contributes around 10% of muscle strength. It is the only tendon that runs inside a joint, and it moves with the ball of the shoulder as the arm moves.
Diagnosing LHB pain can be challenging due to the close anatomical proximity of the LHB to adjacent structures. A careful patient evaluation, including history and physical examination, is necessary to make an accurate diagnosis. Ultrasound scans and MRI may also be used to aid in the diagnosis.
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Frequently asked questions
The LHB is the Long Head of Biceps tendon. It is one of two tendons at the top end of the biceps muscle, the other being the short head of the biceps tendon.
The LHB is located at the front of the shoulder and is a common source of shoulder pain. It can undergo age-related degeneration or "tendinopathy", which can lead to spontaneous rupture in older individuals. Rupture of the LHB tendon can result in a distinctive Popeye deformity where the bicep muscle appears more prominent.
Non-surgical treatment is typically recommended for older patients and those who do not require full supination strength. This includes pain management and physical therapy. Surgical intervention, which involves cutting and reattaching the tendon, may be considered for younger, more active individuals or those who find the Popeye deformity unacceptable.
