About Biceps Tendonitis / SLAP Tears
What is biceps tendonitis?
The biceps is a powerful muscle at the front of your upper arm that bends your elbow and rotates your palm to the ceiling. It’s an interesting muscle because part of it attaches to the bone inside your shoulder joint. It connects via the labrum, which is a rim of cartilage that surrounds the socket (glenoid). From there, it reaches the arm via the bicipital groove, which is a tunnel between two rotator cuff tendons at the front of your humerus. Here, it is surrounded by a covering called the biceps sheath that provides lubrication to stop it from rubbing against the bone.
Sometimes, the biceps can get inflamed within the biceps sheath. This causes pain at the front and side of the shoulder, particularly when lifting or working overhead, or lying on the affected side.
Who gets biceps tendonitis?
The short answer is anyone! Most patients are over 40 years old. It is most common in people who do a lot of repetitive overhead activity or heavy lifting.
How is biceps tendonitis diagnosed?
This starts with a conversation with your doctor to describe when you experience the pain. You will then be examined, with some specialised tests that focus on the biceps tendon. Often, your doctor will request an X-ray to look for other problems with your shoulder. Sometimes, you may be sent for an ultrasound or MRI scan which can see inflammation around the biceps tendon.
What is a SLAP tear?
A SLAP tear is short for Superior Labral Anterior to Posterior tear. As stated above, the biceps connect to the top of the shoulder joint via the labrum, which is a rim of cartilage that surrounds the socket (glenoid). It is possible for this attachment of the biceps to tear from the bone, which is referred to as a SLAP tear.
This does not always cause any problems with your shoulder. When it does, it can cause pain and clicking at the top of your shoulder, particularly when lifting or working overhead, or lying on the affected side. Sometimes, there is an added tear of the rotator cuff tendons.
Who gets SLAP tears?
There are two groups of people who get SLAP tears. The young group is under 40 years old. They are in people who do a lot of repetitive overhead activity, throwing sports or heavy lifting. Sometimes, SLAP tears can happen when you injure your shoulder, for example with a sudden sharp tug on your arm.
The other group are people who are over 60. These people tend to get a SLAP tear due to the general wear inside your shoulder. This type of tear is often referred to as a degenerate SLAP tear. They are often seen alongside other problems, such as rotator cuff tears.
How are SLAP tears diagnosed?
This starts with a conversation with your doctor to describe when you experience the pain. You will then be examined, with some specialised tests that focus on the biceps tendon and labrum. Often, your doctor will request an X-ray to look for other problems with your shoulder. The best way to diagnose a SLAP tear is with an MR arthrogram. This is an MRI scan after dye has been injected into your shoulder.
What are the treatment options?
Subacromial impingement can be treated in several ways:
- Take simple painkillers and change your lifestyle
- Physiotherapy
- Steroid injection
- Surgery
Simple painkillers and change of lifestyle
For some people, just knowing what the problem is, can be enough. The pain can be controlled with simple painkillers, such as paracetamol and anti-inflammatories (if you can take them). This may be coupled with simple changes to your lifestyle, such as sleeping on the opposite side or doing lighter activities at work or in the gym. After a period of rest, biceps tendonitis often settles down.
There is a possibility that if a SLAP tear is left alone, the biceps tendon will separate completely, something called a biceps rupture. This can happen after a minor injury if you already have a SLAP tear and often causes sudden pain and sometimes bruising down your arm. You may also notice a bulge in your arm as the biceps muscle moves further down your arm. This is called the Popeye sign and apart from its appearance does not cause most people any problems. In fact, when the biceps does rupture, some people report that their shoulder pain goes away.
Physiotherapy
A course of physiotherapy can be very effective for biceps tendonitis or SLAP tears. Your physiotherapist will assess your movements and teach you ways of moving your shoulder without experiencing the pain. If you have an imbalance in the muscle strength around your shoulder, this will also be addressed. It can take several months to get the full benefit of physiotherapy, so it is important to work hard early on, even if you do not feel an immediate benefit.
Steroid injection
You may be offered a steroid injection around the biceps tendon. This is sometimes referred to as a cortisone injection. The purpose of this injection is to settle down any inflammation. This is a very effective treatment, especially when coupled with physiotherapy. By taking the pain away, even temporarily, it can make it easier to do the exercises given to you by your physiotherapist. There are several rare risks of steroid injections:
- Allergic reaction: This is very rare, but can be life-threatening.
- Infection: This is rare, but can result in severe pain 1-2 weeks after the injection and may require surgery to wash out the injection.
- Change in the colour or texture of your skin where it is injected. This is very uncommon and more pronounced in people with darker skin colours.
- Steroid ‘flare’: This can result in a temporary worsening of pain from 1-3 days after the injection.
Read more about steroid injections here.
Surgery
If the above treatments are not successful, surgery may be helpful to treat biceps tendonitis or SLAP tears. This is usually performed ‘keyhole’, with an extra 2-3cm cut near your armpit. For most people, Mr. Davies performs a subpectoral biceps tenodesis, by detaching the tendon from your shoulder, removing the inflamed part, and reattaching it to the upper arm near the armpit. On some occasions, it is not necessary to reattach the biceps tendon and it is instead simply detached from inside your shoulder.
Click here to find out more about what this type of surgery involves.
Finally, if you have problems with your shoulder dislocating, Mr. Davies will instead repair the SLAP tear by reattaching the biceps tendon back to the bone inside your shoulder. This is called an arthroscopic SLAP repair. It is a similar operation to an arthroscopic stabilisation for shoulder dislocations. More information about that type of surgery can be found here.