The biceps tendon is not having a good era. It is frequently implicated in shoulder pain, injected with steroids, cut out at surgery or severed and reattached, all in the belief that it is the primary generator of shoulder pain in active people. [1] As with the meniscus tissue of olden days, top surgeons around the world believe that removing the tendon is the best way to effect a cure. [2]

How old fashioned and unfortunate does that sound?

The biceps is the "Popeye" muscle of the arm. It not only flexes the arm, but stabilizes the shoulder by exerting downward pressure on the humeral head. [3] The biceps is attached by a strong tendon inside the shoulder, just underneath the four tendons that make up the rotator cuff. [4] It is this tendon that can become inflamed or partially torn when the arm is overused, or when the rotator cuff is impinged from bony spurs or the swollen inflammation of bursitis. [5] Athletes and others who use their arm in overhead activities often irritate the tendon and present to their doctor with shoulder pain. [6]

Traditional treatments of shoulder pain from inflammation have been rest, ice, physical therapy and cortisone injections. Unfortunately, cortisone weakens all of the tissues of the shoulder while shutting down the inflammatory process. [7] When these non-operative methods fail, or if there is an associated tear of the rotator cuff, surgery is often deployed. The inflamed biceps tendon is removed from the shoulder by cutting it free, or cutting and then re-anchoring it away from the rotator cuff. [2]

The thinking behind this is that the inflamed tendon is a pain generator, and its role in shoulder function is not very important. This logic sounds uncomfortably similar to the reasoning once used to justify excising the meniscus cartilage when torn -- a procedure we now know leads to arthritis in the knee joint. [8] While tendon amputation may not lead to arthritis, the function of the shoulder cannot be normal without all of its key structures.

The obvious question asked by my insightful patients is, "Why can't you doctors figure out a way to heal the inflamed or frayed tendon? It has been there for millions of years, and just because you don't understand its full role doesn't mean you should amputate it! Figure out how to repair it!"

The future, clearly, is not in the removal of major attachments of muscles. It will lie in novel ways of stimulating healing of injured tendons such as the biceps. These advances are on the way, they include the integration of new matrices (such as collagen sheets), pre-loaded with the patient's stem cells and growth factors and surgically wrapped around the injured tendons or injected into their sheaths. Another novel approach is to provide a self-assembling, injectable collagen material, which is then melded with UV light stimulation. [9] A third approach will use a resorbable artificial material that will stimulate tendon regeneration. [10]

Stay tuned for the new era of anabolic tissue healing -- brought to you by biologists, chemists and tissue engineers, in the hopes of ending the primitive amputation of temporarily damaged joint structures.

References:

1. Boileau, Pascal, Philip M. Ahrens, and Armodios M. Hatzidakis. "Entrapment of the long head of the biceps tendon: the hourglass biceps--a cause of pain and locking of the shoulder." Journal of shoulder and elbow surgery 13, no. 3 (2004): 249-257.

2. Elser, F., Braun, S., Dewing, C. B., Giphart, J. E., & Millett, P. J. (2011). Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 27(4), 581-592.

3. McGough, R. L., Debski, R. E., Taskiran, E., Fu, F. H., & Woo, S. L. (1996). Mechanical properties of the long head of the biceps tendon. Knee Surgery, Sports Traumatology, Arthroscopy, 3(4), 226-229.

4. Shah, M. A., & Shah, M. (1946). Quadricipital m. biceps brachii. Journal of anatomy, 80(Pt 1), 54.

5. Chew, M. L., & Giuffrè, B. M. (2005). Disorders of the Distal Biceps Brachii Tendon 1. Radiographics, 25(5), 1227-1237.

6. Ho, C. P. (1999). MR imaging of rotator interval, long biceps, and associated injuries in the overhead-throwing athlete. Magnetic resonance imaging clinics of North America, 7(1), 23-37.

7. Coombes, B. K., Bisset, L., & Vicenzino, B. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. The Lancet, 376(9754), 1751-1767.