CORR Insights®: Long Head of Biceps Tendinopathy Is Associated With Age and Cuff Tendinopathy on MRI Obtained for Evaluation of Shoulder Pain

Where Are We Now?

Long head of the biceps (LHB) tendinopathy is a common cause of anterior shoulder pain [9]. Nonoperative treatments, such as physical therapy, antiinflammatory medications, and local corticosteroid injections, are the initial approach for managing acute biceps symptoms. For patients who do not respond to these measures, surgical interventions such as biceps tenotomy and tenodesis have proven effective at alleviating symptoms when performed in isolation or alongside rotator cuff repairs [7, 11].

The LHB originates intraarticularly at the supraglenoid tubercle, exits the glenohumeral joint at the biceps reflection pulley, and continues distally into the bicipital groove. The pulley system—composed of fibers from the coracohumeral and superior glenohumeral ligaments and tendons of the supraspinatus and subscapularis—stabilizes the LHB. The supraspinatus, which also plays a key role in stabilizing the humeral head, shares a close functional relationship with the LHB tendon. Previous radiographic and histologic studies have confirmed the relationship between LHB tendinopathy and rotator cuff tendinopathy. While these studies report a wide variability in the presence of pathologic lesions of both tendons (22% to 78.5%), it is posited that damage to either structure can adversely affect the other, underscoring that they are interconnected [16]. Furthermore, as rotator cuff tears increase in size, the presence of LHB tendinopathy becomes more common, occurring in up to 92% of patients with massive rotator cuff tears [5]. LHB tendinopathy is also often associated with degenerative intraarticular conditions of the shoulder such as superior labrum anterior-to-posterior (SLAP) lesions and glenohumeral osteoarthritis [1], as well as acromioclavicular (AC) joint arthritis [13], the combination of which can contribute to the presentation of anterior-superior shoulder pain [10].

Several studies have specifically explored the relationship between LHB tendinopathy and rotator cuff pathology. Murthi et al. [15] examined 200 patients undergoing arthroscopic subacromial decompression for shoulder impingement syndrome. Patients either underwent biceps tenodesis if they demonstrated macroscopic degeneration of the LHB or they received an extraarticular tenosynovectomy. The authors’ findings revealed that 91% of shoulders treated with biceps tenodesis had concomitant rotator cuff tears. Among patients undergoing tenosynovectomy, 63% demonstrated chronic inflammation on histology and 70% had rotator cuff tears. Notably, histologic abnormalities were more prevalent in older patients; only 11% of patients over 40 years had normal LHB tendons. Braun et al. [3] further reported an association between LHB lesions (for example, tendinosis, tenosynovitis, partial tears) and injuries to the pulley complex, which often co-occur with rotator cuff tears. Kowalczuk et al. [12] added further evidence by showing that 85% of patients with acute proximal biceps rupture had some degree of supraspinatus or subscapularis tearing on MRI. These patients were significantly older than those with intact rotator cuffs, leading to the conclusion that acute atraumatic proximal biceps ruptures may be a harbinger for underlying rotator cuff disease.

The study by Canavan et al. [4] published in this issue of Clinical Orthopaedics and Related Research® characterizes how LHB tendinopathy is part of a broader degenerative process involving the aging shoulder and provides valuable insights into the relationship between LHB tendinopathy and rotator cuff pathology in people as they age. Analyzing MRI data from 406 patients, the authors found that LHB tendinopathy is strongly associated with advancing age, with a 4% annual increase in the odds of developing LHB tendinopathy. By age 85 years, all patients with shoulder pain displayed LHB tendinopathy. Additionally, patients with LHB tendinopathy had much higher odds of also having rotator cuff tendinopathy (OR 6.9). I agree with the authors, who have advocated for reframing LHB tendinopathy as a normal aspect of aging rather than a standalone problem calling for aggressive treatment. This approach could reduce unhelpful interventions and promote nonsurgical management strategies that focus on preserving shoulder function and quality of life.

Where Do We Need to Go?

While the study by Canavan et al. [4] highlights the need for clinicians to view LHB tendinopathy through the lens of a degenerative process, it also raises questions about how degenerative changes in the shoulder exist along a spectrum of disease and where along that spectrum we should intervene. Tendinopathy alone does not always account for shoulder pain and dysfunction. Other degenerative conditions, such as degenerative SLAP tears, glenohumeral osteoarthritis, and AC joint osteoarthritis, can be concomitant pain generators within the shoulder. While it may seem straightforward to explain these conditions as part of age-related degeneration, clinicians must still perform a thorough evaluation to determine the extent to which each lesion or finding contributes to a patient’s pain. Understanding how much the combination of these finding affects each patient’s quality of life is paramount. The diagnostic utility of special tests differentiating biceps and SLAP pathology from rotator cuff–related pain or AC joint–related pain cannot be overstated. In cases where symptoms overlap, lidocaine injection with or without corticosteroid in specific locations—such as the subacromial space, bicipital groove, glenohumeral joint, or AC joint—can serve as both diagnostic and therapeutic tools for degenerative shoulder pain [17]. Subsequent treatment plans should consider the patient’s age, physical demands, activity level, and response to prior nonsurgical measures that have been tried.

While nonsurgical management should be the first line of treatment, the role of surgical intervention should not be dismissed, even in older patients. Rotator cuff repair with biceps tenotomy or tenodesis often yields satisfactory results [6], as does biceps tenotomy/tenodesis coupled with arthroscopic debridement of the glenohumeral joint for glenohumeral osteoarthritis or degenerative SLAP tears [8, 14]. Similarly, Boileau et al. [2] reported favorable outcomes with biceps tenotomy or tenodesis in managing massive irreparable rotator cuff tears. While reverse shoulder arthroplasty is now more common for some of those indications, addressing LHB symptoms remains an effective, less-invasive option for those with well-functioning shoulders and persistent anterior shoulder pain. A more recent systematic review by Descamps et al. [7] further validates the benefits of biceps tenotomy or tenodesis for massive irreparable rotator cuff tears.

These findings highlight the importance of targeted surgical interventions for degenerative shoulder conditions, which can improve symptoms and function in selected patients who have not achieved substantial improvement with conservative measures. However, these studies still provide limited guidance on patient selection and offer little insight into the longer term durability of the surgical results shown in some of those earlier studies. What is clear is that surgeons must inform patients that these interventions do not reverse the degenerative process. While biceps tenotomy or tenodesis provide definitive management for LHB pathology, arthroscopic debridement for massive cuff tears or glenohumeral osteoarthritis is primarily palliative. Although outcomes may be favorable in the intermediate term, long-term relief is unpredictable. This raises further questions about managing degenerative shoulder conditions when conservative treatments fail and arthroplasty is not indicated: Who benefits from targeted surgical interventions for conditions like LHB tendinopathy, and can we predict the duration of relief that these interventions provide?

How Do We Get There?

Moving forward, clinicians should adopt a tailored approach to managing LHB tendinopathy, balancing conservative and surgical options based on patient age, functional demands, and coexisting findings in the shoulder.

There are several factors that we should consider. Patient education is key. We need to develop and disseminate educational materials and counseling strategies to help patients understand LHB tendinopathy as part of the aging process. We need to empower those patients to make informed decisions about their care. Conservative management remains the first-line treatment. We should prioritize nonoperative treatments, including physical therapy, activity modification, and pain management, as first-line interventions, but I believe that selective surgical intervention still has a role. That said, we should reserve surgical options for patients with substantial functional impairment, refractory symptoms, or associated degenerative conditions that would also benefit from surgical treatment. In the near future, I hope that data will help guide us in determining the optimal timing for surgical intervention. Additionally, we should encourage future studies that refine diagnostic criteria for degenerative shoulder conditions and identify when the combination of conditions—such as LHB tendinopathy, rotator cuff tendinopathy, glenohumeral osteoarthritis, or AC joint arthritis—indicates a higher likelihood of improvement with surgery rather than conservative treatment. Understanding these factors will be crucial in improving patient outcomes. Understanding the interplay between aging and degenerative pathologies of the shoulder will be critical to guiding future innovations in shoulder care.

Read This Next

• This study speaks to the correlation between LHB pathology and progressive rotator cuff pathology [5].

• This study articulates the overlap between LHB pathology and other degenerative conditions of the shoulder that one should be aware of when considering treatment [10].