As the rumors swirl about the possible return of Brett Favre to the National Football League, we have learned more about his ailing shoulder. Per the reports of the media, he has a partially torn biceps tendon in his throwing arm that may be a source of discomfort and potentially limit his ability to "air it out" if he is the Viking's future quarterback.
The biceps, as its name implies, is a two-headed muscle with origins around the shoulder that insert in the forearm just below the elbow. In this location, the biceps can function as one the key flexors of the elbow and rotators of the forearm. Disorders of the biceps can affect the muscle belly itself of the tendon components at either the shoulder and/or elbow. In Favre's case, the problem appears to be with the long head of the biceps tendon. This tendon is unique in that it takes origin and courses directly through the shoulder joint. For this reason, tears or inflammation of the long head tendon can be a source of significant pain in the shoulder. The presentation of biceps tendonitis or tear at the shoulder can be highly variable and therefore difficult to reliably diagnose. There may direct tenderness over the tendon in its groove at the front of the shoulder. Pain with or without clicking or catching may be experienced in the cocked position of the arm when throwing. Pain with resisted flexion or rotation of the arm can be consistent with long head of the biceps pathology. Any of these symptoms should prompt an evaluation with your local sports orthopaedist or shoulder specialist for further evaluation. Based on their physical examination, imaging studies and/or diagnostic injections may be performed to confirm the diagnosis.
The treatment of long head of the biceps pathology is not straightforward. This is largely because the function of the long of the biceps tendon remains highly controversial. Some studies have shown the long head to be an important passive and active stabilizer of the shoulder. Other studies, however, have been unable to demonstrate a clear functional role for this tendon, particularly since the other "short head" tendon has a distinct origin and can function in its absence. For this reason, long of the biceps disorders have been effectively treated by simple release of tendon at its origin in the shoulder. While some loss in elbow flexion and forearm rotational strength is inevitable, simple tenotomy can provide effective pain relief. However, a "popeye" deformity with bulging of the released muscle in the upper arm can be predicted and is often undesirable to some patients. Furthermore, this loss of strength may not be well-tolerated in elite throwing athletes. In these patients, a "tenodesis" surgery may be more desirable; in this procedure, the tendon is released within the shoulder but re-attached under resting tension to soft tissue or bone outside of the shoulder joint. This procedure ameliorates the cosmetic deformity of an isolated release and may help to preserve some strength and function attributable to the muscle belly.
The next time you experience pain in your shoulder serving a tennis ball or throwing a baseball, keep in mind that it could be your biceps tendon. While the stakes may not be as high as those for Brett Favre, seeking the counsel of your local sports specialist can certainly help you to diagnose the problem and design a treatment plan to keep you pain-free.