Long Head of Biceps Tendinopathy Is Associated With Age and Cuff Tendinopathy on MRI Obtained for Evaluation of Shoulder Pain
Authors: Canavan Kathryn , Zai Qais , Bruni David , Alexander Jeremiah , Oude Nijhuis Koen D. , Ring David 
Published: December 2024

Background
Shoulder pain—mostly related to rotator cuff tendinopathy—is the most common reason adults seek upper limb specialty care. Tendinopathy of the long head of the biceps may be part of rotator cuff tendinopathy, which most of us develop as we age. Evidence that these processes are related and that both are part of human shoulder senescence could contribute to a reconceptualization of shoulder tendinopathy as a single set of age-related changes, which are often well-accommodated, sometimes misinterpreted as an injury, and associated with notable nonspecific treatment effects, thus meriting caution regarding the potential for overtreatment.

Questions/purposes
This study reviewed a consecutive series of MRI scans ordered for the evaluation of shoulder pain and asked: (1) Is long head of the biceps tendinopathy associated with advancing age? (2) Is long head of the biceps tendinopathy associated with concomitant degeneration of the rotator cuff tendons?

Methods
Five hundred consecutive radiologist interpretations of MRIs of the shoulder obtained between May 2016 and June 2017 for assessment of shoulder pain in adults at a radiology group that provides approximately 80% of the imaging in all practices in our region were reviewed. Patients with bilateral MRIs had one MRI included at random. Patients with fractures, dislocations, previous surgery, and soft tissue masses seen on MRI were excluded, leaving 406 shoulder MRI interpretations for review. The radiology reports were used to identify the presence and severity of rotator cuff and long head of the biceps tendinopathy. Forty-nine percent (197 of 406) were men with a mean ± SD age of 55 ± 14 years, and 54% (220 of 406) were right shoulders. Multivariable analyses accounting for age and gender evaluated the association of long head of the biceps tendinopathy with age and tendinopathy of the rotator cuff tendons.

Results
After controlling for tendinopathy of the other rotator cuff tendons, long head of the biceps tendinopathy was more common with advancing age (OR 1.04 [95% CI 1.02 to 1.06] per year; p < 0.001), meaning the prevalence increases by approximately 4% per year. Among people who were imaged for shoulder pain, everyone 85 years or older had both long head of the biceps and rotator cuff tendinopathy. Any rotator cuff pathophysiology was also notably associated with any long head of the biceps pathophysiology (OR 6.9 [95% CI 2.4 to 20]; p < 0.001). About half (49% [162 of 328]) of long head of the biceps tendons were normal in the presence of any supraspinatus tendinopathy, and 5% (9 of 175) of supraspinatus tendons were normal in the presence of any long head of the biceps tendinopathy.

Conclusion
The finding that among people seeking care for shoulder pain, long head of the biceps tendinopathy and rotator cuff tendinopathy occur together and are more common with increasing age (and ubiquitous by the latter half of the ninth decade) suggests that most shoulder pain in adults is associated with expected aging of the shoulder tendons inclusive. In this light, clinicians can guide patients to an understanding of shoulder pain as age-appropriate, safe and sound, and accommodated by a large percentage of people as they age, all of which may be unexpected and counterintuitive. Effective assimilation of this knowledge—which may take time and merits patience—has the potential to both put people at ease and open up possibilities for fewer visits, tests, and treatments addressing tendinopathy, allowing patients to manage on their own (agency) with a set of simple exercises and perhaps occasional use of over-the-counter analgesics.

Level of Evidence
Level III, prognostic study.