Long Head of the Biceps Tendinopathy: Diagnosis and Management

Review Article Long Head of the Biceps Tendinopathy: Diagnosis and Management

Abstract Shane J. Nho, MD, MS Tendinopathy of the long head of the biceps brachii encompasses Eric J. Strauss, MD a spectrum of pathology ranging from inflammatory tendinitis to degenerative tendinosis. Disorders of the long head of the biceps Brett A. Lenart, MD often occur in conjunction with other shoulder pathology. A CDR Matthew T. Provencher, thorough patient history, physical examination, and radiographic MD, MC, USN evaluation are necessary for diagnosis. Nonsurgical management, Augustus D. Mazzocca, MD, MS including rest, nonsteroidal anti-inflammatory drugs, physical Nikhil N. Verma, MD therapy, and injections, is attempted first in patients with mild Anthony A. Romeo, MD disease. Surgical management is indicated for refractory or severe disease. In addition to simple biceps tenotomy, a variety of tenodesis techniques has been described. Open biceps tenodesis has been used historically. However, promising results have recently been reported with arthroscopic tenodesis.

espite considerable research superior labrum anterior-posterior Dinto the anatomy of the long (SLAP) lesions, bursitis, and acro- head of the biceps (LHB) brachii ten- mioclavicular joint disorders. The don and the pathologic conditions sheath of the LHB is an extension of From the Department of that affect it, controversy persists in the synovium of the glenohumeral Orthopaedic Surgery, Section of the literature regarding the function joint and is closely associated with Shoulder and Elbow Surgery, Division of Sports Medicine, Rush of the LHB and the appropriate the rotator cuff; thus, inflammation University Medical Center, Chicago, management of its disorders. Tendi- of one structure can lead to the de- IL (Dr. Nho, Dr. Strauss, Dr. Lenart, nopathy of the LHB has inflamma- velopment of disease in the other.3,4 Dr. Verma, and Dr. Romeo), Department of Orthopaedic Surgery, tory, degenerative, overuse-related, and traumatic causes. Naval Medical Center San Diego, Anatomy San Diego, CA (Dr. Provencher), Tendinitis of the LHB is an inflam- and New England Musculoskeletal matory tenosynovitis that occurs as Institute, University of Connecticut The LHB originates at the supragle- Health Center, Farmington, CT the tendon courses along its con- noid tubercle and the superior gle- (Dr. Mazzocca). strained path within the bicipital noid labrum. It inserts distally, along 1,2 The views expressed in this article groove of the humerus. Similar to with the short head of the biceps, are those of the authors and do not other types of biceps tendinopathy, onto the radial tuberosity, with an reﬂect the official policy or position LHB tendinitis presents with anterior of the Department of the Navy, attachment to the fascia of the me- Department of Defense, or US shoulder pain and is often exacer- dial forearm via the bicipital aponeu- Government. bated by overuse. Although isolated rosis. The site of the LHB origin J Am Acad Orthop Surg 2010;18: bicipital tendinitis has been de- from the glenoid labrum is variable; 645-656 scribed, LHB tendinitis more com- in most cases, it arises either mostly Copyright 2010 by the American monly presents in combination with posterior or completely posterior Academy of Orthopaedic Surgeons. other shoulder pathology, including (55.4% and 27.7%, respectively).5 impingement, rotator cuff disorders, The intra-articular portion of the

November 2010, Vol 18, No 11 645 Long Head of the Biceps Tendinopathy: Diagnosis and Management

Figure 1 excursion is provided by the sur- no identifiable transverse humeral rounding soft tissues. Recent clinical ligament exists. Instead, they found and anatomic studies have attempted the roof of the biceps sheath to be to better define the soft-tissue contri- formed by fibers from the subscapu- butions to biceps stability within the laris tendon, supraspinatus tendon, groove.7,8 These studies have noted and CHL. Distal to the tuberosities, the importance of the subscapularis the pectoralis major muscle insertion tendon, supraspinatus tendon, cora- appears to play a role in stabilizing cohumeral ligament (CHL), and the LHB. The falciform ligament, a superior glenohumeral ligament fibrous expansion from the sterno- (SGHL), which together serve as a costal head, has been shown to at- stabilizing tendoligamentous biceps tach to both sides of the bicipital sling or pulley that maintains the bi- groove, enveloping the biceps.6,9 ceps within its groove (Figure 1). The LHB tendon is a primary pain In an anatomic study, Gleason generator in the anterior aspect of Anatomic structures around the et al7 noted that superficial fibers the shoulder, and it has been shown long head of the biceps. The from the subscapularis tendon con- to receive both sensory and sympa- musculotendinous junction lies just 10 proximal to the inferior border of tinued over the biceps and inserted thetic innervation. In a cadaver the pectoralis major tendon. The onto the base of the greater tuberos- study, Alpantaki et al10 demonstrated dashed lines delineate underlying ity. Along with lateral fibers from the the presence of an asymmetrically structures. CHL = coracohumeral ligament supraspinatus tendon, these superfi- distributed neuronal network com- cial fibers helped to form the roof of posed of thinly myelinated and un- the biceps sheath. The authors also myelinated fibers along the course of LHB tendon is extrasynovial, and it noted that deep fibers from the sub- the tendon. This innervation was obliquely spans the glenohumeral scapularis tendon continued along shown to predominate in the proxi- joint anterosuperiorly, adjacent to the bottom of the bicipital groove, mal area of the LHB, near its origin. the rotator interval. thereby helping to form the floor of The blood supply to the LHB is de- The bicipital groove is an the biceps sheath. Contributions to rived primarily from branches of the hourglass-shaped corridor between the biceps sling were provided by the anterior circumflex humeral artery, the greater and lesser tuberosities of CHL and SGHL. which course along the bicipital the humeral head; this groove is nar- The transverse humeral ligament groove.1 Labral branches from the rowest and deepest at its mid por- was once believed to be of primary suprascapular artery also may pro- tion.6 Although the contours of the importance for LHB stability; how- vide blood supply, especially to the tuberosities help to contain the LHB ever, its presence and role have been proximal portion of the biceps ten- tendon within the bicipital groove, questioned.6,7 Based on their dissec- don near its origin.11 However, re- most of the restraint during tendon tions, Gleason et al7 concluded that cent studies have shown that there is

Dr. Nho or an immediate family member has received research or institutional support from Arthrex, DJ Orthopaedics, Linvatec, Smith & Nephew, Athletico, and MioMed. Dr. Provencher or an immediate family member serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, American Academy of Orthopaedic Surgeons, and Society of Military Orthopaedic Surgeons. Dr. Mazzocca or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of, serves as a paid consultant to or is an employee of, and has received research or institutional support from Arthrex. Dr. Verma or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Smith & Nephew and Arthrosurface; serves as a paid consultant to or is an employee of Smith & Nephew; has received research or institutional support from Smith & Nephew, DJ Orthopaedics, Arthrex, and Össur; and has stock or stock options held in Omeros. Dr. Romeo or an immediate family member has received royalties from Arthrex; is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex and DJ Orthopaedics; serves as a paid consultant to or is an employee of Arthrex; has received research or institutional support from Arthrex, Össur, and Smith & Nephew; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non- research–related funding (such as paid travel) from Arthrex and DJ Orthopaedics; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, and Arthroscopy Association of North America. Neither of the following authors nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Strauss and Dr. Lenart.

646 Journal of the American Academy of Orthopaedic Surgeons Shane J. Nho, MD, MS, et al a relatively avascular zone in the re- Figure 2 gion of the superior glenoid, which may contribute to the overall poor vascularity of the tendon.12 Examina- tion of the LHB within the groove characteristically shows vascularity on the superficial portion of the tendon, whereas the gliding undersur- face has been noted to be avascular. The biomechanical function of the LHB tendon is debated in the literature, and its role in glenohumeral ki- nematics remains controversial. The LHB has been described to function as a head depressor,2,13 an anterior stabilizer,14-16 and a posterior stabilizer.17 It has even been said to have no role and has been described as a vesti- gial structure.18 Cadaver biomechanical studies have demonstrated that the LHB tendon restricts glenohumeral translation in all directions but especially in the anterior and inferior directions; however, the manner in which the LHB tendon was loaded in these Algorithm demonstrating the pathophysiology of long head of the biceps studies may not accurately represent its (LHB) tendinitis. loading in vivo.13-16 Recent electro- myographic data presented in studies glenohumeral joint, and this sheath using controlled elbow motion sug- can become inflamed in conjunction Clinical Evaluation and gest little biceps activity specific to with inflammatory processes that af- Diagnosis the glenohumeral joint.4,6 However, fect the rotator cuff tendons. In a it is possible that, in vivo, tension on prospective arthroscopic evaluation History the LHB during active elbow motion of 89 patients, Neviaser et al3 corre- Most patients report a progressive may contribute to anterior shoulder lated inflammatory changes in the course of anterior shoulder pain and stability.4,6 LHB with rotator cuff tendinopathy. declining function as a result of This association was found to be- chronic overuse, typically from re- Pathophysiology come more pronounced with increas- petitive overhead activities. It is diffi- ing severity of rotator cuff disease. cult to differentiate the various Disorders of the LHB include a spec- Isolated or primary bicipital tendi- causes of anterior shoulder pain, and trum of pathologic conditions, from nitis is seen less commonly in con- a thorough history is important to inflammatory tendinitis to degenera- junction with LHB tendinopathy elucidate activities and positions that tive tendinosis. This continuum of than with other shoulder pathology. are provocative (Table 1). Often, pa- disease likely arises secondary to re- However, it may occur secondary to tients report pain in the anteromedial petitive traction, friction, and gleno- direct or indirect trauma, underlying aspect of the shoulder, in the region humeral rotation, with resultant inflammatory disease, and in associ- of the bicipital groove. This pain pressure and shear forces occurring ation with tendon instability. Such may radiate down anteriorly to the on the tendon at distinct, anatomi- tendinitis progresses through a biceps muscle belly. cally narrow sites within the long course from LHB tenosynovitis to Patients with primary isolated bi- proximal tendon course.19 The LHB tendinosis, which is marked by ceps tendinitis tend to be younger sheath of the biceps tendon is an ex- specific gross and microscopic find- and participate in overhead sports tension of the synovial lining of the ings3,4,6 (Figure 2). such as baseball, softball, and volley-

November 2010, Vol 18, No 11 647 Long Head of the Biceps Tendinopathy: Diagnosis and Management

20 Table 1 ball. Patients with symptoms re- bow is in 90° of flexion. The Speed lated to biceps instability may report test is positive with pain in the bicip- Differential Diagnosis of Anterior Shoulder Pain an acute event with ensuing clicking ital groove on resisted forward flex- or popping in the anterior shoulder, ion of the arm with the forearm supi- Acromioclavicular joint pathology and some patients may hear an audi- nated, the elbow fully extended, and Impingement syndrome ble snap with throwing motions.20,21 the humerus in 90° of forward flex- Rotator cuff tendinitis LHB subluxation generally occurs in ion. Both tests are specific but not Rotator cuff tears the setting of a partial- or full- sensitive in detecting biceps tendini- Long head of the biceps tendinopathy thickness subscapularis tear, and the tis, rupture, and SLAP lesions.25 Superior labrum anterior-posterior tears reported symptoms are usually con- Medial biceps instability can be elu- Subacromial bursitis current with those found in rotator cidated with a painful click or ten- Glenohumeral arthritis cuff disease.6 However, LHB sublux- derness to palpation on full abduc- Adhesive capsulitis ation and dislocation have been re- tion and external rotation of the Glenohumeral instability ported in patients with an intact ro- arm. When dislocated, the biceps Cervical spine pathology tator cuff, as well22 (Figure 3). tendon can be rolled under the ex- Humeral head osteonecrosis aminer’s fingers, eliciting increased Physical Examination tenderness.6 The O’Brien active compression test may indicate a SLAP le- Figure 3 The physical examination and clinical diagnosis of symptomatic biceps sion; however, this test is also often tendinopathy is often difficult be- positive in patients with LHB tendi- cause the findings are similar to nitis or acromioclavicular arthrosis. those of other pathologic entities Selective injections may further aid that affect the glenohumeral joint. in the diagnosis of shoulder pathol- 26 One of the most common physical ogy associated with LHB tendinitis. examination findings in patients A subacromial injection may relieve with disorders of the LHB is point pain caused by impingement. When tenderness elicited by palpation of biceps pain persists, an injection into the tendon within the bicipital the bicipital groove may be given, groove. In the subpectoral LHB as well, to help differentiate LHB tendon test, the examiner palpates tendinitis from other common causes the tendon just medial to the pecto- of anterior shoulder pain. An intra- ralis major tendon insertion while articular injection is also diagnosti- the patient internally rotates the cally and therapeutically useful, arm against resistance.23 A greater especially when a SLAP tear is sus- amount of pain on the affected side pected. Long head of the biceps (LHB) during the test suggests that synovitis subluxation and dislocation may is localized to the bicipital groove. Imaging Studies occur in patients with an intact rotator cuff secondary to injury to The unaffected, contralateral side Imaging studies may be useful in the the coracohumeral ligament (CHL), should be tested for comparison. identification of biceps tendinitis and superior glenohumeral ligament Gross deformity of the biceps muscle associated pathology. The typical (SGHL), or transverse humeral (ie, Popeye sign) is indicative of LHB plain radiographic views for shoul- ligament, which is composed in 24 part of ﬁbers from the CHL and tendon rupture. der evaluation (ie, AP, lateral, axial) SGHL. The arrow signiﬁes medial Several tests have been described to should be obtained. Although these dislocation of the LHB tendon identify LHB tendinitis and associ- views are useful in diagnosing gross (dashed line). (Redrawn with ated pathology. However, no specific bony abnormalities and glenohu- permission from Gambill ML, Mologne TS, Provencher MT: test or combination of tests has been meral degeneration, they are seldom Dislocation of the long head of the reported to have a reliable positive helpful in the diagnosis of LHB ten- biceps tendon with intact predictive value. The Yergason test is dinitis and rupture. A visible outline subscapularis and supraspinatus tendons. J Shoulder Elbow Surg positive in the presence of pain on of the tendon sheath on plain ar- 2006;15:e20-e22.) palpation of the proximal biceps thrography is suggestive of lack of with resisted supination while the el- inflammation; however, a negative

648 Journal of the American Academy of Orthopaedic Surgeons Shane J. Nho, MD, MS, et al arthrogram is seen in >30% of cases Figure 4 with biceps pathology.27,28 MRI allows visualization of the biceps tendon, bicipital groove, bony osteophytes, and fluid. MRI is par- ticularly helpful in identifying other associated pathology. However, most studies are neither precise nor accurate, and their quality is too varied to allow consistent identification of biceps tendinopathy. MRI has demonstrated poor concordance with arthroscopic findings in the detection of biceps pathology and poor to moderate sensitivity for inflamma- A, T2-weighted axial magnetic resonance arthrogram demonstrating the long tion, partial-thickness tear, and rup- head of the biceps (LHB) tendon lying in the bicipital groove. B, T2-weighted ture.29 axial magnetic resonance image demonstrating a torn subscapularis tendon (SSc) and medial dislocation of the LHB tendon. Magnetic resonance arthrography is sensitive and moderately specific for the diagnosis of biceps tendon the groove without injecting the ten- pathology and aids in detection of Nonsurgical Management don itself.26 Although not well- associated pathology with tendinitis documented, intratendinous cortico- LHB tendinopathy is often initially of the LHB, including rotator cuff steroid injection may predispose the 30,31 managed nonsurgically, with tech- tears and SLAP lesions. On mag- patient to tendon rupture. netic resonance arthrography, the niques similar to those for the man- Nonsurgical management of symp- LHB is normally surrounded by con- agement of tendon disorders. This tomatic biceps tendinopathy is the trast fluid, with a shape similar to includes a period of rest and activity first-line treatment and is often suc- that of a kidney bean; neither finding modification coupled with nonsteroi- cessful. However, data are lacking in should be mistaken as pathologic dal anti-inflammatory drugs. Physi- the literature to support the efficacy (Figure 4). Close inspection of ad- cal therapy is prescribed to correct of this common approach. vanced imaging studies (ie, MRI, the underlying scapular rhythm and magnetic resonance arthrography) is to manage concomitant shoulder dis- warranted in the axial plane and the orders. Should this initial treatment Surgical Management sagittal oblique plane because LHB prove to be unsuccessful, corticoster- subluxation and dislocation are oid injections may be attempted, first The decision to perform surgical correlated with partial- and full- in the subacromial space and gleno- management of biceps pathology is thickness subscapularis tendon humeral joint, to reduce the extent of dependent on the clinical presenta- tears.22 inflammation that occurs secondary tion, results of provocative physical Ultrasound is cost-effective and ac- to the commonly associated shoulder examination tests, presence of associ- curate in the diagnosis of shoulder pathology seen with biceps tendini- ated shoulder pathology, and failure pathology, although this modality is tis. The sheath of the LHB is contin- of nonsurgical management. Indica- highly operator-dependent. Ultra- uous with the synovium of the gleno- tions for surgical management in- sound is highly accurate for detec- humeral joint, and the effects of clude partial-thickness tear of the tion of full-thickness tears of the these injections often extend to the LHB tendon of >25% to 50%, me- rotator cuff as well as biceps disloca- LHB, leading to a reduction in in- dial LHB subluxation, and LHB sub- tion, subluxation, and rupture; how- flammation and an improvement in luxation in the setting of a tear of the ever, it is less accurate in detecting symptoms.26 When the biceps re- subscapularis tendon or biceps partial-thickness tears of the biceps mains symptomatic, the surgeon may pulley/sling.4,33-36 Relative indications tendon.32 To date, the role of ultra- inject the tendon sheath within the for LHB surgery include type IV sound in the diagnosis of biceps ten- bicipital groove. The objective of a SLAP tear, symptomatic type II SLAP don inflammation has not been indirect tendon sheath injection is to tear in an older patient (>50 years), vestigated. infiltrate the area in and around failed SLAP repair, and chronic pain

November 2010, Vol 18, No 11 649 Long Head of the Biceps Tendinopathy: Diagnosis and Management

Table 2 Studies Comparing Long Head of the Biceps Tenotomy and Tenodesis No. of Shoulders

Mean Age Mean Associated Popeye Study (yr) Tenotomy Tenodesis Follow-up (mo) Shoulder Pathology Sign

Osbahr 56 80 80 22 RCT impingement, AC No et al42 arthrosis

Edwards 53 13 48 45 Subscapularis tear NR et al43

Boileau 68 39 33 35 RCT Yes et al41

Franceschi 59 11 11 47 RCT No et al44 Paulos and 55 10 39 20 RCT and impingement Yes Berg45

AC = acromioclavicular, LHB = long head of the biceps, NR = not reported, ROM = range of motion, RCT = rotator cuff tear, UCLA = University of California Los Angeles attributable to LHB tendinitis that is to be displeasing to older persons Several clinical studies have been refractory to nonsurgical manage- and those with obese arms. Fatigue performed recently comparing the ment.1,4,37 Other indications for sur- cramping of the biceps muscle belly outcomes of tenotomy versus tenode- gical management include intraoper- has also been reported; this occurs sis (Table 2). Overall, despite a po- ative findings of an inflamed more commonly in younger persons, tentially higher incidence postopera- “lipstick” biceps tendon and signifi- typically aged <40 years.24 In a re- tively of the Popeye sign, muscle cant hypertrophy of the tendon (ie, view of 54 patients with biceps ten- cramping, and pain in the bicipital hourglass LHB) during diagnostic ar- dinitis treated with arthroscopic te- groove with tenotomy compared throscopy in the setting of persistent notomy, Kelly et al24 reported that with tenodesis, these studies have not symptoms attributable to biceps pa- 38% had fatigue discomfort in the identified significant differences in thology.23,38 biceps muscle after resisted elbow functional scores or patient satisfac- Optimal surgical management of flexion activities. Thus, tenotomy is tion between the two techniques. In LHB tendon pathology remains con- generally reserved for persons who a systematic review, Frost et al39 troversial.39 The two most commonly are older, do not work as laborers, found no significant differences in performed procedures are biceps te- are unlikely to be displeased with outcomes between biceps tenotomy notomy and tenodesis. Biceps tenot- cosmesis, and are unable or unwill- and tenodesis. The authors con- omy can be performed with a rela- ing to comply with postoperative cluded that tenotomy may be the tively simple and reproducible care following tenodesis. procedure of choice because of its technique that provides predictable The goal of biceps tenodesis is to simplicity and the reduced need for pain relief and requires little post- maintain the length-tension relation- postoperative rehabilitation. operative rehabilitation. However, ship of the biceps muscle, which may Controversy persists regarding the post-tenotomy cosmesis and fatigue prevent postoperative muscle atro- optimal course of surgical manage- discomfort are potential problems. phy and which helps to maintain the ment, and continued study is re- The Popeye deformity has been re- normal contour of the biceps muscle. quired. However, both tenotomy and ported to occur in 3% to 70% Some authors believe that biceps te- tenodesis have been shown to be ef- of cases following tenotomy.24,39,40 nodesis should be used in younger, fective in the management of LHB However, this outcome is less likely active patients with LHB pathology. tendinopathy.

650 Journal of the American Academy of Orthopaedic Surgeons Shane J. Nho, MD, MS, et al

Table 2 (continued) Figure 5 Studies Comparing Long Head of the Biceps Tenotomy and Tenodesis

Difference Between Techniques Comments No No difference with respect to cosmesis, extent of postoperative pain, or muscle spasm No Tenodesis or tenotomy of the LHB with subscapularis repair was associated with improved subjective and objective results Higher incidence of Popeye sign with No difference in Constant score, patient tenotomy vs tenodesis (62% vs 3%, satisfaction, or shoulder ROM respectively), postoperative muscle Dry arthroscopic image of a left cramping (21% vs 9%, respectively), shoulder demonstrating hyperemic and pain in the bicipital groove (46% vs tenosynovium (ie, lipstick biceps). 30%, respectively) LHB = long head of the biceps, No All patients had good to excellent results RI = rotator interval on UCLA score Higher incidence of Popeye sign (80% No difference in UCLA score or patient tenotomy vs 5% tenodesis) satisfaction the components of the biceps pulley/ sling (ie, CHL, SGHL) is carefully as- AC = acromioclavicular, LHB = long head of the biceps, NR = not reported, ROM = range of motion, RCT = rotator cuff tear, UCLA = University of California Los Angeles sessed to aid in determining the surgical approach.8,22,47 Some surgeons may elect to dé- Arthroscopic Débridement to cause mechanical symptoms. bride the LHB tendon with a shaver and Biceps Tenotomy It is critical that the intertubercular in the patient with arthroscopic evi- Arthroscopic tenotomy can be per- groove portion of the LHB be dence of <30% to 50% of intra- formed with the patient in the beach- brought into the joint because the articular LHB fraying without insta- chair or the lateral decubitus posi- pathologic areas are commonly lo- bility. When arthroscopic tenotomy tion, depending on the concomitant cated in this portion. In addition, the is indicated, an arthroscopic basket procedures required. A standard pos- surgeon should evaluate the stability is used to release the LHB as close as terior portal is established and is of the LHB within the biceps pulley possible to the superior labrum, used for diagnostic arthroscopy, after by attempting to subluxate the ten- thereby ensuring that the confluence which an anterior portal is created in don out of the sling using the of the superior labral ring is main- the rotator interval under direct visu- probe.46,47 Although the arthroscopic tained. After release, the LHB tendon alization. The LHB is evaluated active compression test is typically should easily retract toward the bi- “dry,” with no pump pressure, be- used in the diagnosis of unstable cipital groove. In some instances the cause the intra-articular pressure of SLAP lesions, it can also be used to LHB is hypertrophic and is unable to the infusion fluid may compress the identify medial and inferior LHB retract, leaving a portion of the ten- peritendinous vessels, causing the in- subluxation.47 In the case of LHB in- don intra-articular. This may serve as flamed synovium to appear washed stability, the tendon is noted to dis- a potential source of postoperative out.23 A lipstick biceps has been de- place medially and inferiorly during pain. In these cases, the end of the scribed as an inflamed LHB within internal rotation, becoming en- tendon must be débrided until it can the bicipital groove. This is visual- trapped within the glenohumeral retract untethered into the bicipital ized as a high amount of inflamma- joint. On external rotation of the groove.38 In an effort to decrease the tion on the tendon surface when the arm, the entrapment is relieved, and incidence of Popeye deformity fol- LHB is retracted into the joint23 (Fig- the tendon returns to its normal po- lowing tenotomy, Bradbury et al48 ure 5). An hourglass LHB tendon sition. Following arthroscopic confir- suggest releasing the LHB along with can be visualized arthroscopically.38 mation of LHB instability, the integ- a portion of the superior labrum. In this finding, hypertrophy of the rity of the subscapularis and This technique produces a T-shaped biceps within the groove is believed supraspinatus tendons as well as of structure at the proximal end of the

November 2010, Vol 18, No 11 651 Long Head of the Biceps Tendinopathy: Diagnosis and Management

LHB, leading to entrapment at the within the biceps sheath.54,55 Sanders tenotomy, the arthroscope, which is entrance to the bicipital groove. et al56 reported a 12% revision rate placed in the posterior portal, and Gill et al40 explored biceps tenotomy with proximal tenodesis techniques the anteromedial working cannula as an option for the management of in which the LHB remained within are redirected into the subacromial primary LHB pathology. After ar- the bicipital groove, compared with space. The arthroscope is then in- throscopic tenotomy, patients reported a 2.7% rate when the LHB was fixed serted into an anterolateral portal for high rates of pain-free recovery, return distally, outside the groove. viewing. A probe is used to identify to work, and return to sports, with a Proximal fixation can be performed the location of the bicipital groove, mean American Shoulder and Elbow with an all-arthroscopic technique which typically lies just medial to the Surgeons (ASES) score of 81.8. In a sim- within the glenohumeral joint or sub- lateral aspect of the greater tuberos- ilar study of 40 patients with biceps ten- deltoid space to the surrounding intact ity.58 dinitis with or without associated shoul- rotator cuff57 or to the conjoint ten- The bicipital groove is opened us- der pathology, Kelly et al24 reported don,58 or just proximal within the bi- ing a cautery device, exposing the that patient satisfaction was high fol- cipital groove.9,24,35,36,50,51,53 In a re- LHB. The LHB is then grasped while lowing arthroscopic tenotomy (aver- view of 43 patients treated with the spinal needle is removed, which age ASES score, 77.6). Although im- arthroscopic proximal tenodesis us- allows removal of the tendon from provement with respect to pain was ing interference screw fixation, Boi- the groove (Figure 7). Using a shaver high, 70% of the patients in this leau and Neyton52 found the power or cautery device, the bicipital study displayed the classic Popeye of the biceps to be 90% that of groove is cleared of tissue in prepara- sign at rest or during active elbow the unaffected contralateral side. tion for drilling of the humeral flexion, and 38% reported fatigue Elkousy et al57 reported preliminary socket. Approximately 1 cm distal to discomfort after resisted elbow flex- results in 11 patients following ar- the most superior aspect of the ion. throscopic biceps tenodesis using a groove, a guidewire is drilled perpen- percutaneous intra-articular trans- dicular to the humerus and parallel Long Head of the tendon technique. All 11 patients to the lateral border of the acromion. Biceps Tenodesis had biceps strength equal to that of Using a 7- or 8-mm cannulated Tenodesis is the preferred technique the contralateral side, and all were reamer, the guidewire is then over- for managing pathology of the LHB satisfied with their postoperative drilled to a depth of 25 mm (Figure in younger persons, athletes and la- outcome. 8). An arthroscopic grasper is used borers, and those who wish to avoid Distal fixation may involve the use of to apply tension to the LHB, and the 55 33 cosmetic deformity. Tenodesis allows bone tunnels, keyholes, suture to a LHB tendon is inserted into the hu- for preservation of the length-tension bed of decorticated bicipital groove, meral socket using a tendon fork. A 23,33,36,50,51,53,55,58-60 relationship of the biceps muscle, interference screws, guidewire for the interference screw 24,33,55,59,60 which may prevent postoperative and suture anchors. Several is inserted through the tendon fork, muscle atrophy and fatigue cramp- biomechanical studies have shown maintaining appropriate tension on ing, and which helps to maintain the the interference screw technique to the LHB. The tendon is then fixed normal contour of the biceps muscle. have the highest ultimate load to fail- within the socket using a 9- × 25-mm Recent controversy surrounding bi- ure and the least amount of displace- interference screw with the patient’s ceps tenodesis pertains to the loca- ment on cyclic loading compared elbow in 45° to 90° of flexion (Fig- tion and method of fixation. Biceps with suture anchor and other meth- ure 9). Tension in the tenodesed LHB 33,55,60-62 58 tenodesis can be performed proxi- ods of fixation. is assessed using the probe. mally, with the tendon maintained within the bicipital groove,41,49,50 or Arthroscopic Subpectoral Open distally, with the tendon removed Biceps Tenodesis Biceps Tenodesis from the groove.9,35,36,50-53 Advocates Arthroscopic biceps tenodesis can be Several open techniques have been of distal fixation report that remov- performed in either the lateral decu- described for both proximal and dis- ing the LHB from the bicipital bitus or beach-chair position. Prior tal LHB tenodesis. However, we pre- groove and excising the proximal to tenotomy, the tendon undergoes fer to use a mini-open subpectoral portion of the tendon limits the po- intra-articular transfixion with a spi- approach. Following release of the tential for postoperative pain sec- nal needle at its entrance into the bi- LHB tendon, the head of the bed is ondary to residual tenosynovitis cipital groove (Figure 6). Following lowered to 30° from the beach-chair

652 Journal of the American Academy of Orthopaedic Surgeons Shane J. Nho, MD, MS, et al

Figure 6 Figure 7

Arthroscopic image demonstrating the long head of the biceps tendon Prior to tenotomy, the long head of the biceps tendon is pierced with a spinal being delivered from the bicipital needle (A) and tagged with a polypropylene suture (B). groove.

Figure 8 Figure 9 Figure 10

Arthroscopic humeral socket drilling Arthroscopic long head of the using an 8-mm cannulated reamer biceps tenodesis ﬁxation using a 9- over an inserted guidewire. × 25-mm interference screw. position. The arm is abducted and fascia overlying the coracobrachialis internally rotated so that the inferior and biceps muscles is incised from Open subpectoralis biceps border of the pectoralis tendon is proximal to distal. Digital palpation tenodesis incision (dashed line). palpable. An incision is made along helps to identify the LHB sitting in The incision is approximately 3 cm the axillary fold or along the medial the groove just medial to the pecto- in length, with 1 cm superior to the inferior border of the pectoralis aspect of the arm, beginning 1 cm ralis major tendon insertion. major tendon and 2 cm inferior to superior to the inferior border of the Once the LHB is mobilized, it is that structure. pectoralis tendon and continuing 2 delivered out of the wound. A clamp cm distally (Figure 10). The dissec- is placed on the proximal end of the tion is carried down directly over the tendon, and a Krakow stitch with a stitch is excised to maintain the cor- humerus, taking care to avoid exces- No. 2 permanent braided suture is rect length-tension relationship for sive medial exposure to prevent in- passed from 15 mm proximal to the the tenodesis (Figure 11). A perios- jury to the neurovascular structures. musculotendinous junction. The ap- teal elevator is used to prepare the The inferior border of the pectoralis proximately 20 mm of remaining humeral bone approximately 1 cm major tendon is identified, and the tendon proximal to the Krakow proximal to the inferior border of

November 2010, Vol 18, No 11 653 Long Head of the Biceps Tendinopathy: Diagnosis and Management

Figure 11 Figure 12 visit. Patients may resume light work at 3 to 4 weeks depending on their occupation. Depending on their progress with physical therapy, patients are typically able to return to unrestricted activity at 3 to 4 months postoperatively.

Complications

Nho et al63 recently reported on the complications after open subpectoral biceps tenodesis over a 3-year period. Seven of 353 patients presented with postoperative complications, for an incidence of 0.7% per year. Two patients had persistent bicipital Long head of the biceps tendon preparation. The proximal 20 mm is pain, and two had failed fixation excised, and a Krakow stitch is Biceps tenodesis site preparation. with an associated Popeye deformity made through the proximal tendon A guidewire is positioned in the (0.2% for each). One patient each end to the musculotendinous bicipital groove 1 cm proximal to presented with the following compli- junction (inset). the inferior border of the pectoralis cations (0.1%): wound infection, major tendon and over-reamed with an 8-mm reamer (inset). temporary musculocutaneous neu- ropathy, complex regional pain syn- the pectoralis major tendon. drome, and proximal humerus frac- Several fixation techniques have suture limb through the screw and ture. been described for use with open the limb next to the tendon are subpectoral biceps tenodesis. We pre- tied together. The wound is irri- fer to use interference screw fixation, Summary gated and closed with No. 2-0 ab- as described by Mazzocca et al.23 sorbable, monofilament sutures and The intent is to position the muscu- LHB tendinopathy is a common Dermabond (Ethicon, Somerville, lotendinous junction at its normal source of shoulder pain, and it often NJ) to reduce contamination from resting position, just beneath the in- occurs in combination with other the axilla. ferior border of the pectoralis major shoulder pathology. Once the diag- tendon, to maintain an anatomic nosis of LHB tendinitis has been es- length-tension relationship. A guide- Postoperative Protocol tablished, patients are treated non- wire is positioned in the center of the surgically with rest, ice, nonsteroidal bicipital groove 1 cm proximal to the Postoperatively, the patient is placed anti-inflammatory drugs, activity inferior border of the pectoralis main a sling. For isolated biceps tenode- modification, and physical therapy. jor tendon. Using an 8-mm cannu- sis the sling is discontinued at 3 to 4 Selective cortisone injections play a lated reamer, the guidewire is over- weeks, but the length of immobiliza- role in nonsurgical management, reamed to a depth of 15 mm. One tion and the rehabilitation protocol serving both diagnostic and thera- suture is passed through the tenode- are dictated by concomitant proce- peutic purposes. sis screwdriver and screw (eg, 8- × dures. The patient progresses to full Patients with symptoms refractory 12-mm polyetheretherketone tenode- glenohumeral active and passive to nonsurgical management are indi- sis screw; Bio-Tenodesis, Arthrex, range of motion during the first 6 cated for biceps tenotomy or tenode- Naples, FL), and the other limb is weeks. Elbow range of motion and sis. To date, the literature does not left out (Figure 12). The driver is grip strengthening may commence provide evidence to support one placed into the bone tunnel, fully during this initial postoperative pe- technique over the other, and there seating the tendon within the tunnel, riod, but patients are restricted from are advantages to each procedure. and the screw is advanced until it is active elbow flexion and supination The authors’ preferred method is flush with the surrounding bone. The exercises until the 6-week follow-up open subpectoral biceps tenodesis

654 Journal of the American Academy of Orthopaedic Surgeons Shane J. Nho, MD, MS, et al with interference screw fixation, 9. Romeo AA, Mazzocca AD, Tauro JC: Arciero RA: Subpectoral biceps tenodesis which provides the strongest fixation Arthroscopic biceps tenodesis. with interference screw fixation. Arthroscopy 2004;20(2):206-213. Arthroscopy 2005;21(7):896. construct with a technique that re- 10. Alpantaki K, McLaughlin D, Karagogeos 24. Kelly AM, Drakos MC, Fealy S, Taylor moves the intertubercular portion of D, Hadjipavlou A, Kontakis G: SA, O’Brien SJ: Arthroscopic release of the LHB tendon and provides fixa- Sympathetic and sensory neural elements the long head of the biceps tendon: tion at the resting position of the bi- in the tendon of the long head of the Functional outcome and clinical results. biceps. J Bone Joint Surg Am 2005; Am J Sports Med 2005;33(2):208-213. ceps tendon. 87(7):1580-1583. 25. Holtby R, Razmjou H: Accuracy of the 11. 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656 Journal of the American Academy of Orthopaedic Surgeons