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Supraspinatus Muscle Tendon Lesion and Its Relationship with Long THIEME Original Article 329 Supraspinatus Muscle Tendon Lesion and Its à Relationship with Long Head of the Biceps Lesion Lesãodotendãodomúsculosupraespinalesuarelação comalesãodotendãodacabeçalongadobíceps Cassiano Diniz Carvalho1 Carina Cohen1 Paulo Santoro Belangero1 Alberto de Castro Pochini1 Carlos Vicente Andreoli1 Benno Ejnisman1 1 Orthopedics and Traumatology Department, Centro de Address for correspondence Cassiano Diniz Carvalho, Rua Teixeira Traumatologia do Esporte (CETE), Escola Paulista de Medicina, Santana 185, Fundinho, Uberlândia, 38400-196, Brasil Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil (e-mail: cassianodiniz@labsforfit.com.br). Rev Bras Ortop 2020;55(3):329–338. Abstract Objective To identify the clinical, radiological, and arthroscopic correlation of long head of the biceps tendon injuries and their influenceonpainwhenassociatedwith rotator cuff injuries. Methods Between April and December 2013, 50 patients were evaluated, including 38 (76%) women and 12 (24%) men, with a mean age of 65.1 years old. The patients were operated by the Shoulder and Elbow Group, Discipline of Sports Medicine, Orthopedics and Traumatology Department, Universidade Federal de São Paulo. The subjects underwent repair of the rotator cuff lesion with clinical, radiological and/or arthroscopic evidence of involvement of the long head of the biceps tendon. Results An association between pain at palpation of the intertubercular groove of the humerus and high-grade partial lesions (partial rupture of the tendon affecting more than 50% of its structure) was observed at the arthroscopy (p ¼ 0.003). There was also an association between the high-grade lesion of the long head of the biceps and injury Keywords to the supraspinatus muscle tendon (p < 0.05). For each centimeter of the supra- ► long head of the spinatus muscle tendon injury, the patient presented a 1.7 higher probability of having biceps a high-grade lesion at the long head of the biceps. ► tendinopathy Conclusion Pain at the anterior shoulder region during palpation of the intertuber- ► rotator cuff cular groove of the humerus may be related to high-grade lesions to the long head of ► tenotomy the biceps. Rotator cuff injury and its size are risk factors for high-grade injuries to the ► tenodesis long head of the biceps tendon. à Work performed at the Orthopedics and Traumatology Depart- ment, Centro de Traumatologia do Esporte (CETE), Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil. received DOI https://doi.org/ Copyright © 2020 by Sociedade Brasileira July 21, 2018 10.1055/s-0039-3402472. de Ortopedia e Traumatologia. Published accepted ISSN 0102-3616. by Thieme Revinter Publicações Ltda, Rio February 5, 2019 de Janeiro, Brazil 330 Supraspinatus Muscle Tendon Lesion Carvalho et al. Resumo Objetivo Identificar a correlação clínica, radiológica, e artroscópica das lesões do tendão da cabeça longa do bíceps e sua influência na dor do paciente quando associada às lesões do manguito rotador. Métodos Entre abril e dezembro de 2013, foram avaliados 50 pacientes, sendo 38 (76%)dosexofemininoe12(24%)dosexomasculino, com idade média de 65,1 anos. Os pacientes foram operados pelo Grupo de Ombro e Cotovelo da Disciplina de Medicina Esportiva do Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo. Os indivíduos foram submetidos a reparo da lesão do manguito rotador com evidência clínica, radiológica e/ou artroscópica de acometimento do tendão da cabeça longa do bíceps. Resultados Observou-se associação entre dor à palpação do sulco intertubercular do úmero com lesão parcial de alto grau (ruptura parcial acometendo mais de 50% do tendão) na artroscopia (p ¼ 0,003). Encontramos ainda uma associação entre a lesão de alto grau da cabeça longa do bíceps e a lesão do tendão do músculo supraespinhal Palavras-chave (p < 0,05), sendo que, para cada centímetro de lesãodotendãodomúsculosupraespi- ► cabeça longa do nhal, o paciente apresenta probabilidade 1,7 maior de ter uma lesão de alto grau da bíceps cabeça longa do bíceps. ► tendinopatia Conclusão A dor na região anterior do ombro à palpação do sulco intertubercular do ► manguito rotador úmero pode estar relacionada às lesões de alto grau da cabeça longa do bíceps. A lesão ► tenotomia do manguito rotador e o seu tamanho são fatores de risco para lesão de alto grau do ► tenodese tendão da cabeça longa do bíceps. 2,10 Introduction groove. Therefore, the arm position dictates the relation- ship between the intra- and extra-articular portions. For Throughout history, the long head of the biceps (LHB) brachii instance, during arm adduction and extension, most of the tendon has been the subject of great controversy, being tendon is intra-articular. In contrast, in extreme abduction, considered either a major source of shoulder pain or an only a small part of the tendon is intra-articular.1 insignificant structure.1 Kessell and Watson2 described it as As such, LHB tendinopathy may arise from repeated an easy-to-blame but hard-to-condemn structure. friction, traction and glenohumeral rotation, which result There is still no consensus on the true role of the LHB in pressure and shear forces. Since the intertubercular groove tendon in shoulder biomechanics. Nevertheless, its function, is a constricted environment, it is usually affected by the as well as its important role in static and dynamic stabiliza- inflammatory process.11 tion, have been investigated by different authors.3 Several Diagnostic tests for LHB tendon injuries have limited authors have noted an important stabilizing role,4 in addition clinical utility when applied alone.12 to humeral head centralization at the secondary glenoid, as Today, magnetic resonance imaging (MRI) is the most described by Pagnani.5 used complementary test for LHB tendon injury diagnosis. In 1934, biceps tendinitis was questioned by Codman,6 who Studies indicate that MRI sensitivity ranges from 52% to even doubted there was a tendinous inflammatory process, 69.8%, with 86% to 98% of specificity for complete lesions.13 and considered that the pain was much more likely caused by However, the arthroscopic evaluation is considered the gold supraspinatus muscle tendon injuries. Codman was unable to standard for intra-articular LHB tendon injury diagnosis.14 prove biceps involvement in any of his cases. From the 50’s, Neviaser et al15 observed a close relationship between several authors considered biceps tendinitis an important LHB tendinopathy and rotator cuff injuries on arthrography cause of shoulder pain, and treated it with tenodesis.2,7 In and intraoperative observation of macroscopic changes. 1950 DePalma7 described degenerative tendon changes and The present study aimed to evaluate the clinical, radiologi- their conservative and surgical treatment. In 2015, Godinho et cal, and arthroscopic correlation of the LHB tendon lesions al8 described a new surgical technique for LHB tenodesis. associated with rotator cuff injuries and their relationshipwith The LHB tendon is 9 cm long,9 and it is divided into an intra- referred shoulder pain. articular and an extra-articular portion; the extra-articular fi portion is brocartilaginous and slides on the intertubercular Materials and Methods groove of the humerus. Such a division, however, is not 100% accurate. The humeral head moves as on a rail to the tendon, A total of 56 patients were evaluated and operated on by a whereas the tendon does not move in relation to the bicipital surgeon from the Shoulder and Elbow Group, Discipline of Rev Bras Ortop Vol. 55 No. 3/2020 Supraspinatus Muscle Tendon Lesion Carvalho et al. 331 Sports Medicine, Orthopedics and Traumatology Depart- The associations between pain and the physical tests, the ment, Universidade Federal de São Paulo, São Paulo, Brazil, MRI and the intraoperative findings were assessed by simple from April to December 2013. In total, 6 patients were logistic regression models. excluded from the initial sample of 56 subjects. Among the The analyses were performed using the Statistical Package excluded patients, two had incomplete MRI data, three had for the Social Sciences (SPSS, SPSS, Inc., Chicago, IL, US) no intraoperative LHB tendon lesion, and one subject did not software, version 18, adopting a significance level of 5%. agree to sign the informed consent form (ICF). Of the The agreement and disagreement between LHB tendon remaining 50 patients, 38 (76%) were female and 12 (24%) injuries at the physical examination, MRI scans and arthros- were male, with a mean age of 65.1 years. copy, specifically high-grade partial LHB lesion and SLAP The inclusion criteria were patients with anterior shoul- lesion, were evaluated using the McNemar nonparametric der pain submitted to rotator cuff injury repair and with test, adopting a 5% significance level. clinical, radiological and/or arthroscopic evidence of LHB tendon involvement. Results The exclusion criteria were patients who underwent rotator cuff lesion repair with no indication of tenotomy The final sample consisted of 50 symptomatic patients due to the lack of symptoms related to LHB lesion or absence who underwent rotator cuff lesion repair with symptoms of injury at the time of the arthroscopy, as well as patients and/or magnetic resonance imaging indicating LHB tendon with no rotator cuff lesion associated with LHB injury. involvement. The patients were questioned and examined by specialists Symptom duration ranged from 2 to 240 months, and half from the Brazilian Society of Shoulder and Elbow Surgery of the patients had symptoms for at least 12 months. The (Sociedade Brasileira de Cirurgia do Ombro e Cotovelo, right shoulder was affected in 70% of the subjects, and the SBCOC). The MRI scans were performed using the Achieva affected limb was the dominant one for 72% of the patients. 1.5T (Philips, Amsterdam, Netherlands) scanner, and they At the physical examination, half of the patients had up to were evaluated by two experienced surgeons, who were also 160° (Q1 ¼ 140° and Q3 ¼ 180°) of active flexion range and up SBCOC members, according to the same criteria specified in to 180° (Q1 ¼ 170° and Q3 ¼ 180°) of passive range.
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