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 ten- don, whereas the gliding undersur- face has been noted to be avascular. The biomechanical function of the LHB tendon is debated in the litera- ture, 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 stabi- lizer.17 It has even been said to have no role and has been