While debate exists about whether pathology of the LHBT is a primary disease process ² or is secondary to concurrent disease processes such as impingement or subscapularis dysfunction,^1,3 the end result is a painful shoulder that can be a persistent cause of disability for patients who are often young and active. Treatment methods devised for the surgical management of biceps pathology and include tenotomy,^4–6 tenodesis,^7–9 and tendon relocation with reconstruction of the biceps pulley.¹⁰

Multiple surgical procedures have been described to address the pathology associated with the LHBT. Although the pathologic tendon was commonly debrided or treated with tenotomy in the past, tenodesis has become a more common method of treatment. Currently, there is no clear consensus as to whether tenotomy or tenodesis is superior ⁴; biomechanical^2,3,5,11,12 and clinical^8,13,14 studies have shown both procedures to be effective. Tenodesis is more commonly being performed over tenotomy for several reasons, including improved cosmetic appearance, maintenance of elbow flexion and supination strength, and maintenance of the biceps muscle length-tension relationship.⁹

The course of the LHBT is unique, and the path taken by the tendon can contribute to pathologic conditions that result in a painful shoulder. The tendon is intra-articular, but transitions to an extrasynovial portion that averages 9 cm in length and 5 to 6 cm in diameter. The tendon originates from the superior glenoid tubercle and the superior labrum,¹² which is known as the biceps anchor. From this starting position the tendon exits the glenohumeral joint by passing through the rotator interval descending into the intertubercular groove. The “bicipital groove” has been reported to be variable in its dimensions, with an average depth of 4.3 mm.¹⁵ This variation has been reported to be a factor in biceps instability and other pathologic conditions including tendinopathy of the LHBT.^15,16 The LHBT is contained between the greater and lesser tuberosities by a sling of tissue composed of fibers from the anterior rotator cuff (supraspinatus and subscapularis), the coracohumeral ligament, and the superior glenohumeral ligament (SGHL).¹¹ The SGHL, which arises from the supraglenoid and the base of the coracoid, travels within the rotator interval, forming a semicircular sling anteriorly for the lateral part of the intra-articular LHBT before attaching at the lesser tuberosity of the proximal humerus.¹⁷ Pain localized to the bicipital groove can be a cause of failure for those patients undergoing a proximal biceps tenodesis or tenotomy when adhesions are present.

Both arthroscopic and open techniques can be used for tenodesis. Fixation methods include interference screws, suture anchors, fixation to the coracoid process, or suture fixation to the rotator interval. Interference screw fixation has been shown to be a superior method in terms of biomechanical load to failure compared with suture anchor or soft tissue fixation. Some surgeons believe that failure to remove diseased tendon from the bicipital groove and retention of pain-generating synovial tissue in this confined space may be a cause of failure for some forms of tenodesis. Although both arthroscopic and open techniques will be discussed in this chapter, a mini-open subpectoral biceps tenodesis with a soft tissue interference screw is our preference.

Preoperative Considerations

History

• Pain is localized to the anterior aspect of the shoulder (in or near the location of the bicipital groove). This pain may or may not radiate to the biceps muscle belly distally

• Associated shoulder pathology may include rotator cuff disease, glenohumeral arthritis, subscapularis pathology, previous fracture, and superior labral pathology (superior labral anterior-posterior [SLAP] tears)

• Pain occurs with functions that require use of the biceps: forward shoulder elevation, active forearm supination, active elbow flexion.

Physical Examination

• Tenderness over the bicipital groove, which lies 7 cm distal to the acromion, is the most common finding in this patient population ¹⁴ and is seen to migrate laterally with external rotation and medially with internal rotation of the shoulder.

• Pain is elicited by tests specific for biceps pathology:

– Speed test: Pain elicited by resisted forward flexion.

– Yergason test: Result is considered positive if anterior shoulder pain is experienced with resisted forearm supination.¹³

• The biceps tendinosis test (BTT) described by Mazzocca and colleagues ⁹ is a test to diagnose pain from biceps pathology located in the subpectoral triangle. A two-part test, the BTT begins with examiner placing his or her index finger into the axilla underneath the pectoralis major tendon, allowing palpation of the biceps in this region. If the patient’s discomfort is reproduced and is asymmetrical to the contralateral (normal) side, a combination of local anesthetic and steroid is injected into the glenohumeral joint. The patient is then allowed to rest for 3 to 5 minutes, and the first part of the test is repeated. If a significant portion of the patient’s pain is relieved, the test result is considered positive; this is indicative of biceps pathology.