The long head of the biceps tendon (LHBT) runs a unique anatomic course through the anterior shoulder, ascending proximally through the intertubercular groove before turning 30° medially and posteriorly, where a “pulley” composed of the coracohumeral ligament, the superior glenohumeral ligament, the supraspinatus tendon, and the subscapularis tendon supports the LHBT. The LHBT then travels intra-articularly but extrasynovially through the glenohumeral joint and inserts onto the supraglenoid tubercle and/or superior labrum.² LHBT pathology can occur at several locations through its anatomic course: in the intertubercular groove, within the glenohumeral joint, and at its attachment site. These regions of pathology have recently been divided into three zones (inside, junction, and bicipital tunnel).¹ The inside zone includes the superior labrum and the biceps anchor where labral tears and dynamic LHBT incarceration can exist. The junction includes the intra-articular portion of the LHBT and its stabilizing pulley where LHBT partial tears, LHBT subluxation, and biceps chondromalacia are often seen. The bicipital tunnel includes the extra-articular portion of the LHBT, beginning at the articular margin and continuing through the subpectoral region and the fibro-osseous confinement of the LHBT (now known as the bicipital tunnel). This area is often affected by extra-articular bicipital tunnel scar/stenosis, loose bodies, LHBT instability, and LHBT partial tears.

Depending on the location, the etiology of this tendinopathy may be osteophytes within the intertubercular groove, microtrauma from repetitive overhead activities, acromial morphology, internal impingement, ischemia, tendon instability, or trauma.³ Tendinitis and tendinosis commonly occur in association with subacromial impingement, rotator cuff pathology, tears of the anterior capsuloligamentous complex, labral tears, glenohumeral instability, and acromioclavicular arthrosis.² Acutely, the tendon may be swollen and hemorrhagic, but with chronic friction and traction the tendon can become thinned, frayed, and atrophied, which can lead to tendon rupture, commonly with subsequent pain relief. The functional consequences of this rupture are unclear. The importance of the LHBT in shoulder function has been debated in the literature, with some authors arguing that contraction of the LHBT plays no role in shoulder motion or stability and others arguing that the LHBT acts as an important humeral head depressor.³

The LHBT is among the primary pain-generating structures of the anterior shoulder. Because LHBT tendinosis rarely occurs in isolation, however, determining whether a patient’s pain is due in part to LHBT pathology can be challenging. The history should elicit a full description of the location of the pain, the shoulder positions and movements that exacerbate this pain (eg, typically overhand or underhand throwing, lifting, or extending the arm behind the patient when placing on a seat belt), and the patient’s occupation and sporting activities. Patients may or may not give a history of a specific traumatic event.⁴ Classically, LHBT pain begins in the anterior shoulder and radiates distally into the biceps muscle belly. Snapping, grinding, or popping symptoms may be described. Physical examination should include a standard shoulder evaluation, including inspection, palpation, and range of motion; a complete neurovascular examination; and a battery of provocative maneuvers to test for subacromial impingement, rotator cuff tears, instability, and acromioclavicular
pathology. Unfortunately, physical examination maneuvers (O’Brien’s test, Speed test, Yergason test) are often unreliable in diagnosing biceps pathology as there is crossover with other pathologies. The “three pack” of biceps tunnel tenderness, positive O’Brien’s test, and positive throwing test has been reported to have excellent increase interrater reliability, sensitivity, and negative predictive value in the diagnosis of biceps tendon pathology.⁵ Of these, tenderness to palpation in the bicipital groove under the pectoralis is the most sensitive.