Disorders of the Long Head of the Biceps

Christopher S. Ahmad MD

History of the Technique

Surgical treatment options for long head of biceps tendon disorders have included debridement, tenotomy, and tenodesis. Gilcreest¹ in 1936 described surgical management of a ruptured proximal biceps tendon with suturing the stump of the tendon to the coracoid process. Hichcock and Bechtol² described fixation of the tendon in the bicipital groove by creating an osteoperiosteal flap raised from the floor of the groove and securing the tendon deep to this flap with sutures. In 1960, Michele³ described keystone tenodesis, which placed the proximal biceps into a bony trough created in the bicipital groove followed by covering the trough with a bone block. Froimson⁴ in 1974 described keyhole tenodesis, which rolled the tendon into a ball and inserted it into a fashioned “keyhole” in the bicipital groove.

More recently, all arthroscopic biceps tenodesis techniques have been described and especially advocated when concomitant rotator cuff pathology or AC joint pathology are being addressed arthroscopically. Gartsman and Hammerman⁵ described an arthroscopic biceps tenodesis technique employing suture anchors. Boileau et al.⁶ presented a technique using interference screw fixation with a guide pin drilled through the humerus to tension the biceps within a bony tunnel. Klepps et al.⁷ described a technique using interference screw fixation with tensioning of the biceps delivered into a bony tunnel using suture anchors.

An alternative approach to tenodesis that is becoming more popular is simple tenotomy of the biceps tendon. Significant controversy exists regarding both options of tenotomy versus tenodesis for treatment of painful biceps disorders.⁴^,⁸^,⁹^,¹⁰^,¹¹ Biceps tenodesis has suggested advantages over tenotomy that include maintenance of the length tension relationship, prevention of muscle atrophy, improvement of elbow flexion and supination strength, avoidance of cramping pain, and avoidance of cosmetic deformity.¹² Gill et al.,¹³ however, reported that simple biceps tenotomy for the treatment of bicipital pathology results in significant reduction in pain and improvement in function. Osbahr et al.¹⁴ evaluated intra-articular biceps tenotomy versus tenodesis. In the majority of patients, cosmetic appearance, the grade of muscle spasms, and the level of anterior shoulder pain were not different for either tenotomy or tenodesis.

Anatomy

The long head of the biceps originates from both the supraglenoid tubercle and the glenoid labrum with variation in the amount of tendon directly attached to glenoid and the amount attached to labrum.¹⁵^,¹⁶ The 9-cm long tendon changes its geometry during its course. A recent study showed that the proximal cross-sectional area was 22.7 mm² and the distal was 10.8 mm².¹⁷ The tendon is flatter and horizontal while on top of the humeral head and then becomes more triangular as it courses inferior into the bicipital groove. Once out of the groove, the tendon continues down the anterior aspect of the humerus and becomes musculotendinous near the insertion of the deltoid and pectoralis major tendons. The bicipital portion of the tendon is intra-articular but extra synovial with a synovial sheath that reflects upon itself and encases the tendon. Arm position dictates how much intra-articular tendon is present with the maximum intra-articular tendon in arm adduction and extension, while the minimum is in arm abduction.

Soft tissues stabilize the long head of the biceps within the bicipital groove. At the entrance to the groove, the rotator interval and confluence of soft tissue of the supraspinatus and subscapularis bridge the lesser and greater tuberosities. The coracohumeral ligament has bands that insert into the
subscapularis, transverse humeral ligament, and the lesser tuberosity, thereby creating a roof overlying the biceps tendon. The superior glenohumeral ligament forms the floor of the rotator interval and creates a pulley that acts as a circular sleeve guiding the long head of biceps into the bicipital groove. The transverse humeral ligament and the falciform ligament from the sternocostal portion of pectoralis major stabilize the tendon within the bicipital groove.

The function of the long head of the biceps remains controversial. Biomechanical studies indicate that the biceps contributes to stability of the glenohumeral joint.¹⁸^,¹⁹^,²⁰ Itoi et al.¹⁸ reported decreased anterior and posterior displacement as well as decreased external rotation of the humeral head with loading of the biceps tendon. Similarly, Rodosky et al.²⁰ simulated contractions of the biceps muscle and observed increased torsional stability of the glenohumeral joint. Other studies have suggested that the long head of the biceps functions more with elbow activity and less with shoulder activity.²¹^,²²

Pathology

Although the function of the long head of the biceps tendon in the shoulder remains controversial, there is less doubt that the biceps tendon can be a significant source of pain.²^,²³^,²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰ Biceps disorders have been classified as either biceps instability or biceps tendonitis.³¹ Tendonitis is more commonly associated with other shoulder disorders such as rotator cuff disease. Because of the intimate association of the biceps tendon with the rotator cuff, the principal cause of biceps degeneration is attributed to mechanical impingement of the tendon against the coracoacromial arch, similar to rotator cuff impingement.³²^,³³^,³⁴^,³⁵ The tendon is either atrophic from the degenerative process or hypertrophic in response to the chronic inflammation from the impingement.²² Synovitis of the biceps tendon most often occurs in the segment within the bicipital groove.³⁶ Primary bicipital tendonitis is less usual and requires exclusion of rotator cuff pathology for the diagnosis.

Subluxation of the long head of the biceps is most commonly associated with loss of soft tissue restraints from rotator cuff tears.²³^,³⁷^,³⁸^,³⁹^,⁴⁰ In the presence of a subscapularis tear, the tendon can sublux medial and deep to the subscapularis. A frank dislocation of the long head of the biceps is nearly always associated with a subscapularis tear.³¹

Rupture of the long head of the biceps tendon typically occurs in the setting of a diseased tendon and a previous history of subacromial impingement. Alternatively, more acute trauma, involving either a powerful supination force or a fall on the outstretched arm, can cause proximal biceps rupture. With partial tearing of the biceps tendon, significant pain and dysfunction is common. In contrast, full thickness traumatic ruptures of the biceps tendon are generally less symptomatic following the acute event.³⁹^,⁴¹ Spontaneous or traumatic ruptures of the long head of the biceps generally do not require surgical intervention.

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