The typical description of LHB pathology is progressive anterior shoulder pain associated with chronic overuse syndromes. In younger patients with suspected LHB pathology, participation in overhead sports is common. A single traumatic event is also possible, during which the patient may hear an audible pop. Additional shoulder pathology can raise suspicion for LHB tendon instability. For instance, a tear of the subscapularis tendon may lead to LHB instability due to its intimate association as part of the biceps pulley.

One indication of LHB pathology is point tenderness to palpation of the tendon within the bicipital groove. The tendon can be palpated in the rotator interval, at the transverse humeral ligament, and beneath the attachment of the pectoralis major tendon insertion. We believe palpation to be the most diagnostic physical exam finding of biceps pathology. Physical exam maneuvers that elicit LHB tendon pain include Speed’s test and Yergason’s test. A positive Speed’s test is indicated by pain with resisted forward flexion with the forearm extended and fully supinated. The Yergason test evokes pain with resisted forearm supination with the elbow flexed at 90 degrees and the arm adducted. These tests, however, may also be positive in SLAP tears, but in true SLAP lesions, there will be humeral head subluxation and a positive labral click, with the pain felt “deep,” while the biceps will be less deep, more painful, and usually without a labral click. The “3-Pack” exam, coined by O’Brien, incorporates bicipital groove palpation, the throwing test, and active compression test. With high inter-rater reliability and sensitivity, the “3-Pack” exam can isolate biceps-labral complex lesions specific to three different zones: inside, junctional, and bicipital groove (Taylor et al. 2016). If the patient has sustained a spontaneous rupture of the biceps tendon, a “Popeye” sign may be evident in which an enlarged distal biceps mass is visualized (Rudzki et al. 2015) (Figs. 20.3 and 20.4).

Differential Diagnosis for Long Head of the Biceps Tendon Pathology:

Further workup of suspected LHB tendon lesions may include imaging and injections. A standard radiographic series of the shoulder will assist in identifying other potential causes of shoulder pain. Magnetic resonance imaging (MRI) is frequently utilized in the assessment of shoulder pathology. Not only can MRI assist in diagnosis of isolated LHB tendon injuries, but it can also aid in diagnosing concomitant shoulder pathology. MRI allows assessment of the tendon itself and its milieu, including its sheath, peritendinous fluid, and the bicipital groove. Further, magnetic resonance arthrography may be useful in isolated LHB tendon injuries. Ultrasound is another imaging modality of use, in particular, due to the ability for a dynamic exam. The tendon can be visualized during a subluxation event and assessed for complete rupture. If a skilled ultrasonographer is available, ultrasound can be more cost-effective. Corticosteroid injections into the biceps tendon sheath can prove to be both diagnostic and therapeutic (Nho et al. 2010).

Non-operative management of LHB tendinopathy consists of rest, activity modifications, anti-inflammatory medications, and physical therapy. Corticosteroid injections, as mentioned above, can be administered in the subacromial space, glenohumeral joint, or directly into the tendon sheath. The glenohumeral injection may spread to the LHB tendon sheath based on their anatomic relationship (Nho et al. 2010). Hashiuchi et al. (2011) determined that LHB tendon sheath injections performed under ultrasound guidance were more accurate in their series of 30 biceps sheath injections evaluated with postinjection computed tomography. Care must be taken to inject corticosteroids into the bicipital groove and not the tendon substance, which may be detrimental to the tendon itself (Nho et al. 2010). Spontaneous complete ruptures of the LHB tendon are typically treated non-operatively with minimal consequence due to the “autotenodesis” phenomenon. Residual symptoms may include cosmetic concerns related to the “Popeye” deformity and a fatigue-related cramping of the biceps brachii muscle. The “autotenodesis” effect occurs due to the tendon’s soft tissue restraints keeping it in the bicipital groove and the hourglass shape of the groove creating a bottleneck for the wide portion of the tendon as it retracts distally (Rudzki et al. 2015).

When non-operative treatment fails, the discussion of surgical management is initiated and may relate to associated shoulder pathology. Isolated LHB tendinopathy surgical indications include partial-thickness tearing or fraying greater than 25–50% of the tendon diameter and persistent subluxation or dislocation. Other relative indications for surgical management of the LHB are SLAP tears and intraoperative findings suggestive of biceps pathology at the time of surgery for other pathologies (Khazzam et al. 2012). Factors to consider in surgical decision-making include the patient’s activity level, hand dominance, age, and functional expectations.

Current surgical management of the long head of the biceps tendon can be categorized as debridement, tenotomy, or tenodesis. Debridement is typically elected if less than 30% of the tendon diameter is involved (Khazzam et al. 2012). Arthroscopic tenotomy is performed utilizing the standard posterior viewing portal and working through the anterosuperior portal. Various instruments can be used to transect the tendon at its origin and the LHB tendon retracts into the bicipital groove. Some authors have described maintaining a wider portion of tendon to secure in the narrow portion of the groove or including a piece of labrum in the transection to prevent distal migration of the tendon through the bicipital groove (Rudzki et al. 2015) (Fig. 20.5). Goubier et al. (2014) described looping the free edge of biceps tendon about itself to provide substantial bicipital groove restraint. A neat tendon edge should be maintained to prevent subsequent mechanical symptoms.