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Painful Proximal Biceps Tendon
Tenosynovitis to Rupture
Biceps tendon tenosynovitis is a very common diagnosis; prior to 1972 it was the most common diagnosis for a painful shoulder. With Dr. Neer’s description of the impingement syndrome, biceps tenosynovitis is now almost universally considered a secondary issue. Treatment traditionally has been aimed at the source of the irritant rather than the biceps tendon itself. The tenosynovitis was expected to resolve on its own. A hint that this was not always successful was implicit in the article entitled: “The 4 in 1 Arthroplasty for the Painful Arc Syndrome” written by the Neviasers in 1982. The 4 in 1 procedure included a biceps tenodesis in all cases. This approach declined in popularity following the development of the arthroscopic subacromial decompression (ASAD) by Dr. Harvard Ellman. While utilizing Ellman’s approach, the authors have noticed that some of their patients had persistent anterior shoulder pain, which seemed to be biceps tenosynovitis. This provoked us to develop a prospective study to devise a logical approach for the treatment of biceps tenosynovitis as part of the impingement syndrome.
Bicipital pain is secondary to a wide spectrum of pathology that a surgeon must understand and appropriately address as outlined in the following algorithm. While the authors recognize this broad spectrum of causes, our chapter specifically addresses biceps tenosynovitis as a stand-alone problem or in conjunction with other shoulder disorders.
The author’s treatment plan was developed through a prospective study, which is described briefly. Every painful shoulder over a 1-year period that presented with impingement symptoms and rotator cuff complaints was carefully assessed to see whether not the biceps tendon was part of the overall complaint. Upon arthroscopy, the surgeon focused on whether there was bicipital pathology on the intraarticular and extraarticular portion of the tendon. Specifically, we noted any tenosynovitis and/or structural changes in the biceps tendon. In all cases an ASAD was performed along with an extraarticular subdeltoid biceps tendon release. This included a release of the transverse humeral ligament and a synovectomy as if it were a deQuervain’s tenosynovitis. As a result of this study, we have come to the following conclusions: (1) if the tendon is normal but inflamed, it will respond predictably to an ASAD and a deQuervain’s type approach; (2) if the tendon shows intrinsic damage, such as partial rupture, only a tenotomy or tenodesis will resolve the biceps pain; and (3) biceps tenosynovitis in the face of instability or a superior labrum anterior and posterior (SLAP) lesion requires treatment of the primary problem as well as the deQuervain’s release.
Implementing the results from this study has led the authors to adjust their treatment of the painful biceps tendon to the following logical approach when biceps tenosynovitis is identified as part of the impingement process:
1. If the clinical diagnosis of biceps tneosynovitis is made preoperatively and the tendon has a normal structure arthroscopically, the tendon is released in a deQuervain’s fashion following the ASAD.
2. If the clinical diagnosis of biceps tenosynovitis is made preoperatively and the tendon of the biceps shows signs of rupture either intraarticularly or in the groove, a tenodesis or tenotomy is performed.
Indications
1. Localized pain in the bicipital groove
2. Tenosynovitis of the biceps tendon identified arthroscopically
3. No structural damage to the biceps tendon in the joint or bicipital groove
Contraindications
1. Unstable biceps.
2. Acute or chronic biceps tendon rupture.
3. A relative contraindication is a significant tear in the subscapularis muscle, which may contribute to instability of the biceps tendon.
Mechanisms of Injury
1. The insidious onset of biceps-type pain that is mildly progressive and is associated with secondary pathology from impingement and or rotator cuff pathology
2. Isolated avulsion of the biceps secondary to traction injury to the shoulder
Physical Examination
1. Asymmetrical pain over the bicipital groove when compared to the contralateral side. Must have this finding!
2. Often a positive impingement test.
3. Increased pain with Yergenson, Speeds, and or O’Brien tests.
Diagnostic Tests
1. Standard radiographs (bicipital groove view not helpful).
2. Differential injections.
a. Subacromial bursa; pain in the bicipital groove persists
b. Bicipital groove; pain resolves
3. Magnetic resonance imaging may show tenosynovial proliferation and/or fluid accumulation around the biceps tendon as well as associated pathology such as: subluxed/dislocated biceps tendon, tear in the rotator cuff especially the subscapularis, and labral damage.
4. This is a clinical diagnosis. The diagnostic tests support the clinical opinion, but do not make the diagnosis.
Special Considerations
1. If tenotomy is to be a consideration, it is critical to warn the patient preoperatively of a possible “Popeye” deformity of the biceps tendon.
2. Biceps stability. Understanding the anatomy of the biceps tendon is essential to our treatment plan. The biceps tendon arises from the supraglenoid tubercle at approximately the 12 o’clock position on the glenoid. The intraarticular structure is extrasynovial and passes through the rotator interval to the bicipital groove. An intact coracohumeral ligament, which is the roof of the rotator interval, is the primary stabilizer of the biceps as it blends into the insertion of both the subscapularis and supraspinatus at the level of the tuberosities. The transverse humeral ligament, which forms the roof of the bicipital groove between the tuberosities, does not play an important role in stabilizing the biceps tendon. Distally, the biceps tendon is stabilized by the split insertion of the sternal head of the pectoralis major as it inserts into both sides of the bicipital groove.
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