Although the function of the long head of the biceps (LHB) has been long debated, its ability to generate pain in the shoulder generates little controversy. Proximal LHB pathology is varied and may include inflammatory and degenerative tendonitis, chronic tendinopathy, partial tearing, acute rupture, subluxation, and dislocation. This chapter focuses on identifying biceps pathology and selecting the proper treatment and reviews current surgical techniques.
Disease of the proximal biceps tendon presents diagnostic challenges because of the close proximity of associated structures within the glenohumeral joint. Concomitant pathologic conditions such as rotator cuff disease, glenohumeral impingement, and lesions of the labrum are common and can obscure the diagnostic differential.
A patient with disease of the proximal biceps tendon typically presents with a history of shoulder and arm pain that may be worse at night or with overhead lifting. A definite inciting event may have occurred, such as lifting a heavy object with the arms bent 90 degrees. Ruptures usually result from a significant eccentric force to a flexed arm, and the patient will often describe an audible “pop,” swelling of the arm, and ecchymosis. A visible defect may or may not be apparent. Pain is typically in the anteromedial aspect of the shoulder near the bicipital groove and may radiate distally along the arm with overhead activities. Pain due to concomitant rotator cuff and subacromial space pathology is typically localized in the anterolateral shoulder region.
The diagnosis of biceps pathology can often be elusive because the clinical symptoms and physical examination findings tend to overlap with multiple other pathologies that affect the glenohumeral joint ( Table 51-1 ). When the patient has gross deformity with a distally translated biceps muscle belly, the so-called “Popeye sign,” the diagnosis of a ruptured LHB tendon (LHBT) is obvious. However, other biceps pathology can be more challenging to diagnose. In patients with rotator cuff tears, physical examination is even less reliable in detecting biceps tendon disorders. Most tests are extremely specific but not sensitive, indicating that these tests are better at ruling out biceps disease than detecting it. Perhaps the best physical finding is point tenderness elicited directly over the biceps tendon within the bicipital groove. The examiner palpates the anterior proximal humerus while rotating the proximal brachium in internal and external rotation until the sulcus between the greater and lesser tuberosities, the intertubercular groove, is palpated. Palpable tenderness should be compared with the contralateral side because even the normal biceps tendon is mildly tender to deep palpation. In the subpectoral LHB test, the biceps is palpated below the intertubercular groove by feeling under the pectoralis major for the LHB tendon just medially to the pectoralis insertion. The biceps is palpated while the patient internally rotates the arm against resistance. Greater tenderness palpated on the affected side is suggestive of proximal biceps pathology.
|LHBT||Biceps instability||LHBT within the groove||Full abduction, external rotation; palpate bicipital groove||Palpable “click”|
|Point tenderness||LHBT within the groove||Palpate the bicipital groove 3-6 cm below the acromion; internally rotate the arm 10 degrees||Reproducible pain; dynamic evaluation shows groove tenderness laterally as the arm is externally rotated|
|Speed||LHBT within the groove; SLAP||Elbow extended, forearm supinated, arm elevated to 90 degrees||Pain localized within the bicipital groove|
|Yergason||LHBT||With the elbow flexed and the forearm pronated, the examiner holds the arm at the wrist and the patient actively supinates against resistance||Bicipital groove pain|
|Gerber’s lift-off test||Subscapularis LHBT||The patient stands with his/her hand behind the back and the dorsum of the hand resting on the midlumbar spine; the patient attempts to raise his/her hand off the back by maintaining or increasing internal rotation of the humerus and extension of the shoulder||Inability to move the dorsum of the hand off the back|
|Concomitant RC||Belly press||Subscapularis||The hand is on the abdomen and attempts are made to move it anteriorly||Difficulty moving the elbow forward|
|Neer impingement||AC joint||The arm is maximally passively elevated forward, with internal rotation with the scapula stabilized||Pain/weakness in the subacromial space/edge of the acromion of the biceps region|
|Kennedy-Hawkins||Impingement of the greater tuberosity and CH ligament||The arm is forward-flexed 90 degrees, then quickly rotated internally||Pain/weakness in deltoid or anterior shoulder|
|Empty can||Supraspinatus||The arm is forward-flexed 90 degrees, with full internal rotation 90 degrees; downward force is resisted||Pain/weakness deep in the shoulder|
|Concomitant labrum||Compression rotation||Labrum||The patient lies supine; the affected arm is elevated 90 degrees and the arm is rotated while an axial load is applied||Pain or clicking deep in the shoulder|
|O’Brien’s active compression||AC joint superior labrum||The patient stands with the arm adducted 15 degrees and forward-flexed 90 degrees with the elbow fully extended; the arm is maximally internally rotated and elevated with the palm up and the thumb pointing down against resistance||Pain in the AC joint and pain or a deep “click” in the GH joint|
|Anterior slide||Labrum||The patient stands with a hand on the hip of the affected side while the examiner applies an axial load along the humerus||Pain or a “click” is produced|
Several other maneuvers have been classically described, but none individually has been shown to reliably correlate with LHBT pathology. The Speed test is positive when pain is elicited by resisted forward flexion with the arm in full supination, the shoulder at 90 degrees of flexion, and the elbow nearly fully extended. The Yergason test is positive when pain is elicited by palpation in the bicipital groove as the patient resists supination with the elbow flexed 90 degrees. The O’Brien active compression test may be positive in patients with biceps tendinitis, but it is also positive in persons with superior labral anterior to posterior (SLAP) tears and acromioclavicular (AC) arthropathy. The test is performed with the arm adducted with the elbow in full extension. Pain with resisted forward flexion with the arm in internal rotation suggests a SLAP tear, whereas pain with both external and internal rotation suggests AC pathology. These classic tests have been shown to be sensitive but not specific for biceps tendinitis, rupture, and SLAP tears. More recently, the upper cut test has been described ( Fig. 51-1 ). This maneuver simulates an “upper cut” punch in boxing. The shoulder is in neutral, the elbow is flexed 90 degrees, and the forearm is supinated. The patient is instructed to bring the fist up toward the chin against resistance. A positive test is elicited if the patient experiences shoulder pain or feels a pop anteriorly. Regression analysis has demonstrated that the combination of a positive Speed and upper cut test was significantly better at detecting biceps pathology than any single test alone. The available evidence suggests that the combination of the Speed test and the upper cut test is recommended for the clinical detection of biceps pathology.
Medial biceps tendon subluxations and dislocations occur when the biceps reflection pulley mechanism has been disrupted, which is frequently accompanied by a partial tear of the subscapularis tendon. A palpable click can be elicited when the arm is abducted at 90 degrees and is taken into external rotation. When fully dislocated, the biceps can be palpated medially, anterior to the lesser tuberosity, by rolling it under the examiner’s finger.
Selective injections are perhaps the best way to differentiate biceps pathology. A subacromial injection will mitigate the symptoms of impingement. If anterior pain persists, an injection within the bicipital groove may also be performed. Relief of the pain strongly suggests LHB pathology, and care should be directed accordingly. An intraarticular glenohumeral injection may be considered when a SLAP tear is suspected.
Imaging studies may be helpful in evaluating proximal biceps tendon pathology. Plain radiographs with three orthogonal views (anteroposterior, lateral, and axillary) should always be obtained first. Although no findings specific to the biceps tendon exist, plain radiographs can be used to rule out other potential bony or degenerative pathology. Patients with advanced glenohumeral arthritis will frequently report pain that is deep and anterior in the region of the biceps tendon. Additionally, the Fisk view may be helpful in visualizing bicipital groove pathology such as osteophytes and narrowing. When magnetic resonance imaging (MRI) is contraindicated, a plain arthrogram or computed tomography (CT) arthrogram may be useful. A sharp, well-demarcated shadow of the biceps tendon rules out significant biceps inflammation. However, a false-negative arthrogram may be seen in up to 30% of cases.
MRI is extremely helpful in visualizing the biceps tendon and concomitant pathology. The biceps is best visualized on the axial and sagittal oblique views. Although complete ruptures and dislocations are readily apparent ( Fig. 51-2 ), more subtle biceps pathology such as partial-thickness tears, tendinitis, and tendinopathy is more difficult to assess. MRI for these disorders is neither accurate nor precise. MRI shown poor correlation with arthroscopic findings in the detection of biceps pathology and poor to moderate sensitivity for inflammation, partial-thickness tear, and even rupture. The addition of intraarticular contrast material—MR arthrography—enhances the sensitivity and specificity of diagnosing biceps pathology and aids in the diagnosis of associated pathology, including SLAP tears and rotator cuff tears. On MR arthrography, the biceps tendon is normally surrounded by contrast material and is shaped like a kidney bean on axial views. Partial-thickness tears, longitudinal tears, and even hourglass deformities may be detected.
With the advent of less expensive ultrasound equipment, interest in the use of in-office ultrasound technology to diagnosis musculoskeletal pathology has exploded ( Fig. 51-3, A and B ). Although it is highly operator dependent, ultrasound offers a low-cost alternative in the diagnosis of shoulder pathology. This modality has the added benefit of providing a dynamic assessment of the pathology. It is highly accurate in the diagnosis of full-thickness rotator cuff tears and biceps complete tears, subluxations, and dislocations ( Fig. 51-3, C ). It is less accurate in diagnosing partial-thickness tears of the biceps tendon. Ultrasonography is extremely useful and enhances accuracy when performing selective injections involving the shoulder, particularly injections in the bicipital sheath.
Patient factors such as age, activity level, body habitus, occupation, sporting activities, and comorbidities should be considered when determining the appropriate treatment for disorders of the proximal biceps. Overlapping pathology of the rotator cuff, AC joint, superior labrum, and anterior capsule creates challenges in evaluating proximal biceps disorders. Identifying pathologic contributors to pain and dysfunction of concomitant shoulder pathology such as rotator cuff tears and SLAP lesions is the key to a successful outcome.
Biceps tenodesis can be performed arthroscopically, with an open procedure, or with a mini open procedure. The tendon can be fixated via a soft tissue approach or a bone-tendon interface. The location of the tenodesis should be customized based on concomitant pathology, the patient’s occupation, and the condition of the intubercular tendon.
The area of greatest controversy is the optimal location to perform the tenodesis—either above the groove, within and below the groove/suprapectorally, or through a subpectoral approach ( Fig. 51-4 ).
Nonoperative treatment for tendinopathy has been the preferred approach for management of proximal biceps pathology. Primary and secondary biceps tendinitis is initially treated with rest, activity modifications, physical therapy, and nonsteroidal antiinflammatory drugs. Steroid injections within the bicipital sheath can provide effective pain relief. Ultrasound-guided injections ( Fig. 51-5 ) improve both diagnostic and therapeutic accuracy, ensuring accurate placement of the injection within the bicipital sheath. Treatment of proximal biceps disease with use of physical therapy that focuses on the underlying pathology of the rotator cuff and labrum, anterior instability, and impingement should be considered.
Effective surgical options are available for the management of biceps disease. Debridement and/or decompression may be appropriate for treatment of mild tendon fraying or a partial tear (<50%) in a sedentary older patient. A biceps tenotomy also may be considered in older patients who do not perform manual labor and for whom cosmesis (e.g., Popeye deformity) is not a concern. A biceps tenotomy is also ideal when longer rehabilitation times are not desired, and it has been successfully performed in National Football League players seeking a quick return to sport. Tenotomy has the advantages of being technically easy to perform with no need for immobilization. Reported disadvantages include a cosmetic deformity (i.e., the Popeye sign) caused by distalization of the muscle belly, fatigue with resisted elbow flexion and supination, and muscle belly cramping. The Popeye sign has been reported to occur in up to 70% of patients, fatigue has been reported in up to 38% of younger patients, and muscle belly cramping has been reported in 8% of patients.
Tenodesis is typically performed in younger, more active patients for whom nonoperative treatment has failed. The most common indications include degenerative partial-thickness tearing that is greater than 25% of the diameter of the biceps in younger, active patients, medial subluxation or dislocation of the LHBT due to an incompetent medial sling, and an hourglass biceps tendon deformity. The hourglass deformity occurs when hypertrophy and entrapment of the LHBT occurs within the bicipital sheath akin to the thickening and entrapment of the flexor tendon seen with trigger fingers. Biceps tenodesis is rarely indicated in cases of an acute complete rupture and is generally only performed in power lifters or those who are overly concerned about cosmesis. Often, a biceps tenodesis is performed when other concurrent shoulder pathology is present, such as full or partial rotator cuff tears of the supraspinatus and subscapularis tendons, type II or IV SLAP lesions, and instability of the coracohumeral and superior glenohumeral ligaments. Contraindications include medically unfit patients, the presence of active infection, and true pseudoparalysis.
Biceps tenodesis prevents muscle atrophy and preserves the contour of the biceps, avoiding a cosmetic deformity (i.e., a Popeye deformity). It does not require a protracted period of postoperative immobilization or a significantly prolonged period of rehabilitation. Shoulder strength and function are preserved, especially during supination and elbow flexion. Fatigue, muscle spasms, and cramping in the anterior aspect of the arm have been reported to be lower in patients undergoing tenodesis versus tenotomy. Furthermore, the muscle length-tension relationship of the LHBT is preserved, and tenodesis prevents migration of the distal biceps when it is tenotomised. Disadvantages of tenodesis compared with tenotomy are that it is a more technically challenging operation, it requires a longer period of rehabilitation, it requires an immobilization period, the potential exists for increased fracture risk from stress risers in the proximal humerus, and fixation failure is a possibility.
Setup, Diagnostic Arthroscopy, and Tendon Preparation
The patient is placed in the beach chair or lateral decubitus position, depending on surgeon’s preference. In the beach chair position, the shoulder is placed at 30 degrees to 60 degrees of flexion, 30 degrees of abduction, and 20 degrees to 30 degrees of internal rotation, with the elbow resting on a padded Mayo stand. In the lateral decubitus position, the operative extremity is placed into a foam sleeve with 10 degrees forward flexion and 30 degrees to 45 degrees abduction and is attached to a traction tower that allows external and internal rotation of the shoulder.
Diagnostic arthroscopy is performed to examine the biceps, the pulley system, and associated structures. A standard posterior glenohumeral viewing portal is created, along with an anterior portal 2 cm inferior and 2 cm medial to the anterolateral corner of the acromion. The biceps tendon is evaluated with no inflow, because the presence of fluid may result in compression of vessels by the intraarticular pressure of the fluid and decrease the actual appearance of the inflamed synovium. Traction (5 to 10 lb) is placed on the glenohumeral joint to pull the groove portion of the LHBT intraarticularly. A 30-degree arthroscope is inserted through the posterior portal and a probe or other atraumatic instrument can be placed through the anterior portal to pull the biceps tendon further into the joint. Burkhart (personal communication) found that in a small series of 10 patients, the uppermost 23 mm of the bicipital groove could be visualized using an arthroscope through the posterior portal. A recent anatomic study performed by Denard and colleagues showed an average groove length of 25 mm. Forward elevation of the arm and elbow flexion can also provide further excursion of the biceps tendon. Alternatively, an arthroscope can be used to visualize and evaluate the bicipital groove without pulling the biceps into the joint.
Intraarticularly, the LHBT is evaluated for the degree of degeneration, partial tearing, instability, and tenosynovitis. Upon exiting the joint, the LHB immediately enters the bicipital groove, which is about 6 mm wide and 30 mm long and is covered by the transverse humeral ligament. The falciform ligament may cover the inferior part of the bicipital groove and is attached to the pectoralis major tendon. Additionally, the coracohumeral ligament and the leading edge of the supraspinatus and subscapularis are evaluated for pathology.
To ensure adequate visualization within the subacromial space, a subacromial bursectomy is performed using the posterior viewing portal; the anterior and lateral subacromial space gutters are cleared with a motorized shaver. The shaver should be positioned so the opening faces the acromion. Suction is used intermittently, and electrocautery is used to coagulate bleeders. For arthroscopic approaches to the tendon, the camera should be transitioned to the lateral portal and the shaver is used from the anterior portal to clear the anterior and lateral gutters. As long as the surgeon stays lateral to the conjoint tendon, the area is devoid of neurovascular structures and can be safely debrided. The bursectomy and debridement should be carried distally to the top of the pectoralis insertion, and the long head can be easily located by following the lateral border of the conjoint tendon downward until it merges with the long head tendon.
An anterosuperolateral portal is made 2 to 3 cm anterior and lateral to the anterolateral corner of the acromion and a 8.25 Gemini Self-Retaining Cannula (Arthrex, Inc., Naples, FL) is inserted perpendicular to the bicipital groove just as the tendon exits the groove. One or two half-racking traction tag stitches (No. 2 FiberWire; Arthrex) are placed through the LHBT using a Penetrator (Arthrex) or Scorpion (Arthrex) ( Fig. 51-6, A and B ). The traction sutures are brought out through the anterior portal ( Fig. 51-6, C ). The LHBT is then released at its origin on the superior labrum and pulled into the anterior portal ( Fig. 51-6, D and E ). The residual tenotomized stump, if any, and superior labrum are then debrided to obtain a smooth appearance of the labrum.
Above the Groove
Biceps tenodesis may be performed above the bicipital groove or at the top of the groove (see Fig. 51-6 ). The ideal indication is intraarticular biceps disease with minimal to no pathology distally, within the intertubercular groove, and a concomitant tear of the rotator cuff. This presentation gives the surgeon easy access to the tendon and a good view of the groove. Some authors recommend incorporating the tenodesis into the anterior medial anchor, whereas others recommend securing the biceps independently. This technique has generated considerable controversy, because the intertubercular biceps has been shown to be a pain generator, and a tenodesis in this location opens up the possibility of failure as a result of chronic pain from the residual tendon within the groove. Some authors believe that removal of the majority of the tendon and its associated tenosynovium is important to avoid persistent postoperative anterior shoulder pain, whereas other investigators have found no increase in residual anterior shoulder pain with this technique. Because the LHB no longer spans the glenohumeral joint, little to no movement of the tendon occurs within the groove. The absence of contractile and elastic elements avoids excursion over bicipital groove osteophytes or overuse tenosynovitis and thus eliminates presurgical pain.
An 18-gauge spinal needle is used to determine the appropriate bone socket position and angle of approach. A 2.4-mm guide wire is inserted through the cannula, followed by a cannulated headed reamer that is used to drill the bone socket to the appropriate size of the biceps tendon (typically 8 to 9 mm) with a depth of 25 mm to implant the 23-mm screw. A Bio-Tenodesis cannulated screwdriver (Arthrex) that is 1 mm smaller than the reamed hole is then loaded on the Bio-Tenodesis driver. The sutures are pulled to advance the biceps tendon either directly through the Bio-Tenodesis driver or through a No. 2 FiberWire loop suture that is fed through the end of the driver. Alternatively, suture anchors or SwiveLock anchors (Arthrex) can be used to fix the tendon in this location ( Fig. 51-7 ).