History

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.

Physical Examination

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.

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.

The upper-cut test. A, The patient makes a fist with the shoulder in a neutral position, 90 degrees of elbow flexion, and a supinated forearm. B, The examiner places his hand over the patient’s fist and resists during an upward upper-cut maneuver. Pain and/or a painful pop in the anterior shoulder indicates a positive test.

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

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.

Magnetic resonance imaging of a subluxed long head biceps tendon. Note the location of the tendon relative to the bicipital groove. BT, Biceps tendon; GT, greater tuberosity; LT, lesser tuberosity.

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.

Ultrasound images. A, An axial view of long head biceps tenosynovitis. B, An ultrasound longitudinal view of long head biceps tenosynovitis. C, An ultrasound axial view of a subluxed long head biceps tendon and subscapularis tear. BT, Biceps tendon; GT, greater tuberosity; LT, lesser tuberosity; SSc, subscapularis.

Decision-Making Principles

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 ).

Various tenodesis locations of the proximal long head biceps tendon.

Treatment Options

Nonoperative

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.

Ultrasound-guided injection approaches. A, Ultrasound probe position for the short-axis (“out of plane”) approach. The needle is then inserted in the skin directly beneath the midline and parallel to the long axis of the transducer. B, Ultrasound position for the long-axis (“in plane”) approach. The needle is then inserted in the skin directly beneath the midline and parallel to the long axis of the transducer.

Surgical Techniques

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.

Bursectomy

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.

Tenotomy

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 arthroscopic tenodesis procedure. A and B, A tag stitch through tendon. C, A tag stitch with tension applied through cannula. D and E, Tendon release. F, Tap to appropriate depth. G, Tendon localization. H, Tendon fixation.

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.

Tendon Localization

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 ).

Suture anchors or SwiveLock anchors (Arthrex, Inc., Naples, FL) can be used to fix the tendon.

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