The Unstable and Painful Long Head of the Biceps

Fig. 24.1

Left shoulder. Arthroscopic view from the posterior portal. Biceps Pulley. Subs subscapularis, MCHL medial branch of the coracohumeral ligament. LCHL lateral branch of the coracohumeral ligament, SGHL superior glenohumeral ligament

Fig. 24.2

Right shoulder. Specimen dissection. C coracoid, CHL coracohumeral ligament, arising from the coracoid base, LT lesser tuberosity, GT greater tuberosity, BT biceps tendon. (Pau Golano picture with permission)

Fig. 24.3

Left shoulder. Arthroscopic view from the posterior portal. MCHL medial coracohumeral ligament, Subs subscapularis. The MCHL constitutes part to the Comma Tissue in cases of SUBS ruptures

The arthroscopic evaluation of the involved anatomic structures is very important. Coraco-humeral ligament, subscapularis and supraspinatus attachments close to the biceps groove need to be assessed during the diagnostic arthroscopy. The patient’s arm need to be placed in 80 degrees of forward flexion and mild external rotation in order to obtain the best view of these structures from the posterior portal.

The roof of the pulley is reinforced by subscapularis and supraspinatus tendon expansions. Therefore, we may consider the subscapularis fiber insertions not only at the lesser tuberosity but at the greater as well. The supraspinatus fibers contribute in less proportion to the pulley’s lateral wall and roof. The clinical implications of these anatomic findings are that when we repair a supraspinatus cuff tear, we should try to fix it at the edge of the bicipital groove. Non anatomic SSP repairs may lead to lateral biceps tendon instability and postoperative symptoms. (Fig. 24.4).

Fig. 24.4

Right shoulder. Arthroscopic view from the posterior portal. Pulley’s lateral wall. SSP Supraspinatus, HH Humeral Head

Base on these anatomic features, the medial sling (MCHL and Subscapularis) and the lateral sling (LCHL and Supraspinatus) need to be repaired at their natural footprint at the edge of the bicipital groove in order to recover biceps tendon stability.

These structures should be evaluated not only with a static view but also with dynamic maneuvers during the arthroscopic procedure.

For lateral stability, the greater tuberosity’s bony shape and the LCHL are the main structures to assess.

The transverse ligament and a well-vascularized tendon sheath are the main restraints of the lower pulley (Fig. 24.5). The subscapularis and the lesser tuberosity are other contributors.

Fig. 24.5

Right Shoulder. Specimen dissection. Lower pulley restraints. GT Greater tuberosity. LT Lesser tuberosity. Transverse ligament. Biceps pulley vascularity comes from the ascending branch of the anterior circumflex artery. (Pau Golano’s picture with permission)

It is very important to get used to seeing the biceps pulley anatomy in every case of shoulder arthroscopy. In this way, small changes of the normal anatomy can be identified (Fig. 24.6).

Fig. 24.6

Left Shoulder. Arthroscopic view from the posterior portal. Arthroscopic biceps pulley anatomy. BT biceps tendon, MCHL medial coraco-humeral ligament, LCHL lateral coraco-humeral ligament, PR pulley’s roof

Motley described the Ramp Test to evaluate biceps tendon stability and part of the extra-articular portion of the biceps tendon. With a nerve hook, pulling from the tendon downward, we assess the tendon quality and stability (Fig. 24.7).