Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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A Patient’s Guide to the Biceps Tendon

Biceps Tendon

Biceps Tendon

Key Points

  • The long head of the biceps (LHB) originates at and around the supraglenoid tubercle. Although it is intra-articular, it is extrasynovial.
  • Although acute ruptures of the LHB do occur, LHB ruptures are more commonly the result of chronic biceps tendonitis.
  • There is such a close association between subacromial impingement and biceps tendonitis that the two conditions have closely overlapping symptoms. They can be difficult to distinguish and more often than not occur in tandem.
  • The hallmark of biceps tendon related pathology is point tenderness in the bicipital groove.
  • Given the close relationship between biceps tendon pathology and concomitant subacromial impingement and/or rotator cuff tear, it is important to examine the remainder of the shoulder. Specific tests for range of motion, impingement, rotator cuff integrity, and instability should be performed.
  • Ultrasound and arthrography are equally effective for the diagnosis of biceps tendon and rotator cuff problems, but ultrasound is superior when evaluating the biceps tendon.
  • Complications of the biceps tenotomy primarily involve the anticipated 21% risk of a “Popeye” deformity of the biceps muscle as it retracts distally. Arthroscopic biceps tenotomy is otherwise a relatively safe procedure with very minor risks of infection, blood clots, or neurovascular injury. Biceps tenodesis may be appropriate for younger, more active patients to maximize shoulder and elbow function.

The long head of the biceps (LHB) tendon … what does it do? What symptoms does it cause? What is the etiology of its pathology? What is the best treatment of biceps associated disorders? These are just a few of the questions concerning the biceps tendon for which opinions are abundant but firm conclusions are elusive. In our understanding of the shoulder, the LHB is still somewhat of an enigma. There are many beliefs and a plethora of data which provide much information but little clarity on the biceps tendon.

Basic Science

Anatomy

The anatomy of the LHB has been thoroughly examined and little controversy exists in this realm. The LHB originates at and around the supraglenoid tubercle. Although it is intra-articular, it is extrasynovial. Its blood supply is dependant on the portion of tendon in question. The proximal and middle portions receive blood supply from branches of the anterior humeral circumflex artery and the distal third of the tendon receives nourishment from branches of the deep brachial artery. The blood supply is markedly reduced in the portion of the tendon which slides in the bicipital groove.

The length of the tendinous portion of the LHB measures approximately 9 cm and the musculotendinous junction is at the level of the deltoid and pectoralis major insertions. Its shape is relatively flat at its origin, becoming more tubular as it proceeds distally and into the intertubercular groove .

The course of the LHB is from the posterosuperior aspect of the glenoid obliquely over the top of the humeral head. It then enters the bicipital (intertubercular) groove. This groove is formed by the confluence of the lesser tuberosity (anteriorly) and the greater tuberosity (superiorly). Anatomic studies have demonstrated varying depths of the groove (average = 4.3 mm) and varying inclination of the walls of the groove.

The most critical anatomical consideration to understand regarding the LHB is that of its stabilizing structures. Specifically, a thorough understanding of the rotator interval is essential. The rotator interval is the triangular interval bordered superiorly by the anterior margin of the supraspinatus, inferiorly by the superior margin of the subscapularis, and medially by the anterior aspect of the glenoid. Within this triangular space exists anterior glenohumeral capsule as well as the coracohumeral ligament (CHL) and the superior glenohumeral ligament (SGHL). The SGHL and the medial head of the CHL join to form a medial sling for the LHB and this is the major restraint to medial subluxation/dislocation of the LHB .

The CHL originates from the base of the coracoid process and divides into two bands—a superior band, which inserts into the anterior supraspinatus, and an inferior band whose medial head inserts into the superior subscapularis and then onto the superior aspect of the lesser tuberosity. The SGHL also contributes to this medial sling as it courses from the anterior labrum (just anterior to the biceps origin) and inserts onto the superior aspect of the lesser tuberosity. The fibers of the medial head of the CHL are much more robust and structurally important to the medial sling than the fibers of the SGHL. This sling is critical in preventing the LHB from displacing medially onto the lesser tuberosity. In this way, the sling protects the proximal insertion of the subscapularis from the stresses that would result from a medially displaced LHB.

The medial sling and its relationship to the biceps tendon has been described as “the comma sign” . This comma sign is an arthroscopic description of the aforementioned anatomy of the medial sling and was so named because of its arthroscopic appearance. The comma sign consists of the medial head of the CHL and SGHL (medial sling of the biceps) intersecting with the superior border of the subscapularis. Although the comma sign is visible in the absence of pathology, it is much more prominent, recognizable, and useful in the presence of a torn and retracted subscapularis tendon. When the subscapularis is torn from its insertion on the lesser tuberosity, the medial sling of the biceps is also pulled off and its association maintained with the subscapularis. Identification of this comma structure is critical when searching for the subscapularis tendon because it is always located at the superolateral border of the subscapularis tendon .

Biomechanics

Few would dispute the critical role of the biceps brachii at the elbow joint and its function has been well documented at this position . It is with the LHB’s role at the shoulder where the arguments intensify. Many authors have suggested that the LHB has a role in humeral head depression—particularly with shoulder external rotation .

Pathophysiology

Multiple classification schemes have been developed to describe disorders of the LHB tendon. These divisions have been only marginally useful in regards to diagnosis and treatment decisions. More important is to understand the various pathological processes involving the biceps tendon and how to treat each process accordingly. The three biceps tendon pathologies that we will discuss are biceps tendinitis, rupture, and instability. Lesions involving the biceps origin (SLAP lesions) will be discussed in greater detail elsewhere.

Biceps Tendinitis

Biceps tendinitis has been partitioned into primary tendinitis versus secondary tendinitis. Primary tendinitis involves inflammation of the tendon within the bicipital groove. To be considered primary, no other pathological findings (such as impingement, bony abnormalities within the groove, or biceps subluxation) should be present. It is considered an uncommon condition and should be thought of as a diagnosis of exclusion .

Much more common is the condition of secondary biceps tendinitis. As the LHB has an intimate relationship with its adjacent rotator cuff structures—most notably the anterior supraspinatus and superior subscapularis—it is affected by the same forces that produce pathology in these areas. Although subacromial impingement produces undue forces on the anterior rotator cuff, it also compresses the underlying LHB and produces concomitant pathology (and thereby symptoms) in this structure. In fact, the impingement upon the LHB worsens as a rotator cuff tear progresses and increased contact between the LHB and the coracoacromial arch occurs.

Another potential cause of secondary biceps tendinitis is the presence of bony anomalies of the proximal humerus. Most commonly these bony anomalies are secondary to malunion or nonunion of a proximal humerus fracture. If a fracture extends into the bicipital groove, significant irritation of the LHB can occur.

Biceps Tendon Rupture

Although acute ruptures of the LHB do occur, they are more commonly the end result of chronic biceps tendinitis. Acute ruptures can occur with a violent force placed on the LHB such as with a fall on an outstretched hand. Another traumatic event, which can cause significant damage to the LHB, is rapid deceleration of the arm during throwing activities. In this case the deceleratory force can result in trauma to the origin of the LHB resulting in a SLAP lesion. If the force is great enough in a single traumatic event or on a repetitive basis, it can result in LHB rupture with an associated SLAP tear.

Chronic biceps tendinitis is a more common etiology resulting in eventual LHB rupture. The LHB becomes attenuated and weakened by the continued impingement between the humeral head and the coracoacromial arch. In these cases of impingement causing rupture, the rupture typically occurs around the area of the rotator cuff interval (a weak point for the LHB) rather than at its origin.

Biceps Instability

Biceps instability takes the form of either frank dislocation or more subtle subluxation. As noted previously, the primary restraining structures holding the LHB in the bicipital groove are the medial sling and subscapularis tendon. The much less common extra-articular dislocations dislodge from the bicipital groove and travel over (anterior to) an intact subscapularis tendon. More commonly a LHB dislocation from within the bicipital groove is associated with a partial or complete tear of the subscapularis tendon, allowing the LHB to dislocate posterior to the subscapularis. The medial sling remains attached to the superolateral border of the subscapularis tendon—even when that tendon retracts medially. This arthroscopic anatomic landmark has been termed the “comma sign”. It is a critical arthroscopic finding because the comma easily guides the surgeon to the superolateral border of the subscapularis tendon thereby assisting in anatomic arthroscopic repair of the tendon back to the lesser tuberosity bone bed.

Biceps tendon subluxation can be a much more subtle diagnosis and we believe it is frequently missed even during arthroscopy. Again the critical anatomic components to prevent biceps subluxation are the medial sling and subscapularis tendon. In the early phases of biceps subluxation, the medial sling structures may remain largely intact while creating mechanical wear to the anteromedial portion of the LHB, which resides in the bicipital groove. It is therefore quite important to thoroughly examine the anteromedial portion of the LHB by pulling the structure intra-articularly with a probe while visualizing “over the top.” This maneuver often requires a 70-degree arthroscope to adequately visualize these structures. As the pathology progresses, the medial sling becomes detached from its insertion on the superior aspect of the lesser tuberosity and the LHB begins to act as a knife cutting its way through the subscapularis tendon insertion, causing it to become detached from the lesser tuberosity. Early findings of this phenomenon can only be seen with the 70 degree scope visualizing “over the top” to look down at the bone bed of the lesser tuberosity. The senior author has described this view with the 70-degree scope as the “aerial view”. Fraying may also be appreciated on the medial sling. This finding is termed a “pre-comma sign”.

As the humerus is internally and externally rotated the biceps tendon can be seen “breaking” posterior to the plane of the anterior border of the subscapularis . As a normal biceps tendon should remain anterior to the plane of the subscapularis, this “broken plane” phenomenon is a sure sign of early biceps instability. If not recognized, this will likely progress to LHB dislocation and complete tearing of the upper subscapularis insertion.

Clinical Evaluation

History

Anterior shoulder pain (particularly in the region of the bicipital groove) is the hallmark of biceps tendon associated problems. With biceps tendinitis the pain is usually described as a chronic aching pain, which is worsened by lifting and overhead activities. The pain frequently radiates distally to approximately the mid arm level but seldom radiates proximally. Inciting events include repetitive activities involving

lifting and overhead activities. There is such a close association between subacromial impingement and biceps tendonitis that the two conditions have closely overlapping symptoms. They can be very difficult to distinguish and more often than not occur in tandem.

Patients who present with rupture of the LHB are usually much easier to diagnose. These patients complain of a history of chronic anterior shoulder pain consistent with biceps tendinitis and/or impingement. They then usually report an episode of a painful “pop” in the shoulder, followed by partial or complete relief of their impingement symptoms. Subsequently they may develop ecchymosis in the arm and an associated muscular deformity in the arm, frequently termed the Popeye muscle. Sometimes the Popeye deformity does not develop secondary to the LHB becoming incarcerated in a stenotic bicipital groove.

Physical Findings

Distinguishing anterior shoulder pain caused by biceps tendon disorders as opposed to subacromial impingement can be difficult, as these two entities usually co-exist. Although there are some exam maneuvers, which attempt to isolate the biceps tendon, there is still a fair amount of overlap and the definitive diagnosis of isolated biceps tendon pathology is extremely difficult based on history and physical exam alone. Often selective injections are helpful in differentiating the etiology of the pain.

The hallmark of biceps tendon related pathology is point tenderness in the bicipital groove. Without this finding it is extremely unlikely the LHB is involved in the patient’s symptoms. The bicipital groove is best palpated approximately three inches below the acromion with the arm in 10 degrees of internal rotation. As the arm is internally and externally rotated, the pain should move with the arm. This is distinct from subacromial bursitis where the pain location remains relatively constant despite the position of the arm. In the situation in which it is unclear whether the pain is secondary to the LHB or to possible impingement/bursitis, selective injections of these areas can help make the diagnosis.

There are several provocative tests that can be helpful in the diagnosis of LHB pathology; however, the sensitivity/specificity of these tests are questionable. These tests are intended for the diagnosis of LHB pathology. Tests for the diagnosis of SLAP lesions are covered elsewhere in this textbook.

  • Speed’s test —With the elbow in extension, the patient flexes the shoulder against resistance from the examiner. Pain in the bicipital groove is considered positive.
  • Yergason test —The patient attempts to supinate the wrist against resistance (with the elbow flexed at the side). Pain in the bicipital groove is considered positive.
  • Bear Hug test —Because these lesions are almost always associated with LHB instability, it is a good test for LHB pathology. The patient places the open palm of the affected extremity on the contralateral shoulder. In so doing, the ipsilateral elbow is held well anterior to the plane of the patient’s body. As the examiner tries to lift the hand off the shoulder (resisted internal rotation), the patient tries to keep the palm on the shoulder. Weakness (in comparison to the contralateral side is a positive test and indicative of a tear of the upper subscapularis (and thereby likely LHB instability). In general, the examiner should not be able to lift the hand off the contralateral shoulder unless there is tearing of the upper subscapularis, in which case there is usually concomitant subluxation of the biceps tendon.
  • Napoleon test—This test also attempts to assess the integrity of the subscapularis for the reasons noted in the previous bullet point. The patient pushes on the abdomen with the palm of the affected extremity and tries to keep the wrist completely straight. If the patient is unable to keep the wrist straight but rather flexes the wrist to perform the test, this is considered a positive or intermediate test and suggestive of a subscapularis tear.
  • Belly-Press test—This test is similar to the Napoleon test in that the patient places the palm on the abdomen with the wrist held straight. The physician then tries to pull the hand off of the abdomen. If the physician is able to pull the hand off easily, this is considered a positive test and suggestive of a subscapularis tear.
  • Lift-off test—This is the fourth test to assess subscapularis integrity. The patient places the back of the hand of the affected extremity on the ipsilateral buttock. The examiner then lifts the hand posteriorly and asks the patient to hold it in that position. Weakness or inability to lift the hand off the lower back is considered positive and suggestive of a subscapularis tear.

Other tests have been described, such as the Ludington test, biceps instability test , and the deAnguin’s test ; however, we do not utilize these tests and have therefore not described them. The described tests can be useful in assisting the clinician with the diagnosis of biceps tendon disorders. As noted previously, however, the sensitivity/specificity of most of these tests has not been examined. The exceptions include the Speed test, which Bennett determined to be 90% sensitive for shoulder pain, but only 13% specific for bicipital pathology. Its positive predictive value was 23% while its negative predictive value was 83%. The Bear Hug test was determined to have a sensitivity of 60% and specificity of 92% for tears of the upper subscapularis.

Findings associated with complete rupture of the LHB are usually much more obvious. Examination reveals an alteration of the contour of the biceps such that a portion of the biceps feels (and appears) “balled up” at the mid arm level. This is termed the “Popeye” muscle. Rupture of the LHB is also often accompanied by ecchymosis, which migrates down the anterior surface of the arm.

Given the intimate relationship between biceps tendon pathology and concomitant subacromial impingement and/or rotator cuff tear it is important to examine the remainder of the shoulder in this patient population. Specific tests for range of motion, impingement, rotator cuff integrity, and instability should be performed.

Imaging

As with almost every other orthopaedic condition, the clinician should begin by obtaining a complete series of plain film radiographs. For the shoulder, these should include an anteroposterior (AP) view, axillary view, and outlet view (or scapular-Y view). We also include a 30-degree caudal tilt view to better assess the acromioclavicular (AC) joint. Others have described radiographic projections, which are more specific for the bicipital groove region of the proximal humerus. These include the Fisk projection  and the bicipital groove view. The Fisk method has the patient hold the cassette while leaning forward on their elbows and the beam projected perpendicular to the floor (and cassette). This view looks down the bicipital tunnel.

The bicipital groove method has the patient lie prone with the shoulder slightly abducted and the arm in external rotation. The cassette is placed on the top of the shoulder and the beam is directed up the patient’s axilla (parallel to the long axis of the humerus) and perpendicular to the plate. This view can elucidate the depth of the bicipital groove, the inclination of the walls of the groove, as well as any associated spurs within the groove.

Prior to the advent of magnetic resonance imaging (MRI), arthrography was a commonly utilized method of evaluation of the rotator cuff. It was also useful in the evaluation of the biceps tendon. The loss of a sharp delineation of the tendon can indicate biceps tendon pathology. Arthrography remains an invasive technique with possible contrast complications and this constitutes its main disadvantage.

Ultrasound has emerged as a potentially effective and noninvasive technique in the evaluation of biceps tendon pathology. Another study performed a biceps subluxation test and demonstrated 86% sensitivity in the diagnosis of LHB subluxation (as confirmed surgically) with ultrasound . Ultrasound has the added benefit of being a dynamic study. This allows easy evaluation with shoulder motion. In comparison to other imaging modalities, ultrasound is more operator dependent and therefore a well-trained technician is essential to obtain meaningful and helpful studies.

As with the evaluation of most other shoulder disorders, MRI has become increasingly popular. The anatomy (or patho-anatomy) of the biceps tendon and the bicipital groove is well delineated with MRI and associated findings such as rotator cuff pathology are also easily identified. Making the diagnosis of biceps tendon rupture or dislocation is relatively simple with MRI; however, biceps tendinitis and degenerative changes within the tendon are difficult to determine via MRI. Although some authors have suggested that increased fluid around the biceps is suggestive of biceps tendinitis , others report low sensitivity and specificity using this criterion .

Treatment

Nonoperative

The initial treatment of bicipital tendinitis is conservative using the traditional methods of rest, ice, and nonsteroidal anti-inflammatory medications. As symptoms improve, range of motion exercises and strengthening can be added. The actual treatment is frequently directed more toward the treatment of underlying rotator cuff pathology. Subacromial injections or bicipital sheath injections may also be utilized. Caution should be exercised in injecting the bicipital sheath. Intratendinous injection should be avoided due to the risk of tendon rupture or atrophic changes. Although DePalma (62) reported on injection of the tendon directly, other authors recommend sheath injections with 74% good to excellent results. It can be difficult to inject directly into the bicipital sheath, and therefore intra-articular injections have been advocated by some because the proximal portion of the tendon is directly accessible and some of the fluid can track down the bicipital groove.

We prefer an intra-articular injection using a standard posterior portal approach. The joint line is palpated and entered approximately 4 cm inferior and 4 cm medial to the posterolateral corner of the acromion. A 22-gauge 1.5-inch needle is aimed toward the coracoid and a pop is felt as the needle perforates the posterior capsule. This is the same direction as inserting a posterior cannula for glenohumeral arthroscopy. Four ml of Betamethasone (6 mg per ml) and six ml of 0.5% lidocaine HCL are instilled into the glenohumeral joint. In addition to the rapid therapeutic effects of bupivicaine on the intra-articular portion of the biceps, its added volume aids in travel of the mix down the bicipital groove.

Injections of a corticosteroid should be limited to two or three injections due the risk of tendon rupture, fluid retention, and weight gain. The patient is seen back at monthly intervals for re-evaluation and possible repeat injection. If symptoms progress or the condition worsens, further work-up with MRI, ultrasound, or CT arthrogram may be indicated. If symptoms improve with initial conservative therapy, gradual increase in activities is allowed, still limiting any inciting activity until the patient is relatively symptom free. If no other pathology is present, greater than 80% of patients can be expected to achieve good results with nonoperative treatment. If patients continue to have significant pain and further work-up including MRI is negative, other sources of pain must be considered such as cervical radiculopathy, instability, glenohumeral or acromioclavicular arthritis, coracoid impingement, adhesive capsulitis, lung conditions with referred pain such as Pancoast tumor (malignancy in the upper lobe of the lung), or medical conditions including cardiac or gallbladder referred pain.

Associated SLAP tears may be present, but little information regarding success rates with nonoperative treatment of SLAP lesions is available. The same conservative treatments may be employed, but many SLAP tears may ultimately require surgical intervention or may not be definitively diagnosed until arthroscopy is performed. The important subject of SLAP tears will be addressed elsewhere in this text.

Instability lesions of the biceps including subluxations or dislocations are frequently associated with rotator cuff tears. Treatment should be directed toward treatment of the rotator cuff tear and such treatment is frequently operative. Conservative treatment strategies should initially be employed but surgical intervention is often necessary. Ruptures of the LHB tendon typically do not require surgical intervention. Patients with proximal biceps ruptures regain function and have substantial pain relief. Many patients with pain before a biceps rupture will report pain relief once the rupture occurs. An associated cosmetic defect may be present in approximately 21% of proximal biceps ruptures , and patients should be provided information regarding the minimal strength loss if surgical intervention is avoided. Residual arm pain was minimal in both groups. Biomechanical analysis showed a 21% loss of forearm supination strength and 8% loss of elbow flexion strength in the nonsurgical group. The nonsurgical group had no weakness in pronation, elbow extension, or grip. The surgically treated patients had no loss of strength in elbow flexion, extension pronation, supination, or grip. Additionally, surgically treated patients returned to work later than nonsurgical patients, but 11 in the nonsurgical group were not able to return to full work capacity with weakness as their primary complaint. Only two patients in the surgically treated group could not return to full work capacity.

Operative

Indications

After conservative treatment measures have failed, if the patient continues to have biceps associated symptoms, surgical management should be considered. The imaging studies previously discussed should be utilized prior to considering surgical treatment because of the significant overlap of biceps disorders and other shoulder conditions.

Biceps tendinitis is commonly associated with impingement syndrome and rotator cuff tendinitis or tears. Ruptures of the biceps tendon can result from trauma often with associated rotator cuff tears or SLAP lesions. Overload flexion force or flexion with forced extension may cause rupture of the biceps tendon. Other maladies associated with the biceps tendon involve medial dislocation, spontaneous dislocation, and pathologic lesions .

Basically there are only three treatments for biceps tendon disorders. They are debridement of the LHB, biceps tenotomy, or biceps tenodesis. The decision regarding tenotomy vs. tenodesis is a controversial subject. A tenotomy of the proximal biceps has been reported to carry a 21% incidence of a Popeye deformity with distal retraction of the biceps resulting in a larger muscle mass contracted distally and loss of the proximal muscle bulk.

Simple debridement of the biceps tendon is of questionable value. If fraying or partial tearing of the biceps tendon is encountered during arthroscopy its cause should be thoroughly explored. Even a small amount of fraying is suggestive of a mechanical abnormality within the shoulder joint and likely needs further arthroscopic evaluation and treatment. Although some have advocated biceps tendon debridement for tears of less than 50%, we feel tendon debridement is in essence treating the end result of the mechanical problem and not addressing the source of the problem.

The debate over biceps tenotomy vs. tenodesis will not be fully explored in this chapter, as the subject is quite controversial. We weigh many factors when making the decision to perform tenotomy or tenodesis. These factors include the patient’s age, body habitus, activity level, and extent of biceps tendon degeneration. Typically tenotomy is reserved for elderly patients, sedentary patients with a larger body habitus, or patients with significant tendon degeneration which extends into the bicipital groove. Tenodesis in the latter situation may result in persistent pain due to pathology extending distal to the tenodesis site.

In general the authors opt for arthroscopic biceps tenodesis in almost every situation other than those mentioned earlier in this chapter. Many open techniques have been implemented in the tenodesis of the LHB. One commonly used open procedure is the keyhole technique. Alternative methods of open tenodesis involve soft tissue/periosteal tenodesis within the bicipital groove.

Technique

Operative intervention for biceps pathology begins with arthroscopic inspection and debridement. The proximal biceps tendon is easily visualized during standard glenohumeral arthroscopy. The tendon is first visualized thoroughly from the posterior portal. The tendon should be inspected from its origin on the superior glenoid tubercle and/or superior labrum all the way into the bicipital sheath. It is examined for fraying, degenerative changes, thickening or synovitis. The tendon from inside the bicipital sheath should be pulled into the joint with a probe to assess the integrity of the tendon. This can be facilitated by flexing the elbow, supinating the forearm, externally rotating and abducting the arm. This decreases the tension on the biceps and lengthens the amount of tendon that can be brought into the joint. This can expose lesions of the biceps that might otherwise be missed. This step is important to assess the integrity of the tendon. If the surgeon notices any fraying of the biceps tendon adjacent to the medial sling, this can be an important clue to early tendon subluxation. Arthroscopic biceps tenodesis can obviate the need for a repeat surgery to deal with a much more difficult problem such as tendon dislocation with associated subscapularis tears.

The next important portion of the diagnostic arthroscopy is the assessment of the medial sling. This is best done using a 70 degree arthroscope. The scope is directed to obtain an “aerial” view of the confluence of the subscapularis, the biceps tendon, and the medial sling of the biceps (composed of the medial head of the CHL and the SGHL). This view is maintained while an assistant internally and externally rotates the humerus. Special attention is paid to the relationship of the biceps to the anterior border of the subscapularis. In a normal shoulder, the biceps tendon should never cut posterior to the plane of the anterior subscapularis tendon during arm rotation. If the biceps does slip posterior to this plane it is a sure sign of early biceps instability. If the biceps is not addressed by tenotomy or tenodesis, the patient may eventually develop frank biceps instability and an associated subscapularis tear.

At the completion of the diagnostic arthroscopy, if biceps pathology exists the surgeon must make the decision between biceps tenotomy vs. tenodesis as outlined previously. Tenotomy can easily be performed using arthroscopic scissors or electrocautery. The tendon should be cut at its base being sure not to damage the superior glenoid labrum during this procedure. The tendon will usually retract into the bicipital sheath; however, if it does not, the shaver should be used to excise the intra-articular portion of the biceps tendon so it does not impinge during shoulder motion.

The Bio-Tenodesis Screw System

We perform all arthroscopic shoulder procedures in the lateral decubitis position under general anesthesia. Five to 10 pounds of balanced suspension are used with the arm in 20 degrees to 30 degrees of abduction and 20 degrees of forward flexion. Diagnostic glenohumeral arthroscopy is performed through a standard posterior portal with an arthroscopic pump maintaining pressure at 60 mmHg. An anterosuperolateral portal is created using a spinal needle to localize the portal site. A cannula is inserted above the biceps at the superior edge of the safe zone bordered by the biceps superiorly, subscapularis tendon inferiorly and the glenoid medially. The biceps/labrum complex and the LHB are assessed. A complete assessment of the biceps tendon is performed by pulling the intertubecular portion of the biceps tendon intra-articularly and assessing the amount of degeneration, partial tearing, and instability.

The cannulated driver is specially designed with a reverse threaded sleeve and thumb piece on the driver shaft. The pitch of the threads on the sleeve are equal and opposite in direction to the pitch of the threads on the Bio-Tenodesis screw. This design allows the biceps tendon to be maintained at the bottom of the bone socket under tension as the Bio-Tenodesis screw is advanced in the bone socket by the hex-driver and by the reverse threaded pitch of the thumb sleeve. Fixation is achieved using a bio-absorbable PLLA (poly-L-lactic acid) cannulated screw. These BioTenodesis interference screws are available in three diameters (7 to 9 mm) and are 23 mm in length.

After completion of diagnostic arthroscopy, any tendon degeneration is debrided. If a concomitant rotator cuff tear is present, a lateral portal is established directly through the defect created by the torn rotator cuff. Two racking stitches are placed into the biceps tendon. Sutures are placed approximately 1 to 1.5 cm distal to the biceps origin from the superior labrum and are then retrieved through the lateral or anterosuperolateral portal. The racking sutures tightly grip the degenerative biceps tendon. The biceps tendon is then severed from the superior labrum using electrocautery or arthroscopic scissors.

The tendon is then exteriorized extra-corporeally through the anterosuperolateral portal. Flexion of the elbow allows a greater length of tendon to be pulled through the skin. The diameter of the tendon is then measured using the slotted measuring plate on the BioTenodesis driver. Typically the tendon measures approximately 8 mm in men and 7 mm in women. If the tendon will not fit easily through the 8 mm hole, the end of the tendon is tapered such that it will fit through the 8 mm slotted measuring plate. It is important that the tendon fit rather easily through the plate, as this will make insertion into the bone socket much easier later in the case. A Krakow whip stitch is placed in the tendon such that the suture ends exit the superior surface of the tendon 5 mm from its free end and then the racking sutures are removed.

Next, a bone socket is created in the greater tuberosity, approximately 5 mm posterolateral to the top of the bicipital groove. A 2.4 mm guide wire is initially placed and is then over-reamed with a cannulated headed reamer. The bone socket is reamed to the size of biceps tendon previously measured (usually 7 or 8 mm in diameter) and to a depth of 25 mm to accommodate a screw length of 23 mm. If there is not an associated rotator cuff tear involving the supraspinatus tendon, the bone socket should be drilled at the top of the bicipital groove. After the biceps tenodesis portion of the procedure, two or four suture tails (depending on the technique) will be exiting the BioTenodesis screw construct.

The whip-stitch sutures are then passed through a loop of suture at the end of the cannulated driver.

The driver tip is advanced to the end of the tendon (on its superior surface). In this position, the biceps tendon can be manipulated and controlled by the cannulated driver tip. Alternatively, the whip-stitch sutures can be threaded through the cannulated driver. This has the advantage of making manipulation of the biceps tendon easier and has become our preferred method. The disadvantage is that only two suture strands (rather than four) will protrude from the BioTenodesis screw.

The driver tip is used to push the biceps tendon down to the base of the previously drilled bone socket. A BioTenodesis screw (the same size as the drilled socket) is then advanced by turning the driver handle while holding the thumb plate that is attached to the reverse threaded sleeve. This allows the screw to be advanced while the tendon is maintained in a stationary position at the base of the bone socket.

This assures an adequate bone-tendon-screw interface within the bone socket and eliminates the need for transosseous drilling. We prefer to avoid transosseous drilling to eliminate any potential risk to the axillary nerve. The two or four sutures exiting the BioTenodesis screw should be used in place of a suture anchor to augment the rotator cuff repair or can simply be cut if no cuff tear is present.

Suture Anchor Technique

Each used suture anchors inserted in different locations to obtain fixation to the proximal humerus or the greater tuberosity.

The Nord Technique

Glenohumeral arthroscopy is performed in the lateral decubitus position under 10 lbs. of traction as described in the preceding paragraphs. The arm is suspended at approximately a 45-degree angle of abduction and 10 degree forward flexion and distraction of the shoulder joint is accomplished with 10 lbs. of traction. This allows for external and internal rotation of the shoulder while distracted. This technique can be performed in the beach chair position if the surgeon desires. Four to six portals are utilized during the procedure. The anterosuperior, posterior, and lateral portals are made to obtain visualization of anatomical structures and defects. These portals are also used as working portals and cannulas are utilized. When a rotator cuff repair is necessary, the subclavian, anterolateral and modified Neviaser portals are utilized as necessary for passing suture through the tendon. Anchors for rotator cuff repair are typically inserted through an anterolateral portal without a cannula. To facilitate biceps tenodesis, the subclavian portal is used for anchor insertion. The subclavian portal is located 1 to 2 cm medial to the AC joint, above and slightly medial to the coracoid, and directly inferior to the clavicle. A cannula is not needed or recommended for this portal. Instruments or anchors are passed inferior and anterior to the AC joint before entering the subacromial bursa. Subacromial decompression optimizes the use of the subclavian portal.

The scope is introduced into the glenohumeral joint through a standard posterior portal. An anterosuperolateral portal is made following the path of a spinal needle. The anatomical structures are visualized and any abnormalities are assessed. Treatment of other pathology is performed as indicated. The shoulder is evaluated for rotator cuff tears. If present, the rotator cuff defect facilitates access to the biceps tendon. A lateral portal is created and subacromial decompression is performed, which relieves shoulder impingement and facilitates the use of the subclavian portal. The scope is utilized through the posterior portal below the rotator cuff to gain visualization of the biceps tendon. Using a burr through the lateral portal, a small area of the articular and bony surface is abraded under the biceps tendon, just proximal to the bicipital groove. A spinal needle is inserted through the subclavian portal in order to identify the tract through the CHL to the biceps tendon. A 3 mm incision is made for the subclavian portal and no cannula is used. A suture anchor, 5 mm (preferred) or 3.5 mm, is passed through the subclavian portal entering the joint through the rotator interval. The suture anchor is then placed through the biceps tendon slightly proximal to the bicipital groove. Lifting the biceps tendon with a probe will help facilitate visualization of the anchor through the biceps tendon and embedding into bone.

The subclavian approach allows fixation of the tendon “in-situ” just proximal to the point at which the tendon enters the bicipital groove. The anchor can be placed directly through the biceps or adjacent to it. The sutures can be passed via the subclavian or anterosuperolateral portal—whichever provides a better angle. The biceps is left attached while the suture anchor is inserted through the tendon. If a rotator cuff tear is present, the sutures through the biceps may be tied through the lateral portal; however, if a rotator cuff tear is not present, sutures are tied through the anterior portal. One limb of the suture is pulled underneath and over the biceps tendon, and then out the appropriate portal with a crochet hook. The sutures are each tied. Knot security and loop security are assessed. A second suture anchor is introduced into the subclavian portal, passed through the biceps tendon slightly proximal to the other suture anchor, and sutures retrieved. The biceps tendon is found to be firmly attached by testing the tenodesis with a hook probe. The residual intra-articular biceps tendon is released from a site just proximal to the sutures using a basket cutter and the remaining stump is excised at the point of attachment at the superior glenoid labrum utilizing a basket cutter and shaver. Arthroscopic rotator cuff repair is performed as necessary after the completion of the biceps tenodesis. The tenodesis will not add any significant bulk beneath the rotator cuff repair and allows for normal shoulder motion. During range of motion testing of the shoulder and elbow, stability of the biceps tenodesis is arthroscopically assessed.

Soft Tissue Tenodesis Technique

Suture tenodesis to soft tissue has been advocated due to its simplicity. Two methods have been described. One involves open treatment of suturing the biceps tendon to the transverse humeral ligament and the arthroscopic technique involves suturing the tendon to the CHL or the anterior supraspinatus tendon.

The arthroscopic suture tenodesis technique begins with standard glenohumeral arthroscopy. Any associated pathology is treated appropriately. An anterosuperior portal is made for introduction of a suture passing device or alternatively a spinal needle can be used to pass PDS suture through the biceps after passing the needle through the rotator cuff through an anterolateral portal. If the tendon is of poor quality, racking sutures provide better purchase on the tendon. A second suture can then be placed in a similar manner. The biceps is then released from its attachment to the labrum and supraglenoid tubercle. This is accomplished with a radiofrequency device or arthroscopic scissors. The edge of the superior labrum is smoothed. If a spinal needle was used with #1 PDS, the sutures are already passed through the supraspinatus. The camera is then directed into the subacromial space, the sutures retrieved through the lateral cannula and are then securely tied. This anchors the biceps to the supraspinatus or the CHL.

Complications and Special Considerations

Complications of the biceps tenotomy primarily involve the anticipated 21% risk of a Popeye deformity of the biceps muscle as it retracts distally. Most men may not be concerned about this deformity, but it may not be cosmetically acceptable to women or bodybuilders. Patients should be counseled on these risks if this treatment modality is elected. If this is unacceptable to the patient, a tenodesis should be performed.

Arthroscopic biceps tenotomy is otherwise a relatively safe procedure with very minor risks of infection, blood clots or neurovascular injury. The portals used for a tenotomy are the standard arthroscopy portals and the risks are comparable to diagnostic shoulder arthroscopy risks. Pain relief is generally very good although occasionally a patient may have some residual pain or cramping with activities involving forceful elbow flexion. Risks of shoulder arthroscopy include infection, blood vessel or nerve injury, upper extremity deep venous thrombosis, neuropraxia of ulnar nerve secondary to compression of the nerve at the cubital tunnel, and brachial plexus traction injuries which are usually a result of head and neck position.

Prominence of the BioTenodesis screw could potentially cause impingement upon the acromion if it were not adequately seated in the bone bed. Therefore the surgeon must advance the screwhead until it is flush with the bone surface. The tendon may not pull down into the drill hole resulting in a lax tendon or fixation of the tendon down with sutures alone. Close attention to technique will prevent this problem. Fractures could potentially occur depending on the location of screw insertion but we have not seen this complication. Osteoporotic bone may not allow rigid fixation but the BioTenodesis screw would be expected to have better fixation than suture anchors in osteoporotic bone. If the BioTenodesis screw appears somewhat loose after insertion into osteoporotic bone, its stability may be improved by inserting a 5 mm BioCorkscrew suture anchor directly adjacent to it, thereby achieving an interference fit of the anchor against the BioTenodesis screw.

Complications associated with suture anchors carry all the standard arthroscopy risks. Additionally, failure of fixation can occur in the form of anchor pullout or suture breakage. When postoperative anchor pullout occurs an additional procedure is required to retrieve the anchor if a metallic anchor is used. Failure of fixation of the biceps tendon results in a biceps tenotomy with the potential Popeye deformity, so the surgeon should discuss this possibility with the patient.

Conclusions and future directions

The LHB tendon is a fascinating structure that, in many respects, remains somewhat perplexing. A plethora of literature regarding the function, pathology, and treatment of the biceps tendon exists. As the science of our specialty progresses we will continue to discover the truths behind the LHB. Long-term patient outcome studies comparing alternative treatment modalities will also be crucial. As is the trend with most orthopedic shoulder cases, arthroscopic treatment strategies will continue to advance and will likely become the standard of care for the treatment of disorders of the biceps tendon.

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