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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.

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