Shoulder and Elbow

Disorders of the Long Head of the Biceps Tendon: Tendinopathy and Proximal Ruptures

The Problem

Although the function of the long head of the biceps (LHB) tendon in glenohumeral motion and stability remains controversial, it is clearly recognized as a potential source of shoulder pain and dysfunction. Due to the close anatomical proximity of the LHB to adjacent structures it is often difficult to clinically discern LHB tendinopathy from other sources of shoulder pain. No single exam finding is 100% specific for LHB tendinopathy; therefore an accurate diagnosis is made only through careful patient evaluation including history and physical examination. When surgery is necessary, the surgeon must understand the advantages and disadvantages of biceps tenotomy or tenodesis. When tenodesis is chosen, the location and fixation technique must be carefully considered in order to optimize pain relief and restore function.

Clinical Presentation

Patients with LHB tendinopathy typically present with anterior shoulder pain and decreased shoulder function made worse with activity. Patients may describe pain anteriorly along the bicipital groove often reporting radiation distally towards the biceps muscle in comparison to the lateral deltoid pain commonly noted with rotator cuff disease. In a younger individual, isolated LHB tendonitis can result from repetitive overhead activities, such as volleyball or throwing sports. In the older individual, LHB tendinopathy is most often accompanied by additional shoulder pathology, most commonly rotator cuff tears. When a patient complains of an audible or palpable snap or click in the anterior aspect of the shoulder, the clinician should consider LHB instability. LHB instability is commonly associated with tears of the subscapularis tendon.

A spontaneous rupture of the LHB tendon is more common in older individuals and is an attritional rupture of a degenerated tendon. For this reason, patients may have prodromal symptoms of chronic anterior shoulder pain prior to spontaneous rupture. The LHB rupture is acutely painful and often accompanied by ecchymosis and a “popeye” deformity of the biceps muscle belly. In the elderly patient a spontaneous rupture of the LHB is usually well tolerated after the acute pain has resolved. In the younger, higher demand patient a spontaneous rupture of the LHB may be less tolerated due to muscle cramping, perceived decreased supination strength, and cosmesis.

Diagnostic Workup

The differential diagnosis for anterior shoulder pain is broad and includes: subcoracoid impingement, subacromial bursitis, acromioclavicular joint arthrosis or instability, glenohumeral instability, superior labrum anterior posterior (SLAP) tear, subscapularis pathology, rotator cuff tendonitis or tear, subacromial bursitis, glenohumeral arthritis, adhesive capsulitis, and cervical radiculopathy. To differentiate LHB tendinopathy from other sources of anterior shoulder pain it is essential to listen carefully to the patient’s complaints, perform a thorough physical exam and accurately interpret advanced imaging when indicated.

The examination of the shoulder starts with a generalized assessment including inspection, palpation, range of motion and strength testing of both shoulders, scapula, and cervical spine in order to narrow the differential diagnosis for shoulder pain. Cervical range of motion is initially performed to identify cervical radiculopathy which may present with shoulder complaints. Next palpation of the shoulder should be undertaken to identify tenderness with palpation of the bicipital groove which should raise suspicion of LHB tendinopathy. With the humerus in slight internal rotation, the bicipital groove can be located approximately 6 centimeters distal to the corner of the acromion. After initial palpation of the bicipital groove, gradual external rotation of the arm should move the point of tenderness laterally as the bicep tendon moves with humeral rotation. Alternatively, the LHB tendon can be palpated deep to the distal attachment of the pectoralis major tendon with the patient attempting to adduct and internally rotate. Finally, palpation of the AC joint should be carried out to identify AC joint arthropathy as a potential contributing cause of pain.

Although no single provocative test is 100% specific for long head of the biceps tendinopathy, in setting of a detailed history, these tests have an important role in confirming the diagnosis. The most commonly performed LHB provocative tests include the O’Brien active compression test, Speed's test, and Yergason's test.

The O’Brien active compression test is performed by forward flexing the shoulder 90°, adduct 10° with maximum internal rotation with thumb pointing down. The examiner then applies a downward force as the patient resists with an upward force. The test is repeated with the arm fully supinated. Deep shoulder pain with the first maneuver and relieved with the second maneuver indicates a positive test suggestive of biceps/superior labral complex pathology.

In the Speed's test, the patient’s arm is positioned in 90° of forward flexion, elbow fully extended and forearm supinated. The patient is asked to resist the downward force applied by the examiner. Pain experienced in the anterior shoulder indicates a positive test.

The Yergason's test is performed with the humerus in neutral position at the side and the elbow flexed 90°. The patient is asked to supinate their arm against the manual resistance of the examiner. Pain referred to the bicipital groove during resisted supination indicates a positive test.

Corticosteroid injection of the bicipital groove may be diagnostic and therapeutic. The injection is not intended for the tendon itself but rather the adjacent tissues and paratenon. Ultrasound may be useful to improve accuracy of the injection into the bicipital groove, particularly if the injection is used for diagnostic purposes.

In the acute stage following a spontaneous LHB tendon rupture bruising may be appreciated distal to the axillary crease. In addition, as a result of distal retraction of the muscle, a “popeye sign” or a deformity of the biceps muscle belly may be noted.

Diagnostic Imaging

Although not usually helpful in the diagnosis of LHB tendinopathy, standard shoulder radiographs are routinely obtained to evaluate for concomitant bony or soft tissue abnormalities. The dynamic imaging capability of the ultrasound makes it especially useful in detecting biceps dislocation or subluxation. However, ultrasound is heavily operator-dependent and is overall less sensitive in detecting LHB tendinopathy compared to magnetic resonance imaging (MRI).

MRI is the advanced imaging modality of choice in diagnosing LHB tendinopathy. The LHB tendon is an intra-articular structure and fluid seen around the tendon on axial cuts is a nonspecific finding that may or may not represent tendinopathy. Abnormalities within the tendon itself seen on axial views are more specific to biceps tendinopathy. While partial tendon tears can be relatively difficult to detect, complete ruptures of the LHB are comparatively easy to identify on MRI. Rarely, longitudinal tears of the LHB tendon present as fluid within the tendon on the axial plane MRI. If the LHB is located medial to the bicipital groove on axial images this should raise suspicion for LHB instability and concomitant subscapularis tear. It is important to note that the MRI is a static image and that LHB tendon instability can still be present despite anatomic position of the tendon on MRI. To improve detecting other shoulder conditions such as rotator cuff tears and labrum defects, MR arthrograms can be used and may be more sensitive for LHB abnormalities.

Non–Operative Management

Although the literature on nonsurgical management of LHB tendinopathy is limited, initial treatment consists of rest, activity modification, structured physical therapy, nonsteroidal anti-inflammatory drugs and corticosteroid injections. Glenohumeral joint injections may treat tendonitis of the intra-articular portion of the LHB tendon. An injection into the bicipital groove can reduce more distal inflammation of the tendon and may serve both diagnostic and therapeutic roles.

In the elderly patient, a spontaneous rupture of the LHB is usually well tolerated after the acute pain has resolved and for this reason nonoperative treatment is usually indicated. In the younger, higher demand patient a spontaneous rupture of the LHB may be less tolerated due to muscle cramping, perceived decreased supination strength, and cosmesis. If a younger, higher demand patient presents with an acute spontaneous rupture of the LHB, the patient should be counseled about risks and benefits to non-operative treatment versus early tenodesis. In addition, patients should be counseled that if they are unhappy with the function or appearance of the upper extremity after non-surgical management, surgical options for chronic rupture may be limited. Patients who are unsatisfied with nonoperative treatment of a chronic rupture of the LHB need to be counseled on the risks and benefits of surgical exploration of the arm for biceps tenodesis. Physical strengthening with structured physical therapy may be helpful for patients with main complaints of weakness from a LHB chronic rupture. Surgical exploration with resuspension may offer some benefit for pain or cramping but is unlikely to normalize cosmesis.

Indications for Surgery

Surgical indications for management of LHB pathology generally fall into one of four categories. First is primary or secondary tenosynovitis. Secondary tenosynovitis is most commonly associated with rotator cuff pathology. Surgical treatment of the LHB tendinopathy is recommended for a patient who has failed non-surgical management with an appropriate history of anterior shoulder pain localized to the bicipital groove, positive provocative maneuvers on examination, and arthroscopic findings consistent with LHB tendinopathy. The duration of non-surgical management prior to recommending surgical intervention should be individualized for each patient. The second category is biceps instability including tendon subluxation associated with subscapularis tears. Subtle injuries to the coracohumeral ligament or superior glenohumeral ligament may result in more subtle tendon subluxation, often referred to as the "hidden lesion". The third category includes proximal tendon rupture as discussed above. Finally, an evolving indication includes surgical management of type II or type IV SLAP pathology.

During diagnostic shoulder arthroscopy it is important to thoroughly evaluate other sources of shoulder pain before focus is turned to the LHB tendon. Examination of the LHB tendon is performed by viewing through the standard posterior portal. Initially, the LHB and its insertion onto the superior labrum can be assessed without fluid as the pump pressure can compress peritendinous vessels causing inflamed synovium to appear washed out. While viewing through a posterior portal, a probe through the anterior cannula placed through the rotator interval should then be used to deliver the bicipital groove portion of the LHB into view to assess the distal aspect of the tendon which may reveal hyperemic tenosynovium, commonly referred to as the “lipstick sign,” or thinning, fraying, tearing and hypertrophic changes of the tendon. A thickened intra-articular segment of LHB resembling an hourglass shaped biceps tendon, unable to slide into the bicipital groove during elevation of the arm, may be noted in cases of shoulder pain associated with a loss of 10 - 20 degrees of passive elevation. The tendon stability should be tested by attempting to subluxate the tendon with a probe. The arthroscopic active compression test, normally performed to assess for instability of SLAP tears, can be performed to assess for anterior-medial instability of the LHB as well. Internal rotation of the humerus will subluxate the LHB medially and external rotation will reduce the tendon to the bicipital groove. In the presence of LHB instability the surgeon should closely examine the integrity of the subscapularis tendon and the rotator interval pulley contents (CHL, SGHL).

LHB tendon pathology found during arthroscopy that should prompt surgical treatment include tears greater than 25% of tendon width, chronic degeneration or tenosynovitis of the tendon, symptomatic bicep tendon instability, type IV SLAP tears, failed previous SLAP repair, and a symptomatic type II SLAP tear in the older (>50 years old) patient or associated with a large cuff tear or repair. In most cases given the limited role of the LHB in shoulder function and the possibility of persistent symptoms or pain with debridement alone, tenodesis or tenotomy should be considered in most cases where LHB pathology is encountered.

Surgical Technique

The two most common surgical procedures for management of LHB tendinopathy are tenotomy and tenodesis. In an appropriately selected patient, both surgical treatments have been proven to provide symptomatic relief and patient satisfaction. However, the optimal surgical management remains controversial.

Biceps Tenotomy

Biceps tenotomy involves using an arthroscopic basket or scissors to release the LHB tendon from the origin at the labrum. After tenotomy, the LHB should spontaneously retract distally through the bicipital groove with elbow extension. In the presence of a hypertrophic hourglass deformity or a badly frayed LHB this spontaneous retraction may not occur and the tendon will remain in an intra-articular position, which can be a source of continuing pain post-operatively. Advantages of tenotomy include no postoperative limitations or immobilization, no implant cost, decreased operative time, and technical ease. Potential disadvantages include biceps cramping and fatigue, decreased supination strength, and cosmetic “popeye” deformity.

Management of LHB pathology is frequently required in patients undergoing surgery for rotator cuff disease. Arthroscopic tenotomy of the LHB performed in isolation has been reported to provide pain relief in patients with irreparable rotator cuff tears. The senior author performs LHB tenotomy for the following patients: over 60 years old, non-overhead athletes or laborers, patients who are unconcerned with cosmesis or obese patients who may not recognize a potential deformity, or patients unwilling to comply with postoperative restrictions following biceps tenodesis.

Biceps Tenodesis

The senior author prefers to perform biceps tenodesis in younger patients, overhead athletes, laborers, patients with workers compensation or legal cases who may misconstrue a deformity as a disability and patients with cosmetic concerns of a popeye deformity. Potential advantages of a properly performed biceps tenodesis include improved cosmesis and function, secondary to the preservation of the normal length-tension relationship, and avoidance of muscle fatigue or cramping. Potential disadvantages of biceps tenodesis include post-operative rehabilitation, higher implant cost, increased surgical time, and potential complications such as injury to adjacent structures, or loss of tenodesis fixation.

The ideal location for the LHB tenodesis and the method of fixation remain controversial. In general, LHB tenodesis options include all-arthroscopic or open technique, proximal or distal subpectoral location, and soft tissue or osseous fixation. Osseous fixation techniques include trans-osseous, keyhole, suture anchors, button fixation, and interference screws. Biomechanical testing has shown that interference screw techniques have the highest ultimate load to failure and least displacement at time zero. Further biomechanical testing of interference screw fixation has demonstrated no difference in failure rate when comparing large and small diameter interference screw sizes and therefore the senior author recommends using a smaller interference screw to minimize humerus stress risers and risk of fracture through the tenodesis site.

Proximal All-Arthroscopic LHB Tenodesis

All-arthroscopic LHB tenodesis can be performed to provide fixation proximal to the bicipital groove, within the bicipital groove, or distal to bicipital groove but proximal to the pectoralis insertion. All-arthroscopic LHB soft tissue fixation tenodesis has been described via a percutaneous intra-articular transtendinous technique (PITT) to the intact rotator cuff or to the transverse humeral ligament. There are a few drawbacks to this technique. Soft tissue tenodesis has shown to be weaker at time zero during load to failure biomechanical testing. Another potential drawback of proximal all-arthroscopic fixation is persistent pain due to continued tendinopathy within the confines of the bicipital groove. Clinical studies have shown a higher rate of revision needed for tenodesis performed within the groove compared to a subpectoral location (Figure 1).

Figure 1.

Radiograph demonstrating distal location of an open subpectoral LHB tenodesis.

Open Subpectoral LHB tenodesis

Open Subpectoral LHB tenodesis (OSPBT) is the senior author’s preferred technique because it is safe, reproducible, and associated with excellent clinical outcomes. OSBPT is performed in the lazy beach chair position (head of the bed dropped to 30 degrees) with the elbow supported by a mayo stand with the operating surgeon in the axilla and assistant on the lateral side.

With the arm abducted and internally rotated, palpate the inferior border of the pectoralis major tendon in the axilla and mark a 4 cm vertical incision starting 1 cm superior to the inferior border of the pectoralis tendon. For cosmetic purposes, the incision can be incorporated into the skin folds of the axilla. The incision is infiltrated with local anesthetic with epinephrine. Sharp dissection is made through skin and subcutaneous fat and skin retractors are used to enhance superficial exposure. The overlaying fatty tissue is cleared until the fascia overlying the pectoralis major, coracobrachialis, and biceps is identified (Figure 2).

Figure 2.

Pectoralis major, coracobrachialis, and biceps are identified after clearing the overlying fatty tissue.

If these anatomic landmarks are not seen, the dissection could be too lateral. If the cephalic vein is seen in the deltopectoral groove, the dissection is too proximal and too lateral. Identify the inferior border of the pectoralis major as it runs in an oblique orientation and incise the fascia overlying the coracobrachialis and biceps in a proximal to distal manner. Bluntly finger dissect under the pectoralis major tendon to palpate the biceps tendon along the medial border of the pectoralis major tendon. The bicep tendon can be pulled out into the wound at this point but a safer approach is to place a broad hohmann retractor under the pectoralis tendon and around the lateral border of the humerus. Next a blunt chandler retractor is placed over the medial border of the humerus to pull the coracobrachialis and short head of the biceps medially. The medial blunt retractor will sit over the fibers of the latissimus tendon and should not be expected to be placed around the posterior border of the humerus. Vigorous medial retraction or excessive external humeral rotation should be avoided to protect the musculocutaneous nerve. The tendon should be visualized within the bicipital groove and can be delivered out of the wound with a curved clamp (Figure 3).

Figure 3.

The LHB tendon being safely delivered out of the wound after proper exposure.

To ensure appropriate tensioning of the biceps tendon, the proximal portion of the tendon is resected to leave 20 to 25 mm of tendon proximal to the musculotendinous portion of the biceps. Using a Krackow or whip-stitch, a No. 2 nonabsorbable suture is weaved into the proximal 15 mm of tendon. Enough of the tendon is secured to ensure adequate interference fixation within bone and to position the musculotendinous portion of the biceps muscle beneath the inferior border of the pectoralis major tendon. This is critical for the proper tensioning of the muscle-tendon unit as well for cosmesis.

The proposed tenodesis site is within the bicipital groove 1 cm proximal to the inferior border of the pectoralis tendon which is typically located in the proximal ? of the surgical exposure. The site can be marked with bovie cautery. A guidewire and cannulated reamer are typically used to make a unicortical tunnel through the anterior cortex into the canal. The surgeon can choose from various commercially available interference screws to provide tendon interference fixation within the hole in the humerus. It is important to properly “dunk” the tendon into the hole prior to advancing the interference screw. Place the interference screw flush with the anterior humeral cortex (Figure 4). After irrigation, the fascial layer and deep dermal layer are closed in normal fashion.

Figure 4.

Proper seating of the interference screw flush with the anterior humeral cortex.

Pearls and Pitfalls of Technique

Pearls:

  1. Regional anesthetic blocks do not cover the incision site for an open subpectoral LHB tenodesis which is innervated by T1. Additional local anesthetic is necessary.

  2. When performing an open subpectoral tenodesis the tendon may be palpated within the bicipital groove and pulled out of the wound blindly but this is not recommended for the inexperienced surgeon. Use a blunt retractor medially and a broad hohmann retractor under the pectoralis tendon around the lateral humerus to safely maximize surgical exposure. Avoid excessive medial retraction which may place the musculocutaneous nerve at risk.

  3. When performing a tenodesis with an interference screw take care to seat the interference screw flush to the humeral cortex to obtain maximum fixation strength.

Pitfalls:

  1. Careless sharp medial retractor placement and excessive external rotation during open subpectoral tenodesis can result in iatrogenic injury to neurovascular structures.

  2. When using an interference screw for tenodesis, care must be taken to avoid recessing the screw threads completely into the humeral canal as this will result in loss of fixation.

  3. Tenodesis of symptomatic chronic LHB ruptures is technically more difficult and may require extensive surgical exploration to locate the retracted, scarred tendon with increased risk of neurovascular injury. This surgery should be approached with caution.

Potential Complications

Complications after LHB tenotomy may include: popeye deformity (76% in men, 31% in women), cramp-like arm pain on exertion (8%). However, this procedure is generally well tolerated by elderly low demand patients.

Complications after open subpectoral biceps tenodesis are low-0.7%. Neurovascular injuries associated with OSPBT have been reported. Anatomic studies have demonstrated that the musculocutaneous, radial nerve, and deep brachial artery are all within 1cm of the medial retractor. The senior author recommends using a blunt medial retractor and avoiding external rotation of the arm during exposure to limit neurovascular injury. Other complications include persistent bicipital pain, failure of fixation, deep infection, brachial plexopathy, complex regional pain syndrome and humerus fractures through the tenodesis site have been reported following biceps tenodesis.

Post–operative Rehabilitation

LHB tenotomy does not require postoperative immobilization or restrictions and the rehabilitation protocol is often directed by concomitant procedures.

The postoperative protocol following LHB tenodesis requires sling immobilization for 3-4 weeks and subsequent progression to full passive and active range of motion by 6 weeks, if concomitant procedures allow. Patients are restricted from resisted elbow flexion and supination exercises for 6 weeks, although early active assist and active elbow range of motion is allowed with an interference screw technique. Progression to strengthening is initiated at 8 weeks. Full activity without restriction is usually achieved by 3-4 months. Overhead athletic activity should be delayed until the patient develops full shoulder range of motion and strength. In many cases, however, post-operative rehabilitation is dictated by concomitant procedures performed at the time of tenodesis such as rotator cuff repair.

Outcomes/Evidence in the Literature

Itoi, E, Kuechle, DK, Newman, SR. "Stabilising function of the biceps in stable and unstable shoulders". J Bone Joint Surg Br. vol. 75. 1993. pp. 546-550.

(A cadaver study that tested the contributions of the long and short heads of the biceps to anterior shoulder stability. It found that both long and short heads functioned as anterior stabilizers with the arm in abduction and external rotation, and that their role increased when there was a Bankart lesion. Authors conclude that consideration should be given to strengthen the biceps during rehabilitation for chronic anterior shoulder instability.)

Warner, JJP, McMahon, PJ. "The role of the long head of the biceps in superior stability of the glenohumeral joint". J Bone Joint Surg Am. vol. 77. 1995. pp. 366-372.

(A clinical study which radiographically analyzed the superior translation of the humeral head in patients who had isolated loss of proximal LHBT. Two to 6mm of superior translation occurred as the arm was abducted from 0 to 120 degrees. However, the patients reported no loss in function postoperatively. Authors conclude that the long head of the biceps brachii act as stabilizer of humeral head during shoulder abduction.)

Bennett, W. "Arthroscopic repair of anterosuperior (supraspinatus/subscapularis) rotator cuff tears: a prospective cohort with 2-to 4-year follow-up. Classification of biceps subluxation/instability". Arthroscopy. vol. 19. 2003. pp. 21-33.

(This study reports on treatment of lesions anterosuperior rotator cuff tears, medial/lateral pulleys, long head of the biceps, and superior subscapularis. The biceps was debrided if the lesion was less than 50%, and tenodesed if the injury was greater than 50%. There was improvement in patient reported outcomes, scores revealed improvement in all groups. Authors of this paper proposed a classification system for biceps instability that allowed for treatment based on differential injury to the subscapularis alone, the lateral pulley alone, or combined lesions.)

Habermeyer, P, Magosh, P, Pritsch, M. "Anterosuperior impingement of the shoulder as a result of pulley lesions: a prospective arthroscopic study". J Shoulder Elbow Surg. vol. 13. 2004. pp. 5-12.

(The purpose of this study was to determine the factors influencing the development of an anterosuperior impingement of shoulder. Eighty-nine patients with pulley lesions were evaluated. Four patterns of intraarticular lesions were identified – isolated lesions of the superior glenohumeral ligament (SGHL), SGHL and partial supraspinatus injury, SGHL and partial subscapularis injury, and SGHL and both supraspinatus and subscapularis injury. Of these patients, 89.9% also had involvement of the LHBT including: synovitis, subluxation, dislocation, and partial or complete tearing. The authors concluded that pulley lesions lead to biceps instability, causing increased humeral head translation, and resulting in impingement. This study highlights the importance of evaluating all patients with biceps tendinopathy for rotator cuff pathology.)

Walch, G, Edwards, TB, Boulahia, A. "Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears". J Shoulder Elbow Surg. vol. 14. 2005. pp. 238-246.

(This study reported on the outcomes in selected patients who had arthroscopic biceps tenotomy as part of treatment for full thickness rotator cuff tears. If the patients either had irreparable cuff tears or were unable/unwilling to undergo rehabilitation after rotator cuff repair, they were selected for tenotomy. Constant scores improved significantly in the follow-up period, and 87% of patients were satisfied or very satisfied with the result. Author concluded that biceps tenotomy in select patients can decrease symptoms and results in high degree of patient satisfaction.)

Kelly, AM, Drakos, MC, Feally, S. "Arthroscopic release of the long head of the biceps tendon". Am J of Sports Med. vol. 33. 2005. pp. 208-21.

(A case series documenting outcomes of 54 biceps tenotomies, either isolated or as part of a concomitant shoulder procedure. Outcome scores were good to excellent in 68%; 82.7% men and 36.5% women had a “popeye” sign. Thirty eight percent reported fatigue discomfort or soreness isolated to the biceps after resisted elbow flexion. In patients over 60 years of age, there were no fatigue-related discomfort and 0% loss in flexion strength. The authors concluded that tenotomy is acceptable in less active individuals.)

Mariani, EM, Cofield, RH, Askew, LJ, Li, GP, Chao, EY. "Rupture of the tendon of the long head of the biceps brachii. Surgical versus nonsurgical treatment". Clin Orthop Relat Res. 1988. pp. 233-9.

(This paper reports on surgical versus nonsurgical management of LHBT rupture. Nonsurgically treated patients had 21% loss in supination strength and 8% elbow flexion strength whereas the surgical group had no loss in strength. Although surgically treated patients returned to work later than the nonsurgical patients, greater number of surgically treated patients were able to return to work. Surgical treatment can be recommended for younger individuals, manual workers and athletes.)

Sanders, B, Lavery, KP, Pennington, S, Warner, JJ. "Clinical success of biceps tenodesis with and without release of the transverse humeral ligament". J Shoulder Elbow Surg. vol. 21. 2012. pp. 66-71.

(A retrospective study looking at 127 biceps tenodesis procedures over a 2 year period. Those that had biceps sheath release are compared to those that did not have release of the biceps sheath. Patients who received proximal arthroscopic technique were revised at a significantly higher rate than distal tenodesis technique. Authors conclude that biceps tenodesis methods which do not release the sheath have higher rate of failure. Findings from this study support the theory that leaving pathologic tendon in the bicipital groove is a cause of failure of proximal tenodesis techniques.)

Gregory, JM, Harwood, DP, Gochanour, E, Sherman, SL, Romeo, AA. "Clinical outcomes of revision biceps tenodesis". Int J Shoulder Surg. vol. 6. 2012. pp. 45-50.

(A retrospective study reporting outcomes of 21 patients who had undergone revision biceps tenodesis using open subpectoral technique. Indications for revision were for failures defined as continued pain and ruptured biceps. Seventeen of 21 patients received concomitant procedures during the revision surgery. All patients in this series experienced significant relief. The authors concluded that revision subpectoral biceps tenodesis provides functional improvement and significant pain relief.)

Nho, SJ, Strauss, EJ, Lenart, BA, Provencher, MT, Mazzocca, AD, Verma, NN, Romeo, AA. "Long head of the biceps tendinopathy: diagnosis and management". J Am Acad Orthop Surg. vol. 18. 2010. pp. 645-56.

(This article reviews pertinent anatomy, function, pathology, relation to biceps tendinopathy, and treatment. It details the intricate overlap of biceps function with rotator cuff and labral function. It points out that biceps injury or symptoms rarely occur in the absence of rotator cuff tears. It discusses the various treatment techniques, including tenodesis and tenotomy. It provides a framework for treatment of biceps disorders in a high demand population.)

Summary

The LHB tendinopathy is an important source of pain in the shoulder. LHB tendinopathy is rarely seen in isolation and commonly associated pathology includes rotator cuff tears, glenohumeral arthritis, and subacromial bursitis. Combination of thorough history, physical examination, imaging and diagnostic injections will guide diagnosis and management. Both biceps tenotomy and biceps tenodesis are surgical options in patients who have failed conservative management. Biceps tenotomy is reserved for older, less active patients who will tolerate a potential cosmetic deformity, possibly fatigue related cramping and slightly diminished strength. Biceps tenodesis is advised in younger, higher demand patients but requires more rehabilitation time. When tenodesis is indicated, the preferred technique is an open subpectoral biceps tenodesis using an interference screw because this has shown to be the strongest fixation with the lowest complication rate. Persistent shoulder pain following bicep tenodesis is most commonly due to missed or untreated concomitant shoulder pathologies.

Other complications of biceps tenodesis, such as brachial plexus injury or loss of fixation can be avoided with careful surgical technique.

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