Management of proximal biceps tendon pathology

Abstract

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician's knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient's next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

Keywords: Biceps tenodesis; Biceps tenotomy; Biceps-labral complex; Long head of the biceps tendon; Shoulder pathology; Superior labrum anterior to posterior lesions.

Figure 1

Schematic illustration of anterior shoulder anatomy from Blum et al[9]. Citation: Blum K, Chen AL, Chen TJ, Waite RL, Downs BW, Braverman ER, Kerner MM, Savarimuthu SM, DiNubile N. Repetitive H-wave device stimulation and program induces significant increases in the range of motion of post operative rotator cuff reconstruction in a double-blinded randomized placebo controlled human study. BMC Musculoskelet Disord 2009; 10: 132. Copyright© The Authors 2009. Published by BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons CC BY license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Figure 2

Anterior view of the left shoulder joint depicting tendons and ligaments from Miniato et al[10]. Citation: Miniato MA, Anand P, Varacallo M. Anatomy, Shoulder and Upper Limb, Shoulder. [Updated 2020 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536933/. Copyright© The Authors 2021. Published by StatPearls Publishing LLC. This book is distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits use, duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, a link is provided to the Creative Commons license, and any changes made are indicated.

Figure 3

Visual depiction of biceps-labral complex with zone 2 red circle as site for arthroscopic suprapectoral tenodesis and zone 3 red circle as open subpectoral tenodesis location from Forsythe et al[120]. Citation: Forsythe B, Zuke WA, Agarwalla A, Puzzitiello RN, Garcia GH, Cvetanovich GL, Yanke AB, Verma NN, Romeo AA. Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodeses Produce Similar Outcomes: A Randomized Prospective Analysis. Arthroscopy 2020; 36: 23-32. Copyright© The Authors 2020. Published by Elsevier. The authors have obtained the permission for figure (Supplementary material). AM: Articular margin; CT: Conjoined tendon; d: Deltoid; DMSS: Distal margin of subscapularis tendon; PMPM: Proximal margin of pectoralis major; SS: Subscapularis.

Figure 4

Special tests for subscapularis from Jain et al[47]. Citation: Jain NB, Wilcox RB 3rd, Katz JN, Higgins LD. Clinical examination of the rotator cuff. PM R 2013; 5: 45-56. Copyright© The Authors 2013. Published by John Wiley and Sons. The authors have obtained the permission for figure (Supplementary material). Top left: Lift-off test; Top right: Belly-press test; Bottom: Bear hug test.

Figure 5

Lateral view showing Popeye deformity from José et al[48]. Citation: José AG, Luís Felipe HFS, Gabriel RSM, Fernando MI. Treatment of the Distal Biceps Brachii Tendon Rupture Using the Three Mini-Incisions Technique: Evaluation through MEPS and DASH. Ortho Rheum Open Access J. 2019; 14: 555888. Copyright© The Authors 2019. Published by Juniper Publishers INC. This work is licensed under Creative Commons Attribution 4.0 License.

Figure 6

Speed test from Jain et al[47]. Citation: Jain NB, Wilcox RB 3rd, Katz JN, Higgins LD. Clinical examination of the rotator cuff. PM R 2013; 5: 45-56. Copyright© The Authors 2013. Published by John Wiley and Sons. The authors have obtained the permission for figure (Supplementary material).

Figure 7

O’Driscoll dynamic labral shear test from Myer et al[57]. Citation: Myer CA, Hegedus EJ, Tarara DT, Myer DM. A user's guide to performance of the best shoulder physical examination tests. Br J Sports Med 2013; 47: 903-907. Copyright© The Authors 2013. Published by BMJ Publishing Group Ltd. The authors have obtained the permission for figure (Supplementary material).