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Proximal Biceps

The document discusses the anatomy, examination, imaging, and management of proximal biceps tendon disorders. Key points include: 1) The proximal biceps tendon attaches to the superior labrum and has four anatomical variants of attachment. It has intra-articular and extra-articular zones within the bicipital groove. 2) Clinical examination involves tests like Speed's test, dynamic and static instability tests, and Yergason's test. Imaging studies like ultrasound and MRI can detect tendinopathy, instability, and rupture. 3) Non-operative management includes NSAIDs, steroid injections, regenerative injection therapies, and rehabilitation. Operative options include tenotomy or tenodes

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Prabath Chinthaka
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61 views23 pages

Proximal Biceps

The document discusses the anatomy, examination, imaging, and management of proximal biceps tendon disorders. Key points include: 1) The proximal biceps tendon attaches to the superior labrum and has four anatomical variants of attachment. It has intra-articular and extra-articular zones within the bicipital groove. 2) Clinical examination involves tests like Speed's test, dynamic and static instability tests, and Yergason's test. Imaging studies like ultrasound and MRI can detect tendinopathy, instability, and rupture. 3) Non-operative management includes NSAIDs, steroid injections, regenerative injection therapies, and rehabilitation. Operative options include tenotomy or tenodes

Uploaded by

Prabath Chinthaka
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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PROXIMAL BICEPS TENDON

ANATOMY
• Biceps Labral Complex (BLC) - Superior
labrum + LHBT
• BLC – Three zones; Inside, Junction,
Tunnel
• Inside – Sup. Labruum + Biceps anchor
• Junction – Intra articular LHBT + Pulleys
• Tunnel – Extra articular LHBT + Bicipital
tunnel (fibro – osseous)
• Superior labrum – histologically distinct
from inferior labrum
• Posterior labrum – closely resembles
LHBT

(Clin Sports Med 2016;35(1):01-18)


ANATOMY
Biceps Anchor
• LHBT directly attaches to supraglenoid tubercle –
50%
• Closely associated with sup. Labrum – 50%
• Four anatomical variants of attachment described
• Type I – entirely post. Labrum
• Type II – predominantly posterior
• Type III – equally anterior & posterior
• Type IV – mostly anterior

(Clin Sports Med 2016;35(1):01-18)


ANATOMY
Intra-articular LHBT
• Average length – 99 – 138 mm
• Needs 19 mm excursion for normal ROM
• Blood supply – sup. labral tributaries proximally &
ascending branches of ant. circumflex
• LHBT has nocioceptive neural elements
(Musculocutaneous nerve)
• Intra articular delivery of LHBT – gold standard
diagnostic modality for pathologic lesions
ANATOMY
Biceps Reflexion Pulley
• Capsulo – ligamentous complex
• Stabelizes LHBT within zone I of bicipital groove
• Contribution – CHL, SGHL, Subscapularis &
Supraspinatus tendons
• Arthroscopically – anteromedial and posterolateral
biceps reflection pulleys
• Pulleys are vulnerable to injury due to repeated
shear forces

(Clin Sports Med 2016;35(1):01-18)


ANATOMY
Bicipital Tunnel
• Fibro-osseous enclosure of extra-articular LHBT
• Often conceal hidden lesions
• Divided in to 3 anatomic zones

Function
• Source of debate & controversy
• EMG – show relative inactivity during isolated shoulder mvt
• Cadaver studies – mainly depressor, important for anterior/ posterior &
inferior stability
• Most clinically relevant study by Giphart et. al. – little effect on gleno-
humeral kinamatics
(J Shoulder Elbow Surg 2015;24(4):215 -24)
EXAMINATION
• Popeye deformity (do not miss a SOL) • Biceps Tenderness – hallmark of biceps
• Ludington Test – complete tear disorders
• Elbow flexed & arm 10 IR
EXAMINATION
Biceps Instability tests Yergason’s Test
• Dynamic – tendon subluxate in & out of • Used to diagnose degenerative &
the groove with mvt inflammatory conditions
• Static – typically seen with pulley injury or • Reliability is controversial
Ssc tendon tear
EXAMINATION
Speed’s Test Other Tests
• Main clinical utility for biceps pathology • Lift - off Test
• Also positive for SLAP, Cuff tears & OA • Biceps Entrapment Test
• Dynamic Shear Test
• Active Compression Test – O’Brien
PROXIMAL BICEPS DISORDERS
Inflammatory Instability
Primary Tendonitis • Subluxation/ dislocation of LHBT
• Inflammation in the groove without • Rotator interval injury, pulley rupture, SSC
tendon injury, SLAP injuries
associated pathology
• Overuse
Rupture
• Partial split/ fraying/ complete rupture
Secondary Tendonitis
• secondary to: overuse, attrition,
• Chronic inflammation with associated
impingement, chronic inflammation,
shoulder pathology
instability
SYMPTOMS OF BICEPS DISORDERS
Tendonitis Instability
• Anterior shoulder pain • Snapping or clicking
• Along bicipital groove • Anterior shoulder pain
• Made worse by activity
• Worse at night Rupture
• Unable to sleep on the affected shoulder • Sudden audible pop
• Radiates down the arm • Sudden onset severe sharp pain
• Biceps cramps
• Anterior arm bruising
• weakness
• Popeye sign
IMAGING STUDIES - USS
Cheap but highly operator dependent Instability
Tendinopathy • USS can not assess pulley injuries
• Tendon thickening • “chondral Print” indirect US sign due to
• Synovial hypertrophy chondral erosion
• Fluid around the tendon in the groove
• Accuracy – 50% - 96%
IMAGING STUDIES - USS
• Rupture
Instability
• Absence of LHBT in the groove & cranially
• USS shows excellent accuracy to detect – “empty groove”
LHBT subluxation/ dislocation
• Retracted tendon stump
• Dynamic studies can be done
• +/- upper SSC tendon injury
IMAGING STUDIES - MRI
• Preferred imaging modality with/without
contrast
• Visualisation relies on sequences on the
proper plane

Degeneration Subluxation/ Dislocation


IMAGING STUDIES - MRI
Tendonitis Rupture
MANAGEMENT – NON OPERATIVE
NSAIDS Other Modalities
• Beneficial in short term to control pain &
swelling • Topical Nitro-glycerine
• Little benefit in treating chronic tendon • Iontophoresis
injuries
• Phonophoresis
(Am Fam Physician 2013;87(7):486)
• Theraputic US therapy
Steroids
• Extracorporeal shock wave therapy
• Provide short term anti inflammatory effect
• Low - level laser therapy
• Can be US guided injection
(Am Fam Physician 2013;87(7):486)
• Risk of LHBT rupture
• Preferred LA – Ropivacain (less chondrotoxic)
(J bone Joint Surg Am 2008;90(5):986-91)
MANAGEMENT – NON OPERATIVE
Regenerative Injection Therapy Rehab Programmes
• US guided • Acute Phase
• Important role in non surgical Mx • Pain control, restore muscle balance, baseline
dynamic stability
• Induce an inflammatory response to regenerate
damaged tissue • Intermediate phase
• strengthening, increasing flexibility, Improving ROM,
- Dextrose enhancing neuro muscular control
- PRP • Advanced strengthening Phase
- WBC • Aggressive strengthening, restore muscular endurance & power,
prepare to return to activity
- RBC
• Return to activity phase
- Stem cells
(Phys Med Rehabil Clin N Am 2010;21(3):585 – 605) (Clin Sports Med 2016;35(1):75-92)
MANAGEMENT - OPERATIVE
Indications Tenotomy vs. Tenodesis
• LHBT injury/ tear (25% - 50% OF tendon • Several variables need to be considered
diameter)
- Age
• Instability
- Functional demand
• Tenosynovitis
- Cosmesis
• Bicipital groove pain (usu. due to poor gliding
IIry to longitudinal tear) - Body Habitus
• Failed conservative treatment - Operative time
• SLAP tear - Workers compensation
• Subscap tear with LHBT subluxation - Patient compliance with rehab
MANAGEMENT – OPERATIVE; TENOTOMY
Tenotomy – Surgical options
Arthroscopic Tenotomy
• Quick & technically simple
• Posterior viewing portal & antero superior
working portal
• LHBT retracts in to the groove
• Stump is trimmed

Looped Tenotomy
• Described by Goubier et. al.
• LHBT is looped on itself to prevent retraction
(Arthrosc Tech 2014;3(4):e427-30)
MANAGEMENT – OPERATIVE; TENODESIS
Several techniques have been described Surgical options
• Open/ Arthroscopic • A’copic soft tissue tenodesis
• Fixation – interference screw/ suture anchor/ • A’copic suture anchor tenodesis
sutureless anchor • A’copic knotless anchor tenodesis
• Level – sub • Mini-open suture anchor subpectoral
• Intra osseous/ extra osseous tenodesis
• Mini-open interference screw subpectoral
• Some prefer mini open subpectoral tenodesis tenodesis
– remove pain generators from whole groove • Mini-open key hole tenodesis
• Mini-open bone tunnel tenodesis
MANAGEMENT – OPERATIVE; TENODESIS
MANAGEMENT – OPERATIVE; TENOTOMY VS.
TENODESIS
Tenotomy Tenodesis
Pros • Technically easier • Lower incidence of Popeye deformity
• Fewer post op restrictions • Maintenance of length – tension relationship
• Quicker recovery • Retaining good supination strength
• Shorter operative time

Cons • Higher chance of Popeye deformity • More post op restrictions


• Muscle cramping/ fatigue • Longer recovery
• Longer operative time

(Clin Sports Med 2016;35(1):93-111)


THANK YOU!

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