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Biceps Tendinopathy and Long-Head Rupture

Long head of biceps tendinopathy and rupture: tenotomy vs tenodesis (corpus-synthesised).

Overview

Surgical management of long head of the biceps pathology is indicated based on clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment [1]. High-resolution ultrasound is reliable to confirm suspected long head of the biceps tendon pathologies [2]. Most shoulder pain in adults is associated with expected aging of the shoulder tendons, and long head of the biceps tendinopathy and rotator cuff tendinopathy occur together more commonly with increasing age [3]. A comprehensive evaluation to determine causative factors is critical in developing an appropriate treatment program for long head of the biceps pain [5].

There is currently no consensus regarding the use of tenotomy versus tenodesis for the treatment of lesions of the long head of the biceps brachii [8]. Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively [6]. Both arthroscopic suprapectoral biceps tenodesis (ASPBT) and open subpectoral biceps tenodesis (OSPBT) yield excellent clinical and functional results for the management of isolated superior labrum or long head of the biceps lesions [7]. Open subpectoral biceps tenodesis and all-arthroscopic suprapectoral biceps tenodesis are both successful surgeries with consistently positive outcomes [20].

Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients, with no identifiable differences between the two approaches [10]. Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure [22]. Clinicians may miss a significant number of rotator cuff tears by not routinely ordering MRI on patients with spontaneous proximal biceps tendon ruptures [9].

Anatomy & Pathophysiology

Clinical Presentation and Diagnosis: Decision-making for surgical management of long head of the biceps tendon pathology depends on clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment [1]. High-resolution ultrasound is reliable to confirm suspected long head of the biceps tendon pathologies in the clinical setting [2].

Epidemiology and Natural History: Long head of the biceps tendinopathy and rotator cuff tendinopathy occur together and are more common with increasing age [3]. Most shoulder pain in adults is associated with expected aging of the shoulder tendons [3]. Nonsurgical treatment can resolve pain effectively and restore function in patients with SLAP tears or biceps lesions [13].

Biomechanics: Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions [24]. In vivo studies have not yet established the stabilizing effect of the long head of the biceps on the glenohumeral joint [24]. The physiologic load required for the long head of the biceps to stabilize the glenohumeral joint remains unknown [24].

Classification

Surgical management of long head of the biceps pathology is indicated based on clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment [1]. High-resolution ultrasound is reliable to confirm suspected long head of the biceps tendon pathologies [2]. Long head of the biceps tendinopathy and rotator cuff tendinopathy occur together and are more common with increasing age [3].

Biceps Pain Classification: A classification system exists for long head of the biceps pain, emphasizing that a comprehensive evaluation to determine causative factors is critical in developing an appropriate treatment program [5].

Tendon Pathology Classifications: Various classifications for the pathology of the long head of the biceps tendon exist, including variants of origin, SLAP lesion classifications, and topographic or disorder-specific subtypes [11]. Tendinopathy of the long head of the biceps tendon is characterized by a prevalence of degeneration and the presence of a marginal inflammation process [12].

Clinical Presentation

Surgical management decisions for long head of the biceps (LHB) tendon pathology depend on clinical presentation, physical examination findings, associated pathologies, and failure of nonsurgical treatment [1]. High-resolution ultrasound is reliable to confirm suspected LHB pathologies in the clinical setting [2]. Most shoulder pain in adults is associated with expected aging of the shoulder tendons [3]. LHB tendinopathy and rotator cuff tendinopathy occur together and are more common with increasing age [3]. A comprehensive evaluation to determine causative factors is critical in developing an appropriate treatment program for LHB pain [5].

Tendinopathy of the LHB is characterized by a prevalence of degeneration and the presence of a marginal inflammation process [12]. Various classifications exist for LHB pathology, including variants of origin, SLAP lesion classifications, and topographic or disorder-specific subtypes [11].

The "Popeye" deformity occurs after spontaneous proximal biceps tendon rupture [9]. Clinicians may miss a significant number of rotator cuff tears by not routinely ordering MRI on patients with spontaneous proximal biceps tendon ruptures [9].

Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examination maneuvers to aid in the diagnosis of LHB pathology compared with diagnostic arthroscopy [23].

Investigations

Surgical management of long head of the biceps pathology is determined by clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment [1]. High-resolution ultrasound is reliable to confirm suspected long head of the biceps tendon pathologies [2].

Physical Examination: Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examination maneuvers to aid in the diagnosis of LHB pathology compared with diagnostic arthroscopy [23]. A comprehensive evaluation to determine causative factors is critical in developing an appropriate treatment program for long head of the biceps pain [5].

Imaging and Pathology Characteristics: Long head of the biceps tendinopathy and rotator cuff tendinopathy occur together and are more common with increasing age [3]. Most shoulder pain in adults is associated with expected aging of the shoulder tendons [3]. Tendinopathy of the long head of the biceps tendon is characterized by a prevalence of degeneration and the presence of a marginal inflammation process [12].

Other Considerations: Various classifications for long head of the biceps tendon pathology exist, including variants of origin, SLAP lesion classifications, and topographic or disorder-specific subtypes [11]. Nonsurgical treatment can resolve pain effectively and restore function in patients with SLAP tears or biceps lesions [13].

Treatment

Non-Operative

Nonsurgical treatment can effectively resolve pain and restore function in patients with SLAP tears or biceps lesions [13]. A comprehensive evaluation to determine causative factors is critical in developing an appropriate treatment program for the painful long head of the biceps [5].

Operative

Indications: Surgical management of long head of the biceps pathology is indicated based on clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment [1]. High-resolution ultrasound is reliable to confirm suspected long head of the biceps tendon pathologies [2]. Long head of the biceps tendinopathy and rotator cuff tendinopathy occur together and are more common with increasing age [3]. Clinicians have been missing a significant number of rotator cuff tears by not routinely ordering MRI on patients with spontaneous proximal biceps tendon ruptures, though further data is needed on whether these findings change treatment [9].

Surgical Approach / Technique: There is currently no consensus regarding the use of tenotomy versus tenodesis for the treatment of lesions of the long head of the biceps brachii [8]. Both arthroscopic suprapectoral biceps tenodesis (ASPBT) and open subpectoral biceps tenodesis (OSPBT) yield excellent clinical and functional results for the management of isolated superior labrum or long head of the biceps lesions [7]. Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients, with no identifiable differences between the approaches [10]. Subpectoral biceps tenodesis reliably relieves pain and improves function [14]. Open subpectoral biceps tenodesis and all-arthroscopic suprapectoral biceps tenodesis are both successful surgeries with consistently positive outcomes [20].

Implant Selection: Arthroscopic biceps tenodesis has been reported with no noted failures of fixation or residual biceps discomfort [4]. Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively [6]. A new “soft anchor” tenodesis technique could be considered as an alternative for suprapectoral biceps tenodesis [15]. An all-arthroscopic, length-tensioned suprapectoral biceps tenodesis technique offers a viable alternative to the open subpectoral biceps tenodesis [16]. The excellent biomechanical strength, high rate of satisfaction after surgery, and high ASES and UCLA postoperative scores make all-arthroscopic suprapectoral biceps tenodesis a novel option for treatment of biceps tendon pathology [18].

Complications

Missed Rotator Cuff Tears: Spontaneous proximal biceps tendon rupture is associated with a significant number of missed rotator cuff tears when MRI is not routinely ordered [9].

Popeye Deformity: The "Popeye" deformity is a visible consequence of spontaneous proximal biceps tendon rupture [9].

Recovery

Surgical management of long head of the biceps pathology is indicated based on clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment [1]. High-resolution ultrasound is reliable to confirm suspected long head of the biceps tendon pathologies [2]. Long head of the biceps tendinopathy and rotator cuff tendinopathy occur together and are more common with increasing age [3]. Comprehensive evaluation to determine causative factors is critical in developing an appropriate treatment program for long head of the biceps pain [5].

Light activity (weeks): Nonsurgical treatment can resolve pain effectively and restore function in patients with SLAP tears or biceps lesions [13].

Full activity (months): Arthroscopic biceps tenodesis technique has not been associated with failures of fixation or residual biceps discomfort in the reported series [4]. Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively [6].

Complete recovery / outcome plateau (months): Arthroscopic suprapectoral biceps tenodesis (ASPBT) yields excellent clinical and functional results for the management of isolated superior labrum or long head of the biceps lesions [7]. Open subpectoral biceps tenodesis (OSPBT) yields excellent clinical and functional results for the management of isolated superior labrum or long head of the biceps lesions [7].

Rehabilitation protocol: There is currently no consensus regarding the use of tenotomy versus tenodesis for the treatment of lesions of the long head of the biceps brachii [8].

Functional milestones: Open biceps tenodesis provided satisfactory outcomes in most patients [10]. Arthroscopic biceps tenodesis provided satisfactory outcomes in most patients [10]. There were no identifiable differences in outcomes between open and arthroscopic biceps tenodesis in the systematic review [10].

Key Evidence

  • [L4] The decision to perform surgical management of long head of the biceps pathology depends on clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment. (10.1177/2325967114s00246)
  • [L4] High-resolution ultrasound is reliable to confirm suspected long head of the biceps tendon pathologies. (10.2340/16501977-2563)
  • [L3] Long head of the biceps tendinopathy and rotator cuff tendinopathy occur together and are more common with increasing age, suggesting that most shoulder pain in adults is associated with expected aging of the shoulder tendons. (10.1097/corr.0000000000003342)
  • [L5] Using this technique, we have not noted any failures of fixation or residual biceps discomfort. (10.1053/otsm.2002.30651)
  • [Paper] The article describes a classification system of long head of the biceps pain and discusses nonoperative treatment concepts and techniques for the painful LHB, emphasizing that a comprehensive evaluation to determine causative factors is critical in developing an appropriate treatment program. (10.1016/j.csm.2015.08.012)
  • [L4] Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively. (10.1016/j.arthro.2021.12.014)
  • [L3] Both ASPBT and OSPBT yield excellent clinical and functional results for the management of isolated superior labrum or long head of the biceps lesions. (10.1177/0363546514547226)
  • [L1] There is currently no consensus regarding the use of tenotomy versus tenodesis for the treatment of lesions of the long head of the biceps brachii. (10.1016/j.arthro.2011.10.017)
  • [L5] The commentary concludes that a recent case series makes the case that clinicians have been missing a significant number of rotator cuff tears by not routinely ordering MRI on patients with spontaneous proximal biceps tendon ruptures, while noting the need for further data on whether these findings change treatment. (10.1016/j.arthro.2018.01.044)
  • [L4] Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients, and there were no identifiable differences in this review. (10.1016/j.arthro.2015.07.028)
  • [L4] The study demonstrates the prevalence of the degeneration process and the presence of marginal inflammation process in tendinopathy of the long head of biceps tendon. (10.5114/pjp.2017.73928)
  • [L4] Subpectoral biceps tenodesis reliably relieves pain and improves function. (10.1186/1471-2474-9-121)
  • [L5] It could be considered as an alternative for suprapectoral biceps tenodesis. (10.1016/j.clinbiomech.2014.12.001)
  • [Paper] This technique offers a viable alternative to the open subpectoral biceps tenodesis. (10.1016/j.eats.2017.06.016)
  • [L4] The excellent biomechanical strength as well as the high rate of satisfaction after surgery and high ASES and UCLA postoperative scores make this technique a novel option for treatment of biceps tendon pathology. (10.1177/2325967114553558)
  • [L3] Open subpectoral biceps tenodesis and all-arthroscopic suprapectoral biceps tenodesis are both successful surgeries with consistently positive outcomes. (10.1016/j.arthro.2016.07.007)
  • [L4] Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure. (10.1016/j.jse.2018.02.061)
  • [L2] Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of LHB pathology compared with diagnostic arthroscopy. (10.1016/j.jse.2017.03.002)
  • [L5] Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions, though in vivo studies have yet to establish this stabilizing effect and the physiologic load required remains unknown. (10.1016/j.arthro.2010.10.014)

See Also

References

[1] Long head of the biceps tendon pathology. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00246

[2] Accuracy of examination of the long head of the biceps tendon in the clinical setting: A systematic review. Journal of Rehabilitation Medicine. 2019. DOI: 10.2340/16501977-2563

[3] Long Head of Biceps Tendinopathy Is Associated With Age and Cuff Tendinopathy on MRI Obtained for Evaluation of Shoulder Pain. Clinical Orthopaedics & Related Research. 2024. DOI: 10.1097/corr.0000000000003342

[4] Arthroscopic biceps tenodesis: Indications and technique. Operative Techniques in Sports Medicine. 2002. DOI: 10.1053/otsm.2002.30651

[5] The Painful Long Head of the Biceps Brachii. Clinics in Sports Medicine. 2016. DOI: 10.1016/j.csm.2015.08.012

[6] Two‐Year Clinical Outcomes and Survivorship After Isolated Biceps Tenodesis. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.12.014

[7] Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514547226

[8] Biceps Tenotomy Versus Tenodesis: Clinical Outcomes. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2011.10.017

[9] Editorial Commentary: “Popeye” Deformity After Spontaneous Proximal Biceps Tendon Rupture: Image, Treat, or Ignore?. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.01.044

[10] Systematic Review of Biceps Tenodesis: Arthroscopic Versus Open. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.07.028

[11] Classifications of pathology of long head of the biceps tendon. 2006.

[12] Is the inflammation process absolutely absent in tendinopathy of the long head of the biceps tendon? Histopathologic study of the long head of the biceps tendon after arthroscopic treatment. Polish Journal of Pathology. 2017. DOI: 10.5114/pjp.2017.73928

[13] Chapter 78 Superior Labrum Anterior to Posterior Tears and Lesions of the Proximal Biceps Tendon. 2019.

[14] Interference Screw vs. Suture Anchor Fixation for Open Subpectoral Biceps Tenodesis: Does it Matter?. BMC Musculoskeletal Disorders. 2008. DOI: 10.1186/1471-2474-9-121

[15] Suprapectoral biceps tenodesis: A biomechanical comparison of a new “soft anchor” tenodesis technique versus interference screw biceps tendon fixation. Clinical Biomechanics. 2015. DOI: 10.1016/j.clinbiomech.2014.12.001

[16] An All‐Arthroscopic, Length‐Tensioned Suprapectoral Biceps Tenodesis Technique. Arthroscopy Techniques. 2017. DOI: 10.1016/j.eats.2017.06.016

[18] Clinical and Biomechanical Evaluation of an All-Arthroscopic Suprapectoral Biceps Tenodesis. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114553558

[20] All‐Arthroscopic Suprapectoral Versus Open Subpectoral Tenodesis of the Long Head of the Biceps Brachii Without the Use of Interference Screws. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.07.007

[22] Immediate physical therapy without postoperative restrictions following open subpectoral biceps tenodesis: low failure rates and improved outcomes at a minimum 2-year follow-up. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.02.061

[23] A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.03.002

[24] Anatomy, Function, Injuries, and Treatment of the Long Head of the Biceps Brachii Tendon. Arthroscopy. 2011. DOI: 10.1016/j.arthro.2010.10.014

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