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Ch. ChrysovergisResident OrthopaedicUniversity Hospital LarisaDirector : Prof. K. Malizos

www.Ortho-uth.org

PROXIMAL BICEPS BRACHII TENDON PATHOLOGY

PROXIMAL BICEPS BRACHII PROXIMAL BICEPS BRACHII TENDON IS GENERALY REFERED TENDON IS GENERALY REFERED AS THE LONG HEAD OF THE AS THE LONG HEAD OF THE BICEPS TENDON (LHBT)BICEPS TENDON (LHBT)

THE LONG HEAD OF THE BICEPS THE LONG HEAD OF THE BICEPS TENDON (LHBT) IS RECOGNIZED TENDON (LHBT) IS RECOGNIZED AS AN IMPORTANT PAIN AS AN IMPORTANT PAIN GENERATOR OF THE SHOULDERGENERATOR OF THE SHOULDER

LHBT PATHOLOGY IS RARELY AN LHBT PATHOLOGY IS RARELY AN ISOLATED ENTITY.FREQUENTLY IS ISOLATED ENTITY.FREQUENTLY IS CORRELATED WITH ROTATOR CORRELATED WITH ROTATOR CUFF (RC) AND LABRAL CUFF (RC) AND LABRAL PATHOLOGYPATHOLOGY

TRAUMA,DEGENERATION,OVERUTRAUMA,DEGENERATION,OVERUSE,SUBLAXATION & DISLOCATION SE,SUBLAXATION & DISLOCATION OF LHBT MAY OCCUR OF LHBT MAY OCCUR SIMULTANEOUSLY WITH RC SIMULTANEOUSLY WITH RC PATHOLOGYPATHOLOGY

THEY NEED TO BE IDENTIFIED THEY NEED TO BE IDENTIFIED AND TREATED AT THE SAME TIMEAND TREATED AT THE SAME TIME

ANATOMY OF THE LHBT COMPLEX ANATOMY WITH COMPLEX ANATOMY WITH

RELATION TO THE RC OF RELATION TO THE RC OF THE SHOULDERTHE SHOULDER

IT HAS INTRA-ARTICULAR IT HAS INTRA-ARTICULAR (INTRA-CAPSULAR) AND (INTRA-CAPSULAR) AND EXTRA-ARTICULAR (EXTRA-EXTRA-ARTICULAR (EXTRA-CAPSULAR) PORTIONCAPSULAR) PORTION

INTRA-CAPSULAR INTRA-CAPSULAR THROUGH THE BICEPS THROUGH THE BICEPS PULLEY , EXTRA-CAPSULAR PULLEY , EXTRA-CAPSULAR THROUGH THE BICIPITAL THROUGH THE BICIPITAL GROOVEGROOVE

LHBT LHBT TOTAL LENGTH 9 – 10 cmTOTAL LENGTH 9 – 10 cm LHBT LHBT DIAMETER 5 – 6 mmDIAMETER 5 – 6 mm

LHB TENDON ARISES LHB TENDON ARISES FROM THE FROM THE SUPRAGLENOID SUPRAGLENOID TUBERCLE OF THE TUBERCLE OF THE SCAPULA AND PARTLY SCAPULA AND PARTLY FROM THE SUPERIOR FROM THE SUPERIOR GLENOID LABRUM (BICEPS GLENOID LABRUM (BICEPS ANCHOR) WITH A 50% ANCHOR) WITH A 50% ANATOMIC VARIATION ANATOMIC VARIATION FROM THE POSTERIOR FROM THE POSTERIOR GLENOID LABRUMGLENOID LABRUM

THE INTRA-THE INTRA-CAPSULAR CAPSULAR PORTION PORTION (FLATTENED & (FLATTENED & LARGER) LARGER) STABILIZED BY STABILIZED BY THE BICEPS THE BICEPS PULLEY (RUNS PULLEY (RUNS ALONG THE ALONG THE LATERAL HALF LATERAL HALF OF THE OF THE ROTATOR ROTATOR INTERVAL)INTERVAL)

BICEPS PULEY BICEPS PULEY IS FORMED BY : IS FORMED BY : SUPERIOR SUPERIOR GLENOHUMERGLENOHUMERAL LIGAMENT AL LIGAMENT (SGHL),CORAC(SGHL),CORACOHUMERAL OHUMERAL LIGAMENT LIGAMENT (CHL),FIBERS (CHL),FIBERS OF OF SUPRASPINATUSUPRASPINATUS (SSt) & S (SSt) & SUSCAPULARIS SUSCAPULARIS (SSc) (SSc) TENDONSTENDONS

THE INTRA-CAPSULAR PORTION UNDERGOES AN ABRUPT THE INTRA-CAPSULAR PORTION UNDERGOES AN ABRUPT ANGULATION OF 30 – 40 DEGREESANGULATION OF 30 – 40 DEGREES

FUSING INFERIORLY TO THE BICIPITAL GROOVE THE EXTRA-FUSING INFERIORLY TO THE BICIPITAL GROOVE THE EXTRA-CAPSULAR PORTION (ROUNDED & SMALLER IN CALIBER) IS CAPSULAR PORTION (ROUNDED & SMALLER IN CALIBER) IS STABILIZED BY THE TRANSVERSE HUMERAL LIGAMENT & STABILIZED BY THE TRANSVERSE HUMERAL LIGAMENT & PECTORALIS MAJOR TENDONPECTORALIS MAJOR TENDON

THE BICIPITAL GROOVE IS ABOUT 4mm IN DEPTH WITH A 56 THE BICIPITAL GROOVE IS ABOUT 4mm IN DEPTH WITH A 56 DEGREES MEDIAL WALL ANGLEDEGREES MEDIAL WALL ANGLE

ARTERIAL SUPPLY DESCRIBED BY CHENG et al. FROM ARTERIAL SUPPLY DESCRIBED BY CHENG et al. FROM 3 POTENTIAL SOURCES3 POTENTIAL SOURCES

1.BRANCHES OF THE BRACHIAL ARTERY1.BRANCHES OF THE BRACHIAL ARTERY2.THORACOACROMIAL ARTERY2.THORACOACROMIAL ARTERY3.A RARE VARIANT OF THE CIRCUMFLEX HUMERAL 3.A RARE VARIANT OF THE CIRCUMFLEX HUMERAL

ARTERYARTERY THE TENDON HAS A HYPOVASCULAR ZONE AT 1.2 TO 3 THE TENDON HAS A HYPOVASCULAR ZONE AT 1.2 TO 3

cm FROM IT’S ORIGIN & AN AVASCULAR ZONE WITHIN cm FROM IT’S ORIGIN & AN AVASCULAR ZONE WITHIN THE BICIPITAL GROOVE AT IT’S DEEPER SLIDING THE BICIPITAL GROOVE AT IT’S DEEPER SLIDING PORTION (COMPOSED OF FIBROCARTILAGE)PORTION (COMPOSED OF FIBROCARTILAGE)

SENZORY & SYMPATHETIC INNERVATION NETWORK SENZORY & SYMPATHETIC INNERVATION NETWORK DESCRIBED BY ALPANTAKI et al. IS DISTRIBUTED DESCRIBED BY ALPANTAKI et al. IS DISTRIBUTED ASYMMETRICALLY & PLAY A ROLE IN THE ASYMMETRICALLY & PLAY A ROLE IN THE PATHOGENESIS OF SHOULDER PAIN DURING LHBT PATHOGENESIS OF SHOULDER PAIN DURING LHBT PATHOLOGYPATHOLOGY

LHBT A MULTIFUNCTIONAL TENDON AT THE SHOULDER & ELBOW LHBT A MULTIFUNCTIONAL TENDON AT THE SHOULDER & ELBOW LEVELLEVEL

FUNCTION

HAS CLOSE ANATOMIC RELATION WITH THE ROTATOR CABLE OF THE HAS CLOSE ANATOMIC RELATION WITH THE ROTATOR CABLE OF THE SHOULDER (AS DESCRIBED BY BURKHART et al. FORMING THE SHOULDER (AS DESCRIBED BY BURKHART et al. FORMING THE SUSPENSION BRIDGE MODEL OF THE SHOULDER) AND SUSPENSION BRIDGE MODEL OF THE SHOULDER) AND CONTRIBUTING TO THE SHOULDER STABILITYCONTRIBUTING TO THE SHOULDER STABILITY

PRIMARILY A FLEXOR PRIMARILY A FLEXOR & SUPINATOR OF THE & SUPINATOR OF THE ELBOWELBOW

AT THE SHOULDER AT THE SHOULDER LEVEL IS A DYNAMIC LEVEL IS A DYNAMIC STABILIZER OF THE STABILIZER OF THE HUMERAL HEAD AND HUMERAL HEAD AND WORKS AS :WORKS AS :

1:DEPRESSOR 1:DEPRESSOR (SUPERIOR (SUPERIOR STABILIZER) & STABILIZER) & COMPRESSOR OF COMPRESSOR OF THE HUMERAL HEAD THE HUMERAL HEAD INTO THE GLENOID INTO THE GLENOID CAVITY.CENTERS THE CAVITY.CENTERS THE HEAD INTO THE HEAD INTO THE CAVITYCAVITY

2:LIMITER OF 2:LIMITER OF EXTERNAL ROTATIONEXTERNAL ROTATION

3:LIFTER OF THE 3:LIFTER OF THE GLENOID LABRUM GLENOID LABRUM WHILE ABDUCTIONWHILE ABDUCTION

Αλεξ. Ε. Αγιος Αλεξ. Ε. Αγιος ““ΑνατομικηΑνατομικη””

CLINICAL PATHOLOGYCLINICAL PATHOLOGY LHBT HAS WIDE LHBT HAS WIDE

RANGE OF PATIENT RANGE OF PATIENT GROUPS & IS GROUPS & IS CORELATED WITH CORELATED WITH RC & LABRAL RC & LABRAL PATHOLOGYPATHOLOGY

HEAVY LABORERSHEAVY LABORERS WEIGHTLIFTERSWEIGHTLIFTERS

OVERHEAD OVERHEAD THROWERSTHROWERS

BASEBALL BASEBALL PITCHERSPITCHERS

DISCUS & DISCUS & LANCE LANCE THROWERSTHROWERS

MOST LESIONS HAPPEN DURING THE MAXIMUM EXTERNAL MOST LESIONS HAPPEN DURING THE MAXIMUM EXTERNAL ROTATION AND THE DECELERATION PHASE OF THE THROWROTATION AND THE DECELERATION PHASE OF THE THROW

LHBT LESIONS ALSO APPEAR IN LHBT LESIONS ALSO APPEAR IN PARACHUTERS WHILE TRYING TO PARACHUTERS WHILE TRYING TO CONTROL THE PARACHUTE SLINGSCONTROL THE PARACHUTE SLINGS

OVERUSE & REPETITIVE OVERUSE & REPETITIVE TRACTION,FRICTION,GLENOHUMERTRACTION,FRICTION,GLENOHUMERAL ROTATION ARE THE AL ROTATION ARE THE MECHANICAL CAUSES OF LESIONMECHANICAL CAUSES OF LESION

IN AGES > 45 THE MAIN CAUSE IS IN AGES > 45 THE MAIN CAUSE IS DEGENERATIVE LESIONSDEGENERATIVE LESIONS

MANY AUTHORS TRIED TO CLASSIFY THE PATHOLOGY OF LHBT MANY AUTHORS TRIED TO CLASSIFY THE PATHOLOGY OF LHBT BASED ON ANATOMIC LOCATION , INFLAMMATORY & BASED ON ANATOMIC LOCATION , INFLAMMATORY & DEGENERATIVE CHANGES , INSTABILITY & DISLOCATION , DEGENERATIVE CHANGES , INSTABILITY & DISLOCATION , ARTHROSCOPIC REAL TIME EVALUATION FINDINGSARTHROSCOPIC REAL TIME EVALUATION FINDINGS

(Patte et al. 1990 , Neviaser 80’s , Miller & Savoie , Refior & Sowa , Ahmad et al. , Burkhart et al. , Walch et al. , (Patte et al. 1990 , Neviaser 80’s , Miller & Savoie , Refior & Sowa , Ahmad et al. , Burkhart et al. , Walch et al. , Habermeyer et al. , Lafosse et al.)Habermeyer et al. , Lafosse et al.)

A SIMPLIFIED CLASSIFICATION PROPOSED BY CHENG et al. A SIMPLIFIED CLASSIFICATION PROPOSED BY CHENG et al. INCLUDES 6 TYPES OF LESIONSINCLUDES 6 TYPES OF LESIONS

Type I : TendinopathyType I : TendinopathyType II : SubluxationType II : SubluxationType III : DislocationType III : DislocationType IV : Partial tearsType IV : Partial tearsType V : Complete ruptutreType V : Complete ruptutreType VI : SLAP lesionsType VI : SLAP lesions AN ALTERNATIVE CLASSIFICATION IS INTRA-CAPSULAR & EXTRA-AN ALTERNATIVE CLASSIFICATION IS INTRA-CAPSULAR & EXTRA-

CAPSULAR LESIONSCAPSULAR LESIONSIntra-capsular : SLAP tears , Tendinopathy , Subluxation & DislocationIntra-capsular : SLAP tears , Tendinopathy , Subluxation & DislocationExtra-capsular : Lesions at the level of the bicipital groove Extra-capsular : Lesions at the level of the bicipital groove

(Tenosynovitis , ‘’Hour-glass’’ biceps)(Tenosynovitis , ‘’Hour-glass’’ biceps)

THE CLINICAL PRESENTATION OF THE PATIENT WITH LHBT THE CLINICAL PRESENTATION OF THE PATIENT WITH LHBT PATHOLOGY IS SIMILAR TO THAT OF A PATIENT WITH RC PATHOLOGY IS SIMILAR TO THAT OF A PATIENT WITH RC LESIONSLESIONS

ANTERIOR SHOULDER PAIN AND IMPAIRED FUNCTION AS A ANTERIOR SHOULDER PAIN AND IMPAIRED FUNCTION AS A RESULT OF OVERUSE OR ACUTE TRAUMA IS THE MOST COMMON RESULT OF OVERUSE OR ACUTE TRAUMA IS THE MOST COMMON SYMPTOMSYMPTOM

PAIN MAY OCCUR AT REST OR BE WORSE AT NIGHT & MAY PAIN MAY OCCUR AT REST OR BE WORSE AT NIGHT & MAY RADIATE DISTALY INTO THE MUSCLERADIATE DISTALY INTO THE MUSCLE

A “CLICK” MAY BE PRESENT IN CASE OF INSTABILITY & IN CASE A “CLICK” MAY BE PRESENT IN CASE OF INSTABILITY & IN CASE OF OVERHEAD THROWERS DURING THROW PHASEOF OVERHEAD THROWERS DURING THROW PHASE

THE TENDON MAY BE PALPABLE AT THE BICIPITAL GROOVE AREATHE TENDON MAY BE PALPABLE AT THE BICIPITAL GROOVE AREA

CLINICAL EVALUATION & CLINICAL EVALUATION & TRIALS :TRIALS :

Yergason’s testYergason’s testSpeed’s testSpeed’s testUppercut trialUppercut trialO’Brien’s testO’Brien’s testBear hug trialBear hug trialBelly press trialBelly press trial

Belly press trial : HBelly press trial : Hands on ands on abdomen, elbows abdomen, elbows outout..Press in on Press in on abdomen or keep abdomen or keep elbows out while elbows out while posteriorly directed posteriorly directed force is applied to force is applied to elbowselbows..Positive test if Positive test if unable to keep elbows unable to keep elbows outout (Inability to keep (Inability to keep humerus internal humerus internal rotation).Indicates SSc rotation).Indicates SSc tear , Biceps instability.tear , Biceps instability.

Uppercut trial : Positive if pain presents to the bicipital Uppercut trial : Positive if pain presents to the bicipital groove area or unable to execute an uppercut groove area or unable to execute an uppercut punch under resistance.Indicates Biceps punch under resistance.Indicates Biceps tendinopathy and/or instability , posible SSc teartendinopathy and/or instability , posible SSc tear

Bear hug trial : Bear hug trial : Patient Patient cannot hold cannot hold the hand the hand against the against the shoulder as shoulder as examiner examiner applies anapplies an external external rotation rotation force. force. Indicates Indicates SSc tear , SSc tear , Biceps Biceps instability.instability.

INDICATION OF SLAP INDICATION OF SLAP LESIONLESION

GENERALY THERE’S GENERALY THERE’S NO ABSOLUTE NO ABSOLUTE RELIABILITY TO RELIABILITY TO CLINICAL TESTSCLINICAL TESTS

AUTHORS AUTHORS COMPARED THE COMPARED THE CLINICAL TESTS CLINICAL TESTS RESULTS TO REAL RESULTS TO REAL TIME TIME ARTHROSCOPIC ARTHROSCOPIC EVALUATIONEVALUATION(Holtby & (Holtby & Razmjou , Kibler et al.)Razmjou , Kibler et al.)

CONCLUSION : CONCLUSION : WHEN THE RESULTS WHEN THE RESULTS ARE POSITIVE , IT’S ARE POSITIVE , IT’S QUITE RELIABLE QUITE RELIABLE THAT SOME THAT SOME SHOULDER SHOULDER PATHOLOGY IS PATHOLOGY IS PRESENTPRESENT

TYPE I : TENDINOPATHYTYPE I : TENDINOPATHY- RESULT OF DEGENERATIVE CHANGES:FIBROSIS,CHRONIC INFLAMTION,SCAR RESULT OF DEGENERATIVE CHANGES:FIBROSIS,CHRONIC INFLAMTION,SCAR

TISSUE,FIBROTIC THICKENING,COLLAGEN DISORGANIZATIONTISSUE,FIBROTIC THICKENING,COLLAGEN DISORGANIZATION- MAY BE RESULT OF LHBT INSTABILITYMAY BE RESULT OF LHBT INSTABILITY- MAY BE RESULT OF PARTIAL TEARSMAY BE RESULT OF PARTIAL TEARS- DEGENERATION DURING AGE (OVER 40 – 45)DEGENERATION DURING AGE (OVER 40 – 45)- YOUNGSTERS MOSTLY DUE TO OVERUSEYOUNGSTERS MOSTLY DUE TO OVERUSE- SUBACROMIAL IMPINGEMENTSUBACROMIAL IMPINGEMENT- MECHANICAL CAUSES (TRACTION,FRICTION,SHEARING FORCES)MECHANICAL CAUSES (TRACTION,FRICTION,SHEARING FORCES)- BICIPITAL GROOVE LESIONSBICIPITAL GROOVE LESIONS- ““HOUR-GLASS” BICEPSHOUR-GLASS” BICEPS

Arthroscopic appearance of Arthroscopic appearance of tendon degeneration. tendon degeneration. Normal LHBT (left). Normal LHBT (left). Moderate tendinosis at Moderate tendinosis at the level of the bicipital the level of the bicipital groove with frayed groove with frayed tissue (middle), Severe tissue (middle), Severe diffuse tendinosis diffuse tendinosis (right). (Arthroscopic (right). (Arthroscopic Images courtesy of Dr. Images courtesy of Dr. Allen Anderson, Allen Anderson, Tennessee Orthopaedic Tennessee Orthopaedic Alliance)Alliance)

- “HOUR-GLASS” BICEPS :- “HOUR-GLASS” BICEPS : HYPERTROPHIC TENDINOPATHY RESULTS HYPERTROPHIC TENDINOPATHY RESULTS IN ENTRAPMENT OF LHBT WITHIN THE BICIPITAL GROOVE.THE “HOUR-IN ENTRAPMENT OF LHBT WITHIN THE BICIPITAL GROOVE.THE “HOUR-GLASS” BICEPS , UNABLE TO SLIDE THROUGH , CAUSES “LOCKING” OF THE GLASS” BICEPS , UNABLE TO SLIDE THROUGH , CAUSES “LOCKING” OF THE SHOULDER IN ABDUCTION OR FORWARD FLEXION (AUTHORS COMPARE IT SHOULDER IN ABDUCTION OR FORWARD FLEXION (AUTHORS COMPARE IT WITH A “TRIGGER” FINGER AT THE SHOULDER LEVEL).WITH A “TRIGGER” FINGER AT THE SHOULDER LEVEL).

TYPE II & III : SUBLAXAION & DISLOCATION (INSTABILITY)TYPE II & III : SUBLAXAION & DISLOCATION (INSTABILITY)- SUBSCAPULARIS TEARS ARE MOST COMMONLY ASSOCIATED WITH LHBT INSTABILITYSUBSCAPULARIS TEARS ARE MOST COMMONLY ASSOCIATED WITH LHBT INSTABILITY- ROTATOR INTERVAL MAY ALSO BE CORELATED WITH LHBT INSTABILITYROTATOR INTERVAL MAY ALSO BE CORELATED WITH LHBT INSTABILITY- TRAUMATIC INJURY MECHANISM MAY BE A FALL ON AN OUTSTRECHED ARM WITH FULL TRAUMATIC INJURY MECHANISM MAY BE A FALL ON AN OUTSTRECHED ARM WITH FULL

INTERNAL OR EXTERNAL ROTATION , BACKWARD FALL ON FULLY EXTENDED ARM OR INTERNAL OR EXTERNAL ROTATION , BACKWARD FALL ON FULLY EXTENDED ARM OR WITH ELBOW IMPACT , DIRECT ANTERIOR SHOULDER IMPACTWITH ELBOW IMPACT , DIRECT ANTERIOR SHOULDER IMPACT

- COULD LEAD TO BICEPS TENDINOPATHYCOULD LEAD TO BICEPS TENDINOPATHY- WALCH & BENNET PROPOSED RESPECTIVELY A 4 & 5 TYPES PATTERN OF LHBT ISTABILITYWALCH & BENNET PROPOSED RESPECTIVELY A 4 & 5 TYPES PATTERN OF LHBT ISTABILITY- A RECENTLY MODIFIED PATTERN BY HABERMEYER PROPOSES 6 TYPES OF INSTABILITY A RECENTLY MODIFIED PATTERN BY HABERMEYER PROPOSES 6 TYPES OF INSTABILITY

(SUBLAXATION , INTRA & EXTRA-ARTICULAR DISLOCATION)(SUBLAXATION , INTRA & EXTRA-ARTICULAR DISLOCATION)

(Adapted from Resnick24) Normal: (Adapted from Resnick24) Normal: Graphic depicting the biceps Graphic depicting the biceps pulley region from an oblique pulley region from an oblique axial perspective, perpendicular axial perspective, perpendicular to the course of the LHBT just to the course of the LHBT just superior and medial to the superior and medial to the bicipital groove. The bicipital groove. The coracohumeral ligament (CHL) is coracohumeral ligament (CHL) is the most superficial layer of the the most superficial layer of the biceps pulley mechanism and biceps pulley mechanism and extends over the subscapularis extends over the subscapularis (SScT) and supraspinatus (SST) (SScT) and supraspinatus (SST) tendons. The superior tendons. The superior glenohumeral ligament fuses glenohumeral ligament fuses with the CHL laterally and forms with the CHL laterally and forms a ligament layer between the a ligament layer between the biceps tendon (BT) and the biceps tendon (BT) and the superior-most inserting superior-most inserting subscapularis tendon (SScT) at subscapularis tendon (SScT) at the lesser tuberosity (LT).the lesser tuberosity (LT).

Type I: Tendon displacement-Type I: Tendon displacement-subscapularis tendon (SScT) subscapularis tendon (SScT) tear alone. Medial shift or tear alone. Medial shift or minor subluxation of the minor subluxation of the biceps tendon secondary to a biceps tendon secondary to a partial intrasubstance or partial intrasubstance or anterior tear of theanterior tear of the subscapularis tendon with subscapularis tendon with intact medial ligament intact medial ligament component of the biceps component of the biceps pulley.pulley.

Type II: Tendon displacement-Type II: Tendon displacement-medial ligament tears alone. medial ligament tears alone. Slightly greater medial Slightly greater medial subluxation of the biceps subluxation of the biceps tendon through the torn portion tendon through the torn portion of the ligaments, but the intact of the ligaments, but the intact subscapularis tendon fibers subscapularis tendon fibers prevent medial dislocation.prevent medial dislocation.

Type III: Extra-articular Type III: Extra-articular tendon dislocation-tears tendon dislocation-tears of the medial ligaments of the medial ligaments and subscapularis tendon. and subscapularis tendon. A partial intrasubstance A partial intrasubstance tear of the subscapularis tear of the subscapularis tendon allows the biceps tendon allows the biceps tendon to dislocate tendon to dislocate medially without entering medially without entering the joint because of intact the joint because of intact deep fibers of the deep fibers of the subscapularis tendon.subscapularis tendon.

Type IV: Extra-articular tendon dislocation-Type IV: Extra-articular tendon dislocation-tears of the lateral limbs of the tears of the lateral limbs of the ligaments with an intact subscapularis ligaments with an intact subscapularis tendon. The biceps tendon dislocates tendon. The biceps tendon dislocates anteriorly becoming located anterior anteriorly becoming located anterior to the intact subscapularis tendon. to the intact subscapularis tendon. This pattern has a high association This pattern has a high association with partial or full-thickness tears of with partial or full-thickness tears of the supraspinatus tendon. Although a the supraspinatus tendon. Although a full-thickness tear of the subscapularis full-thickness tear of the subscapularis is not required for this pattern, partial is not required for this pattern, partial articular-sided, bursal-sided, and articular-sided, bursal-sided, and interstitial tears may be seen.interstitial tears may be seen.

Type V: Intra-articular tendon dislocation-Tears Type V: Intra-articular tendon dislocation-Tears of the medial and lateral limbs of the of the medial and lateral limbs of the coracohumeral and superior glenohumeral coracohumeral and superior glenohumeral ligaments with a full-thickness tear of the ligaments with a full-thickness tear of the subscapularis allows medial dislocation of subscapularis allows medial dislocation of the LHBT into the joint. Most commonly the the LHBT into the joint. Most commonly the superior subscapularis tendon superior subscapularis tendon demonstrates a full-thickness tear while demonstrates a full-thickness tear while the lower portion of the tendon remains the lower portion of the tendon remains attached along the inferior portion of the attached along the inferior portion of the lesser tuberosity and surgical neck. The lesser tuberosity and surgical neck. The course of the LHBT moves from a course of the LHBT moves from a dislocated intra-articular position superiorly dislocated intra-articular position superiorly to an extra-articular location anterior to to an extra-articular location anterior to the intact subscapularis fibers inferiorly.the intact subscapularis fibers inferiorly.

Type VI: Intra-articular tendon Type VI: Intra-articular tendon dislocation-tear of the medial limbs of dislocation-tear of the medial limbs of the ligaments and detachment of the the ligaments and detachment of the subscapularis from the lesser subscapularis from the lesser tuberosity. Bridging fibers from the tuberosity. Bridging fibers from the subscapularis to the greater subscapularis to the greater tuberosity remain intact. Medial tuberosity remain intact. Medial dislocation of the biceps tendon dislocation of the biceps tendon remains deep to the subscapularis remains deep to the subscapularis and enters the glenohumeral joint.and enters the glenohumeral joint.

TYPE IV & V : PARTIAL/COMPLETE RUPTURE OF LHBTTYPE IV & V : PARTIAL/COMPLETE RUPTURE OF LHBT- NORMALY LHBT CAN ENDURE HIGH TRACTION FORCES (667 – 890 newtons)NORMALY LHBT CAN ENDURE HIGH TRACTION FORCES (667 – 890 newtons)- RUPTURE OF A HEALTHY LHBT IS RARERUPTURE OF A HEALTHY LHBT IS RARE- CAN OCCUR IN WEIGHTLIFTERS AND MALES AGED 50 OR OLDERCAN OCCUR IN WEIGHTLIFTERS AND MALES AGED 50 OR OLDER- USUALY PARTIAL/COMPLETE THICKNESS RUPTURES ARE ASSOCIATED WITH USUALY PARTIAL/COMPLETE THICKNESS RUPTURES ARE ASSOCIATED WITH

UNDERLYING SHOULDER PATHOLOGY (DEGENERATION , IMPINGEMENT , RC AND/OR UNDERLYING SHOULDER PATHOLOGY (DEGENERATION , IMPINGEMENT , RC AND/OR SLAP TEARS , TENDON INSTABILITY)SLAP TEARS , TENDON INSTABILITY)

- MOST COMMON POINT OF RUPTURE IS THE HYPOVASCULAR AREA (1.2 TO 3 cm FROM MOST COMMON POINT OF RUPTURE IS THE HYPOVASCULAR AREA (1.2 TO 3 cm FROM ANCHOR) OR PROXIMAL TO THE BICIPITAL GROOVE (“GROOVE ENTRY LESION”)ANCHOR) OR PROXIMAL TO THE BICIPITAL GROOVE (“GROOVE ENTRY LESION”)

Fraying of long head of the biceps tendon (LHBT) involving less than 50% of the tendon diameter.Also note abrasion of the humeral head from the LHBT.

Fraying of the long head of the biceps tendon (LHBT) exceeding 50% of the tendon diameter. HH, humeral head.

- PARTIAL THICKNESS TEAR CAUSES SHOULDER PAIN & DISFUNCTIONPARTIAL THICKNESS TEAR CAUSES SHOULDER PAIN & DISFUNCTION- COMPLETE RUPTURE OF A PARTIAL TEAR MAY ACTUALLY RELIEVE THE PAINCOMPLETE RUPTURE OF A PARTIAL TEAR MAY ACTUALLY RELIEVE THE PAIN- THE MOST CHARACTERISTIC SIGN OF A COMPLETE RUPTURE IS THE MOST CHARACTERISTIC SIGN OF A COMPLETE RUPTURE IS “POPEYE DEFORMITY”“POPEYE DEFORMITY” AS AS

THE LHBT SLIDES DISTALY TO THE GROOVE FORMING A MUSCLE BULGE OF THE BICEPSTHE LHBT SLIDES DISTALY TO THE GROOVE FORMING A MUSCLE BULGE OF THE BICEPS- COMPLETE RUPTURE ON “HOUR-GLASS” BICEPS MAY NOT PRESENT THAT SIGNCOMPLETE RUPTURE ON “HOUR-GLASS” BICEPS MAY NOT PRESENT THAT SIGN

TYPE VI : SLAP TEARS TYPE VI : SLAP TEARS (Superior Labrum Anterior – Posterior tears)(Superior Labrum Anterior – Posterior tears)- UP TO 10 TYPES OF SLAP LESIONS HAVE BEEN DESCRIBEDUP TO 10 TYPES OF SLAP LESIONS HAVE BEEN DESCRIBED- BICEPS ANCHOR IS INVOLVED TO A SLAP TEARBICEPS ANCHOR IS INVOLVED TO A SLAP TEAR- Snyder Classification: Original classification which includes Types I-IVSnyder Classification: Original classification which includes Types I-IV- MMECHANISMS : ECHANISMS : repetitive overhead activities (often seen in throwing athletes)repetitive overhead activities (often seen in throwing athletes),,fall on fall on

outstretched arm with tensed bicepsoutstretched arm with tensed biceps,,traction on the armtraction on the arm- SSYMPTOMS : YMPTOMS : deep shoulder paindeep shoulder pain,,mechanical symptoms of popping and clickingmechanical symptoms of popping and clicking,,weakness,easyweakness,easy

fatigue,decrease athletic performancefatigue,decrease athletic performance,instability,,instability,biceps tendon tendernessbiceps tendon tenderness

IMAGINGIMAGING IMAGING SHOULD START WITH PLAIN SHOULDER X-RAYS MAINLY IMAGING SHOULD START WITH PLAIN SHOULDER X-RAYS MAINLY

TO OBSERVE CORELATED GLENOHUMERAL AND/OR TO OBSERVE CORELATED GLENOHUMERAL AND/OR ACROMIOCLAVICULAR BONY PATHOLOGY ACROMIOCLAVICULAR BONY PATHOLOGY (ARTHROSIS)(ARTHROSIS) THAT COULD THAT COULD CAUSE SYMPTOMS CAUSE SYMPTOMS (IMPINGEMENT , CALCIFIC TENDONITIS)(IMPINGEMENT , CALCIFIC TENDONITIS)

ULTRASOUND :ULTRASOUND :- INEXPENSIVEINEXPENSIVE- GOOD DETECTION OF LHB TENDINOPATHYGOOD DETECTION OF LHB TENDINOPATHY- VERRY GOOD DETECTION OF RUPTURES,SUBLUXATION & DISLOCATIONVERRY GOOD DETECTION OF RUPTURES,SUBLUXATION & DISLOCATION- LOW SENSITIVITY FOR DETECTION OF PARTIAL TEARSLOW SENSITIVITY FOR DETECTION OF PARTIAL TEARS- HIGHLY OPERATOR DEPENDENT TECHNIQUE WITH LONG LEARNING CURVEHIGHLY OPERATOR DEPENDENT TECHNIQUE WITH LONG LEARNING CURVE

Biceps tendinopathy : Accumulation of Biceps tendinopathy : Accumulation of fluid within LHBT sheathfluid within LHBT sheath

Biceps dislocation : Biceps groove Biceps dislocation : Biceps groove empty,tendon visible medial to empty,tendon visible medial to it under the SSc fibersit under the SSc fibers

Biceps RuptureBiceps Rupture

Empty Bicipital groove Empty Bicipital groove (transverse)(transverse)

Retracted Biceps Retracted Biceps stump (transverse)stump (transverse)

Retracted Biceps Retracted Biceps stump (longitudinal)stump (longitudinal)

Empty Bicipital Groove Empty Bicipital Groove (longitudinal)(longitudinal)

MRI & MRA : MRI & MRA : - MRI allows verry good visualisation of labrum,Biceps tendon,Bicipital groove,Bony MRI allows verry good visualisation of labrum,Biceps tendon,Bicipital groove,Bony

osteophytesosteophytes- Can detect partial & complete tears of LHBT,SLAP lesions,subluxation & dislocation,associated Can detect partial & complete tears of LHBT,SLAP lesions,subluxation & dislocation,associated

RC pathologyRC pathology- MRA has high accuracy on partial thickness tears & tendinopathy,Biceps pulley lesions,SLAP MRA has high accuracy on partial thickness tears & tendinopathy,Biceps pulley lesions,SLAP

lesionslesions- Both techniques are expensive,MRA needs presence of contrast substance but can raise Both techniques are expensive,MRA needs presence of contrast substance but can raise

sensitivity up to 90%sensitivity up to 90%

SLAP tear (arrow)SLAP tear (arrow)

Biceps dislocation : Biceps Biceps dislocation : Biceps groove empty,tendon groove empty,tendon visible medial to it , SSc visible medial to it , SSc teartear

Biceps rupture : Retracted tendon Biceps rupture : Retracted tendon (arrow)(arrow)

SLAP tear (in circle)SLAP tear (in circle)

TREATMENT STRATEGYTREATMENT STRATEGY METHODS OF TREATMENT INCLUDE CONSERVATIVE (NON-METHODS OF TREATMENT INCLUDE CONSERVATIVE (NON-

SURGICAL) & SURGICAL MANAGEMENTSURGICAL) & SURGICAL MANAGEMENT USUALY THE MANAGEMENT IS NOT ONLY TARGETED TO USUALY THE MANAGEMENT IS NOT ONLY TARGETED TO

SYMPTOMS BUT ALSO AGE , ACTIVITY & COSMETIC DEFORMITY SYMPTOMS BUT ALSO AGE , ACTIVITY & COSMETIC DEFORMITY DEPENDENT.DEPENDENT.

AGE <40 AND/OR >40 WITH HIGH ACTIVITY DEMANDS OR AGE <40 AND/OR >40 WITH HIGH ACTIVITY DEMANDS OR COSMETIC DEFORMITY END UP TO SURGICAL TREATMENTCOSMETIC DEFORMITY END UP TO SURGICAL TREATMENT

AGE >40 AND LOW DEMANDING PATIENTS COULD BE MANAGED AGE >40 AND LOW DEMANDING PATIENTS COULD BE MANAGED WITH NON-SURGICAL TREATMENTWITH NON-SURGICAL TREATMENT

WE MUST KEEP IN MIND TO REPAIR ANY ASSOCIATED RC OR WE MUST KEEP IN MIND TO REPAIR ANY ASSOCIATED RC OR LABRAL LESIONS LABRAL LESIONS

NON-SURGICAL MANAGEMENT :NON-SURGICAL MANAGEMENT :- ACTUVITY MODIFICATIONACTUVITY MODIFICATION- NSAID MEDICATIONNSAID MEDICATION- PHYSICAL THERAPYPHYSICAL THERAPY- STEROID + LOCAL ANESTHETIC INJECTION TO THE BICIPITAL GROOVE STEROID + LOCAL ANESTHETIC INJECTION TO THE BICIPITAL GROOVE (but (but

not into tendon) not into tendon) OR SUBACROMIAL SPACE MAY RELIEVE TENDINOPATHY OR OR SUBACROMIAL SPACE MAY RELIEVE TENDINOPATHY OR IMPINGEMENT SYMPTOMSIMPINGEMENT SYMPTOMS

POOR RESULTS OF THE TREATMENT INVOLVE :POOR RESULTS OF THE TREATMENT INVOLVE :- RC ASSOCIATED PATHOLOGYRC ASSOCIATED PATHOLOGY- MUSCLE SPASMMUSCLE SPASM- ““POPEYE” DEFORMITY POPEYE” DEFORMITY (PARTICULARLY IN THIN PATIENTS)(PARTICULARLY IN THIN PATIENTS)- 8% - 29% DECREASE IN ELBOW FLEXION STRENGTH 8% - 29% DECREASE IN ELBOW FLEXION STRENGTH (Mariani et al. , Deuch et al.)(Mariani et al. , Deuch et al.)- 21% - 23% DECREASE IN FOREARM SUPINATION 21% - 23% DECREASE IN FOREARM SUPINATION (Mariani et al. , Deuch et al.)(Mariani et al. , Deuch et al.)

LHB RUPTURE MAY NOT BE COMPLETELY BENIGN WITH LHB RUPTURE MAY NOT BE COMPLETELY BENIGN WITH CONSERVATIVE TREATMENT,RESULTING IN POSSIBLE PAINFULL CONSERVATIVE TREATMENT,RESULTING IN POSSIBLE PAINFULL SYMPTOMS AND DYSFUNCTION,ESPECIALLY IN YOUNGER PATIENTSSYMPTOMS AND DYSFUNCTION,ESPECIALLY IN YOUNGER PATIENTS

SURGICAL MANAGEMENT :SURGICAL MANAGEMENT :- EITHER PATIENTS <40 , OR FAILURE OF CONSERVATIVE TREATMENT EITHER PATIENTS <40 , OR FAILURE OF CONSERVATIVE TREATMENT

(REPAIR OF ASSOCIATED SHOULDER LESIONS)(REPAIR OF ASSOCIATED SHOULDER LESIONS)- OPEN SURGERY OR ARTHROSCOPIC SURGERYOPEN SURGERY OR ARTHROSCOPIC SURGERY- TENOTOMY OR TENODESISTENOTOMY OR TENODESIS- INDICATED WHEN EXISTS : INDICATED WHEN EXISTS : PARTIAL TEAR (>25% OF THE TENDON CALIBER) , PARTIAL TEAR (>25% OF THE TENDON CALIBER) ,

LONGITUDINAL TEAR WITH POOR TENDON GLIDING INTO THE BICIPITAL GROOVE , LONGITUDINAL TEAR WITH POOR TENDON GLIDING INTO THE BICIPITAL GROOVE , SSc TEAR & LHBT SUBLUXATION/DISLOCATION , COMPLETE LHBT RUPTURE , SLAP SSc TEAR & LHBT SUBLUXATION/DISLOCATION , COMPLETE LHBT RUPTURE , SLAP TEAR , BICEPS PULLEY/ROTATOR INTERVAL LESION WITH LHBT INSTABILITYTEAR , BICEPS PULLEY/ROTATOR INTERVAL LESION WITH LHBT INSTABILITY

BICEPS BICEPS ARTHROSCOPIARTHROSCOPIC TENOTOMY C TENOTOMY NEAR BICEPS NEAR BICEPS ANCHORANCHOR

Bradbury proposed tenotomy with a portion of the superior labrum to Bradbury proposed tenotomy with a portion of the superior labrum to create a bulbous biceps stump entrapped into the bicipital groove as a way create a bulbous biceps stump entrapped into the bicipital groove as a way to prevent “Popeye” deformityto prevent “Popeye” deformity

““Anchor Shape” tenotomy to prevent “Popeye” deformityAnchor Shape” tenotomy to prevent “Popeye” deformity

- A- Appearance after the 2ppearance after the 2 iincisionsncisions..The remnant of The remnant of the LHBthe LHB forms an forms an “A“Anchor shapenchor shape” ” that that anchors the LHB at the anchors the LHB at the articular entrance of the articular entrance of the bicipital groove. Because bicipital groove. Because this remnant is lodged at this remnant is lodged at the bicipital groove, the the bicipital groove, the risks of distal migration risks of distal migration of the tendon and, thus, of the tendon and, thus, ““PopeyePopeye”” deformity are deformity are reduced.reduced.

BICEPS TENODESIS : Usualy to athletes , heavy laborers , active and/or younger BICEPS TENODESIS : Usualy to athletes , heavy laborers , active and/or younger patients , avoid cosmetic deformity.Maintain length-tension relationship of patients , avoid cosmetic deformity.Maintain length-tension relationship of biceps muscle.Can be executed under or into the bicipital groove.biceps muscle.Can be executed under or into the bicipital groove.

Biceps Biceps tenodesis tenodesis with with interferencinterference screw e screw

Biceps tenodesis with suture anchors Biceps tenodesis with suture anchors

Tenotomy versus tenodesis: advantages and disadvantages.

Tenotomy Tenodesis

Advantages

Simple procedure Length-tension relation maintenanceWell-tolerated Normal elbow flexionLess rehabilitation protocol Normal supination power

Faster return to activity Minimize cosmetic deformityAvoid cramping pain

Disadvantages

Cosmetic deformity (Popeye sign) Longer rehabilitationCramping More demanding procedureFatigue pain Low rates of failure fixation, humeralLoss of supination strength Shaft fractures, CRPS, infection

TENOTOMY vs TENODESISTENOTOMY vs TENODESIS- Frost et al. Frost et al. Tenodesis 40% - 100% of patients good/excellent results , failure rate 5% - 48%Tenodesis 40% - 100% of patients good/excellent results , failure rate 5% - 48%Tenotomy 65% - 100% of patients good/excellent results , failure rate 13% - 35%Tenotomy 65% - 100% of patients good/excellent results , failure rate 13% - 35%- Hsu et al.Hsu et al.Tenodesis post op. bicipital pain 24% of patientsTenodesis post op. bicipital pain 24% of patientsTenotomy post op. bicipital pain 17% of patientsTenotomy post op. bicipital pain 17% of patients- UCLAUCLATenodesis 25% of patients , muscle belly deformityTenodesis 25% of patients , muscle belly deformityTenotomy 41% of patients , muscle belly deformityTenotomy 41% of patients , muscle belly deformity

CONCLUSIONSCONCLUSIONS PATIENTS WITH LHBT LESIONS MAY PRESENT ASSOCIATED PATIENTS WITH LHBT LESIONS MAY PRESENT ASSOCIATED

SHOULDER PATHOLOGYSHOULDER PATHOLOGY CLINICAL EVALUATION MUST BE FOLLOWED BY IMAGING TO CLINICAL EVALUATION MUST BE FOLLOWED BY IMAGING TO

DETECT DAMAGED STRUCTURESDETECT DAMAGED STRUCTURES IF FIRST ATTEMPT WITH CONSERVATIVE TREATMENT FAILS , THEN IF FIRST ATTEMPT WITH CONSERVATIVE TREATMENT FAILS , THEN

SURGERYSURGERY TENOTOMY & TENODESIS GIVE GOOD RESULTSTENOTOMY & TENODESIS GIVE GOOD RESULTS TREATMENT & TECHNIQUE DEPEND ON INDIVIDUAL NEEDS OF THE TREATMENT & TECHNIQUE DEPEND ON INDIVIDUAL NEEDS OF THE

PATIENTPATIENT

References & SourcesReferences & Sources Αλεξ. Ε. Αγιος Αλεξ. Ε. Αγιος ““ΑνατομικηΑνατομικη”” Απ. Καραντανας Απ. Καραντανας ““Απεικονιση Αθλητικων κακωσεωνΑπεικονιση Αθλητικων κακωσεων””

Preventing the Popeye Deformity After Release of the Preventing the Popeye Deformity After Release of the Long Head of the Biceps Tendon: An Alternative Long Head of the Biceps Tendon: An Alternative Technique and Biomechanical EvaluationTechnique and Biomechanical Evaluation

Thomas Bradbury, M.D.Thomas Bradbury, M.D. , Warren R. Dunn, M.D., John E. , Warren R. Dunn, M.D., John E. Kuhn, M.D. Kuhn, M.D.

Department of Orthopaedics and Rehabilitation, Vanderbilt Department of Orthopaedics and Rehabilitation, Vanderbilt Sports Medicine, Vanderbilt University Medical Center, Sports Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.Nashville, Tennessee, U.S.A.

MRI Web Clinic — February 2014MRI Web Clinic — February 2014Pathology of the Long Head of the Biceps TendonPathology of the Long Head of the Biceps Tendon

Michael E. Stadnick, M.D.Michael E. Stadnick, M.D. See more at: http://radsource.us/pathology-of-the-See more at: http://radsource.us/pathology-of-the-

long-head-of-the-biceps-tendon/long-head-of-the-biceps-tendon/#sthash.wETKkYCq.dpuf #sthash.wETKkYCq.dpuf

Arthrosc Tech. 2013 May; 2(2): e167–e170.Arthrosc Tech. 2013 May; 2(2): e167–e170.Published online 2013 May 11. doi:  Published online 2013 May 11. doi:  10.101610.1016//j.eats.2013.01.008j.eats.2013.01.008PMCID: PMC3716228PMCID: PMC3716228The “Anchor Shape” Technique for Long Head of the The “Anchor Shape” Technique for Long Head of the

Biceps Tenotomy to Avoid the Popeye DeformityBiceps Tenotomy to Avoid the Popeye DeformityA. A. AliAli NarvaniNarvani, , EhudEhud AtounAtoun, , AlexanderAlexander VanVan TongelTongel, , GiuseppeGiuseppe

SforzaSforza, and , and OferOfer LevyLevy∗∗

Thank YouThank You