Atypical pattern of acute severe shoulder pain: contribution of sonography

A patient presented with an atypical pattern of acute severe shoulder pain. Sonography elucidated the mechanism of the pain and allowed effective treatment. The patient was unable not only to move her shoulder but also to flex and to extend her elbow. Sonography showed a calcific deposit in the subscapularis tendon with local edema displacing the long head of the biceps tendon out of the bicipital groove. Local injection of a glucocorticoid under ultrasonographic control was followed within 7 days by subsidence of the subscapularis tendon edema and by a return of the long head of the biceps tendon to its normal position in the bicipital groove.     

Arthroscopic absence of the long head of the biceps tendon

Absence of the long head of the biceps tendon was detected during arthroscopic evaluation of shoulder pain in a weight-lifter. Magnetic resonance imaging and ultrasound showed the presence of a hypoplastic tendon with altered depth and width of the bicipital groove. The tendon-glenoid insertion shown by magnetic resonance imaging was apparently normal.     

Subscapularis Tendon Tears: Identifying Mid to Distal Footprint Disruptions

We present an arthroscopic technique used to identify mid to distal subscapularis tendon disruptions. These tears can be easy to miss and require a thorough arthroscopic evaluation of the medial biceps sling and the medial side wall of the bicipital groove to detect. The arthroscopic procedure is performed with the patient in the lateral decubitus position, and the same portals used for standard subscapularis repair are used for this technique. If a high degree of clinical suspicion exists for subscapularis pathology and no tendon disruption is initially identified, an inspection of the medial biceps sling and medial side wall of the bicipital groove may show mid to distal subscapularis tendon disruptions. A 70° arthroscope is essential in visualizing the medial sling, the subscapularis tendon, the biceps tendon, and the proximal 2 cm of the bicipital groove. Any disruptions or rents in the medial sling or medial side wall are suggestive of a subscapularis tear. Once a tear is identified, we proceed with a biceps tenodesis and then take down the medial sling from the lesser tuberosity to better delineate the subscapularis footprint. The subscapularis may then be repaired in standard fashion.     

The role of the bicipital groove in tendopathy of the long biceps tendon.

Long biceps tendon disease is often underrated but plays an important role in anterior shoulder pain. We studied prospectively the anatomy of the bicipital groove and its relationship to clinical symptoms. Sixty-seven consecutive patients were investigated by mutual ultrasonography and radiographs of the intertubercular groove. All images were scrutinized for biceps tendon status (ultrasonography) and groove anatomy (radiography). Thirty-seven patients (21 male, 16 female, average age 48 years) had chronic anterior shoulder pain, and 30 patients (16 male, 14 female, average age 46 years) served as a control group. In 28 shoulders we found sonographic signs of tendovaginitis, and in 14 we found degenerative changes. The mean age of patients with pathologic conditions of the long biceps tendon was 40 years, significantly lower than that of the complete study group. The x-ray films revealed a great variation in the medial and total opening angle of the groove, whereas width, depth, and humeral head diameter showed sex-related differences. Radiologic signs of groove degeneration correlated in 43.6% with biceps tendon disease on the sonogram. Our study revealed statistically significant correlations between groove anatomy and long biceps tendon disease, which should be considered more while shoulder problems are evaluated.     

Die arthroskopische Tenodese bei Schädigung der langen Bizepssehne

OBJECTIVE: Resection of the intraarticular part of the long head of the biceps and tenodesis to decrease shoulder pain due to a pathologically altered biceps tendon and to improve shoulder function. INDICATIONS: Tenosynovitis. State of prerupture. Instability (subluxation or dislocation of tendon from intertubercular groove). Intraarticular entrapment secondary to hypertrophy of the long head of the biceps in the presence of an intact cuff. To be performed during arthroscopic cuff repair or during debridement of an irreparable cuff tear. CONTRAINDICATIONS: Very thin, frayed, almost ruptured biceps tendon. Complete rupture of the long head of the biceps. SURGICAL TECHNIQUE: Standard arthroscopy with 30 degrees scope inserted through the posterior portal. Detachment of the long head from the glenoid origin. Longitudinal opening of the bicipital groove. Exteriorization and doubling of the tendon. Drilling of a socket starting in the groove but perforating the posterior cortex only with a guide wire. Passing of the tendon in an anteroposterior direction and securing the anchorage with a bioresorbable PLA interference screw. RESULTS: Between 1997 and 1999, an arthroscopic tenodesis was performed in 43 patients. Minimum follow-up 2 years. The absolute Constant Score improved from 43 points preoperatively to 79 points at the time of follow-up. No loss of elbow extension or flexion; power of biceps after tenodesis 90% of opposite side. Early on, two failures of tenodesis occurred.     

Disorders of the long head of the biceps tendon

Without a clear understanding of the functional role of the biceps tendon, treatment recommendations have been a subject of controversy. An objective review of the available information would suggest that some humeral head stability may be imparted through the tendon. However, the magnitude of this function is likely to be small and possibly insignificant. In contrast, the symptomatic significance of the long head of the biceps is less controversial, and it has become increasingly recognized as an important source of persistent shoulder pain when not specifically addressed. When present, persistent pain from the long head of the biceps is likely to have more negative functional consequences than loss of the tendon itself. Given these concerns, evaluation and treatment of patients with long head of the biceps disorders should be individualized, based on the likelihood that biceps-related pain will resolve. Although not universally accepted, we recommend tenodesis of the long head of the biceps in those cases in which there are either chronic inflammatory or structural changes, which would make it unlikely that the pain would resolve. These clinical situations in which tenodesis would be required include greater than 25% partial thickness tearing of the tendon, chronic atrophic changes of the tendon, any luxation of the biceps tendon from the bicipital groove, any disruption of associated bony or ligamentous anatomy of the bicipital groove that would make autotenodesis likely (i.e., 4-part fracture), and any significant reduction or atrophy of the size of the tendon that is more than 25% of the normal tendon width. Relative indications for biceps tenodesis also include biceps disease in the context of a failed decompression for rotator cuff tendinitis. It should be emphasized that routine tenodesis is not recommended during operative treatment for the rotator cuff. Rather, we avoid tenodesis whenever it is believed that inflammatory changes to the biceps tendon are reversible. Because of this, tenodesis is not required in most cases.     

Visualization of the anatomy of the rotator interval and bicipital sheath

A systematic evaluation of the glenohumeral joint should be routinely performed with all shoulder arthroscopy and include all anatomic areas. However, to date, less attention has been given to the insertion of the subscapularis tendon, superior glenohumeral ligament (SGHL), and medial head of the coracohumeral ligament (MCHL). This article outlines arthroscopic techniques that may aid in the evaluation of the anatomy of the rotator interval and bicipital sheath. In this apical region, the CHL contributes fibers to the SGHL (forming the internal reflection of the bicipital groove–SGHL/CHL complex), the subscapularis tendon, and the joint capsule. The CHL is more anterior to the SGHL. There is a distinct anatomic difference between the SGHL/CHL insertion complex and the subscapularis insertion. The normal insertion of the subscapularis tendon is into a small trough on the lesser tuberosity. Together, these structures make up the medial wall of the superior biceps pulley. With the arthroscope advanced to the anterior portion of the joint, the shoulder is elevated from 60° to 90° and a neuroprobe is advanced through the anterior cannula. By internally rotating the arm, the subscapularis tendon insertion and SGHL/CHL complex slacken. A neuroprobe can be placed under the insertion of the subscapularis tendon and SGHL/CHL complex. A 70° arthroscope can aid in visualization with less shoulder elevation. These techniques allow for a thorough visualization of the structures of the rotator interval and medial bicipital sheath.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp 107–111     

Proximal coracobrachialis tendon rupture,subscapularis tendon rupture,and medial dislocation of the long head of the biceps tendon in an adult after traumatic anterior shoulder dislocation

Rupture of the coracobrachialis is a rare entity, in isolation or in combination with other muscular or tendinous structures. When described, it is often a result of direct trauma to the anatomic area resulting in rupture of the muscle belly. The authors present a case of a 57-year-old female who suffered a proximal coracobrachialis tendon rupture from its origin at the coracoid process, with concomitant subscapularis tear and medial dislocation of the long head of biceps tendon after first time traumatic anterior shoulder dislocation. Two weeks after injury, magnetic resonance imaging suggested the diagnosis, which was confirmed during combined arthroscopic and open technique. Soft-tissue tenodesis of coracobrachialis to the intact short head of the biceps, tenodesis of the long head of biceps to the intertubercular groove, and double-row anatomic repair of the subscapularis were performed. The patient did well postoperatively, and ultimately at 6 months follow-up, she was without pain, and obtained 160° of active forward elevation, 45° of external rotation, internal rotation to T8, 5/5 subscapularis and biceps strength. Scoring scales had improved from the following preoperative to final follow-up: American Shoulder and Elbow Surgeons, 53.33-98.33; constant, 10-100; visual analogue scale-pain, 4-0. DASH score was 5.     

Entrapment of the long head of the biceps tendon: the hourglass biceps--a cause of pain and locking of the shoulder

We describe an unrecognized mechanical condition affecting the long head of the biceps (LHB) tendon with entrapment of the tendon within the joint and subsequent pain and locking of the shoulder on elevation of the arm. We identified 21 patients with a hypertrophic intraarticular portion of the LHB tendon during open surgery (14 patients) or arthroscopic surgery (7 patients). All cases but one were associated with a rotator cuff rupture. Patients were treated by biceps tenotomy (2 patients) or tenodesis (19 patients) after removal of the hypertrophic intraarticular portion of the tendon and appropriate treatment of concomitant lesions. Minimum follow-up was 1 year. All patients presented with anterior shoulder pain and loss of active and passive elevation averaging 10 degrees to 20 degrees. A dynamic intraoperative test, involving forward elevation with the elbow extended, demonstrated entrapment of the tendon within the joint in each case. This test creates a characteristic buckling of the tendon and squeezing of it between the humeral head and the glenoid (hourglass test). The mean Constant score improved from 38 to 76 points at the final follow-up (P <.05). Complete and symmetric elevation was restored in all cases after resection of the intraarticular portion of the LHB tendon. The hourglass biceps is caused by a hypertrophic intraarticular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm; it can be compared with the condition of trigger finger in the hand. A loss of 10 degrees to 20 degrees of passive elevation, bicipital groove tenderness, and radiographic findings of a hypertrophied tendon can aid in the diagnosis. A definitive diagnosis is made at surgery with the hourglass test: incarceration and squeezing of the tendon within the joint during forward elevation of the arm with the elbow extended. The hourglass biceps is responsible for a mechanical block, which is similar to a locked knee with a bucket-handle meniscal tear. Simple tenotomy cannot resolve this mechanical block. Excision of the intraarticular portion of the LHB tendon, during bipolar biceps tenotomy or tenodesis, must be performed. The hourglass biceps is an addition to the familiar pathologies of the LHB (tenosynovitis, prerupture, rupture, and instability) and should be considered in cases of shoulder pain associated with a loss of elevation.     

Stabilization of the long head of the biceps tendon in the context of early repair of traumatic subscapularis tendon tears

BACKGROUND: Tears of the subscapularis tendon commonly are associated with instability of the long head of the biceps tendon. Standard surgical treatment includes tenodesis or tenotomy of the biceps tendon. However, chronic discomfort from spasms and cosmetic disadvantages have been reported following both procedures, while the potential for functional impairments remains controversial. We investigated the outcome of stabilization of the long head of the biceps tendon in the context of early repair of traumatic tears of the subscapularis tendon. METHODS: We performed stabilization of an unstable, structurally intact long head of the biceps tendon in twenty-one patients in the acute phase after a traumatic tear of the subscapularis tendon. The average period from the injury to the surgery was 6.2 weeks. Open tendon stabilization and subscapularis reconstruction were performed with transosseous sutures. The follow-up consisted of clinical examination (with determination of the absolute, age and gender-related, and individual relative Constant scores; clinical evaluation of the long head of the biceps; and subjective determination of shoulder function) and dynamic ultrasound examination. RESULTS: The average follow-up period was 28.4 months. The mean absolute Constant score increased from 26.3 points preoperatively to 79.3 points postoperatively (p < 0.01). The mean age and gender-related Constant score improved from 28.0% to 87.0% (p < 0.01). Seven patients showed clinical symptoms consistent with mild biceps tendinopathy. Using dynamic ultrasound examination, we found two cases of recurrent instability (medial subluxation) of the long head of the biceps tendon. Secondary rupture of the long head of the biceps tendon occurred in one patient, twenty-six months after the surgery. CONCLUSIONS: The functional outcomes of stabilization of the long head of the biceps tendon in the context of early repair of a traumatic tear of the subscapularis tendon were comparable with the results of tenodesis or tenotomy reported in previous studies. The cosmetic results were superior, and chronic discomfort from spasms was not observed. Stabilization of the tendon of the long head of the biceps can be recommended as a treatment option for selected patients and should be discussed as an alternative to tenodesis or tenotomy, particularly in a young patient.     

The biceps tendon footprint

Background By arthroscopy, we observed a phenomenon that, according to our knowledge not previously described, we call the "biceps tendon footprint" (BTF)-an area of chondromalacia beside the bicipital groove.

Patients and methods We studied 118 shoulder arthroscopies prospectively. We documented whether a BTF could be observed and what the main pathology associated with it was. We used 3 grades of cartilage wear to describe BTF, and we analyzed pathological changes in associated structures (subscapularis, biceps tendon and humeral head).

Results We found a BTF in 16% of the cases. Associated diagnoses were cuff tears and instabilities, most often multidirectional. We observed all 3 grades of cartilage wear, grade 3 being the commonest. Biceps synovitis occurred more often in the BTF group.

Interpretation BTF is not a rare phenomenon. Mal-traction of the intraarticular biceps tendon in MDI and cuff tears in addition with biceps synovitis appear to cause BTF.     

Die subpektorale Tenodese der langen Bizepssehne bei Pathologien der langen Bizepssehne und des Pulley-Systems

Objective

The presented surgical technique aims at fixation of the long head of the biceps tendon at the proximal humerus, distal to the bicipital groove, after arthroscopic tenotomy. This preserves the length and shape of the biceps muscle belly and avoids groove tenderness.

Indications

All forms of degenerative changes of the long head of the biceps tendon, biceps instability due to pulley lesions, irreparable SLAP tears. The technique offers a cosmetically favorable outcome compared to a tenotomy.

Contraindications

Old complete tears of the long head of the biceps, significant loss of bone density due to osteoporosis, tumor or bone cysts, implants in the proximal humerus, such as intramedullary nails, stem of total shoulder replacement. The presented technique is not indicated for patients with unspecific chronic shoulder pain or if asymmetric shape of the upper arm due to distal migration of the biceps is not relevant.

Surgical technique

After arthroscopic tenotomy of the long head of the biceps tendon, a small incision at the level of the pectoralis major tendon is made to the axillary fold. The stump of the long head of the biceps tendon is tenodesed to a predrilled hole with a bioabsorbable screw.

Postoperative management

No active training of the biceps for 6?weeks, a sling for comfort is optional until healing of the wound is completed.

Results

Clinical studies of several authors have shown significant postoperative increase in all scores evaluated. Safety of the screw fixation and a low complication rate have been proven.     

Biceps tendon and superior labral injuries

Twenty-two patients sustained injury to the biceps tendon, rotator cuff interval, or superior labrum. Seven patients with "interval lesions" underwent biceps tenodesis, one biceps repair, and three subscapularis repairs. All were satisfied, although one tenodesis failed with distal biceps retraction. Key arthroscopic findings included biceps or subscapularis fraying. Thirteen patients with "S.L.A.P. (superior labrum anterior to posterior) lesions" underwent labral debridement. All but one obtained pain relief. Eight cadaveric shoulders exhibited extreme anatomic variability of the bicipital origin/superior labral attachment. Biomechanical study showed anterior-superior and posterior-superior labral strain with simulated biceps contraction to be greatest in shoulder abduction (p < 0.01). Biceps tendon strain was greatest in shoulder adduction (p < 0.05). A continuum of injuries to the biceps tendon exist, from the rotator cuff interval to the labral attachment. Key arthroscopic findings may assist in the difficult diagnosis of interval lesions. Individual anatomy and mechanism of injury may determine the site of the lesion.     

Cross-sectional area of the tendon and the muscle of the biceps brachii in shoulders with rotator cuff tears

Background The intraarticular portion of the long head of the biceps tendon is often widened in shoulders with cuff tears. It is unclear whether this is a local phenomen or is caused by muscle hypertrophy.

Methods We investigated morphological changes of the biceps brachii in 14 embalmed shoulders: 7 with intact rotator cuff and 7 with rotator cuff tears.

We measured the cross-sectional area (CSA) of the tendon of the long head of the biceps (LHB) at 9 levels between the glenoid origin and the musculotendinous junction. The muscle volume and the muscle fiber length of the long and short heads of the biceps were measured to calculate the physiological CSA (PCSA) by dividing the volume by the fiber length.

Results The CSA of the LHB tendon at the entrance to the bicipital groove was greater in cuff tear shoulders than in normal shoulders. The PCSA of the biceps was similar in normal and cuff tear shoulders.

Interpretation Hypertrophy of the LHB tendon appears to be a localized morphological change near the entrance to the bicipital groove.     

Cross-sectional area of the tendon and the muscle of the biceps brachii in shoulders with rotator cuff tears: a study of 14 cadaveric shoulders

Background The intraarticular portion of the long head of the biceps tendon is often widened in shoulders with cuff tears. It is unclear whether this is a local phenomen or is caused by muscle hypertrophy.

Methods We investigated morphological changes of the biceps brachii in 14 embalmed shoulders: 7 with intact rotator cuff and 7 with rotator cuff tears.

We measured the cross-sectional area (CSA) of the tendon of the long head of the biceps (LHB) at 9 levels between the glenoid origin and the musculotendinous junction. The muscle volume and the muscle fiber length of the long and short heads of the biceps were measured to calculate the physiological CSA (PCSA) by dividing the volume by the fiber length.

Results The CSA of the LHB tendon at the entrance to the bicipital groove was greater in cuff tear shoulders than in normal shoulders. The PCSA of the biceps was similar in normal and cuff tear shoulders.

Interpretation Hypertrophy of the LHB tendon appears to be a localized morphological change near the entrance to the bicipital groove.     

Arthroscopic tenodesis using a bioabsorbable interference screw and soft anchor: A case series of 60 patients

BackgroundVarious arthroscopic tenodesis techniques for the treatment of long head of the biceps tendon pathologic abnormalities have been described.PurposeThis study evaluated the clinical outcomes of using a bioabsorbable interference screw and soft anchor for long head of the biceps tendon arthroscopic tenodesis.MethodsSixty patients treated by this technique between February 2013 and March 2015 were followed up for at least 2 years. In our operative technique, after the bone hole was made just proximal to the pectoralis major, the soft anchor was inserted at the bottom of the hole. After tenotomy of the long head of the biceps tendon proximal to the bone hole, the tendon was fixed into the bottom of the hole temporarily using the soft anchor. Finally, the tendon was fixed in the hole with a bioabsorbable interference screw.ResultsThe UCLA score 15.1 points preoperatively and 32.4 points at follow-up (p < 0.05). The Constant 55.8 points preoperatively and 93.9 points at follow-up (p < 0.01). After biceps tenodesis, no cosmetic deformities were found in 56 patients (93.3%), and four patients (6.7%) had a Popeye deformity. On postoperative magnetic resonance evaluation, the long head of the biceps tendon was located on the bicipital groove without deviation in 53 cases (88.3%), on the bicipital groove with a partial deviation in 6 cases (10.0%), and outside the bicipital groove with complete deviation (dislocated) in 1 case (1.7%).ConclusionWe found that arthroscopic biceps tenodesis using a soft anchor provided a reliable means for treating biceps pathology with no cosmetic deformities and with good clinical results.     

Arthroscopic Tenodesis for Lesions of the Long Head of the Biceps

Abstract Objective: Resection of the intraarticular part of the long head of the biceps and tenodesis to decrease shoulder pain due to a pathologically altered biceps tendon and to improve shoulder function. Indications: Tenosynovitis. State of prerupture. Instability (subluxation or dislocation of tendon from intertubercular groove). Intraarticular entrapment secondary to hypertrophy of the long head of the biceps in the presence of an intact cuff. To be performed during arthroscopic cuff repair or during debridement of an irreparable cuff tear. Contraindications: Very thin, frayed, almost ruptured biceps tendon.Complete rupture of the long head of the biceps. Surgical Technique: Standard arthroscopy with 30° scope inserted through the posterior portal. Detachment of the long head from the glenoid origin. Longitudinal opening of the bicipital groove. Exteriorization and doubling of the tendon. Drilling of a socket starting in the groove but perforating the posterior cortex only with a guide wire. Passing of the tendon in an anteroposterior direction and securing the anchorage with a bioresorbable PLA interference screw. Results: Between 1997 and 1999, an arthroscopic tenodesis was performed in 43 patients. Minimum follow-up 2 years. The absolute Constant Score improved from 43 points preoperatively to 79 points at the time of follow-up. No loss of elbow extension or flexion; power of biceps after tenodesis 90% of opposite side. Early on, two failures of tenodesis occurred. The following is a reprint from Operat Orthop Traumatol 2005:17 601–23 and continues the new series of articles at providing continuing education on operative techniques to the European trauma community. Reprint from: Oper Orthop Traumatol 2005;17:601–23 DOI 10.1007/s00064-005-1154-y     

Morphologic changes in long head of biceps brachii in rotator cuff dysfunction

Morphologic changes in the long head of the biceps brachii (LHB) and bicipital groove associated with cuff tears were studied in 170 cadavers. In specimens with minimum or moderate cuff tears, the primary finding was relative stenosis at the bicipital groove induced by enlargement of the LHB. However, this stenosis was not apparent in specimens with massive cuff tears and in these specimens, the medial wall of the groove exhibited wear and tear, a potential cause of LHB instability. We suggest that the long head of the biceps brachii muscle can potentially compensate for inadequate rotator cuff function. This increasing activity could lead to enlargement of the tendon and cause deterioration of the bicipital gliding mechanism. Received for publication on Jan. 8, 1998; accepted on Jan. 13, 1998     

Primary tendinitis of the long head of the biceps

Seventeen patients with chronic painful shoulders who showed evidence of isolated bicipital tendinitis involving only the extracapsular, intertubercular portion of the long head of the biceps were chosen for surgical treatment when conservative treatment failed. The patients were thought to have primary bicipital tendinitis. The latter condition is secondary to other shoulder pathologies. Thirteen patients had tenodeses and four patients had transfer of the long head of the biceps to the origin of the conjoined tendon. Overall, excellent and good results were noted in 94% of both groups of patients when the long head of the biceps was tenodesed or transferred. Whether or not the long head of the biceps is a significant depressor of the humeral head requires further investigation.     

Biomechanical and histological analysis after tenotomy of the long head of the biceps in the rabbit shoulder model

Tenotomy of the long head of the biceps tendon (LHBT) is gaining popularity in shoulder surgery. We evaluated biomechanical and histological changes after tenotomy in a rabbit LHBT tenotomy model to confirm that autotenodesis is a phenomenon that occurs after the procedure. Twenty‐three rabbits were included. The right shoulder was harvested from 10 randomly selected rabbits. The shoulders were tested to determine the pullout strength of LHBT at the bicipital groove immediately after being tenotomized. The left shoulder of three of these rabbits also underwent histological analysis. The other 13 rabbits underwent LHBT tenotomy (tenotomy model). Six weeks post‐operatively, 10 were assigned for biomechanical study, and three underwent histological analysis. The pullout strength and histology were compared with the immediate post‐tenotomy data. The pullout strength of the immediate post‐tenotomy (5.53 ± 2.22 N) was significantly (p < 0.001) less than the pullout strength of the 6 weeks post‐tenotomy model (44.07 ± 7.75 N). On histological analysis, marked fibrosis was noted around the LHBT at the bicipital groove in the 6 weeks post‐tenotomy model. Adhesion of the LHBT at the bicipital groove after tenotomy, which is called “autotenodesis,” is a definite phenomenon that could help the tendon resist distal migration of the LHBT after tenotomy. These results support execution of biceps tenotomy in shoulder surgery. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 30:416–422, 2012