Tendinosis / Rupture / Subluxation / Hypertrophy

FunctionNormal Biceps

 

LHB primary function is humeral head depressor

 

Also accelerate / decelerate arm in overhead sports

 

Problems

 

Biceps problems usually occur with other pathology 

- rotator cuff / instability

 

3 main problems

 

1.  Degeneration

- "Tendinosis"

- usually associated with impingement

- can lead to rupture

 

Rupture

- rarely associated with weakness

- 80% flexion strength from brachialis and short head biceps

 

2.  Instability

 

Stability contributed by

- transverse humeral ligament

- coracohumeral ligament

- superior GH ligament

 

Almost always associated with cuff tears

- SS tears

- medial subluxation with SSC tear

 

Lafosse et al Arthroscopy 2007

- biceps can be unstable anteriorly or posteriorly

- anterior with SSC tears

- posterior with SS tears

 

3.  Disorders of the origin (SLAP)

 

4.  Hourglass Biceps

 

Wiley etal J Shoulder Hand Surg 2004

- thickened intra-articular portion biceps

- unable to travel in groove

- with forward flexion of arm, arthroscopically see bunching of biceps

- requires double release  / tenotomy / tenodesis

 

Anatomy

 

Origin 

- from postero-superior labrum and supraglenoid tubercule

 

Tendon is intra-articular

- passes deep to CH ligament, through rotator interval

- enters bicipital groove, beneath transverse humeral ligament

 

Examination 

 

Tenderness over biceps tendon crucial

 

Rupture

- Popeye appearance

 

Popeye Sign BicepsPopeye Biceps

 

Speed's

- forward flexed shoulder against resistance

- elbow kept extended and supinated

- feel pain or palpate tenderness

 

Yergason's

- elbow flexed and pronated

- resist supination

- pain over LHB

 

O'Brien's / SLAP

- arm forward flexed and adducted in plane of scapula

- point thumb down and resist downwards force

- this generates pain

- no / less pain with thumb up

 

MRI

 

Normal

 

MRI Enlocated Biceps Tendon

 

Tendonitis

 

Biceps Tendonitis MRI

 

Tendonosis / thickening

 

Biceps Tendinosis MRI

 

Medial Subluxation

 

Biceps Tendon Medially DislocatedMedially Dislocated Biceps Tendon with Torn SubscapularisBiceps Medially Dislocated and Torn SSC

 

Arthroscopy 

 

Normal

 

Arthroscopy Normal Biceps Tendon Arthroscopy Normal Biceps Exit

 

Mild Tendonopathy

 

Biceps Tendonopathy Grade 2 Arthroscopy

 

Moderate Tendonopathy

 

Shoulder Biceps Moderate Tendonopathy

 

Severe Tendonopathy

 

Biceps Tendonopathy ArhroscopyBiceps Tear near complete

 

Dislocated Biceps in Presence of complete SSC Rupture

 

Shoulder Scope Dislocated Biceps TendonMedially Subluxed Biceps Tendon

 

Management

 

1.  Tendonitis

 

Non Operative

 

As per rotator cuff / impingement

- HCLA

- physio

 

Surgical Options

 

1.  SAD

2.  Manage rotator cuff pathology

3.  Consider for inflamed but intact LHB

- release THL

- spare CH ligament

 

2.  Tendon Fraying / Tendinosis / Rupture

 

Grade tendon integrity

 

I     Minor fraying <25%

II    Fraying 25-50%

III   Fraying >50%

IV   Complete rupture

 

Management Strategy

 

I & II

- SAD & debride tendon 

 

III & IV

- SAD & biceps tenodesis / tenotomy

 

Tenotomy v Tenodesis

 

Frost et al Am J Sports Medicine April 2009

- reviewed all articles on tenotomy / tenodesis

- concluded that there is no evidence for superiority of one over another

 

Koh et al Am J Sports Med 2010

- tenotomy v tenodesis in setting RC tears

- 9% popeye in tenodesis (suture anchor) and 27% in tenotomy

- no other difference in terms elbow flexion power / shoulder scores

 

Tenotomy

 

Popeye deformity

 

Lim et al Am J Sports Med 2011

- incidence of pop-eye of 45% post tenotomy

- more common in men

 

Cosmetic deformity acceptable in elderly

- not in young

- avoided by tenodesis

 

Strength

 

Shank et al Arthroscopy 2011

- no evidence of decreased elbow flexion or supination strength

 

Tenodesis

 

Indications

- young patient grade II, III, IV

- slim arm (where popeye would cause significant cosmetic problem)

 

Issues

- screw prominence / pain

- failure of fixation

 

Options

- arthroscopic

- open

- see techniques

 

Arthroscopic

 

Soft tissue or bony fixation

- in inter-tubercular groove

- suprapectoral

 

Sheibel Am J Sports Med 2011

- soft tissue v bony anchor fixation

- superior cosmetic and functional outcome with bony

 

Open

 

Suprapectoral or subpectoral

 

Nho et al J Should Elbow Surgery 2010

- 353 patients treated with subpectoral bioabsorbable tenodesis screw

- 2% complication rate

- 2 patients with popeye

- 2 with tenderness over screw

- 1 deep infection

- 1 MCN injury

 

3.  Subluxation

 

Issues

 

Usually medial from SSC tear

- must manage LHB or SSC repair will fail

 

Options

 

1.  Tenodesis / Tenotomy + SSC repair

 

2.  Stabilisation + SSC repair

 

Issue

- can get stenosed painful tendon  

 

Maler et al JBJS Am 2007

- 21 patients with traumatic tear of SSC treated within 6 weeks

- open SSC repair and LHB stabilisation

- 7 had symptoms of mild tenodinopathy

- 2 recurrent instability and 1 rupture on US