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UT Southwestern Medical Center, Sports Medicine & Shoulder Service, Dallas, TX, USA
KSF Orthopaedic Center, Houston, TX, USA
c
Aurora Advanced Healthcare, Milwaukee, WI, USA
d
Vanderbilt Sports Medicine & Shoulder Center, Nashville, TN, USA
b
Anatomy
The LHB tendon originates from the superior labrum and
the supraglenoid tubercle. The exact location of labral
attachment varies, but is usually in the posterior portion of
the superior labrum.18,60
The intra-articular portion of the LHB tendon is partially
stabilized by the biceps reection pulley, which consists of
the superior glenohumeral ligament (SGHL), the coracohumeral ligament, and deep bers of the subscapularis
and supraspinatus tendons64 (Fig. 1). The superior glenohumeral ligament runs spirally along the LHB tendon adjacent to the coracohumeral ligament3 (Fig. 2). The pulley
stabilizes the LHB tendon as the tendon makes a 30 to 40
turn while exiting the glenohumeral joint.32 The LHB tendon
travels deep to the coracohumeral ligament and through the
rotator interval before exiting the glenohumeral joint.
Function
Investigational Review Board approval was not required for this article.
*Reprint requests: Michael Khazzam, MD, UT Southwestern Medical
Center, Sports Medicine & Shoulder Service, 1801 Inwood Rd, Dallas, TX
75390-8883, USA.
E-mail address: drkhazzam@yahoo.com (M. Khazzam).
The function of the LHB tendon is controversial. Electromyography analysis has shown that the LHB tendon serves
as a glenohumeral joint stabilizer in the unstable
1058-2746/$ - see front matter 2011 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2011.07.016
M. Khazzam et al.
adjacent rotator cuff tendons. Direction of tendon instability was seen as anterior, posterior, or anteroposterior.
Extent of instability was graded as none, subluxation
(dened by translation of less than one-third of the LHB
without passing over the pulley insertion sites of the greater
and or lesser tuberosities), and dislocation. LHB tendon
lesions were graded as grade 0 (normal tendon), grade I
(minor lesion with fraying or erosion involving <50% of
the diameter of the tendon (Fig. 3), grade II (major lesion
fraying or erosion involving >50% of the tendon diameter;
Fig. 4). Status of the rotator cuff was evaluated and graded
as A (intact), B (partial-thickness tear), or C (full-thickness
tear). This was the rst classication system to recognize
the importance of posterior LHB instability and its relationship to tears involving the supraspinatus tendon.
Classication
Disorders involving the LHB tendon can be classied in 3
broad subgroups: (1) inammation, (2) instability, or (3)
traumatic.65 A number of authors12,41,44,53,54,56,58,62 have
further subclassied biceps tendon lesions according to
anatomic location,12,62 pathologic process,58 and the status
of the biceps tendon.12
Burkhead et al12 and Walch et al62 classied lesions of
the LHB by the anatomic location of the pathology. Lesions
at the origin affect the biceps anchor at the attachment to
the supraglenoid tubercle and superior labrum. Rotator
interval lesions consist of biceps tendinitis, isolated tendon
ruptures, and subluxation.62 Habermeyer et al32 also classied biceps pathology by the status of the biceps sling,
which provides information about where the LHB tendon
will sublux. An isolated lesion of the SGHL is group 1,
lesions of the SGHL and partial articular sided tears of the
supraspinatus tendon (PASTA) are group 2 (results in
lateral LHB tendon subluxation), deep surface tears of the
subscapularis and SGHL are group 3 (results in medial
LHB tendon subluxation), and group 4 is when there is
tearing of the deep surface of the subscapularis tendon,
PASTA, and SGHL (LHB tendon can sublux or dislocate
medial or lateral).32
Lafosse et al44 classied LHB disorders by arthroscopic
ndings related to LHB instability (both direction and
extent), macroscopic lesions of the LHB, and status of the
Pathology
The LHB tendon may be affected by tendinopathy, dislocation, and partial or complete tears. Disorders of the LHB
tendon are associated with rotator cuff tear in up to 90% of
cases.5,51 Glenohumeral arthritis is also commonly associated with LHB tendon pathology.51
LHB tendinopathy is characterized by chronic inammation, brotic degeneration, a decrease in the number of
axons in the distal portion of the tendon, and an increase in
the calcitonin gene-related peptide and substance P within
associated nerve roots and blood vessels.51,57 Hypertrophic
tendinopathy may result in entrapment of the tendon within
the glenohumeral joint. The resultant hourglass biceps
may be unable to slide through the bicipital groove, causing
locking of the shoulder, which has been likened to the
trigger nger in the hand.8 In addition, inammation and
hypertrophy or stenosis of the bicipital groove, or both, are
thought to incarcerate the LHB tendon, which may produce
Diagnosis
Physical examination is unreliable in the diagnosis of LHB
tendon pathology. Anterior shoulder tenderness may
M. Khazzam et al.
Treatment
Isolated LHB lesions are relatively uncommon; therefore, it
is important to properly recognize and treat associated
shoulder pathology such as rotator cuff dysfunction, scapular dyskinesis, adhesive capsulitis, or glenohumeral joint
arthritis. We review the nonoperative and operative treatment options for the LHB. We also have reviewed the
current literature to aid in clinical decision making.
Nonsurgical
Management of patients with symptoms related to inammation or abnormalities involving the LHB tendon should
begin with nonoperative treatment, including activity
modication, nonsteroidal anti-inammatory medication,
and physical therapy directed at associated underlying
shoulder disorders as well as scapulothoracic mechanics.
An injection of steroid with local anesthetic may be
benecial, either intra-articularly into the glenohumeral
joint or directly into the bicipital tendon sheath within the
bicipital groove. Subacromial injection may also be used
for concomitant impingement symptoms. No published
studies have specically evaluated the nonoperative treatment of LHB disorders.
Several studies12,14,47,65 report the results after nonsurgical treatment of complete LHB ruptures. Traumatic or
spontaneous ruptures of the LHB are commonly associated
with cosmetic deformity of the biceps muscle, Popeye
deformity, and biceps muscle spasm, particularly in thin
patients. Patients typically report resolution of biceps muscle
Surgical
Surgical treatment options for LHB tendinitis that remains
symptomatic despite nonoperative treatment consists of
tenotomy or tenodesis in conjunction with addressing
any additional concomitant shoulder pathology, including
impingement syndrome, rotator cuff tears, and labral
pathology. The ideal surgical treatment for LHB
pathology continues to remain an area of signicant
controversy.25,35,52
Many surgical techniques have been reported for
arthroscopic and open biceps tenotomy and tenodesis.
Tenotomy or tenodesis of the LHB tendon is indicated
when there is partial tearing (>25% to 50% of the tendon
diameter), longitudinal tears that result in poor tendon
gliding in the bicipital groove (symptomatic catching),
medial subluxation of the tendon, disruption of the biceps
sling, or in the setting of a subscapularis tear.12,52,56,65
Several authors25,35,40 have attempted to answer the
question of which surgical treatment is betterdtenotomy or
tenodesisdand provide evidence to support one rather than
the other.
5
Frost et al,25 in a systematic review (LOE IV), hypothesized that there would be no difference in outcome
between tenotomy and tenodesis for treatment of pathology
involving the LHB tendon. This review analyzed the results
of 5 studies that evaluated the results of tenotomy, 8 that
examined tenodesis, and 6 that reported results of both.
Overall, tenodesis resulted in good or excellent results in
40% to 100% of patients, with a failure rate of 5% to 48%.
Tenotomy resulted in 65% to 100% good or excellent
results, with a failure rate of 13% to 35%. The comparative
studies did not show any signicant differences between the
groups, other than the Popeye sign being present in 3% to
70% of the tenotomy patients. The authors concluded that
the available evidence shows there is little difference in
outcomes using tenodesis or tenotomy; however, welldesigned, prospective, randomized controlled trials
comparing these procedures should be performed to
provide stronger evidence for treatment decisions.
Hsu et al35 conducted a systematic review (LOE IV) to
determine if there were any signicant differences in the
incident of cosmetic deformity or load-to-tendon failure, or
both, between tenotomy and tenodesis. They included 8
studies in the nal analysis. Postoperative bicipital pain was
present in 17% of patients in the tenotomy group and in
24% in the tenodesis group. The corresponding odds ratio
(1.5) and relative risk (1.4) reected that bicipital pain was
more common in the tenodesis group. The average
Constant score was 66.9 for the tenotomy group and 76.1
for the tenodesis group, and the average University of
California, Los Angeles (UCLA) score was 33 for the
tenotomy group and 28 for the tenodesis group. In the
tenotomy group, 41% of patients had biceps muscle belly
deformity at nal follow-up compared with only 25% in the
tenodesis group. The corresponding odds ratio was 2.15 and
the relative risk was 1.7 for the tenotomy group to be more
likely to have a Popeye muscle deformity at nal follow-up.
Again, evidence-based recommendations are limited due
to the lack of high-quality studies in the current literature.
On the basis of what is available, tenotomy is recommended for older patients with sedentary lifestyle, obese
arms, or those not concerned with cosmesis, and tenodesis
is recommended for young (<40 years) active patients with
high physical demands, thin arms, or concern for cosmesis.
These authors similarly recommended more high-quality,
well-designed, prospective, randomized controlled studies
to help support the decision-making process.
Recently, Koh et al40 compared tenotomy and tenodesis
results in the setting of rotator cuff tears in a prospective
cohort study (LOE II). At a nal follow-up that averaged
27-months, 5% of patients in the tenodesis group and 10%
in the tenotomy group complained of arm pain during
resisted elbow exion (P .43), and 9.3% in the tenodesis
group had a Popeye deformity compared with 26.8% in the
tenotomy group (P .036, statistically signicant difference). The American Shoulder and Elbow Surgeons
(ASES) scores improved from 52.1 to 84.7 in the tenodesis
6
group and from 48.1 to 79.6 in the tenotomy group, and
these differences were clinically and statistically signicant
(P < .0001). Constant scores for tenodesis (38.9 to 82.9)
and tenotomy (35.2 to 78.3) were clinically and statistically
signicantly improved (P < .0001) in both groups. There
was no difference in outcome scores between the 2 groups.
The authors concluded from these results that besides
biceps deformity, there was no signicant difference
between these 2 treatment modalities.
Arthroscopic biceps tenotomy
Walch et al61 described arthroscopic biceps tenotomy
for the treatment of biceps tendinopathy in the setting
of massive irreparable rotator cuff tears in 307 shoulders (LOE IV). The tendon is arthroscopically transected at the superior labrum or supraglenoid tubercle
and allowed to retract out of the glenohumeral joint into
the bicipital groove. If this does not occur, the intraarticular portion is removed until the tendon can then
retract out of the joint. At the follow-up evaluation
(average, 57 months), the authors reported statistically
signicant (P < .0001) improvement in Constant score
(preoperatively, 48.4; postoperatively, 67.6) and that
87% of patients were satised or very satised with
their treatment results.
Gill et al28 reported the results after arthroscopic biceps
tenotomy in a retrospective case series (LOE IV) in 30
shoulders at an average follow-up of 19 months (range, 1269 months). They demonstrated improvement in symptoms
at the nal evaluation, with an ASES score of 81.8, average
time to return to work of 1.9 weeks, and 90% of patients
returned to their previous level of sporting activity with no
complaints of pain. The complication rate was 13.3% (4 of
30 shoulders), 2 related to impingement, 1 with persistent
pain, and 1 as a result of the cosmetic biceps deformity,
with no pain, who was subsequently revised to a tenodesis.
Kelly et al36 reviewed the results after arthroscopic
biceps tenotomy in 40 patients with an average follow-up of
2.7 years (range, 24-42 months) in a retrospective case
series (LOE IV). The authors reported the following
outcomes scores: LInsalata, 75.6 (range, 29.1-100),
UCLA, 27.6 (range, 10-35), and ASES, 77.6 (range 13.3100). They also found that 70% of patients had a Popeye
deformity at rest or during active elbow exion, and 37.5%
of patients complained of fatigue, discomfort, and soreness
after resisted elbow exion. The authors concluded that this
technique might be useful for a select patient population,
specically an older less active patient population with no
concern for cosmesis.
Bradbury et al10 described an arthroscopic biceps
tenotomy technique in which the tendon is released with
a portion of the superior labrum to prevent the Popeye
deformity. Tenotomy performed in this fashion creates
a bulbous proximal biceps stump that becomes entrapped in
the intra-articular portion of the bicipital groove, thereby
limiting tendon excursion and retraction down the arm.
M. Khazzam et al.
Biomechanical testing of this technique showed signicantly increased force was required to pull the tendon
through the bicipital groove (73.2 N, with-labrum group;
25.0 N, without-labrum group; P .001).
Open biceps tenodesis
Open biceps tenodesis historically has been the surgical
treatment of choice for young active patients, such as
athletes and heavy laborers, and those who wish to avoid
cosmetic deformity. The goal of tenodesis of the LHB
tendon is to maintain the length-tension relationship of the
biceps muscle.52 A variety of reattachment sites have been
described, including xation to the lesser tuberosity,12
coracoid,12,31 intertubercular (bicipital) groove33; suture
xation to the transverse humeral ligament, short head of
the biceps,6 or pectoralis major tendon1,6,47; or by a bone
tunnel in a subpectoralis major location.33,48 Ultimately, the
biggest controversy exists about optimal location of
tenodesis and if xation should occur above, within, or
below the bicipital groove. To our knowledge, no LOE I or
II studies have compared the outcomes after tenodesis
above, within, or below (subpectoral) the bicipital groove to
guide surgical decision making using an evidenced- based
approach.
Becker et al6 evaluated the results of 51 patients in
a retrospective case series (LOE IV) after open biceps
tenodesis at an average follow-up of 7 years (range, 1-21
years). Three different surgical techniques were used in
these patients: (1) suture of the tendon stump in or adjacent to the bicipital groove, as described by Hitchcock
et al,33 (2) a keyhole technique,12 or (3) side-to-side
suturing to the short head of the biceps.12 All patients
underwent tenotomy with resection of the intra-articular
potion of the LHB tendon in conjunction with tenodesis.
At nal follow-up, only 22 of the 51 shoulders (43%)
were still pain-free, whereas 26 (50%) continued to have
moderate to severe pain. The authors concluded that
biceps tenodesis should not be recommended as a primary
procedure but should be performed in conjunction with
a larger surgical procedure.
Crenshaw and Kilgore19 retrospectively reviewed (LOE
IV) the results of 3 tenodesis techniques in 92 shoulders at
1 year. The techniques included suturing LHB tendon to the
lesser tuberosity without tenotomy, transfer of the tendon to
the coracoid, or the Hitchcock procedure,12,33 in which the
tendon is reattached into the bicipital groove beneath
a periosteal ap. Pain relief was good to excellent in 90%
of patients, but only 85% had return of their normal
shoulder motion at nal follow-up.
Froimson and Oh,24 Dines et al,22 and Berlemann and
Bayley,7 in small retrospective case series (LOE IV),
reviewed the results of keyhole tenodesis and found good to
excellent results at nal follow-up. These authors attributed
clinical failures of this technique to unrecognized additional shoulder pathologies such as subacromial impingement with rotator cuff tearing.
7
at an average follow-up of 28 months (range, 24-53
months). The average LInsalata score was 78.9 (range,
35.7-100), UCLA score was 27.8 (range, 12-35), and ASES
score was 79.6 (range, 30-100) at the nal follow-up. Of the
40 shoulders, only 2 patients (5%) had a Popeye deformity
at rest or with active elbow exion, 5 (12.5%) had fatigue
soreness after resisted elbow exion, 38 (95%) reported
relief of tenderness on palpation of the bicipital groove, and
32 (80%) rated their shoulders as good, very good, or
excellent.
Several authors26,39,45,55 have reported arthroscopic
techniques for performing this procedure (LOE V), with no
real outcomes data to support or refute its use.
Once the decision has been made to perform tenodesis
of the LHB tendon, the next controversial question that
arises is: what is the optimal location of tenodesis? Lutton
et al,46 in a retrospective case-control study (LOE III),
compared results after tenodesis into the upper or lower
half of the bicipital groove to determine if location was
related to residual postoperative pain. A more distal location resulted in a decreased incidence of persistent postoperative pain in the bicipital groove. This study was
limited due to its retrospective nature and limited sample
size, but to our knowledge, this is the only study in the
literature that attempts to answer this important question.
Treatment algorithm
The diagnosis and management of disorders involving the
LHB tendon can be challenging. We present an algorithm
for the management of these patients (Fig. 7). It is clear
from the current literature that the approach to patients who
present with biceps pathology begins with an accurate
diagnosis, which can be the most challenging aspect in the
management of biceps pathology. Physical examination
ndings with use of a biceps-specic test, such as the upper
cut test and Speeds test, may provide useful clues about the
status of the LHB tendon. Imaging of the shoulder with
MRI, CT arthrogram, or ultrasound provides detailed
visualization of the anatomy of the shoulder and should be
considered a critical part of the workup. In our practice, we
typically use MRI as our diagnostic study of choice.
Treatment should initially begin with a trial of conservative measures such as nonsteroidal anti-inammatory
medications and physical therapy. Physical therapy should
be tailored to other concomitant shoulder pathology with
a focus on regaining range of motion and eliminating
scapular dyskinesis. Corticosteroid injections placed in the
glenohumeral joint, subacromial space, or biceps tendon
sheath may be considered initially or after a 6-week trial of
physical therapy.
Surgical intervention is appropriate a minimum of 12
weeks of conservative management has failed. Surgical
treatment is generally dictated by the major underlying
shoulder pathology that coexists with LHB tendon
M. Khazzam et al.
Figure 7 Treatment algorithm for the long head of the biceps (LHB). MRI, magnetic resonance imaging; NSAIDS, nonsteroidal antiinammatory drugs; OA, osteoarthritis; PT, physical therapy; RC, rotator cuff; RCT, rotator cuff tear.
Conclusion
Patients presenting with symptomatic LHB tendon
lesions must be thoroughly evaluated for other
concomitant shoulder pathology, which may make
a denitive diagnosis challenging. There are few highlevel evidence studies in the current literature to support
decision-making strategies. Thorough clinical evaluation
9.
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15.
Disclaimer
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