The incidence of pathologic changes of the long head of the biceps tendon

Long head of biceps tendon pathology: management alternatives

The role of biceps tendon as a source of shoulder pain and pathology has been well documented in orthopedic literature. Recently, interest in the long head of the biceps tendon has been renewed as its association with subscapularis lesions, superior labral anterior to posterior (SLAP) lesions, rotator cuff pathology, impingement, and pulley or "hidden" lesions of the rotator interval are demonstrated. Advances in imaging and arthroscopy have increased our breadth of knowledge about the anatomy, pathology, and role of the biceps tendon. Management and treatment methods have evolved with improved patient selection and proper diagnosis of long head biceps pathology.

Mechanical properties of the long-head of the biceps tendon are altered in the presence of rotator cuff tears in a rat model

Rotator cuff tears are disabling conditions that result in changes in joint loading and functional deficiencies. Clinically, damage to the long-head of the biceps tendon has been found in conjunction with rotator cuff tears, and this damage is thought to increase with increasing tear size. Despite its importance, controversy exists regarding the optimal treatment for the biceps. An animal model of this condition would allow for controlled studies to investigate the etiology of this problem and potential treatment strategies. We created rotator cuff tears in the rat model by detaching single (supraspinatus) and multiple (supraspinatus + infraspinatus or supraspinatus + subscapularis) rotator cuff tendons and measured the mechanical properties along the length of the long-head of the biceps tendon 4 and 8 weeks following injury. Cross-sectional area of the biceps was increased in the presence of a single rotator cuff tendon tear (by approximately 150%), with a greater increase in the presence of a multiple rotator cuff tendon tear (by up to 220%). Modulus values decreased as much as 43 and 56% with one and two tendon tears, respectively. Also, multiple tendon tear conditions involving the infraspinatus in addition to the supraspinatus affected the biceps tendon more than those involving the subscapularis and supraspinatus. Finally, biceps tendon mechanical properties worsened over time in multiple rotator cuff tendon tears. Therefore, the rat model correlates well with clinical findings of biceps tendon pathology in the presence of rotator cuff tears, and can be used to evaluate etiology and treatment modalities.

Long head of the biceps tendon pain: differential diagnosis and treatment

Though the role of the long head of the biceps tendon (LHBT) in shoulder pathology has been extensively investigated, it remains controversial. Historically, there have been large shifts in opinions on LHBT function, ranging from being a vestigial structure to playing a critical role in shoulder stability. Today, despite incomplete understanding of its clinical or biomechanical involvement, most investigators would agree that LHBT pathology can be a significant cause of anterior shoulder pain. When the biceps tendon is determined to be a significant contributor to a patient's symptoms, the treatment options include various conservative interventions and possible surgical procedures, such as tenotomy, transfer, or tenodesis. The ultimate treatment decision is based upon a variety of factors, including the patient's overall medical condition, severity, and duration of symptoms, expectations, associated shoulder pathology, and surgeon preference. The purpose of this manuscript is to review current anatomic, functional, and clinical information regarding the LHBT, including conservative treatment, surgical treatment, and postsurgical rehabilitation regimens.

LEVEL OF EVIDENCE

Level 5.

Interference screw versus suture anchor fixation for subpectoral tenodesis of the proximal biceps tendon: a cadaveric study

PURPOSE

The purpose of this study was to compare the biomechanical properties of 2 fixation methods for subpectoral proximal biceps tenodesis.

METHODS

In 9 matched pairs of cadaveric shoulders, an open subpectoral tenodesis was performed 1 cm proximal to the inferior border of the pectoralis major tendon by use of either an 8 x 12-mm Bio-Tenodesis screw (Arthrex, Naples, FL) with No. 2 FiberWire sutures (Arthrex) or a 5.5-mm Bio-Corkscrew double-loaded suture anchor (Arthrex) with No. 2 FiberWire sutures. The specimens were dissected and mounted in a material testing machine. Cyclic loading (20 to 60 N, 100 cycles, 0.5 mm/s, 5-N preload) was performed, followed by an unloaded 30-minute rest, a 5-N preload, and a load-to-failure protocol (1.25 mm/s) with a 100-lb load cell. Ultimate load (in Newtons), stiffness (in Newtons per millimeter), and modes of failure were recorded. Data were analyzed by use of paired t tests and Wilcoxon signed rank tests.

RESULTS

Proximal biceps tenodeses with Bio-Tenodesis screws had a significantly higher mean load to failure (169.6 +/- 50.5 N; range, 99.6 to 244.7 N) than those with Bio-Corkscrew suture anchors (68.5 +/- 33.0 N; range, 24.2 to 119.4 N) (P = .002). Bio-Tenodesis screws also had a significantly higher stiffness (34.1 +/- 9.0 N/mm; range, 20.6 to 48.9 N/mm) than Bio-Corkscrews (19.3 +/- 10.5; range, 5.9 to 32.9 N/mm) (P = .038).

CONCLUSIONS

In this cadaveric study the Bio-Tenodesis screw showed a statistically significantly higher load to failure and significantly higher stiffness than the Bio-Corkscrew anchor when used for tenodesis of the proximal biceps tendon in a subpectoral location.

CLINICAL RELEVANCE

Biomechanical comparison of these 2 fixation techniques provides information on stiffness and load to failure of alternate fixation methods.

Biceps tendinitis in chronic rotator cuff tears: a histologic perspective

Patients with chronic rotator cuff tears frequently have anterior shoulder pain attributed to the long head of the biceps brachii (LHBB) tendon. In this study, tenodesis or tenotomy samples and cadaveric controls were assessed by use of immunohistochemical and histologic methods to quantify inflammation, vascularity, and neuronal plasticity. Patients had moderate pain and positive results on at least 1 clinical test of shoulder function. The number of axons in the distal LHBB was significantly less in patients with biceps tendinitis. Calcitonin gene-related peptide and substance P immunostaining was predominantly within nerve roots and blood vessels. A moderate correlation (R = 0.5) was identified between LHBB vascularity and pain scores. On the basis of these results, we conclude that, in the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity.

Arthroscopic management of shoulder osteoarthritis

Osteoarthritis (OA) can cause severe pain and dysfunction of the shoulder. When conservative treatment fails and operative treatments such as shoulder arthroplasty and open glenohumeral resurfacing are not advisable, shoulder arthroscopy may be used to treat shoulder OA. Arthroscopic treatment of concomitant pathology in the shoulder including subacromial decompression, labral repair, capsular release, microfracture, and distal clavicle excision have been shown to yield good results when combined with glenohumeral debridement in the treatment of shoulder OA. Arthroscopic glenohumeral resurfacing has recently been described and has shown encouraging results. Arthroscopic treatment appears to have better results in shoulders with a lesser degree of osteoarthritis.

Arthroscopic prevalence of pulley lesions in 1007 consecutive patients

This study retrospectively analyzed 1007 diagnostic shoulder arthroscopies. The study included 72 patients with an arthroscopically verified pulley lesion as the main pathologic finding. Epidemiologic data and arthroscopic findings were evaluated in all patients, and 53 were clinically examined with the Constant score after a minimum follow-up of 2 years. We observed an incidence of 7.1% for pulley lesions. An isolated rupture of the superior glenohumeral ligament (SGHL) was seen in 53 patients (73.6%) and a combined partial articular-side tear of the rotator cuff adjacent to rotator interval in 19 (26.4%). Thirty-one patients (43%) had a history of trauma, whereas 41 (57%) had none. Overall, the mean postoperative Constant score adjusted for age and gender was 80.1% (range, 47%-135%). Patients with a SGHL lesion only (85.7%) exhibited a significant (P = .047) higher age- and gender-adjusted Constant score compared with patients with a combined partial surface tendon tear (73.1%). Our epidemiologic data accentuate the need for careful evaluation of the superolateral aspect of rotator interval to avoid underdiagnosis of pulley lesions at shoulder arthroscopy. Our findings provide evidence that the clinical outcome of isolated SGHL lesions is better compared with combined partial articular-side rotator cuff tear. With respect to the progressive pathologic process of pulley lesions, we recommend an early surgical treatment.

The long head of biceps and associated tendinopathy

This paper describes the current views on the pathology of lesions of the tendon of the long head of biceps and their management. Their diagnosis is described and their surgical management classified, with details of the techniques employed.

Physical examination for partial tears of the biceps tendon

BACKGROUND

The accuracy of the physical examination for tears of the long head of the biceps remains controversial.

PURPOSE

The goals were 1) to characterize the occurrence of partial tears of the long head of the biceps tendon in a group of consecutive patients, and 2) to analyze the diagnostic value of various clinical tests for pathologic lesions of the proximal biceps tendon.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Of 847 consecutive patients who underwent arthroscopic procedures for a variety of shoulder conditions, 40 were found at the time of arthroscopy to have partial biceps tendon tears. The average age of these 24 men and 16 women was 59 years (range, 18-83). Preoperative physical examinations had included 9 commonly used tests for shoulder examination. Statistical analysis included sensitivity, specificity, negative predictive value, positive predictive value, and likelihood ratios for these tests.

RESULTS

The prevalence rate of partial tears was 5% (40/847) of all arthroscopic procedures. The most commonly associated conditions included rotator cuff tears (85% [34/40]) and anterior instability (7.5% [3/40]). Tenderness on palpation of the long head of the biceps tendon had a sensitivity of 53%, a specificity of 54%, and a likelihood ratio of 1.13. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios for Speed's test were 50%, 67%, 8%, 96%, and 1.51, respectively.

CONCLUSION

In patients with rotator cuff abnormality, the diagnosis of partial biceps tears cannot be made reliably with existing physical examination tests. Diagnostic arthroscopy is recommended, if clinically indicated, for potential partial tears of the long head of the biceps tendon. The treating physician should be prepared to treat unsuspected tears of the long head of the biceps tendon at the time of surgery.

Factors affecting dropped biceps deformity after tenotomy of the long head of the biceps tendon

PURPOSE

The anatomic and biomechanical factors that influence distal migration of the long head of the biceps tendon (LHBT) after biceps tenotomy procedures are currently not known. This study evaluates the morphology of the proximal LHBT and the force required to cause the biceps to drop distally after tenotomy.

METHODS

Fourteen human fresh-frozen cadaveric shoulders (mean age, 63.6 years) were inspected and placed into diseased and healthy LHBT groups. Diseased tendons showed degenerative changes of fraying, splitting, or hypertrophy, whereas healthy tendons were opaque and intact. The humerus was fixed and the LHBT was detached from the glenoid. The biceps tendon inferior to the bicipital groove was secured to the head of a materials testing device. Force data were recorded to pull the LHBT through the bicipital groove. The tendons were then frozen and cut into 5-mm sections. Digital pictures were taken perpendicular to the sections, and imaging software was used to measure the cross-sectional areas and tendon morphology.

RESULTS

Of the LHBTs, 7 were diseased and 7 were healthy. The force required to simulate a dropped biceps deformity was significantly greater in the diseased tendons than in the healthy tendons (mean, 33.03 +/- 10.46 N v 21.61 +/- 9.1 N; P < .05). The maximum tendon cross-sectional area was also larger in the diseased tendons than in the healthy tendons (mean, 91.29 +/- 39.33 mm2 v 63.93 +/- 19.77 mm2; P = .1). Diseased tendons had broader cross-sectional dimensions (flattening) than healthy tendons (mean, 16.39 +/- 1.50 mm v 10.97 +/- 1.48 mm; P < .05).

CONCLUSIONS

This study shows that diseased tendons with greater flattening have increased force required to travel through the bicipital groove.

CLINICAL RELEVANCE

These data help explain the clinical observation that cosmetic deformity may not result after biceps tenotomy in tendons with disease causing hypertrophy and flattening.

MRI of the rotator interval of the shoulder

The rotator interval of the shoulder joint is located between the distal edges of the supraspinatus and subscapularis tendons and contains the insertions of the coracohumeral and superior glenohumeral ligaments. These structures form a complex pulley system that stabilizes the long head of the biceps tendon as it enters the bicipital groove of the humeral head. The rotator interval is the site of a variety of pathological processes including biceps tendon lesions, adhesive capsulitis and anterosuperior internal impingement. This article describes the anatomy, function and pathology of the rotator interval using magnetic resonance imaging (MRI).

Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations

PURPOSE

The purpose of this study was to evaluate arthroscopically the frequency and type of instability of the long head of the biceps (LHB) tendon in patients undergoing rotator cuff repair.

METHODS

In 200 consecutive patients undergoing arthroscopic rotator cuff repair, LHB instability was assessed statically and dynamically in the anteroposterior direction. In addition, macroscopic lesions of the LHB, as well as lesions of the adjacent rotator cuff tendons, were documented.

RESULTS

LHB instability (subluxation or dislocation) was found in 45% of patients, with isolated anterior instability in 16%, isolated posterior instability in 19%, and combined anteroposterior instability in 10%. Whereas LHB subluxations were observed in both directions, dislocations were only seen in anterior LHB instability. Anterior instability was more associated with a subscapularis lesion, whereas posterior instability was more associated with a supraspinatus tear. Lesions of the LHB tendon were strongly associated with LHB instability and the size of the rotator cuff tear.

CONCLUSIONS

In 200 patients with rotator cuff tears LHB instability could be observed arthroscopically in 45%, with 16% being anterior, 19% being posterior, and 10% being anteroposterior. LHB instability was associated with LHB lesions, with 15% of the LHB tendons showing a normal appearance when unstable versus 70% when stable. Preoperative O'Brien and Speed tests did not correlate with intraoperative observed LHB pathology. The size of the rotator cuff tear could be correlated with the grade of LHB lesion, becoming more significant with augmenting tear size. On the basis of these observations, we created a new arthroscopic classification of LHB instability with respect to the direction and extent of LHB instability, lesions of the LHB, and status of the adjacent rotator cuff tendons.

LEVEL OF EVIDENCE

Level IV, diagnostic study with poor reference standard.

To detach the long head of the biceps tendon after tenodesis or not: outcome analysis at the 4-year follow-up of two different techniques

The aim of this study was to determine whether or not detaching the biceps tendon from the glenoid after tenodesis performed with the inclusion of the biceps in the rotator cuff suture results in an improved outcome. From 1999 to 2001, 22 patients had an arthroscopic rotator cuff repair and associated biceps tendon lesions that were repaired with two new arthroscopic techniques of tenodesis incorporating the biceps tendon in the rotator cuff suture. Patients were randomised into one of two groups: tenodesis without tenotomy (group 1) and tenodesis with tenotomy (group 2). Preoperative and postoperative functions were assessed by means of a modified UCLA rating scale and shoulder ROM. The mean follow-up period was 47.2 months (range 36- 59). In group 1 (tenodesis without tenotomy), eight patients had an excellent postoperative score and three a good postoperative score. The UCLA rating system used for evaluation showed a statistically significant improvement from the preoperative average rating of 10.5 (5-15) to the postoperative average score of 33 (29-35) (P<0.05). In group 2 (tenodesis with tenotomy), the UCLA rating system used for evaluation showed a statistically significant improvement from the preoperative rating of 11.1 to the postoperative score of 32.9 (P<0.05). No statistically significant difference in the total UCLA scores was found when comparing the repairs performed with or without tenotomy. Follow-up results with regard to ROM were not different between the two groups, and the range of motion was improved in all measured directions. In this series, every patient qualified as having good to excellent results according to the UCLA score. This study suggests that there is no difference between detaching and not detaching the biceps after including it in the repair.

Arthroscopic biceps tendon tenodesis: the anchorage technical note

Treatment of long head biceps (LHB) tendon pathology has become an area of renewed interest and debate among orthopaedic surgeons in recent years. The background of this manuscript is a description of biceps tenodesis which ensure continual dynamic action of the tendon which depresses the head and impedes lateral translation. A new technique has been developed in order to treat LHB tendon irreversible structural abnormalities associated with cuff rotator lesions. This technique entails the construction of a biological anchor between the LHB and supraspinatus and/or infraspinatus tendons according to arthroscopic findings. The rationale, although not supported by biomechanical studies is to obtain a triple, biomechanical effect. The first of these biomechanical effects which we try to promote through the procedure of transposition is the elimination of the deviation and oblique angle which occurs as the LHB completes its intra-articular course prior to reaching the bicipital groove. Furthermore, we have found this technique extremely useful in the presence of large ruptures of the rotator cuff with muscle retraction. The most common complication associated to this particular method, observed in less than 3%, is failed biological fixation which manifests as subsidence of the tenodesis and consequent descent of the tendon with evident aesthetic deformity.

Arthroscopic biceps tenodesis using interference screw: end-tunnel technique

The conflict between tenotomy versus tenodesis for biceps lesions of the shoulder has not been resolved. We, however, believe that tenodesis is the treatment of choice until proven otherwise. Hence our department has been performing arthroscopic tenodesis for biceps subluxation or partial tears that involved over 50% of its diameters. We introduce our technique of arthroscopic biceps tenodesis in which the biceps tendon is fixed in the sequentially enlarged bony end-tunnel using bioabsorbable interference screws without transosseous drilling.

Incidence and severity of biceps long head tendon lesion in patients with complete rotator cuff tears

BACKGROUND

Biceps long head tendon lesion is commonly associated with rotator cuff tendon pathology. This study is to determine the pathologic spectrum of biceps long head tendon in surgical cases with complete full thickness rotator cuff tear.

METHODS

Between 1993 and 2002, 122 complete rotator cuff tears with surgery were included for the analysis. During surgery, biceps long head tendon was grossly examined or evaluated via arthroscopy. A simplified classification was used to describe the biceps lesion.

RESULTS

50 (41%) patients had type 1 lesion (tendinitis), 10 (8%) patients had type 2 lesion (subluxation), 12 (10%) patients had type 3 (dislocation), 15 (12%) patients had type 4 (partial tear), and 6 patients (5%) had type 5 (complete rupture). The remaining 29 patients (24%) did not have obvious pathology. All chronic rotator cuff tear (> 3 months) were associated with biceps tendon pathology. A rotator cuff tear greater than 5 cm as determined at surgery was strongly associated with an advanced biceps lesion.

CONCLUSION

Biceps tendon injuries are associated with complete rotator cuff tears and there may be a causal relationship due to the impingement that occurs. Early identification and repair of rotator cuff lesions may prevent further deterioration of the biceps tendon.

Biceps tenodesis associated with arthroscopic repair of rotator cuff tears

Associated lesions of the biceps tendon are commonly found during arthroscopic repair of rotator cuff tears. These lesions are treated with tenodesis, classically performed through an open approach. However, it seems reasonable to seek a single approach to correct both lesions; therefore, we have proposed a new arthroscopic technique that allows an exclusive arthroscopic tenodesis by including the biceps tendon in the rotator cuff suture, a surgical technique with a single suture of the rotator cuff that includes the biceps tendon. We treated 97 shoulders in 96 patients arthroscopically for complete rotator cuff tears. Of these shoulders, 15 required tenodesis for treatment of biceps tendon lesions. Through an arthroscopic approach, a subacromial decompression followed by a rotator cuff repair was carried out in association with a biceps tenodesis. In this technique, one limb of the suture was passed through the biceps tendon, and the other was passed through the rotator cuff tear, bringing both tissues together in the final suture. Of the patients, 9 were men and 5 were women. Their mean age was 71 years (range, 41-80 years). The dominant arm was affected in all patients. Postoperative evaluation, by use of the UCLA score, after a mean follow-up period of 32.4 months showed satisfactory results in 93.4% of patients: 11 had excellent results, 3 had good results, and only 1 had an unsatisfactory result. In this case a postoperative magnetic resonance imaging scan showed an intact rotator cuff and biceps tenodesis. The suture involving the rotator cuff and the biceps tendon proved effective to correct both lesions, with the main advantage being that an additional approach was not required.

Arthroscopic biceps tenodesis using suture anchors through the subclavian portal

Biceps tenodesis is typically performed through an open anterior incision. Even when an arthroscopic rotator cuff repair is performed, an open procedure is typically performed to address the biceps rupture or subluxation. Recently, there has been great interest in performing this procedure arthroscopically. Techniques have included using an interference screw or 2 suture anchors through an anterior cannula. If the biceps is partially ruptured or subluxated and the proximal end is still visible in the joint, a biceps tenodesis can be performed using standard arthroscopic techniques and suture anchors. The senior author (K.D.N.) developed the subclavian portal in 1997 for arthroscopic repair of rotator cuff tears using a pointed suture grasper. This portal is located 1 to 2 cm medial to the acromioclavicular joint line, directly above and slightly medial to the coracoid. It provides an optimal angle for suture anchor placement directly through the anterior supraspinatus or coracohumeral ligament and into the humeral head at the edge of the articular cartilage. Anchors inserted through the subclavian portal reproduce the 45 degrees Deadman's angle, which was described for placing anchors during rotator cuff repair. Using a burr or shaver through the lateral portal, the articular and bony surface under the biceps tendon and just proximal to the bicipital groove are abraded. Suture anchors are inserted through the subclavian portal, then through the biceps tendon, and into the bone. Sutures are retrieved and tied through the lateral cannula if there is a tear of the supraspinatus. If the supraspinatus is intact, the sutures can be tied intra-articularly through the anterior cannula. Release of the biceps is not performed until the repair is accomplished, which prevents the tendon from retracting down the bicipital groove. The anatomy of the subclavian portal is reviewed and the technique of the arthroscopic biceps tenodesis is presented. Preliminary results of 11 cases with average follow-up of 24 months are presented. Ninety-one percent of the cases had good/excellent results. Adhesive capsulitis occurred in 1 Workers' Compensation patient, which resulted in a fair outcome.

Changes in the long head of the biceps tendon in rotator cuff tear shoulders

BACKGROUND

Morphologic changes in the long head of the biceps tendon have been described in association with rotator cuff disease, yet mechanical significance of these changes remains unclear.

METHODS

An experiment was designed to test the hypotheses that the cross-sectional area and material properties of the long head of the biceps tendon are different in shoulders with full thickness rotator cuff tears and shoulders with intact rotator cuff tendons. Seven pairs of cadaver shoulders were tested. In each pair one shoulder had a full thickness rotator cuff tear and the other did not. Thus, a matched design was used. Cross sectional areas were measured. Tendon material properties were measured using an optical strain system.

FINDINGS

We were unable to detect a statistically significant difference in the long head of the biceps area or material properties between tendons in shoulders with and without rotator cuff tears. An a priori power analysis was conducted indicating the sample size was sufficient to detect a difference of 70 MPa in the elastic modulus measurement.

INTERPRETATION

Our data indicate there is no difference in the long head of the biceps cross sectional area or material properties. Therefore, the long head of the biceps tendon appears to retain its material properties in the presence of a rotator cuff tear. The clinical significance of this finding is that the long head of the biceps can be retained in the presence of a rotator cuff tear without concern that mechanical properties have substantially deteriorated.

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.

Arthroscopic assisted mini-open biceps tenodesis: surgical technique

We describe a safe and simple approach for performing biceps tenodesis. This is performed in conjunction with arthroscopic inspection and debridement. This approach is less invasive than a deltopectoral approach and has been tested and proven secure.

Arthroscopic biceps tenodesis

The proximal biceps tendon is a significant source of shoulder pain that may be treated with biceps tenotomy or tenodesis. Biceps tenodesis has suggested advantages over tenotomy that include maintenance of the length-tension relationship, prevention of muscle atrophy, maintenance of elbow flexion and supination strength, avoidance of cramping pain, and avoidance of cosmetic deformity. The recent advancement of all arthroscopic tenodesis techniques has provided sufficient fixation strength while easing technical demands and minimizing neurovascular injury risk. With our newer techniques and better understanding of proximal biceps tendon pathology, the indications for tenodesis are evolving, and longer-term follow-up is required to fully evaluate the outcome of these procedures.