The arthroscopic active compression test

Rotator Cuff and Biceps Injuries in Baseball

Rotator cuff and biceps tendon injuries are a common source of pain and dysfunction among overhead athletes. The stress across the glenohumeral joint and its dynamic stabilizers in high level throwing leads to adaptive anatomic changes that must be recognized and respected. Nonoperative treatment is recommended for partial rotator cuff tears and biceps tendinitis and tendinosis. Surgical treatment is indicated for persistent symptoms despite conservative treatment. For rotator cuff repairs, it is critical to avoid over-tensioning as this will lead to the loss of range of motion and lower rates for return to play.

Arthroscopic Subdeltoid Transfer of the Long Head of the Biceps Tendon to the Conjoint Tendon

Surgical intervention is often recommended for refractory pathology affecting the biceps-labrum complex. Tenodesis of the long head of the biceps tendon (LHBT) is a widely accepted treatment modality; however, the optimal technique remains elusive. Arthroscopic subdeltoid transfer of the LHBT to the conjoint tendon, as described in this technical note, continues to demonstrate excellent clinical results. Its advantages include soft tissue-to-soft tissue healing, an advantageous biomechanical construct, and comprehensive evaluation and decompression of the LHBT including the extra-articular bicipital tunnel. The primary limitation of this procedure is the perceived learning curve for safe navigation within the subdeltoid space.

Management of proximal biceps tendon pathology

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician's knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient's next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

[Injuries of the biceps-labrum complex : Principles, pathologies and treatment concepts]

BACKGROUND

The biceps-labrum complex is prone to acute lesions and degenerative changes due to its anatomical structure and the high load it has to endure. Pathological changes of these structures are common pain generators and can significantly impair shoulder function. Anatomically, the biceps-labrum complex can be divided into three zones: inside, junction and bicipital tunnel.

DIAGNOSTIC PROCEDURE

Despite the focused physical examination and advancements in imaging techniques, the exact localization of pathologies remains challenging. Arthroscopy can be used to accurately diagnose inside and junctional pathologies but extra-articular changes in the region of the bicipital tunnel can only be partially visualized.

TREATMENT

In cases of unsuccessful conservative treatment and correct indications, a high level of patient satisfaction can be surgically achieved. In young patients an anatomical reconstruction of inside lesions or tenodesis of the long head of the biceps tendon is performed; however, even tenotomy is a valuable option and can achieve equally satisfactory results. Unaddressed pathological changes of the bicipital tunnel can lead to persistence of pain. In clinical procedures performing tenodesis, both the different techniques and the implants used have been found to show similar results. This article describes the anatomical principles, pathological changes, the focused clinical instrumental diagnostics and discusses the different treatment philosophies as well as the outcome according to the recent literature.

Injuries of the Biceps and Superior Labral Complex in Overhead Athletes

PURPOSE OF REVIEW

To summarize the current anatomy, biomechanics, presentation, treatment, and outcomes of injuries to the biceps and superior labral complex in overhead athletes.

RECENT FINDINGS

The biceps and superior labral complex is composed of anatomically distinct zones. The inability to accurately diagnose biceps lesions contributes to continued morbidity especially as arthroscopy and advanced imaging fail to fully evaluate the entire course of the biceps tendon. Superior labrum anterior and posterior (SLAP) repair, long head of biceps tenodesis, and tenotomy are the most common operative techniques for surgical treatment of biceps-labral complex (BLC) pathology. Labral repair in overhead athletes has resulted in mixed outcomes for athletes and is best indicated for patients under age 40 years old. Injuries to the BLC are potentially challenging injuries to diagnose and treat, particularly in the overhead athlete. SLAP repair remains the treatment of choice for high-level overhead athletes and patients younger than 40 years of age, while biceps tenodesis and tenotomy are preferred for older patients.

The "3-Pack" Examination Is Critical for Comprehensive Evaluation of the Biceps-Labrum Complex and the Bicipital Tunnel: A Prospective Study

PURPOSE

To determine the diagnostic value of the 3-Pack examination for biceps-labrum complex (BLC) disease, assess interobserver reliability, and generate an evidence-based diagnostic and therapeutic algorithm.

METHODS

A total of 145 consecutive patients were enrolled in this prospective comparative study. The study included 116 chronically symptomatic patients indicated for arthroscopic subdeltoid transfer of the long head of the biceps tendon to the conjoint tendon and 29 asymptomatic comparison subjects. Each patient underwent examination that included the 3-Pack (active compression test [O'Brien sign], throwing test, and bicipital tunnel palpation) and traditional examination (Speed test; Yergason test; full can test; empty can test) in a blinded, randomized fashion by 3 investigators. Intraoperative BLC disease was prospectively categorized by location (inside, junctional, or bicipital tunnel).

RESULTS

3-Pack tests were highly sensitive (73% to 98%), but less specific (46% to 79%) for BLC in all 3 locations than some of the traditional tests, which were less sensitive (20% to 67%), but more specific (83% to 100%) for BLC disease in all 3 locations. With regard to hidden bicipital tunnel lesions, palpation and O'Brien sign were highly sensitive (97.8% and 95.7% respectively) and revealed high negative predictive value (NPV, 96.4% and 92.6% respectively). Speed and Yergason tests, conversely, were poorly sensitive but had high specificities (86.7% and 97.9%, respectively) and positive predictive value (76% and 92.3%, respectively). Inter-rater reliabilities were substantial to almost perfect for the 3-Pack examination (kappa 70% to 85%) and fair to moderate for the 4 traditional examinations (kappa 25% to 56%).

CONCLUSIONS

The 3-Pack has excellent inter-rater reliability, sensitivity, and NPV and is a critical screening tool for BLC disease in all zones. Hidden extra-articular bicipital tunnel disease can reliably be excluded based on negative tenderness to palpation or a negative O'Brien sign (NPV 93% to 96%).

LEVEL OF EVIDENCE

Level III, case control study.

Magnetic Resonance Imaging Currently Fails to Fully Evaluate the Biceps-Labrum Complex and Bicipital Tunnel

PURPOSE

To determine the diagnostic accuracy of magnetic resonance imaging (MRI) for biceps-labrum complex (BLC) lesions, including the extra-articular bicipital tunnel.

METHODS

A retrospective review of 277 shoulders with chronic refractory BLC symptoms that underwent arthroscopic subdeltoid transfer of the long head of the biceps tendon (LHBT) to the conjoint tendon was conducted. Intraoperative lesions were categorized as "inside" (labral tears and dynamic LHBT incarceration), "junctional" (LHBT partial tears, LHBT subluxation, and biceps chondromalacia), or "bicipital tunnel" (extra-articular bicipital tunnel scar/stenosis, loose bodies, LHBT instability, and LHBT partial tears) based on anatomic location. Attending radiologist-generated MRI reports were graded dichotomously as positive or negative for biceps and labral damage and then compared with intraoperative findings. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for MRI with respect to intraoperative findings.

RESULTS

With regard to inside lesions, MRI had an overall sensitivity, specificity, PPV, and NPV for labrum lesions of 77.3%, 68.2%, 57.3%, and 84.5% respectively. The sensitivity, specificity, PPV, and NPV of MRI for junctional lesions were 43.3%, 55.6%, 73.1%, and 26.0%, respectively. For the bicipital tunnel, MRI had a sensitivity, specificity, PPV, and NPV of 50.4%, 61.4%, 48.7%, and 63.0%, respectively.

CONCLUSIONS

MRI was unreliable for ruling out BLC lesions among chronically symptomatic patients, including when the bicipital tunnel was affected.

Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex

PURPOSE

The purpose of this study was to define the limits of diagnostic glenohumeral arthroscopy and determine the prevalence and frequency of hidden extra-articular "bicipital tunnel" lesions among chronically symptomatic patients.

METHODS

Eight fresh-frozen cadaveric specimens underwent diagnostic glenohumeral arthroscopy with percutaneous tagging of the long head of the biceps tendon (LHBT) during maximal tendon excursion. The percentage of visualized LHBT was calculated relative to the distal margin of subscapularis tendon and the proximal margin of the pectoralis major tendon. Then, a retrospective review of 277 patients who underwent subdeltoid transfer of the LHBT to the conjoint tendon were retrospectively analyzed for lesions of the biceps-labral complex. Lesions were categorized by anatomic location (inside, junctional, or bicipital tunnel). Inside lesions were labral tears. Junctional lesions were LHBT tears visualized during glenohumeral arthroscopy. Bicipital tunnel lesions were extra-articular lesions hidden from view during standard glenohumeral arthroscopy.

RESULTS

Seventy-eight percent of LHBT were visualized relative to the distal margin of the subscapularis tendon and only 55% relative to the proximal margin of the pectoralis major tendon. No portion of the LHBT inferior to the subscapularis tendon was visualized. Forty-seven percent of patients had hidden bicipital tunnel lesions. Scarring was most common and accounted for 48% of all such lesions. Thirty-seven percent of patients had multiple lesion locations. Forty-five percent of patients with junctional lesions also had hidden bicipital tunnel lesions. The only offending lesion was in the bicipital tunnel for 18% of patients.

CONCLUSIONS

Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex because it visualizes only 55% of the LHBT relative to the proximal margin of the pectoralis major tendon and did not identify extra-articular bicipital tunnel lesions present in 47% of chronically symptomatic patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series and cadaveric study.

Tendinopathy of the tendon of the long head of the biceps

Pathologies of tendon of the long head of the biceps (LHB) are an important cause of shoulder pain. They include tendinopathy, rupture, superior labrum anterior and posterior lesions, pulley tears, and tendon instability. Conservative management of symptomatic LHB tendinopathy is commonly accepted as the first-line treatment. It consists of rest, nonsteroidal anti-inflammatory drugs, corticosteroid injections, and physical therapy. Biceps tenotomy and tenodesis are the most common surgical procedures to manage both isolated LHB pathology and biceps-glenoid complex tears combined with rotator cuff tears. However, controversy persists about the superiority of one of them because there is no evidence of significant differences in functional scores or patient satisfaction between the 2 techniques. This article provides an overview on biomechanical function of the LHB and current strategies for treatment of LHB disorders.

Variation of tension in the long head of the biceps tendon as a function of limb position with simulated biceps contraction

Purpose:

This study was designed to quantify tensile forces within the intra-articular long head of the bicep tendon (LHBT) under conditions of passive limb positioning and physiologic load, which simulate contraction of the LHBT.

Materials and Methods:

A force probe was inserted into the intra-articular LHBT, just distal to its supra-glenoid origin, in six fresh-frozen cadaveric specimens. Initially, specimens were manually manipulated through 30 glenohumeral joint positions, combining humeral rotation and elbow/forearm position. In the second phase, a 55 N tensile load was applied through the LHBT in 18 limb positions. Intra-tendinous tension was recorded in all positions under both conditions.

Results:

External humeral rotation significantly increased tension with glenohumeral forward flexion (P<0.0001). Conversely, internal humeral rotation significantly increased tension with glenohumeral abduction and extension (P<0.0001). A position of glenohumeral extension and internal rotation, with the elbow extended and forearm pronated, produced the highest tension in the intra-articular LHBT (P<0.0001). Under applied load conditions, observed LHTB tension was not statistically different in any glenohumeral position (P=0.1468, power = 88%). The greater tuberosity was noted to impinge on the force probe in forward flexion and internal rotation in two specimens.

Conclusions:

Variable tensile forces are seen in the intra-articular LHBT as a function of both limb position and simulated biceps contraction. Our findings provide a thorough data set that may be used to help substantiate or refute current or future hypotheses regarding LHBT function, pathology, and clinical tests.

Clinical Relevance:

Identifying positions of glenohumeral motion, which affect LHBT tension will provide an anatomic basis for clinical tests proposed to be for diagnosing LHBT lesions, including superior labral anterior and posterior tears.

Long head of the biceps tendinopathy: diagnosis and management

Tendinopathy of the long head of the biceps brachii encompasses a spectrum of pathology ranging from inflammatory tendinitis to degenerative tendinosis. Disorders of the long head of the biceps often occur in conjunction with other shoulder pathology. A thorough patient history, physical examination, and radiographic evaluation are necessary for diagnosis. Nonsurgical management, including rest, nonsteroidal anti-inflammatory drugs, physical therapy, and injections, is attempted first in patients with mild disease. Surgical management is indicated for refractory or severe disease. In addition to simple biceps tenotomy, a variety of tenodesis techniques has been described. Open biceps tenodesis has been used historically. However, promising results have recently been reported with arthroscopic tenodesis.

Arthroscopic transfer of the long head of the biceps tendon: functional outcome and clinical results

PURPOSE

We sought to evaluate clinical and functional outcome in a cohort of patients who underwent transfer of the long head of the biceps tendon (LHBT).

METHODS

Patients who were diagnosed with biceps pathology or instability underwent an arthroscopic assisted or all arthroscopic transfer LHBT as either an isolated procedure or part of another shoulder procedure by the senior author. The procedure was performed using a new arthroscopic subdeltoid technique. Forty shoulders in 39 patients were examined at a minimum of 2 years. Patients underwent complete shoulder evaluation and clinical outcomes were scored based on American Society of Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles (UCLA), and L'Insalata questionnaires. Ipsilateral and contralateral metrics were also evaluated.

RESULTS

Forty shoulders (13 female, 26 male, 1 bilateral; average age, 38.5 years) were evaluated with L'Insalata, UCLA, and ASES questionnaires, scoring 75.57, 27.32, and 78.72, respectively. In the 25 patients who had an isolated LHBT transfer, the L'Insalata, UCLA, and ASES scores were 85.2, 29.5, and 84.8, respectively. Three patients had early traumatic failure related to noncompliance with postoperative rehabilitation protocol. This included the only 2 patients who had a Popeye sign at follow-up during active elbow flexion. There was not a statistically significant side-to-side strength difference using a 10-pound weight. Eighty percent of patients were self-rated as good to excellent, and 20% of patients were self-graded as fair or poor, which includes the 3 failures mentioned above. All of the patients reported no arm pain at rest with regard to the biceps. Ninety-five percent of patients reported no biceps tenderness upon palpation of the bicipital groove. Five patients complained of fatigue discomfort (soreness) isolated to the biceps muscle following resisted elbow flexion.

CONCLUSIONS

Arthroscopic subdeltoid transfer of the LHBT is an appropriate and reliable intervention for active patients with chronic, refractory biceps pathology. There was no loss of strength for biceps curls. All patients reported no pain isolated to biceps muscle at rest. Ninety-five percent of patients had resolution of their preoperative biceps symptoms.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.