1. ΟρθοπαιδικήΚλινική
ΠανεπιστημίουΘεσσαλίας
Ch. Chrysovergis
Resident Orthopaedic
University Hospital Larisa
Director : Prof. K. Malizos
www.Ortho-uth.org

2. PROXIMAL BICEPS BRACHII TENDON
PATHOLOGY

3.  PROXIMAL BICEPS BRACHIIPROXIMAL BICEPS BRACHII
TENDON IS GENERALY REFEREDTENDON IS GENERALY REFERED
AS THE LONG HEAD OF THEAS THE LONG HEAD OF THE
BICEPS TENDON (LHBT)BICEPS TENDON (LHBT)
 THE LONG HEAD OF THE BICEPSTHE LONG HEAD OF THE BICEPS
TENDON (LHBT) IS RECOGNIZEDTENDON (LHBT) IS RECOGNIZED
AS AN IMPORTANT PAINAS AN IMPORTANT PAIN
GENERATOR OF THE SHOULDERGENERATOR OF THE SHOULDER
 LHBT PATHOLOGY IS RARELY ANLHBT PATHOLOGY IS RARELY AN
ISOLATED ENTITY.FREQUENTLYISOLATED ENTITY.FREQUENTLY
IS CORRELATED WITH ROTATORIS CORRELATED WITH ROTATOR
CUFF (RC) AND LABRALCUFF (RC) AND LABRAL
PATHOLOGYPATHOLOGY
 TRAUMA,DEGENERATION,OVERTRAUMA,DEGENERATION,OVER
USE,SUBLAXATION &USE,SUBLAXATION &
DISLOCATION OF LHBT MAYDISLOCATION OF LHBT MAY
OCCUR SIMULTANEOUSLY WITHOCCUR SIMULTANEOUSLY WITH
RC PATHOLOGYRC PATHOLOGY
 THEY NEED TO BE IDENTIFIEDTHEY NEED TO BE IDENTIFIED
AND TREATED AT THE SAMEAND TREATED AT THE SAME
TIMETIME

4. ANATOMY OF THE LHBT
 COMPLEX ANATOMY WITHCOMPLEX ANATOMY WITH
RELATION TO THE RC OFRELATION TO THE RC OF
THE SHOULDERTHE SHOULDER
 IT HAS INTRA-ARTICULARIT HAS INTRA-ARTICULAR
(INTRA-CAPSULAR) AND(INTRA-CAPSULAR) AND
EXTRA-ARTICULAR (EXTRA-EXTRA-ARTICULAR (EXTRA-
CAPSULAR) PORTIONCAPSULAR) PORTION
 INTRA-CAPSULAR THROUGHINTRA-CAPSULAR THROUGH
THE BICEPS PULLEY ,THE BICEPS PULLEY ,
EXTRA-CAPSULAREXTRA-CAPSULAR
THROUGH THE BICIPITALTHROUGH THE BICIPITAL
GROOVEGROOVE
 LHBTLHBT
TOTAL LENGTH 9 – 10 cmTOTAL LENGTH 9 – 10 cm
 LHBTLHBT
DIAMETER 5 – 6 mmDIAMETER 5 – 6 mm

5.  LHB TENDON ARISESLHB TENDON ARISES
FROM THEFROM THE
SUPRAGLENOIDSUPRAGLENOID
TUBERCLE OF THETUBERCLE OF THE
SCAPULA AND PARTLYSCAPULA AND PARTLY
FROM THE SUPERIORFROM THE SUPERIOR
GLENOID LABRUMGLENOID LABRUM
(BICEPS ANCHOR) WITH(BICEPS ANCHOR) WITH
A 50% ANATOMICA 50% ANATOMIC
VARIATION FROM THEVARIATION FROM THE
POSTERIOR GLENOIDPOSTERIOR GLENOID
LABRUMLABRUM

6.  THE INTRA-THE INTRA-
CAPSULARCAPSULAR
PORTIONPORTION
(FLATTENED &(FLATTENED &
LARGER)LARGER)
STABILIZED BYSTABILIZED BY
THE BICEPSTHE BICEPS
PULLEY (RUNSPULLEY (RUNS
ALONG THEALONG THE
LATERAL HALFLATERAL HALF
OF THEOF THE
ROTATORROTATOR
INTERVAL)INTERVAL)

7.  BICEPS PULEYBICEPS PULEY
IS FORMED BY :IS FORMED BY :
SUPERIORSUPERIOR
GLENOHUMERAGLENOHUMERA
L LIGAMENTL LIGAMENT
(SGHL),CORAC(SGHL),CORAC
OHUMERALOHUMERAL
LIGAMENTLIGAMENT
(CHL),FIBERS(CHL),FIBERS
OFOF
SUPRASPINATUSUPRASPINATU
S (SSt) &S (SSt) &
SUSCAPULARISSUSCAPULARIS
(SSc) TENDONS(SSc) TENDONS

8.  THE INTRA-CAPSULAR PORTION UNDERGOES AN ABRUPTTHE INTRA-CAPSULAR PORTION UNDERGOES AN ABRUPT
ANGULATION OF 30 – 40 DEGREESANGULATION OF 30 – 40 DEGREES
 FUSING INFERIORLY TO THE BICIPITAL GROOVE THE EXTRA-FUSING INFERIORLY TO THE BICIPITAL GROOVE THE EXTRA-
CAPSULAR PORTION (ROUNDED & SMALLER IN CALIBER) ISCAPSULAR PORTION (ROUNDED & SMALLER IN CALIBER) IS
STABILIZED BY THE TRANSVERSE HUMERAL LIGAMENT &STABILIZED BY THE TRANSVERSE HUMERAL LIGAMENT &
PECTORALIS MAJOR TENDONPECTORALIS MAJOR TENDON
 THE BICIPITAL GROOVE IS ABOUT 4mm IN DEPTH WITH A 56THE BICIPITAL GROOVE IS ABOUT 4mm IN DEPTH WITH A 56
DEGREES MEDIAL WALL ANGLEDEGREES MEDIAL WALL ANGLE

9.  ARTERIAL SUPPLY DESCRIBED BY CHENG et al.ARTERIAL SUPPLY DESCRIBED BY CHENG et al.
FROM 3 POTENTIAL SOURCESFROM 3 POTENTIAL SOURCES
1.BRANCHES OF THE BRACHIAL ARTERY1.BRANCHES OF THE BRACHIAL ARTERY
2.THORACOACROMIAL ARTERY2.THORACOACROMIAL ARTERY
3.A RARE VARIANT OF THE CIRCUMFLEX HUMERAL3.A RARE VARIANT OF THE CIRCUMFLEX HUMERAL
ARTERYARTERY
 THE TENDON HAS A HYPOVASCULAR ZONE AT 1.2 TOTHE TENDON HAS A HYPOVASCULAR ZONE AT 1.2 TO
3 cm FROM IT’S ORIGIN & AN AVASCULAR ZONE3 cm FROM IT’S ORIGIN & AN AVASCULAR ZONE
WITHIN THE BICIPITAL GROOVE AT IT’S DEEPERWITHIN THE BICIPITAL GROOVE AT IT’S DEEPER
SLIDING PORTION (COMPOSED OF FIBROCARTILAGE)SLIDING PORTION (COMPOSED OF FIBROCARTILAGE)
 SENZORY & SYMPATHETIC INNERVATION NETWORKSENZORY & SYMPATHETIC INNERVATION NETWORK
DESCRIBED BY ALPANTAKI et al. IS DISTRIBUTEDDESCRIBED BY ALPANTAKI et al. IS DISTRIBUTED
ASYMMETRICALLY & PLAY A ROLE IN THEASYMMETRICALLY & PLAY A ROLE IN THE
PATHOGENESIS OF SHOULDER PAIN DURING LHBTPATHOGENESIS OF SHOULDER PAIN DURING LHBT
PATHOLOGYPATHOLOGY

10.  LHBT A MULTIFUNCTIONAL TENDON AT THE SHOULDER & ELBOWLHBT A MULTIFUNCTIONAL TENDON AT THE SHOULDER & ELBOW
LEVELLEVEL
FUNCTION
 HAS CLOSE ANATOMIC RELATION WITH THE ROTATOR CABLE OF THEHAS CLOSE ANATOMIC RELATION WITH THE ROTATOR CABLE OF THE
SHOULDER (AS DESCRIBED BY BURKHART et al. FORMING THESHOULDER (AS DESCRIBED BY BURKHART et al. FORMING THE
SUSPENSION BRIDGE MODEL OF THE SHOULDER) AND CONTRIBUTINGSUSPENSION BRIDGE MODEL OF THE SHOULDER) AND CONTRIBUTING
TO THE SHOULDER STABILITYTO THE SHOULDER STABILITY

11.  PRIMARILY A FLEXORPRIMARILY A FLEXOR
& SUPINATOR OF THE& SUPINATOR OF THE
ELBOWELBOW
 AT THE SHOULDERAT THE SHOULDER
LEVEL IS A DYNAMICLEVEL IS A DYNAMIC
STABILIZER OF THESTABILIZER OF THE
HUMERAL HEAD ANDHUMERAL HEAD AND
WORKS AS :WORKS AS :
 1:DEPRESSOR1:DEPRESSOR
(SUPERIOR(SUPERIOR
STABILIZER) &STABILIZER) &
COMPRESSOR OFCOMPRESSOR OF
THE HUMERAL HEADTHE HUMERAL HEAD
INTO THE GLENOIDINTO THE GLENOID
CAVITY.CENTERSCAVITY.CENTERS
THE HEAD INTO THETHE HEAD INTO THE
CAVITYCAVITY
 2:LIMITER OF2:LIMITER OF
EXTERNAL ROTATIONEXTERNAL ROTATION
 3:LIFTER OF THE3:LIFTER OF THE
GLENOID LABRUMGLENOID LABRUM
WHILE ABDUCTIONWHILE ABDUCTION
Αλεξ. Ε. ΑγιοςΑλεξ. Ε. Αγιος ““ΑνατομικηΑνατομικη””

12. CLINICAL PATHOLOGYCLINICAL PATHOLOGY
 LHBT HAS WIDELHBT HAS WIDE
RANGE OFRANGE OF
PATIENT GROUPSPATIENT GROUPS
& IS CORELATED& IS CORELATED
WITH RC & LABRALWITH RC & LABRAL
PATHOLOGYPATHOLOGY
 HEAVY LABORERSHEAVY LABORERS
 WEIGHTLIFTERSWEIGHTLIFTERS

13.  OVERHEADOVERHEAD
THROWERSTHROWERS
 BASEBALLBASEBALL
PITCHERSPITCHERS
 DISCUS &DISCUS &
LANCELANCE
THROWERSTHROWERS

14.  MOST LESIONS HAPPEN DURING THE MAXIMUM EXTERNALMOST LESIONS HAPPEN DURING THE MAXIMUM EXTERNAL
ROTATION AND THE DECELERATION PHASE OF THE THROWROTATION AND THE DECELERATION PHASE OF THE THROW

15.  LHBT LESIONS ALSO APPEAR INLHBT LESIONS ALSO APPEAR IN
PARACHUTERS WHILE TRYING TOPARACHUTERS WHILE TRYING TO
CONTROL THE PARACHUTE SLINGSCONTROL THE PARACHUTE SLINGS
 OVERUSE & REPETITIVEOVERUSE & REPETITIVE
TRACTION,FRICTION,GLENOHUMERTRACTION,FRICTION,GLENOHUMER
AL ROTATION ARE THEAL ROTATION ARE THE
MECHANICAL CAUSES OF LESIONMECHANICAL CAUSES OF LESION
 IN AGES > 45 THE MAIN CAUSE ISIN AGES > 45 THE MAIN CAUSE IS
DEGENERATIVE LESIONSDEGENERATIVE LESIONS

16.  MANY AUTHORS TRIED TO CLASSIFY THE PATHOLOGY OF LHBTMANY AUTHORS TRIED TO CLASSIFY THE PATHOLOGY OF LHBT
BASED ON ANATOMIC LOCATION , INFLAMMATORY &BASED ON ANATOMIC LOCATION , INFLAMMATORY &
DEGENERATIVE CHANGES , INSTABILITY & DISLOCATION ,DEGENERATIVE CHANGES , INSTABILITY & DISLOCATION ,
ARTHROSCOPIC REAL TIME EVALUATION FINDINGSARTHROSCOPIC REAL TIME EVALUATION FINDINGS
 (Patte et al. 1990 , Neviaser 80’s , Miller & Savoie , Refior & Sowa , Ahmad et al. , Burkhart et al. , Walch et al. , Habermeyer et al. ,(Patte et al. 1990 , Neviaser 80’s , Miller & Savoie , Refior & Sowa , Ahmad et al. , Burkhart et al. , Walch et al. , Habermeyer et al. ,
Lafosse et al.)Lafosse et al.)
 A SIMPLIFIED CLASSIFICATION PROPOSED BY CHENG et al.A SIMPLIFIED CLASSIFICATION PROPOSED BY CHENG et al.
INCLUDES 6 TYPES OF LESIONSINCLUDES 6 TYPES OF LESIONS
Type I : TendinopathyType I : Tendinopathy
Type II : SubluxationType II : Subluxation
Type III : DislocationType III : Dislocation
Type IV : Partial tearsType IV : Partial tears
Type V : Complete ruptutreType V : Complete ruptutre
Type VI : SLAP lesionsType VI : SLAP lesions
 AN ALTERNATIVE CLASSIFICATION IS INTRA-CAPSULAR & EXTRA-AN ALTERNATIVE CLASSIFICATION IS INTRA-CAPSULAR & EXTRA-
CAPSULAR LESIONSCAPSULAR LESIONS
Intra-capsular : SLAP tears , Tendinopathy , Subluxation & DislocationIntra-capsular : SLAP tears , Tendinopathy , Subluxation & Dislocation
Extra-capsular : Lesions at the level of the bicipital groove (Tenosynovitis ,Extra-capsular : Lesions at the level of the bicipital groove (Tenosynovitis ,
‘’Hour-glass’’ biceps)‘’Hour-glass’’ biceps)

17.  THE CLINICAL PRESENTATION OF THE PATIENT WITH LHBTTHE CLINICAL PRESENTATION OF THE PATIENT WITH LHBT
PATHOLOGY IS SIMILAR TO THAT OF A PATIENT WITH RCPATHOLOGY IS SIMILAR TO THAT OF A PATIENT WITH RC
LESIONSLESIONS

18.  ANTERIOR SHOULDER PAIN AND IMPAIRED FUNCTION AS AANTERIOR SHOULDER PAIN AND IMPAIRED FUNCTION AS A
RESULT OF OVERUSE OR ACUTE TRAUMA IS THE MOSTRESULT OF OVERUSE OR ACUTE TRAUMA IS THE MOST
COMMON SYMPTOMCOMMON SYMPTOM
 PAIN MAY OCCUR AT REST OR BE WORSE AT NIGHT & MAYPAIN MAY OCCUR AT REST OR BE WORSE AT NIGHT & MAY
RADIATE DISTALY INTO THE MUSCLERADIATE DISTALY INTO THE MUSCLE
 A “CLICK” MAY BE PRESENT IN CASE OF INSTABILITY & INA “CLICK” MAY BE PRESENT IN CASE OF INSTABILITY & IN
CASE OF OVERHEAD THROWERS DURING THROW PHASECASE OF OVERHEAD THROWERS DURING THROW PHASE
 THE TENDON MAY BE PALPABLE AT THE BICIPITAL GROOVETHE TENDON MAY BE PALPABLE AT THE BICIPITAL GROOVE
AREAAREA

19.  CLINICAL EVALUATION & TRIALSCLINICAL EVALUATION & TRIALS
::
Yergason’s testYergason’s test
Speed’s testSpeed’s test
Uppercut trialUppercut trial
O’Brien’s testO’Brien’s test
Bear hug trialBear hug trial
Belly press trialBelly press trial
Belly press trial : HBelly press trial : Hands onands on
abdomen, elbowsabdomen, elbows
outout..Press in on abdomenPress in on abdomen
or keep elbows out whileor keep elbows out while
posteriorly directed force isposteriorly directed force is
applied to elbowsapplied to elbows..PositivePositive
test if unable to keeptest if unable to keep
elbows outelbows out (Inability to(Inability to
keep humerus internalkeep humerus internal
rotation).Indicates SScrotation).Indicates SSc
tear , Biceps instability.tear , Biceps instability.

20. Uppercut trial : Positive if pain presents to the bicipitalUppercut trial : Positive if pain presents to the bicipital
groove area or unable to execute an uppercut punchgroove area or unable to execute an uppercut punch
under resistance.Indicates Biceps tendinopathyunder resistance.Indicates Biceps tendinopathy
and/or instability , posible SSc tearand/or instability , posible SSc tear
Bear hug trial :Bear hug trial :
PatientPatient
cannot holdcannot hold
the handthe hand
against theagainst the
shoulder asshoulder as
examinerexaminer
applies anapplies an
externalexternal
rotationrotation force.force.
Indicates SScIndicates SSc
tear , Bicepstear , Biceps
instability.instability.

21.  INDICATION OF SLAPINDICATION OF SLAP
LESIONLESION

23.  GENERALY THERE’SGENERALY THERE’S
NO ABSOLUTENO ABSOLUTE
RELIABILITY TORELIABILITY TO
CLINICAL TESTSCLINICAL TESTS
 AUTHORSAUTHORS
COMPARED THECOMPARED THE
CLINICAL TESTSCLINICAL TESTS
RESULTS TO REALRESULTS TO REAL
TIMETIME
ARTHROSCOPICARTHROSCOPIC
EVALUATIONEVALUATION(Holtby &(Holtby &
Razmjou , Kibler et al.)Razmjou , Kibler et al.)
 CONCLUSION : WHENCONCLUSION : WHEN
THE RESULTS ARETHE RESULTS ARE
POSITIVE , IT’S QUITEPOSITIVE , IT’S QUITE
RELIABLE THATRELIABLE THAT
SOME SHOULDERSOME SHOULDER
PATHOLOGY ISPATHOLOGY IS
PRESENTPRESENT

24.  TYPE I : TENDINOPATHYTYPE I : TENDINOPATHY
- RESULT OF DEGENERATIVE CHANGES:FIBROSIS,CHRONIC INFLAMTION,SCARRESULT OF DEGENERATIVE CHANGES:FIBROSIS,CHRONIC INFLAMTION,SCAR
TISSUE,FIBROTIC THICKENING,COLLAGEN DISORGANIZATIONTISSUE,FIBROTIC THICKENING,COLLAGEN DISORGANIZATION
- MAY BE RESULT OF LHBT INSTABILITYMAY BE RESULT OF LHBT INSTABILITY
- MAY BE RESULT OF PARTIAL TEARSMAY BE RESULT OF PARTIAL TEARS
- DEGENERATION DURING AGE (OVER 40 – 45)DEGENERATION DURING AGE (OVER 40 – 45)
- YOUNGSTERS MOSTLY DUE TO OVERUSEYOUNGSTERS MOSTLY DUE TO OVERUSE
- SUBACROMIAL IMPINGEMENTSUBACROMIAL IMPINGEMENT
- MECHANICAL CAUSES (TRACTION,FRICTION,SHEARING FORCES)MECHANICAL CAUSES (TRACTION,FRICTION,SHEARING FORCES)
- BICIPITAL GROOVE LESIONSBICIPITAL GROOVE LESIONS
- ““HOUR-GLASS” BICEPSHOUR-GLASS” BICEPS
Arthroscopic appearance ofArthroscopic appearance of
tendon degeneration.tendon degeneration.
Normal LHBT (left).Normal LHBT (left).
Moderate tendinosis at theModerate tendinosis at the
level of the bicipital groovelevel of the bicipital groove
with frayed tissue (middle),with frayed tissue (middle),
Severe diffuse tendinosisSevere diffuse tendinosis
(right). (Arthroscopic(right). (Arthroscopic
Images courtesy of Dr.Images courtesy of Dr.
Allen Anderson,Allen Anderson,
Tennessee OrthopaedicTennessee Orthopaedic
Alliance)Alliance)

25. - “HOUR-GLASS” BICEPS :- “HOUR-GLASS” BICEPS : HYPERTROPHIC TENDINOPATHY RESULTSHYPERTROPHIC TENDINOPATHY RESULTS
IN ENTRAPMENT OF LHBT WITHIN THE BICIPITAL GROOVE.THE “HOUR-GLASS”IN ENTRAPMENT OF LHBT WITHIN THE BICIPITAL GROOVE.THE “HOUR-GLASS”
BICEPS , UNABLE TO SLIDE THROUGH , CAUSES “LOCKING” OF THE SHOULDERBICEPS , UNABLE TO SLIDE THROUGH , CAUSES “LOCKING” OF THE SHOULDER
IN ABDUCTION OR FORWARD FLEXION (AUTHORS COMPARE IT WITH AIN ABDUCTION OR FORWARD FLEXION (AUTHORS COMPARE IT WITH A
“TRIGGER” FINGER AT THE SHOULDER LEVEL).“TRIGGER” FINGER AT THE SHOULDER LEVEL).

26.  TYPE II & III : SUBLAXAION & DISLOCATION (INSTABILITY)TYPE II & III : SUBLAXAION & DISLOCATION (INSTABILITY)
- SUBSCAPULARIS TEARS ARE MOST COMMONLY ASSOCIATED WITH LHBT INSTABILITYSUBSCAPULARIS TEARS ARE MOST COMMONLY ASSOCIATED WITH LHBT INSTABILITY
- ROTATOR INTERVAL MAY ALSO BE CORELATED WITH LHBT INSTABILITYROTATOR INTERVAL MAY ALSO BE CORELATED WITH LHBT INSTABILITY
- TRAUMATIC INJURY MECHANISM MAY BE A FALL ON AN OUTSTRECHED ARM WITHTRAUMATIC INJURY MECHANISM MAY BE A FALL ON AN OUTSTRECHED ARM WITH
FULL INTERNAL OR EXTERNAL ROTATION , BACKWARD FALL ON FULLY EXTENDED ARMFULL INTERNAL OR EXTERNAL ROTATION , BACKWARD FALL ON FULLY EXTENDED ARM
OR WITH ELBOW IMPACT , DIRECT ANTERIOR SHOULDER IMPACTOR WITH ELBOW IMPACT , DIRECT ANTERIOR SHOULDER IMPACT
- COULD LEAD TO BICEPS TENDINOPATHYCOULD LEAD TO BICEPS TENDINOPATHY
- WALCH & BENNET PROPOSED RESPECTIVELY A 4 & 5 TYPES PATTERN OF LHBTWALCH & BENNET PROPOSED RESPECTIVELY A 4 & 5 TYPES PATTERN OF LHBT
ISTABILITYISTABILITY
- A RECENTLY MODIFIED PATTERN BY HABERMEYER PROPOSES 6 TYPES OFA RECENTLY MODIFIED PATTERN BY HABERMEYER PROPOSES 6 TYPES OF
INSTABILITY (SUBLAXATION , INTRA & EXTRA-ARTICULAR DISLOCATION)INSTABILITY (SUBLAXATION , INTRA & EXTRA-ARTICULAR DISLOCATION)
(Adapted from Resnick24) Normal:(Adapted from Resnick24) Normal:
Graphic depicting the biceps pulleyGraphic depicting the biceps pulley
region from an oblique axialregion from an oblique axial
perspective, perpendicular to theperspective, perpendicular to the
course of the LHBT just superior andcourse of the LHBT just superior and
medial to the bicipital groove. Themedial to the bicipital groove. The
coracohumeral ligament (CHL) is thecoracohumeral ligament (CHL) is the
most superficial layer of the bicepsmost superficial layer of the biceps
pulley mechanism and extends overpulley mechanism and extends over
the subscapularis (SScT) andthe subscapularis (SScT) and
supraspinatus (SST) tendons. Thesupraspinatus (SST) tendons. The
superior glenohumeral ligament fusessuperior glenohumeral ligament fuses
with the CHL laterally and forms awith the CHL laterally and forms a
ligament layer between the bicepsligament layer between the biceps
tendon (BT) and the superior-mosttendon (BT) and the superior-most
inserting subscapularis tendoninserting subscapularis tendon
(SScT) at the lesser tuberosity (LT).(SScT) at the lesser tuberosity (LT).

27. Type I: Tendon displacement-Type I: Tendon displacement-
subscapularis tendon (SScT) tearsubscapularis tendon (SScT) tear
alone. Medial shift or minoralone. Medial shift or minor
subluxation of the biceps tendonsubluxation of the biceps tendon
secondary to a partialsecondary to a partial
intrasubstance or anterior tear ofintrasubstance or anterior tear of
thethe subscapularis tendon withsubscapularis tendon with
intact medial ligament componentintact medial ligament component
of the biceps pulley.of the biceps pulley.
Type II: Tendon displacement-medialType II: Tendon displacement-medial
ligament tears alone. Slightlyligament tears alone. Slightly
greater medial subluxation of thegreater medial subluxation of the
biceps tendon through the tornbiceps tendon through the torn
portion of the ligaments, but theportion of the ligaments, but the
intact subscapularis tendon fibersintact subscapularis tendon fibers
prevent medial dislocation.prevent medial dislocation.

28. Type III: Extra-articular tendonType III: Extra-articular tendon
dislocation-tears of the medialdislocation-tears of the medial
ligaments and subscapularisligaments and subscapularis
tendon. A partialtendon. A partial
intrasubstance tear of theintrasubstance tear of the
subscapularis tendon allowssubscapularis tendon allows
the biceps tendon to dislocatethe biceps tendon to dislocate
medially without entering themedially without entering the
joint because of intact deepjoint because of intact deep
fibers of the subscapularisfibers of the subscapularis
tendon.tendon.
Type IV: Extra-articular tendon dislocation-tearsType IV: Extra-articular tendon dislocation-tears
of the lateral limbs of the ligaments with anof the lateral limbs of the ligaments with an
intact subscapularis tendon. The bicepsintact subscapularis tendon. The biceps
tendon dislocates anteriorly becomingtendon dislocates anteriorly becoming
located anterior to the intact subscapularislocated anterior to the intact subscapularis
tendon. This pattern has a high associationtendon. This pattern has a high association
with partial or full-thickness tears of thewith partial or full-thickness tears of the
supraspinatus tendon. Although a full-supraspinatus tendon. Although a full-
thickness tear of the subscapularis is notthickness tear of the subscapularis is not
required for this pattern, partial articular-required for this pattern, partial articular-
sided, bursal-sided, and interstitial tearssided, bursal-sided, and interstitial tears
may be seen.may be seen.

29. Type V: Intra-articular tendon dislocation-Tears of theType V: Intra-articular tendon dislocation-Tears of the
medial and lateral limbs of the coracohumeral andmedial and lateral limbs of the coracohumeral and
superior glenohumeral ligaments with a full-superior glenohumeral ligaments with a full-
thickness tear of the subscapularis allows medialthickness tear of the subscapularis allows medial
dislocation of the LHBT into the joint. Mostdislocation of the LHBT into the joint. Most
commonly the superior subscapularis tendoncommonly the superior subscapularis tendon
demonstrates a full-thickness tear while the lowerdemonstrates a full-thickness tear while the lower
portion of the tendon remains attached along theportion of the tendon remains attached along the
inferior portion of the lesser tuberosity andinferior portion of the lesser tuberosity and
surgical neck. The course of the LHBT movessurgical neck. The course of the LHBT moves
from a dislocated intra-articular position superiorlyfrom a dislocated intra-articular position superiorly
to an extra-articular location anterior to the intactto an extra-articular location anterior to the intact
subscapularis fibers inferiorly.subscapularis fibers inferiorly.
Type VI: Intra-articular tendon dislocation-tearType VI: Intra-articular tendon dislocation-tear
of the medial limbs of the ligaments andof the medial limbs of the ligaments and
detachment of the subscapularis from thedetachment of the subscapularis from the
lesser tuberosity. Bridging fibers from thelesser tuberosity. Bridging fibers from the
subscapularis to the greater tuberositysubscapularis to the greater tuberosity
remain intact. Medial dislocation of theremain intact. Medial dislocation of the
biceps tendon remains deep to thebiceps tendon remains deep to the
subscapularis and enters the glenohumeralsubscapularis and enters the glenohumeral
joint.joint.

31.  TYPE IV & V : PARTIAL/COMPLETE RUPTURE OF LHBTTYPE IV & V : PARTIAL/COMPLETE RUPTURE OF LHBT
- NORMALY LHBT CAN ENDURE HIGH TRACTION FORCES (667 – 890 newtons)NORMALY LHBT CAN ENDURE HIGH TRACTION FORCES (667 – 890 newtons)
- RUPTURE OF A HEALTHY LHBT IS RARERUPTURE OF A HEALTHY LHBT IS RARE
- CAN OCCUR IN WEIGHTLIFTERS AND MALES AGED 50 OR OLDERCAN OCCUR IN WEIGHTLIFTERS AND MALES AGED 50 OR OLDER
- USUALY PARTIAL/COMPLETE THICKNESS RUPTURES ARE ASSOCIATED WITHUSUALY PARTIAL/COMPLETE THICKNESS RUPTURES ARE ASSOCIATED WITH
UNDERLYING SHOULDER PATHOLOGY (DEGENERATION , IMPINGEMENT , RC AND/ORUNDERLYING SHOULDER PATHOLOGY (DEGENERATION , IMPINGEMENT , RC AND/OR
SLAP TEARS , TENDON INSTABILITY)SLAP TEARS , TENDON INSTABILITY)
- MOST COMMON POINT OF RUPTURE IS THE HYPOVASCULAR AREA (1.2 TO 3 cm FROMMOST COMMON POINT OF RUPTURE IS THE HYPOVASCULAR AREA (1.2 TO 3 cm FROM
ANCHOR) OR PROXIMAL TO THE BICIPITAL GROOVE (“GROOVE ENTRY LESION”)ANCHOR) OR PROXIMAL TO THE BICIPITAL GROOVE (“GROOVE ENTRY LESION”)
Fraying of long head of the biceps tendon (LHBT)
involving less than 50% of the tendon
diameter.Also note abrasion of the humeral head
from the LHBT.
Fraying of the long head of the biceps tendon (LHBT)
exceeding 50% of the tendon diameter. HH, humeral
head.

32. - PARTIAL THICKNESS TEAR CAUSES SHOULDER PAIN & DISFUNCTIONPARTIAL THICKNESS TEAR CAUSES SHOULDER PAIN & DISFUNCTION
- COMPLETE RUPTURE OF A PARTIAL TEAR MAY ACTUALLY RELIEVE THE PAINCOMPLETE RUPTURE OF A PARTIAL TEAR MAY ACTUALLY RELIEVE THE PAIN
- THE MOST CHARACTERISTIC SIGN OF A COMPLETE RUPTURE ISTHE MOST CHARACTERISTIC SIGN OF A COMPLETE RUPTURE IS “POPEYE“POPEYE
DEFORMITY”DEFORMITY” AS THE LHBT SLIDES DISTALY TO THE GROOVE FORMING A MUSCLEAS THE LHBT SLIDES DISTALY TO THE GROOVE FORMING A MUSCLE
BULGE OF THE BICEPSBULGE OF THE BICEPS
- COMPLETE RUPTURE ON “HOUR-GLASS” BICEPS MAY NOT PRESENT THAT SIGNCOMPLETE RUPTURE ON “HOUR-GLASS” BICEPS MAY NOT PRESENT THAT SIGN

33.  TYPE VI : SLAP TEARSTYPE VI : SLAP TEARS (Superior Labrum Anterior – Posterior tears)(Superior Labrum Anterior – Posterior tears)
- UP TO 10 TYPES OF SLAP LESIONS HAVE BEEN DESCRIBEDUP TO 10 TYPES OF SLAP LESIONS HAVE BEEN DESCRIBED
- BICEPS ANCHOR IS INVOLVED TO A SLAP TEARBICEPS ANCHOR IS INVOLVED TO A SLAP TEAR
- Snyder Classification: Original classification which includes Types I-IVSnyder Classification: Original classification which includes Types I-IV
- MMECHANISMS :ECHANISMS : repetitive overhead activities (often seen in throwing athletes)repetitive overhead activities (often seen in throwing athletes),,fall onfall on
outstretched arm with tensed bicepsoutstretched arm with tensed biceps,,traction on the armtraction on the arm
- SSYMPTOMS :YMPTOMS : deep shoulder paindeep shoulder pain,,mechanical symptoms of popping and clickingmechanical symptoms of popping and clicking,,weakness,easyweakness,easy
fatigue,decrease athletic performancefatigue,decrease athletic performance,instability,,instability,biceps tendon tendernessbiceps tendon tenderness

36. IMAGINGIMAGING
 IMAGING SHOULD START WITH PLAIN SHOULDER X-RAYS MAINLYIMAGING SHOULD START WITH PLAIN SHOULDER X-RAYS MAINLY
TO OBSERVE CORELATED GLENOHUMERAL AND/ORTO OBSERVE CORELATED GLENOHUMERAL AND/OR
ACROMIOCLAVICULAR BONY PATHOLOGYACROMIOCLAVICULAR BONY PATHOLOGY (ARTHROSIS)(ARTHROSIS) THAT COULDTHAT COULD
CAUSE SYMPTOMSCAUSE SYMPTOMS (IMPINGEMENT , CALCIFIC TENDONITIS)(IMPINGEMENT , CALCIFIC TENDONITIS)

37.  ULTRASOUND :ULTRASOUND :
- INEXPENSIVEINEXPENSIVE
- GOOD DETECTION OF LHB TENDINOPATHYGOOD DETECTION OF LHB TENDINOPATHY
- VERRY GOOD DETECTION OF RUPTURES,SUBLUXATION & DISLOCATIONVERRY GOOD DETECTION OF RUPTURES,SUBLUXATION & DISLOCATION
- LOW SENSITIVITY FOR DETECTION OF PARTIAL TEARSLOW SENSITIVITY FOR DETECTION OF PARTIAL TEARS
- HIGHLY OPERATOR DEPENDENT TECHNIQUE WITH LONG LEARNING CURVEHIGHLY OPERATOR DEPENDENT TECHNIQUE WITH LONG LEARNING CURVE

39. Biceps tendinopathy : Accumulation of fluidBiceps tendinopathy : Accumulation of fluid
within LHBT sheathwithin LHBT sheath

40. Biceps dislocation : Biceps grooveBiceps dislocation : Biceps groove
empty,tendon visible medial toempty,tendon visible medial to
it under the SSc fibersit under the SSc fibers

41. Biceps RuptureBiceps Rupture
Empty Bicipital grooveEmpty Bicipital groove
(transverse)(transverse)
Retracted Biceps stumpRetracted Biceps stump
(transverse)(transverse)

42. Retracted Biceps stumpRetracted Biceps stump
(longitudinal)(longitudinal)
Empty Bicipital GrooveEmpty Bicipital Groove
(longitudinal)(longitudinal)

43.  MRI & MRA :MRI & MRA :
- MRI allows verry good visualisation of labrum,Biceps tendon,Bicipital groove,Bony osteophytesMRI allows verry good visualisation of labrum,Biceps tendon,Bicipital groove,Bony osteophytes
- Can detect partial & complete tears of LHBT,SLAP lesions,subluxation & dislocation,associatedCan detect partial & complete tears of LHBT,SLAP lesions,subluxation & dislocation,associated
RC pathologyRC pathology
- MRA has high accuracy on partial thickness tears & tendinopathy,Biceps pulley lesions,SLAPMRA has high accuracy on partial thickness tears & tendinopathy,Biceps pulley lesions,SLAP
lesionslesions
- Both techniques are expensive,MRA needs presence of contrast substance but can raiseBoth techniques are expensive,MRA needs presence of contrast substance but can raise
sensitivity up to 90%sensitivity up to 90%

44. SLAP tear (arrow)SLAP tear (arrow)
Biceps dislocation : BicepsBiceps dislocation : Biceps
groove empty,tendon visiblegroove empty,tendon visible
medial to it , SSc tearmedial to it , SSc tear

45. Biceps rupture : Retracted tendonBiceps rupture : Retracted tendon
(arrow)(arrow)
SLAP tear (in circle)SLAP tear (in circle)

47. TREATMENT STRATEGYTREATMENT STRATEGY
 METHODS OF TREATMENT INCLUDE CONSERVATIVE (NON-METHODS OF TREATMENT INCLUDE CONSERVATIVE (NON-
SURGICAL) & SURGICAL MANAGEMENTSURGICAL) & SURGICAL MANAGEMENT
 USUALY THE MANAGEMENT IS NOT ONLY TARGETED TOUSUALY THE MANAGEMENT IS NOT ONLY TARGETED TO
SYMPTOMS BUT ALSO AGE , ACTIVITY & COSMETIC DEFORMITYSYMPTOMS BUT ALSO AGE , ACTIVITY & COSMETIC DEFORMITY
DEPENDENT.DEPENDENT.
 AGE <40 AND/OR >40 WITH HIGH ACTIVITY DEMANDS OR COSMETICAGE <40 AND/OR >40 WITH HIGH ACTIVITY DEMANDS OR COSMETIC
DEFORMITY END UP TO SURGICAL TREATMENTDEFORMITY END UP TO SURGICAL TREATMENT
 AGE >40 AND LOW DEMANDING PATIENTS COULD BE MANAGEDAGE >40 AND LOW DEMANDING PATIENTS COULD BE MANAGED
WITH NON-SURGICAL TREATMENTWITH NON-SURGICAL TREATMENT
 WE MUST KEEP IN MIND TO REPAIR ANY ASSOCIATED RC ORWE MUST KEEP IN MIND TO REPAIR ANY ASSOCIATED RC OR
LABRAL LESIONSLABRAL LESIONS

48.  NON-SURGICAL MANAGEMENT :NON-SURGICAL MANAGEMENT :
- ACTUVITY MODIFICATIONACTUVITY MODIFICATION
- NSAID MEDICATIONNSAID MEDICATION
- PHYSICAL THERAPYPHYSICAL THERAPY
- STEROID + LOCAL ANESTHETIC INJECTION TO THE BICIPITAL GROOVESTEROID + LOCAL ANESTHETIC INJECTION TO THE BICIPITAL GROOVE (but not(but not
into tendon)into tendon) OR SUBACROMIAL SPACE MAY RELIEVE TENDINOPATHY OROR SUBACROMIAL SPACE MAY RELIEVE TENDINOPATHY OR
IMPINGEMENT SYMPTOMSIMPINGEMENT SYMPTOMS
 POOR RESULTS OF THE TREATMENT INVOLVE :POOR RESULTS OF THE TREATMENT INVOLVE :
- RC ASSOCIATED PATHOLOGYRC ASSOCIATED PATHOLOGY
- MUSCLE SPASMMUSCLE SPASM
- ““POPEYE” DEFORMITYPOPEYE” DEFORMITY (PARTICULARLY IN THIN PATIENTS)(PARTICULARLY IN THIN PATIENTS)
- 8% - 29% DECREASE IN ELBOW FLEXION STRENGTH8% - 29% DECREASE IN ELBOW FLEXION STRENGTH (Mariani et al. , Deuch et al.)(Mariani et al. , Deuch et al.)
- 21% - 23% DECREASE IN FOREARM SUPINATION21% - 23% DECREASE IN FOREARM SUPINATION (Mariani et al. , Deuch et al.)(Mariani et al. , Deuch et al.)
 LHB RUPTURE MAY NOT BE COMPLETELY BENIGN WITH CONSERVATIVELHB RUPTURE MAY NOT BE COMPLETELY BENIGN WITH CONSERVATIVE
TREATMENT,RESULTING IN POSSIBLE PAINFULL SYMPTOMS ANDTREATMENT,RESULTING IN POSSIBLE PAINFULL SYMPTOMS AND
DYSFUNCTION,ESPECIALLY IN YOUNGER PATIENTSDYSFUNCTION,ESPECIALLY IN YOUNGER PATIENTS

49.  SURGICAL MANAGEMENT :SURGICAL MANAGEMENT :
- EITHER PATIENTS <40 , OR FAILURE OF CONSERVATIVE TREATMENTEITHER PATIENTS <40 , OR FAILURE OF CONSERVATIVE TREATMENT (REPAIR(REPAIR
OF ASSOCIATED SHOULDER LESIONS)OF ASSOCIATED SHOULDER LESIONS)
- OPEN SURGERY OR ARTHROSCOPIC SURGERYOPEN SURGERY OR ARTHROSCOPIC SURGERY
- TENOTOMY OR TENODESISTENOTOMY OR TENODESIS
- INDICATED WHEN EXISTS :INDICATED WHEN EXISTS : PARTIAL TEAR (>25% OF THE TENDON CALIBER) ,PARTIAL TEAR (>25% OF THE TENDON CALIBER) ,
LONGITUDINAL TEAR WITH POOR TENDON GLIDING INTO THE BICIPITAL GROOVE , SScLONGITUDINAL TEAR WITH POOR TENDON GLIDING INTO THE BICIPITAL GROOVE , SSc
TEAR & LHBT SUBLUXATION/DISLOCATION , COMPLETE LHBT RUPTURE , SLAP TEAR ,TEAR & LHBT SUBLUXATION/DISLOCATION , COMPLETE LHBT RUPTURE , SLAP TEAR ,
BICEPS PULLEY/ROTATOR INTERVAL LESION WITH LHBT INSTABILITYBICEPS PULLEY/ROTATOR INTERVAL LESION WITH LHBT INSTABILITY

50.  BICEPSBICEPS
ARTHROSCOPIARTHROSCOPI
C TENOTOMYC TENOTOMY
NEAR BICEPSNEAR BICEPS
ANCHORANCHOR

51.  Bradbury proposed tenotomy with a portion of the superior labrum to create a bulbousBradbury proposed tenotomy with a portion of the superior labrum to create a bulbous
biceps stump entrapped into the bicipital groove as a way to prevent “Popeye”biceps stump entrapped into the bicipital groove as a way to prevent “Popeye”
deformitydeformity

52.  ““Anchor Shape” tenotomy to prevent “Popeye” deformityAnchor Shape” tenotomy to prevent “Popeye” deformity
- A- Appearance after the 2ppearance after the 2
iincisionsncisions..The remnant of theThe remnant of the
LHBLHB forms anforms an “A“Anchornchor
shapeshape”” that anchors the LHBthat anchors the LHB
at the articular entrance ofat the articular entrance of
the bicipital groove. Becausethe bicipital groove. Because
this remnant is lodged at thethis remnant is lodged at the
bicipital groove, the risks ofbicipital groove, the risks of
distal migration of thedistal migration of the
tendon and, thus,tendon and, thus, ““PopeyePopeye””
deformity are reduced.deformity are reduced.

53.  BICEPS TENODESIS : Usualy to athletes , heavy laborers , active and/or youngerBICEPS TENODESIS : Usualy to athletes , heavy laborers , active and/or younger
patients , avoid cosmetic deformity.Maintain length-tension relationship of bicepspatients , avoid cosmetic deformity.Maintain length-tension relationship of biceps
muscle.Can be executed under or into the bicipital groove.muscle.Can be executed under or into the bicipital groove.

54.  BicepsBiceps
tenodesistenodesis
withwith
interferenceinterference
screwscrew

55.  Biceps tenodesis with suture anchorsBiceps tenodesis with suture anchors

56. Tenotomy versus tenodesis: advantages and disadvantages.
Tenotomy Tenodesis
Advantages
Simple procedure Length-tension relation maintenance
Well-tolerated Normal elbow flexion
Less rehabilitation protocol Normal supination power
Faster return to activity
Minimize cosmetic deformity
Avoid cramping pain
Disadvantages
Cosmetic deformity (Popeye sign) Longer rehabilitation
Cramping More demanding procedure
Fatigue pain Low rates of failure fixation, humeral
Loss of supination strength Shaft fractures, CRPS, infection

57.  TENOTOMY vs TENODESISTENOTOMY vs TENODESIS
- Frost et al.Frost et al.
Tenodesis 40% - 100% of patients good/excellent results , failure rate 5% - 48%Tenodesis 40% - 100% of patients good/excellent results , failure rate 5% - 48%
Tenotomy 65% - 100% of patients good/excellent results , failure rate 13% - 35%Tenotomy 65% - 100% of patients good/excellent results , failure rate 13% - 35%
- Hsu et al.Hsu et al.
Tenodesis post op. bicipital pain 24% of patientsTenodesis post op. bicipital pain 24% of patients
Tenotomy post op. bicipital pain 17% of patientsTenotomy post op. bicipital pain 17% of patients
- UCLAUCLA
Tenodesis 25% of patients , muscle belly deformityTenodesis 25% of patients , muscle belly deformity
Tenotomy 41% of patients , muscle belly deformityTenotomy 41% of patients , muscle belly deformity

59. CONCLUSIONSCONCLUSIONS
 PATIENTS WITH LHBT LESIONS MAY PRESENT ASSOCIATEDPATIENTS WITH LHBT LESIONS MAY PRESENT ASSOCIATED
SHOULDER PATHOLOGYSHOULDER PATHOLOGY
 CLINICAL EVALUATION MUST BE FOLLOWED BY IMAGING TOCLINICAL EVALUATION MUST BE FOLLOWED BY IMAGING TO
DETECT DAMAGED STRUCTURESDETECT DAMAGED STRUCTURES
 IF FIRST ATTEMPT WITH CONSERVATIVE TREATMENT FAILS , THENIF FIRST ATTEMPT WITH CONSERVATIVE TREATMENT FAILS , THEN
SURGERYSURGERY
 TENOTOMY & TENODESIS GIVE GOOD RESULTSTENOTOMY & TENODESIS GIVE GOOD RESULTS
 TREATMENT & TECHNIQUE DEPEND ON INDIVIDUAL NEEDS OF THETREATMENT & TECHNIQUE DEPEND ON INDIVIDUAL NEEDS OF THE
PATIENTPATIENT

60. References & SourcesReferences & Sources
 Αλεξ. Ε. ΑγιοςΑλεξ. Ε. Αγιος ““ΑνατομικηΑνατομικη””
 Απ. ΚαρανταναςΑπ. Καραντανας ““Απεικονιση Αθλητικων κακωσεωνΑπεικονιση Αθλητικων κακωσεων””
 Preventing the Popeye Deformity After Release of the Long Head ofPreventing the Popeye Deformity After Release of the Long Head of
the Biceps Tendon: An Alternative Technique and Biomechanicalthe Biceps Tendon: An Alternative Technique and Biomechanical
EvaluationEvaluation
Thomas Bradbury, M.D.Thomas Bradbury, M.D. , Warren R. Dunn, M.D., John E. Kuhn, M.D., Warren R. Dunn, M.D., John E. Kuhn, M.D.
Department of Orthopaedics and Rehabilitation, Vanderbilt Sports Medicine,Department of Orthopaedics and Rehabilitation, Vanderbilt Sports Medicine,
Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.
 MRI Web Clinic — February 2014MRI Web Clinic — February 2014
Pathology of the Long Head of the Biceps TendonPathology of the Long Head of the Biceps Tendon
Michael E. Stadnick, M.D.Michael E. Stadnick, M.D.
See more at: http://radsource.us/pathology-of-the-long-See more at: http://radsource.us/pathology-of-the-long-
head-of-the-biceps-tendon/#sthash.wETKkYCq.dpufhead-of-the-biceps-tendon/#sthash.wETKkYCq.dpuf
 Arthrosc Tech. 2013 May; 2(2): e167–e170.Arthrosc Tech. 2013 May; 2(2): e167–e170.
Published online 2013 May 11. doi: Published online 2013 May 11. doi: 10.101610.1016//j.eats.2013.01.008j.eats.2013.01.008
PMCID: PMC3716228PMCID: PMC3716228
The “Anchor Shape” Technique for Long Head of the Biceps TenotomyThe “Anchor Shape” Technique for Long Head of the Biceps Tenotomy
to Avoid the Popeye Deformityto Avoid the Popeye Deformity
A.A. AliAli NarvaniNarvani, , EhudEhud AtounAtoun, , AlexanderAlexander VanVan TongelTongel, , GiuseppeGiuseppe SforzaSforza, and , and OferOfer LevyLevy
∗∗

61. Thank YouThank You