Biceps tendinitis is a relatively common cause of anterior shoulder pain.
The tendinitis can be primary or secondary. Primary bicipital tendinitis is
the isolated inflammation of the long head of the biceps tendon in the
intertubercular groove, with no associated pathological changes in the
shoulder. It has been estimated to represent only 5% of the cases of biceps
tendinitis4.
Secondary biceps tendinitis occurs in conjunction with pathological changes in
the adjacent osseous, ligamentous, and muscular structures. This type of
tendinitis often results in tendon fraying and even failure as the biceps
tendon undergoes wear. As a result of repetitive wear or trauma, the
softtissue restraints surrounding the biceps tendon can lose their stabilizing
function, and medial subluxation or dislocation of the tendon can occur.
Patients with biceps tendinitis or instability present with pain primarily
in the bicipital groove. The history and the results of the physical
examination are usually compatible with an impingement syndrome, although the
pain may be more anterior and may radiate down the biceps itself. Usually,
there is no history of trauma. Patients with biceps instability occasionally
report popping and an audible or palpable snap during the arc of shoulder
motion. Biceps tendon instability is almost always associated with
pathological changes in the subscapularis tendon and rarely occurs in the
absence of at least some subscapularis tearing.
On physical examination, the most common finding in patients with biceps
tendinitis or instability is point tenderness in the bicipital groove. Several
provocative tests have been described for isolating a pathological condition
of the biceps, including the Yergason test, the Speed test, the biceps
instability test, the lift-off test, and the O'Brien active compression
test15-18.
As an adjunct to these provocative tests, selective injections can be very
helpful in differentiating the source of shoulder pain. Unfortunately, there
is no single physical finding that is conclusive evidence of a symptomatic
pathological condition of the biceps. Coexisting impingement and
rotator-cuff-related symptoms may make the diagnosis difficult.
Radiographic evaluation is usually not helpful and almost always reveals
normal findings in cases of primary biceps tendinitis. Secondary causes, such
as an avulsion fragment from the tuberosity, suggest a biceps dislocation, and
a large anterior acromial spur may suggest an impingement syndrome. Additional
radiographic views can be used to evaluate the bicipital groove.
Ultrasonography has become a useful tool for evaluation of the biceps and the
rotator cuff in some
centers19. However,
ultrasonography is heavily operatordependent and can be limited by osseous
anatomy.
Magnetic resonance imaging is an excellent tool for evaluating the biceps
tendon and the superior labral complex. A magnetic resonance imaging
arthrogram continues to be the most appropriate noninvasive diagnostic study
available for confirming a pathological condition of the biceps. Oblique and
sagittal images can demonstrate subluxation and dislocation of the long head
of the biceps tendon. Edema associated with bicipital tendinitis produces an
increased signal intensity on T2-weighted images. Biceps tendon ruptures are
relatively easy to detect on magnetic resonance imaging as well.
Boileau et al. described an hour-glass-shaped biceps tendon that causes
typical tendinitis
symptoms20. It can
be seen on arthrography. It results from an inflamed, thickened
intra-articular segment, which can block tendon excursion during shoulder
motion because the thickened part cannot traverse the bicipital groove. This
so-called shoulder trigger finger can cause anterior shoulder pain and a loss
of 10° to 20° of passive elevation as a result of mechanical locking,
but it is difficult to recognize clinically. A thickened tendon can disrupt
the pulley and destabilize the biceps over time. The treatment is excision of
the thickened part of the biceps and tenodesis if necessary.
When a pathological condition of the biceps is suspected but confirmation
proves elusive, arthroscopic evaluation is the most accurate means of
verifying the diagnosis. During the arthroscopy, it is imperative that the
tendon be inspected thoroughly, and this requires pulling the biceps into the
joint to completely visualize the portion within the bicipital groove. Testing
for instability of the biceps tendon should be done.
Instability of the Biceps Tendon
The biceps tendon makes a 30° to 40° turn into the bicipital groove
as it exits the shoulder and is stabilized by a pulley
system2
(Fig. 2). This pulley system is
made up of the coracohumeral ligament and the superior glenohumeral ligament
along with both supraspinatus and subscapularis tendon fibers
(Fig. 1). Progressive
disruption of the pulley leads to biceps instability with medial subluxation,
which in turn leads to progressive damage of the pulley itself. The biceps can
dislocate immediately on top of the subscapularis, under the subscapularis if
the subscapularis tendon is torn, or even
laterally21. A
clear understanding of the anatomy of the rotator interval is necessary to
appreciate the variations of biceps instability in association with rotator
cuff lesions.
The coracohumeral ligament arises from the coracoid process and separates
into two bands. It invests the biceps at this critical angle as it exits the
joint7. The superior
glenohumeral ligament travels from the labrum to the humeral head. It becomes
a u-shaped sling that supports the biceps tendon at this critical exit
angle5. Also,
rotator cuff fibers reinforce the pulley system. The transverse humeral
ligament appears to be much less important to biceps stability. In fact, its
more distal location means that the critical angle of biceps passage occurs
more proximally and any subluxation would likely occur more proximally. The
description of progressive damage to the pulley system by Habermeyer et al.
has been labeled "pulley
lesions."2
These lesions can be traumatic or degenerative, and the pulley is susceptible
to rotator cuff degeneration as is the biceps tendon itself.
Damage to the pulley system often occurs in a series of steps and is
usually initiated by an articular-sided supraspinatus tear, which then leads
to a tear of the superior glenohumeral
ligament13,14.
The tear of the superior glenohumeral ligament in turn allows subtle
subluxation of the long head of the biceps, which can, in turn, cause a
partial articular subscapularis tear. Progressive subluxation of the long head
of the biceps causes more damage to the subscapularis tendon
(Fig. 1). This cycle of
progressive subluxation leading to subscapularis damage can ultimately lead to
medial dislocation of the biceps and even anterosuperior instability with the
occurrence of labral lesions. The possibility of a subscapularis tear
occurring in conjunction with biceps instability cannot be overemphasized.
Recognition of these tears is important as they often cause substantial
anterior shoulder pain along with the biceps instability.
Nonoperative Treatment of Bicipital Tendinitis and Biceps
Instability
The initial treatment of primary and secondary bicipital tendinitis is
nonoperative. Initially, rest and nonsteroidal anti-inflammatory drugs are
recommended. Subacromial steroid injections can help to treat both primary and
secondary
tendinitis3.
Injections into the glenohumeral joint can reduce intra-articular biceps
irritation. Finally, injections into the bicipital sheath anteriorly, with
care taken to avoid the biceps tendon itself, can be of
benefit3. Once the
symptoms begin to decrease, gentle range-of-motion exercises are begun. When a
patient has secondary bicipital tendinitis due to impingement syndrome,
treatment should be directed toward the rotator cuff lesion. Exercises can be
advanced as dictated by the status of the rotator cuff.
Nonoperative treatment of biceps instability is limited and should be
directed toward the management of the rotator cuff lesions. Intra-articular
injections are sometimes beneficial for older, sedentary patients. Younger,
more active individuals almost always require surgery to address the rotator
cuff lesions and the biceps instability.
Operative Treatment of Biceps Tendinitis and Instability
The most important aspect of treating a pathological condition of the
biceps tendon is to determine its cause, define the degree of structural
compromise, and detect associated pathological conditions, such as rotator
cuff disease and impingement, that need to be addressed concomitantly.
Surgical intervention for biceps tendinitis is generally indicated if the
patient continues to have symptoms after three months of conservative
management or if there is biceps instability.
The surgical options available include tendon débridement, a release
of a constricted synovial sheath, a tenodesis, or a tenotomy.
Biceps Débridement
A simple débridement of the tendon in association with an
arthroscopic subacromial decompression is appropriate for the treatment of
mild tendon fraying. If the patient has a partial tear, involving <50% of
the tendon, and an inactive lifestyle, a simple débridement and
decompression may be sufficient. In younger active patients, partial tears
should be treated more aggressively, with any tear involving >25% of the
tendon being managed with tenodesis. Tenotomy should be avoided in younger
active patients, whereas it is a reasonable option for more sedentary
patients. A so-called Popeye deformity may develop after a tenotomy, but it
will not develop after a tenodesis.
Biceps Decompression
Biceps tendon decompression can relieve the symptoms of primary biceps
tendinitis through a tenosynovial release. A release of the transverse humeral
ligament, sparing the coracohumeral ligament, and an arthroscopic or open
release of the bicipital tendon sheath in the absence of other pathological
entities will decrease symptoms. This surgical option is applicable only for
inflammation of an otherwise intact tendon in the absence of other substantial
pathological entities. If the tenosynovitis is severe and unrelenting, and
occurs above as well as below the bicipital groove, a tenotomy in a less
active patient or a subpectoral tenodesis in a more active individual is
recommended.
Tenotomy
There is controversy about the choice of tenotomy or
tenodesis22.
Tenotomy is currently a more popular option for the treatment of a diseased
biceps
tendon23,24,
but the decision regarding treatment of an inflamed but otherwise intact
biceps tendon is not an easy one. Associated pathological entities and surgery
may render the decision regarding whether to perform a tenotomy and a
tenodesis moot because the prolonged immobilization necessary after an
arthroscopic rotator cuff repair, into which a tenotomy can be easily
incorporated, reduces the benefits of a tenodesis.
Tenotomy has obvious advantages. It is technically very easy to perform,
rehabilitation is simple, and there is no need for immobilization. The
disadvantage of a tenotomy is the potential for a residual Popeye deformity
caused by retraction of the biceps muscle distally. In addition to this
deformity, cramping and weakness with vigorous use of the biceps may be
encountered. In many cases, one can predict the possibility of deformity by
carefully inspecting the proximal end of the biceps. In cases of chronic
inflammation in which the biceps origin is substantially thickened, simple
tenotomies rarely lead to deformity because the proximal end of the biceps is
too large to pass through the bicipital groove.
Clinical studies of simple tenotomies have revealed that pain relief is
achieved and the satisfaction rate usually exceeds 90%, but the Popeye
deformity occurs in up to 70% of patients and as many as 40% of patients
experience fatigue or soreness with resisted elbow flexion. In several
studies, patients over sixty years of age did not experience this
fatigue25,26.
Osbahr et al. noted no significant difference in terms of the cosmetic result,
pain relief, or muscle spasms between tenodesis and tenotomy, but the patients
who were treated with a tenodesis were younger than those who were treated
with a tenotomy27.
Walch et al. reviewed the outcomes of 307 patients who had had a biceps
tenotomy because of an irreparable rotator cuff tear or because they were
unwilling to undergo the lengthy rehabilitation associated with an
arthroscopic rotator cuff
repair23.
Eightyseven percent were satisfied, although a subacromial decompression was
often performed as well. Preoperative fatty infiltration of the rotator cuff
muscles and a high-riding humeral head were prognostic of a poor outcome.
Tenodesis
Tenodesis can be performed either open or arthroscopically, with use of
soft-tissue or osseous fixation, and above or below the bicipital groove. The
advantages of a biceps tenodesis are a better cosmetic result and restoration
of strength, whereas the disadvantages include a more difficult operation, the
possible need for costly implants, a longer rehabilitation, a period of
immobilization, and the possibility of the tenodesis failing. Several
alternatives for arthroscopic fixation are available. The tendon can be
secured with use of an interference screw in a bone tunnel or with suture
anchors in the bicipital groove, or by suturing it to the rotator
interval28,29.
Suturing the biceps remnant to the conjoint tendon has also been
described30. An
open subpectoral approach in which a keyhole type of fixation is achieved can
be utilized. Investigators comparing the mechanical strength values following
tenodesis fixation techniques concluded that the interference screw and bone
tunnel technique provides the greatest initial fixation
strength31.
Tenodesis for treatment of disease of the long head of the biceps is
usually performed in conjunction with the treatment of concomitant rotator
cuff disease. Isolated biceps tenodesis has historically been uncommon, and
the results have been modest at best, perhaps reflecting neglected underlying
pathological conditions such as an impingement phenomenon. Studies in which a
biceps tenodesis was done in conjunction with a decompression have uniformly
revealed satisfactory
results32, although
Walch et al. reported no difference in the success rates of tenodeses done
with and without an accompanying
decompression23.
In the case of a complete biceps rupture, tenodesis is appropriate for a
younger active patient and can be accomplished through an open subpectoral
approach. Technically, reestablishing the proper resting length to the
tenodesed biceps tendon is critical if strength and a good cosmetic appearance
are to be restored. The subpectoral approach helps the surgeon to find the
ruptured proximal stump and permits direct visualization so that the
musculotendinous portion of the biceps can be lined up with the pectoralis
insertion site to reproduce the optimal resting length. Furthermore, with any
open approach, a keyhole-type fixation technique in which the stump of the
tendon is fixed and delivered into the humeral shaft helps to avoid the need
for costly implants. Older patients with lower functional demands have
tolerated benign neglect
well33. Isolated
pathological involvement of the biceps is uncommon, and if a rupture occurs
the presence of associated rotator cuff disease should be considered.
Biceps Instability
Subluxation or dislocation of the biceps tendon is almost invariably
associated with rotator cuff tearing, particularly of the subscapularis, and
pathological involvement of the rotator
interval2. It is
important to determine the direction of the instability, which is most
commonly medial, and the instability is usually fixed rather than dynamic. The
superior portion of the subscapularis tendon is usually torn and must be
addressed in addition to the biceps disease. The treatment options for biceps
instability include tenotomy, tenodesis, or reconstruction of the stabilizing
structures that support the biceps tendon. The indications for tenotomy and
tenodesis parallel those for patients with moderate-to-severe tendinitis and
are the more common choices.
Tenodesis of the biceps, in conjunction with a subscapularis repair, is
appropriate if a patient is young and active, whereas a tenotomy is an
appropriate intervention for a less active patient even when the subscapularis
is being repaired. Not treating the unstable biceps definitively leads to
rupture of the subscapularis repair. These anteriorsuperior tears that include
the biceps and subscapularis often also involve the supraspinatus.
Furthermore, careful evaluation of the subcoracoid space is recommended as
subcoracoid impingement may have led to the cumulative injury to the rotator
interval
structures34,35.
Reconstruction of the stabilizing structures in the rotator interval, with
attention paid to the superior glenohumeral ligament and the coracohumeral
ligament, and the creation of a sling around the tendon can be performed.
However, recurrent instability can be a problem, and a stenosed, painful
tendon may result.
Overview of Surgical Treatments of the Biceps Tendon
Both tenodesis and tenotomy can yield good
results22.
Interestingly, several authors have found that acromioplasty alone relieved
anterior shoulder pain despite a preoperative diagnosis of biceps
tenosynovitis36.
While there is much controversy regarding operative management of a
symptomatic biceps tendon, we typically sacrifice the biceps tendon only when
there is a substantial partial tear, extensive tenosynovitis, or tendon
instability. The decision to perform a tenodesis or tenotomy is usually based
on several factors. Tenotomy is routinely carried out in sedentary patients
and in those for whom the cosmetic result is not a concern. However, tenodesis
is almost always performed in younger, more active patients or any patient for
whom the cosmetic result is an issue, particularly those with thin arms.
Superior glenoid labrum injuries were apparently first defined as SLAP
(superior labrum anterior and posterior) tears by Snyder et al. in
199037. While the
recognized varieties of SLAP injuries have expanded over time, the challenge
is to differentiate between the labral variations that are clinically relevant
lesions and those that are normal variations or simply the effects of
aging.
SLAP lesions can be created by various mechanisms of injury including a
biceps traction overload caused by the long head of the biceps acting as a
decelerator of the arm during the follow-through phase of throwing, arm
acceleration during the late cocking phase, a tight posterior aspect of the
capsule, falling on the outstretched arm creating shearing forces on the
superior biceps labral
complex38, sudden
forced abduction and external rotation of the shoulder, and passive disruption
during a motor-vehicle accident when the shoulder-lap belt restrains the
ipsilateral chest wall, causing the shoulder to roll around the seat belt.
Any classification system should provide a logical method for evaluating
the injury that can positively affect the treatment algorithm. The
classification system now includes many more types than had been initially
described37. A
type-1 SLAP lesion has fraying on the inner margin of the superior aspect of
the labrum (Fig. 3-A) and
probably represents normal degenerative changes associated with increased age
and the retreat of blood supply from the superior aspect of the labrum. This
may be confused with a meniscoid superior part of the labrum, which is a
normal variant.
A type-2 SLAP lesion is the most common clinically relevant abnormality. It
occurs when the superior labral attachment of the biceps tendon pulls off the
superior glenoid tubercle (Fig.
3-B). Burkhart and Morgan further defined the type-2 SLAP lesion
according to three subtypes based on the anatomic location of this elevation:
anterior, posterior, and combined anterior and
posterior39. The
most common of these subtypes is the anterior lesion, which involves a labral
avulsion from the anterosuperior quadrant of the glenoid. The posterior
subtype involves the posterosuperior quadrant of the glenoid and is most
commonly seen in throwing athletes. The combined (anterior and superior)
subtype is the least common. When traction is applied to the biceps tendon of
a patient with a labral separation from the posterosuperior quadrant of the
glenoid, the force on the tendon shifts from an anterior-horizontal to a
posterior-vertical position. This force is transmitted to the labrum at the
base of the biceps tendon and results in the detached labrum sliding medially
or peeling off the posterior-superior aspect of the glenoid; this has been
called the "peel-back"
phenomenon39.
A type-3 SLAP lesion is a superior labral bucket-handle tear often
extending from anterior to posterior at the biceps insertion
(Fig. 3-C). In contrast to the
type-2 lesion, the biceps-labral attachment is not elevated from the glenoid.
In a type-4 SLAP lesion, the buckethandle tear extends into the biceps tendon,
splitting the tendon attachment (Fig.
3-D). Additional SLAP lesions (types 5 through 10) have also been
described40-42
(Figs. 4-A and 4-B,
4-C,
5-A and 5-B,
5-C).
Maffet et al. expanded this classification system to include shoulder
instability
injuries40. Their
type-5 SLAP lesion is a Bankart lesion extending superiorly to the biceps
attachment (Fig. 4-A). A type-6
SLAP lesion has a labral flap with a type-2 biceps elevation
(Fig. 4-B), and a type-7 SLAP
lesion is a lesion of the middle glenohumeral ligament extending to the biceps
attachment (Fig. 4-C). Powell
et al.41 further
expanded this classification system to include a type-8 lesion, which is a
type-2 SLAP lesion with posterior labral extension
(Fig. 5-A); a type-9 lesion,
which is a type-2 SLAP lesion with circumferential labral tearing
(Fig. 5-B); and a type-10
lesion, which is a type-2 SLAP lesion with a posterior-inferior labral
separation (Fig. 5-C). An
additional variation of labral disease includes a type-2 SLAP injury with
articular cartilage avulsions and loose bodies as described by Choi and
Kim42.
Approximately half of clinically relevant SLAP lesions are type 2. Also,
except in series dealing principally with shoulder instability, the overall
prevalence of SLAP tears is very
low37,43-45.
In the original study in which SLAP lesions were
defined38, they
accounted for only 4% of 700 cases in a consecutive series of shoulder
arthroscopic procedures, and a review of 2375 patients in another series of
consecutive shoulder arthroscopic procedures demonstrated a 5.9% prevalence of
SLAP
lesions43-45.
Clinical Presentation
Clinically relevant SLAP lesions are most often found after trauma, in
swimmers, or in long-time overhead-throwing
athletes37,39,40.
The patients describe clicking and popping often associated with anterior
shoulder pain and reduced function, including decreased throwing or serving
velocity or slower swimming speed. The symptoms may appear suddenly or
gradually. The dead-arm syndrome is characterized by the inability to throw at
the preinjury
velocity46.
The key elements to be considered in differentiating a clinically relevant
superior labral injury from normal variations or changes due to aging include
the patient, the mechanism of injury, the findings of the clinical
examination, and the findings of appropriate imaging studies. Demonstrated
improvement after surgical treatment confirms the diagnosis.
Proper patient selection is critical. A SLAP lesion should be anticipated
prior to surgery so that it is not an unexpected finding at arthroscopy. True
type-2 SLAP injuries are seldom associated with substantial glenohumeral
arthritis or rotator cuff tears. When degenerative changes are found, the
labral abnormality is likely to be part of a degenerative process.
Clinically relevant SLAP injuries are most often found in the dominant arm
of a man less than forty years of age who has participated in high-performance
overhead activities for many years, a patient with a specific history of
shoulder trauma, or a patient with shoulder instability. A fall on an
outstretched hand or a prior motor-vehicle accident during which the patient
was wearing a shoulder-lap belt is also suggestive of a SLAP
injury12,47.
Physical Examination
Several tests have been proposed for the diagnosis of a clinically relevant
SLAP injury. However, these tests often provide inconsistent results and are
not consistently
diagnostic18,48-54.
The modified O'Brien test, the crank test, the anterior slide test, the Jobe
relocation test, the biceps load test, and the pain provocation test are
advocated by some and dismissed by
others54. A
positive Speed test and a loss of internal rotation that has not resolved
following a short course of physical therapy have been said to indicate a SLAP
lesion39. Despite
the concerns about the reliability of these tests, they do play a role in the
physical examination of the shoulder. However, no single test should be
completely relied upon.
Diagnostic imaging also provides inconsistent results. Plain radiographs
reveal osseous problems. The superior aspect of the glenoid labrum can be seen
on a gadolinium-enhanced magnetic resonance imaging scan, but correct
interpretation requires special expertise. The variability of the normal
superior aspect of the labrum reduces the diagnostic value of this test.
However, the presence of a sublabral ganglion cyst is very suggestive of a
SLAP lesion55.
Nonoperative Treatment
The initial treatment of a SLAP lesion should include rest,
anti-inflammatory medication, stretching, and strengthening to address
muscular imbalances. Decreased internal rotation is often found in athletes
who throw overhead. A reduction in shoulder rotation to <180° or a loss
of internal rotation suggests a tight posterior aspect of the capsule.
Scapular dyskinesis or weakness of the scapular stabilizers may result in
scapular winging and asymmetrical arm motion. Stretching to attain full motion
(internal rotation) should be performed prior to surgical intervention. If
symptoms persist after three months of nonoperative treatment, surgery may be
indicated.
Surgical Treatment
The arthroscopic treatment of a SLAP lesion depends on the type of lesion.
A type-1 SLAP lesion is treated with débridement of the area of labral
fraying. A type-2 lesion should be treated with reattachment of the superior
aspect of the labrum to achieve a stable biceps-superior labral anchor. A
type-3 SLAP lesion requires removal of the bucket-handle tear. A type-4 lesion
requires débridement of any flap or bucket-handle tear and repair of
the associated biceps tear or a biceps tenodesis. Types-5, 6, and 7 SLAP
lesions are associated with shoulder instability, which should be corrected at
the same time as the SLAP lesion is repaired and any flap should be
débrided. For types 8, 9, and 10, the labrum should be reattached and
any flap should be débrided. The goal of surgical repair is to securely
reattach the biceps-labral complex and to eliminate the peel-back and
drivethrough signs.
Half of all SLAP lesions that require surgery are type 2. While various
techniques have been used in the past, suture anchors are currently the
preferred method of biceps-labral fixation. An anterior type-2 SLAP lesion
requires one suture anchor placed either beneath or slightly anterior to the
biceps tendon origin. In this location, a mattress suture (or two simple
sutures) can fix both sides of the biceps origin. A posterior or combined
type-2 SLAP lesion requires a suture anchor posterior to the biceps origin to
fully stabilize the posterior-superior aspect of the labrum.
The initial step in a repair of a SLAP lesion is to carefully probe and
assess the biceps and the superior labral injury and to débride any
degenerative tissue. After the superior aspect of the labrum has been elevated
to expose the glenoid neck, this area is débrided to prepare it for
biceps-labral reattachment. Roughening the bone surface to create a bleeding
bed, rather than decorticating the superior glenoid tubercle, is sufficient.
The appropriate suture anchor or anchors are inserted into the superior
glenoid articular cartilage margin at an angle (usually 45°) that places
the anchor into the bone without it cutting out either medially or laterally.
Once the anchor is in place, the sutures are passed through the labral tissue
and either a simple or a mattress stitch is used.
Postoperative Treatment
SLAP repairs are often followed by stiffness in the postoperative period,
as the repair can substantially decrease motion, including internal and
external rotation and
translation56.
Thus, a sling is used for only three weeks, and the patient is encouraged to
remove the sling and perform rotation movements to stretch the capsule during
this period. After use of the sling is discontinued, pendulum exercises with
elbow flexion and extension are recommended and should be performed. At six
weeks, strengthening of the rotator cuff, scapular stabilizers, biceps, and
deltoid muscle is initiated. Throwing athletes begin an interval-throwing
program at four months on a level surface. Stretching (of the posterior aspect
of the capsule) and strengthening are continued, and throwing from the mound
begins at six months. A return to full activity is permitted at seven months.
Non-throwing athletes may return to their sports at four months.
While the anatomy of the biceps tendon and the restraining structures
within the rotator interval have been well defined, biceps function and the
importance of the long head of the biceps are not clearly understood at this
time. Pathological involvement of the biceps, when encountered, is usually
associated with rotator cuff disease and possibly an impingement process.
Functionally, some humeral head stability may be imparted through the biceps
tendon. While careful clinical examination along with diagnostic testing can
accurately identify a pathological condition of the biceps, arthroscopy is an
extremely valuable tool with which to establish the accurate diagnosis and
treatment of biceps disease.
Options for the surgical treatment of pathological biceps conditions
include decompression, débridement, tenotomy, and tenodesis. Several
factors must be considered in this decision. The most important factors to be
taken into account when choosing between tenodesis and tenotomy are the
activity expectations of the patient, the importance of the cosmetic result,
patient compliance, associated pathological entities requiring a surgical
procedure that may allow easy incorporation of a tenodesis, and the patient's
age. Those over the age of sixty appear to tolerate a tenotomy with the fewest
side effects.
There are various techniques for arthroscopic tenodesis, including
interference screw fixation to bone, suture anchor fixation, and suture
fixation to adjacent tissue. The interference screw technique yields the best
initial fixation, although soft-tissue fixation can also lead to a
satisfactory result and is easier to perform. An open subpectoral tenodesis is
the appropriate choice for patients with a retracted ruptured tendon or for
those with biceps disease extending distal to the bicipital groove.
The SLAP lesion at the attachment of the biceps tendon to the superior
aspect of the glenoid labrum is uncommon. A clinically relevant SLAP lesion is
found during about 5% of all shoulder arthroscopies and may be confused with a
normal anterior labral variation. Clinical examinations and imaging tests for
the diagnosis of SLAP lesions are often unreliable, and the ultimate
diagnostic confirmation is made with arthroscopy. Surgical treatment is
focused on the reattachment of the unstable biceps-labral complex.