http://upload.orthobullets.com/topic/3045/images/8-1-2012 8-08-59 pm.jpg
http://upload.orthobullets.com/topic/3045/images/popeye.jpg
http://upload.orthobullets.com/topic/3045/images/8-1-2012 8-04-03 pm.jpg
Introduction
  • Well recognized as a pain generator in the shoulder
  • Often associated with other primary shoulder pathology
    • subacromial impingement
    • stenosis of bicipital groove
    • rotator cuff tears
      • especially subscapularis pathology
  • Pathoanatomy
    • more consistent with "tendinosis" than true inflammation
Anatomy
  • Glenohumeral anatomy 
  • Bicep long head tendon 
    • originates off supraglenoid tubercle and superior labrum
    • stabilized within bicipital groove by transverse humeral ligament 
Presentation
  • Symptoms
    • anterior shoulder pain 
  • Physical exam 
    • tenderness with palpation over biceps groove 
      • worse with arm internally rotated 10 degrees
    • Speed test 
      • pain elicited in bicipital groove when patient attempts to forward elevate shoulder against examiner resistance while elbow extended and forearm supinated. 
      • may also be positive in patients with SLAP lesions.
    • Yergason's test 
      • pain elicited in biceps groove when patient attempts to actively supinate against examiner resistance with elbow flexed to 90-degrees and forearm pronated 
    • "popeye" deformity
      • indicates rupture
Imaging
  • Ultrasound
    • can show thickened tendon within bicipital groove
  • MRI 
    • can show thickening and tenosynovitis of proximal biceps tendon
      • increased T2 signal around biceps tendon 
Treatment
  • Nonoperative
    • NSAIDS, PT strengthening, and steroid injections
      • indications
        • first line of treatment
      • technique
        •  direct steroid injection in proximity, but not into tendon
  • Operative
    • arthroscopic tenodesis vs. tenotomy
      • indications 
        • surgical release reserved for refractory cases for bicep pathology seen during arthroscopy 
      • technique 
        • repair vs. release/tenodesis 
      • outcomes
        • tenodesis may decrease subjective arm cramping and improve cosmesis q
 

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Questions (2)

(OBQ11.213) A patient presents to your office for evaluation of arm pain. Upon evaluation, a diagnosis of rupture of the long head of the biceps tendon is made. Which of the following photographs would best corroborate this diagnosis? Review Topic

QID:3636
FIGURES:
1

A

0%

(8/1811)

2

B

7%

(123/1811)

3

C

2%

(29/1811)

4

D

5%

(84/1811)

5

E

86%

(1561/1811)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Figure E depicts the "popeye" deformity of the arm associated with rupture of the long head of the biceps tendon.

Frost et al performed a literature review evaluating the treatment of the long head of the biceps tendon, specifically looking at outcomes of tenotomy vs. tenodesis. They found a lack of sufficient evidence to support one treatment over the other and recommend a RCT to better compare these two treatment options.

Cheng et al performed an anatomical study evaluating the vascular supply of the long head of the biceps tendon. They found a significant zone of hypovascularity located in the region where the tendon most frequently ruptures and advocate that such biological issues should be considered in the prevention and treatment of such tendon ruptures.

Incorrect answers:
1) Brachial plexus palsy
2) Normal biceps
3) Pectoralis major tear
4) Distal biceps rupture with abnormal "hook test" whereby the finger is used to hook the distal biceps tendon. An example of a normal distal biceps is shown in Illustration A where a person places a hangar on their distal biceps tendon.

ILLUSTRATIONS:

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Question COMMENTS (9)

(OBQ05.249) While recent studies have failed to demonstrate a significant clinical difference, proximal biceps tenodesis compared to tenotomy is felt to possibly result in a lower incidence of which of the following? Review Topic

QID:1135
1

Arm cramping

51%

(148/291)

2

Elbow flexion weakness

31%

(91/291)

3

Elbow stiffness

2%

(7/291)

4

Shoulder weakness

9%

(26/291)

5

Shoulder stiffness

6%

(18/291)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

Concern for cosmetic deformity (“popeye” deformity) and muscle spasm or cramping has been an argument against performing tenotomy in the past. The long head of the biceps tendon has been implicated as a common source of anterior shoulder pain. Surgical options to treat it include biceps tenodesis by various methods and intraarticular biceps tendon release- tenotomy. It is felt by some surgeons that a tenodesis may decrease subjective arm cramping and improve cosmesis. Of note, recent studies have failed to show a significant difference between the two groups.

Osbahr et al retrospectively looked at their patients who had undergone either tenotomy or tenodesis and found non statistically significant differences. The patient were non randomized to treatment groups and therefore selection bias prohibits definitive conclusions.

Frost et al performed a comprehensive review of the literature comparing the outcomes of tenotony and tenodesis, and noted that the studies were predominantly low quality. They concluded that there is a lack of quality evidence to advocate one technique over the other.


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Question COMMENTS (8)
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