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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?
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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.
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.
Frost A, Zafar MS, Maffulli N
Am J Sports Med. 2009 Apr;37(4):828-33. PMID: 18762669 (Link to Abstract)
Cheng NM, Pan WR, Vally F, Le Roux CM, Richardson MD
Clin Anat. 2010 Sep;23(6):683-92. PMID: 20821403 (Link to Abstract)
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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?
Elbow flexion weakness
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.
Osbahr DC, Diamond AB, Speer KP.
Arthroscopy. 2002 May-Jun;18(5):483-7. PMID: 11987057 (Link to Abstract)
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Video portrays Speed's test of shoulder for proximal biceps tendonitis.
Video portrays Yergason's test of the shoulder for proximal bicep pathology.
Video shows arthroscopic proximal biceps tenodesis technique.
Short video describing pathology of proximal biceps tendonitis and its treatment...