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Introduction
  • A recognized cause of shoulder symptoms usually associated with a subscalaris tear
  • Pathophysiology
    • most commonly associated with
      • subscapularis tears
        • most common associated pathology
      • coracohumeral ligament tear
      • disruption of the medial biceps sling
Anatomy
  • Biceps tendon anatomy
    • originates off supraglenoid tubercle and superior labrum
    • stabilized by the biceps sling which is comprised of
      • fibers of the subscapularis
      • supraspinatus
      • coracohumeral
      • superior glenohumeral ligaments
  • Function
    • acts as dynamic stabilizer
    • involved in movement such as shoulder flexion, abduction
  • Complete glenohumeral anatomy 
Presentation
  • Symptoms
    • anterior shoulder pain
    • may have sensation of clicking
  • Physical exam of shoulder 
    • strength
      • due to the association with subscapularis tears, strength of the subscapularis muscle should be performed
    • biceps provocation tests
      • Yergason's test
        • anterior shoulder pain with resisted forearm supination with the arm at the side and the elbow flexed to 90 degrees. 
      • Speed's test
        • anterior shoulder pain with resisted shoulder flexion with the shoulder flexed at 90 degrees, elbow in full extension and the palm facing upwards"
      • palpable click
        • may be produced with arm abduction and external rotation
          • occurs when tendon subluxes or dislocates out of groove
Imaging
  • Ultrasound 
    • can give dynamic test of bicep instability
  • MRI 
    • can show increased T2 signal, and displacement out of the bicipital groove
    • coincides with subscapularis tears
Treatment
  • Nonoperative
    • NSAIDS, PT strengthening, and steroid injections
      • indications
        • initial management
      • technique
        •  direct steroid injection in proximity, but not into tendon
  • Operative
    • arthroscopic vs open biceps tenotomy vs tenodesis 
      • indications
        • reserved for refractory cases for bicep pathology
      • technique
        • performed with or without subscapularis repair
        • can test instability intra-operatively 
 

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