Biceps the enigmatic tendon

1. Biceps
The Enigmatic
Tendon
Puneet Monga

2. Make everything as simple as possible
but no simpler
Albert Einstein

3. Biceps is THE Muscle !!
Latin- musculus, “little mouse”

4. Biceps Brachii
• Bi - ceps Brachii =
Two headed
(Muscle) of the Arm
• LHB commonly
involved in pathology
Image courtesy- shoulderdoc.co.uk

5. The pathologies affecting the LHB follow it’s
unique anatomical arrangement

6. RC Tears

7. Long Head of Biceps
Passes between the Supraspinatus and
SubScapularis-
Anatomically related and hence common to see
associated Cuff Tears
Image courtesy- patient.info, shoulderdoc.co.uk

8. Tenosynovitis

9. LHB
Intra-articular But Extra-synovial
Predisposes to Inflammatory conditions

10. LHB Instability

11. Important relations
•Coraco humeral Ligament
•Subscapularis
•Superior Gleno Humeral
Ligament
Disruption of restraints can lead to instability

12. Mechanical Wear

13. Mechanical forces on
LHB
Angular relationship of the biceps as it lies in a
eccentrically placed groove produces anterior
shear forces

14. Mechanical forces on
LHB
Sliding within the
groove
Predisposes to Mechanical wear

15. Mechanical forces on
LHB
? Impingement against
the Acromion
Predisposes to Mechanical wear

16. SLAP Tears

17. Attachment
Postero-superior Labrum- 48%
Superior Glenoid tubercle-20%
Both- 28%
Biceps lesions can be associated with SLAP
tears

18. The pathologies affecting the LHB follow it’s
unique anatomical arrangement

19. LHB disease spectrum-
summary
• Involvement with RC pathology - MOST COMMON
• Inflammation (Tenosynovitis)
• Tendinosis- Mechanical damage (Chronic overuse)
• Tendinosis - Wear (Age-related)
• Instability
• Involvement with SLAP tears

20. Biceps Function

21. Function at the Elbow
• Flexion
• Supination

22. Function at the
Shoulder1. Static Anterior and Superior
stabilizer - Cadaver
2. Depressor - EMG
3. GH joint stability - Lab
4. Deceleration in throwing -
EMG
5. Weak Abductor

23. But.....
1. Static Anterior and
Superior stabilizer -
Cadaver
2. Depressor - EMG
3. GH joint stability - Lab
studies
4. Deceleration in
throwing - EMG
5. Weak Abductor
(1)No Prox migration seen after LHB
ruptures / tenotomy
(2)Contradictory results with elbow
controls
(3)No instability in majority of LHB
ruptures / SLAP tears
(4)Thowers can “train down” their biceps
activity
(5)Weak no difference in abduction in
LHB deficiency

24. If you can’t explain it simply, you don’t
understand it well
Albert Einstein

25. Assessment

26. Clinical Evaluation
• History
• The Classic sequence (Look, Feel, Move)
• Special Tests (Speed’s test, Yergason’s test,
OBrien’s.........)
• Test for other differential diagnoses (eg RC tears)
• Investigations (MR / Ultrasound)

27. Which test
MR Scan
Cross sectional anatomy
Suspected SLAP / labral
tears (MRA)
SLAP / Assoc Pathology
Ultrasound
Dynamic
Availability (1 stop)
Enables Intervention
Instability, Inflammation

28. Beware of MR Reports
•Anatomical variants
•Sublabral recess
•Lax attachment
•False Negative (75% Senstivity for SLAP
tears)
•Insensitive for Tendinopathy
Always Correlate clinically !

29. Management
Golden Rule
Manage associated Pathologies; They coexist in 95%
cases !!!

30. Spectrum of Management options
Tenotomy
Extraarticular tenodesis
Subpectoral tenodesis
Controversies:
Tenotomy vs tenodesis
Site of tenodesis
Technique of tenodesis

31. Proximal Ruptures
POPEYE sign

32. Acute LHB Ruptures
• Investigations: what am I really worried about?
Associated Rotator Cuff tear

33. Management
• Look For Associated RC tears
• Acute Tenodesis for young active athletes

34. Chronic LHB ruptures
• Presentation
- Popeye Sign
- Cramping

35. Management
• Treat Associated Lesions
- Tenodesis Only If symptomatic
- On-bone tenodesis
- 10/11 Good results
Ng Cy, Funk L, IJSS 2012

36. Summary
• Relatively minor / rather controversial role
• Functional anatomy creates environment for pathology
• Look for and treat associated pathology
• Acute Ruptures- Urgently investigate for RC tears
• Chronic Ruptures- Tenodesis only if symptomatic

37. References
• Cohen, SB: Musculoskeletal Examination of the shoulder.
• Gartsman. Shoulder arthroscopy.
• Burkhart SS, Lo KY, Brady PC. A Cowboy’s guide to Advanced Shoulder Arthroscopy.
• Burkhart SS, Lo KY, Brady PC, Denard PJ. The Cowboy’s companion.
• Krishnan SG, Hawkins, RJ, Warren RF. The shoulder and the overhead Athlete
• www.shoulderdoc.co.uk
• McFarland EG, Examination of the shoulder.
• Ellenbecker TS Clinical Examination of the Shoulder