The document discusses the anatomy, function, pathology, clinical evaluation, and treatment of biceps pain. It notes that the biceps helps with elbow flexion, supination, and stability of the humeral head. Common pathologies include inflammation, instability from tears or subluxation, and trauma. Clinical tests evaluate for pain and instability. Treatment options depend on the pathology and include rest, injections, physical therapy, and surgery such as tenodesis or tenotomy. Tenodesis maintains length-tension but has more pain, while tenotomy has less pain but risks a cosmetic deformity. The best approach considers patient factors and functional demands.

1. Biceps – The Pain Generator
Prof. Bijayendra Singh
Consultant Orthopaedic Surgeon, Medway NHS Foundation Trust
Visiting Professor, Canterbury Christ Church University

2. Anatomy

3. Function
 Elbow flexion and supination
 Head depressor in presence of large
cuff defect
 Decreases humeral head translation

4. Pathology
• Inflammation
– Degenerative tendinosis beware cuff tear
– Primary tendinitis rare
• Instability
– subluxation or dislocation (tear of CHL or
subscapularis)
• Trauma
– Tear
– SLAP lesion

5. Clinical Evaluation
1. Pain, Tenderness, Popping
2. Specific Test: Speed, Yergason, Upper Cut
3. Instability Test
4. Associated Lesion Test

6. Tests
 O'Brien Active Compression
 Kibler Anterior Slide
 Compression Rotation
 Resisted Supination External Rotation
 Speed
 Crank
 Biceps Load II (Kim)
 Mayo Shear

7. O’brient’s Test
 90 of flexion, 10 of horizontal
adduction, and maximum internal
rotation with the elbow in full
extension
 Resisted downward force at wrist
 On top of the shoulder = ACJ
 Inside the shoulder = Biceps
 Positive test is indicated by pain or
painful clicking in shoulder

8. Dynamic Labral Shear Test (O’Driscoll)
 Sitting or Supine
 arm at side and elbow
flexed 90
 ER & Abd 90
 Pain
 deep and/or posterior
 90 to 120 abduction
What I describe as Jobe’s
Maneuver for pain

9.  Speed Test
 Resisted active arm elevation with
extended elbow and supinated
forearm
 Yergason test
 Resisted active elbow flexion at 90
degree with supinated forearm

10. Accuracy of Clincal Tests
Jones & Galluch et al

11. Should be wary about relying on these tests when
assessing these indviduals with shoulder dysfunction -
they may have more than one pathology

13. Investigation
 Depends upon the lesion
 Intra-articular
 Groove
 MRI vs US

14. Treatment
 Depends on:
• Pathology of LHB
• Co-existing shoulder pathology
• Age
• Symptoms
• Level of function
 Conservative vs Operative

15. Conservative treatment
• Rotator Cuff Status
• Rest
• NSAIDS
• Steroid injection
• Physical therapy
• ROM exercise
• Muscle strengthening

16. Surgical Treatment
• Resistant to conservative
treatment
• Irreversible changes
• Tearing or fraying > 25%
• Decrease tendon size > 25%
• Subluxation from bicipital groove
• Instability
• Relative indication :
• Failed subacromial decompression with
persistent symptoms
• Bony abnormality

17. Tenodesis
OR
Tenotomy

18. Tenodesis
 Advantages
 Maintains length-tension relationship of tendon
 Prevents loss of forearm supination (Flexion?)
 Prevents cramping in muscle
 Avoids cosmetically unpleasing Popeye deformity
 Disadvantages
 Postoperative pain

19. Techniques
Biceps
Tenodesis
Open
Sub
pectoral
Soft
Tissue
A’scopy
Bony
High in
Groove

20. Soft Tissue Tenodesis
 Short head of biceps (Ambacher 2000)
 Transverse humeral ligament (Sekiya 2003)
 Conjoint tendon (Verma 2005)
 Repair site of rotator cuff (Franceschi 2008)
 Supraspinatus, Rotator interval

21. Bony Tenodesis
 Anchor (Gartsman 2000)
 Bone tunnel + Interference screw
 Keyhole, Periosteal flap, Screw and washer
 Transhumeral head guide pin (Boileau 2002)
 Pulley anchor in tunnel (Klepps 2002)

22. Mini-open Tenodesis

23. Mini-open Tenodesis

24. Mini-open
Tenodesis

25. Mini-open
Tenodesis

26. Mini-open
Tenodesis

27. Arthroscopic Tenodesis
Interference screw in humeral head
Suture anchors

28. Arthroscopic Tenodesis

31. Tenotomy
 ? Function as static and dynamic restraint
 Controversy in function but no controversy in
source of pain
 Advantages
 Lesser incidence of post operative pain
 Does not require p/o immobilization
 No specific rehabilitation program
 Less cost
 Easier to perform
 Lesser operative time

32. - Releasing LHB with portion of
superior labrum (Bradbury 2008)
- Tenotomy of hypertrophic
and flattened LHB (Ahmad 2007)
- Low in female : female 37%,
male 83% (Kelly 2005)

33. Tenodesis vs Tenotomy
• Tenotomy and tenodesis have little difference in
muscle spasm, cramp, anterior shoulder pain
and cosmetic appearance (Osbahr 2002)
• English literatures : Tenotomy and tenodesis
have little difference in outcome (Frost 2009)
• Higher incidence of cosmetic deformity is seen
in patients treated with biceps tenotomy
compared with tenodesis, with an associated
lower load to tendon failure (Andrew 2011)

34. Summary
 Tenotomy
 Age > 55
 Chronic and significant pain relief is primary objective
 Cosmesis and power are lesser objectives
 Concomitant massive irrepairable cuff tear
 Tenodesis
 Age < 55
 Skinny
 Cosmetic concern
 Active functional demand

35. Conclusion
• Still no consensus in the literature
• Patient Factors & Demands
• Need high levels of evidence, control,
randomization and power, with well-
defined study variables

36. Thank You