This document challenges the assumption that shoulder arthroscopy is an adequate gold standard for diagnosing long head biceps (LHB) tendon pathology. A cadaver study found that arthroscopy only allows visualization of a small portion of the extra-articular LHB tendon. A systematic review found the rate of missed LHB tendon diagnoses with arthroscopy alone is 30-50%. The document concludes that arthroscopy does not adequately evaluate the full LHB tendon for pathology and new arthroscopic techniques are needed to improve diagnosis.

1. Challenging the Gold Standard:
Shoulder Arthroscopy Does Not
Adequately Visualise Pathology
of the LHB Tendon
Saithna A1,2, Longo A1, Leiter J1, Old J1, MacDonald PM1
1. The Pan Am Clinic, Winnipeg, Canada
2. Southport and Ormskirk Hospitals Trust, Merseyside, UK

2. Even in 2016 “Identification of symptomatic
long head biceps pathology continues to be a
clinical challenge”
Verma NN.Editorial Commentary: Long Head Biceps Pathology: How Do We Find It? Arthroscopy: The Journal of Arthroscopic and
Related Surgery 2016:32(2):245
• Diagnostic tests have low sensitivities and specificities
• Pathology of the LHB frequently occurs in combination
with other shoulder pathologies which can confuse the
clinical picture

3. “Arthroscopy may be the most sensitive and
specific diagnostic modality”
Carr RM, Shishani Y, Gobezie R. How accurate are we in detecting biceps tendinopathy? Clin Sports Med.
2015
• Consistent with traditional orthopaedic teaching
• BUT, no validation of arthroscopy as a gold standard in
the literature

4. Hypothesis: Arthroscopy is an
Inadequate Gold Standard for
Diagnosis of LHB Pathology
This hypothesis was evaluated through:
• Cadaveric study to evaluate how much LHB is actually
visualized at arthroscopy
• Systematic Review of the Literature

5. Cadaveric Study
• 7 fresh frozen cadavers with intact LHB
• Mean age 74 (range 44-96). All female
• Fully thawed for at least 24 hours
• Arthroscopy performed by two fellowship trained
shoulder surgeons

6. Tagging of LHB

7. Excursion with hook and
re-tagging

8. Excursion with grasper
and re-tagging

9. Determining overall
length visualised
• LHB retrieved at open approach
• MTJ identified and digital calipers
used to determine respective lengths
• Mean overall length 106mm (94-
125mm)
• Statistical analyses using paired t-
test

10. Max excursion

11. *mean difference 2.8mm, p=0.0327
Lat Versus Beach Chair

12. *Lat decubitus: Hook versus grasper, mean difference 4mm, p=0.0032
*Beach chair: Hook versus grasper, mean difference 4.9mm, p=0.0001
Hook versus Grasper

13. Conclusions of Cadaveric
Study
• A grasper allows greater excursion
• Not used clinically due to iatrogenic injury
• Data reported by Gilmer et al 2015 and Taylor et al 2015, over-
estimate tendon excursion

14. Conclusions of Cadaveric
Study
• A beach chair position allows a greater excursion of
compared to lateral decubitus
• But <3mm and unlikely to be of clinical importance
• Main conclusion is that only a small proportion of the
extra-articular portion of the tendon is seen and a large
proportion is not visualized

15. Moon et al, AJSM 2015: 84% had lesions beyond 5.6cm at
OSPBT
Gilmer, Arthroscopy 2015 32mm
Saithna, OJSM 2016 33.7mm
Taylor, Arthroscopy 2015 49.5mm
Festa, Arthroscopy 2015 50mm
Systematic Review

16. Rate of missed diagnoses
in Systematic Review
• Rate of missed diagnoses 30-50%
• 50%, Murthi (n=200), 2000 JSES.
• 30%, Gilmer (n=62), 2014 Arthroscopy.
• 47%, Taylor (n=277), 2015 Arthroscopy.

17. Conclusions and Key
Messages
• Pulling the LHB into joint is an inadequate way of
evaluating for pathology - a “normal” arthroscopy does
not exclude it
• Published sensitivity and specificity data based on
arthroscopy as a gold standard are invalid because it is an
inadequate benchmark
• New arthroscopic techniques are required to reduce the
rate of missed diagnoses

18. Questions?.....