Biceps - an orthopaedic surgeons perspective Melbourne Arm Clinic Upper Limb Orthopaedic Surgeons

1. Biceps
Mr. Devinder Garewal
Orthopaedic Shoulder Surgeon

2. Biceps brachii
• 2 headed muscle of the arm
• Long head commonly involved
in pathology

3. Overview
• Controversy persists regarding the function of LHB
• Tendinopathy has inflammatory, degenerative, overuse-
related and traumatic causes
• Tendinitis of LHB is an inflammatory tenosynovitis that occurs
within the bicipital groove causing anterior shoulder pain
• Can occur independently but more commonly presents in
combination with other shoulder pathology:
• Impingement
• Rotator cuff disorders
• SLAP tears
• Bursitis
• ACJ disorders

4. Anatomy
• LHB originates at the supraglenoid tubercle & superior labrum
• Inserts distally onto radial tuberosity
• Bicipital groove: hourglass shaped corridor between
tuberosities of the humeral head
• Helps to contain LHB but most restraint is provided by
surrounding soft tissues
• Rich sensory and sympathetic innervation
• Some relatively avascular zones (undersurface tendon in
groove, at superior glenoid insertion)

5. Bicipital groove

6. Soft tissue constraints

8. Role of biceps
• Biomechanical function is debatable
• ?humeral head depressor
• ?anterior stabiliser
• ?restricts glenohumeral translation
• ?vestigial structure

9. Pathophysiology
• Spectrum of conditions from inflammatory tendinitis to
degenerative tendinosis
• This continuum likely arises secondary to repetitive traction,
fricition and glenohumeral rotation with resultant pressure
and shear forces at distinct, anatomically narrow sites
• The sheath of the tendon is an extension of the synovial lining
of the shoulder joint which can become inflammed in
conjuction with inflammatory processes that affect the rotator
cuff tendons

10. Clinical Evaluation & Diagnosis

12. History
• Progressive course of anterior shoulder pain
• Declining function as a result of chronic overuse
• Often pain is in the region of the groove
• May radiate down anteriorly to the muscle belly
• Biceps instability can occur:
• Clicking or popping
• May hear audible snap with throwing motions
• Usually occurs in setting of subscapularis tears

14. Examination
• Popeye deformity – indicative of LHB rupture
• Point tenderness over groove
• Subpectoral LHB tendon test:
• Palpate tendon medial to pec whilst pt internally rotates the arm
against resistance
• Speed’s test
• Resisted forward flexion
• Yergason’s test
• Resisted supination & elbow flexion

15. Pop eye deformity

16. Imaging
• Shoulder XR – exclude other causes
• MRI – with arthrogram
• Gold standard
• Investigates tendon and sheath
• Can look at all other shoulder structures
• US
• Operator dependent
• Ix thickening, subluxation/dislocation, rupture
• Ix cuff
• Diagnostic & therapeutic injection with LA/CS

17. Treatment

18. Non-operative Rx
• Rest & activity modification
• NSAIDs
• Physiotherapy
• Correct the underlying scapular rhythm
• Manage concomitant shoulder disorders
• US guided injection
• Into bicipital sheath
• However, intratendinous injection may predispose to tendon
rupture

19. Operative Rx
• Controversial
• Tenotomy Vs tenodesis
• Pros and Cons in each camp
• Studies have not identified significant differences in functional
scores or patient satisfaction between the two techniques

20. Arthroscopic tenotomy
• Evaluate biceps tendon integrity and stability
• Check subscapularis and supraspinatus tendons

21. Arthroscopic tenotomy - Pros
• Quick & simple
• Reproducible technique that produces pain relief
• Requires little post op rehab
• Cheap

22. Arthroscopic tenotomy - Cons
• Cosmesis
• Pop eye deformity (3-70%)
• Fatigue discomfort with repetitive resisted elbow flexion

23. Arthroscopic “release”
• Important to manage patient expectations
• My choice in:
• Older patients
• Obese arms
• Do not work in manual jobs
• Those who aren’t worried about appearance
• Unable or unwilling to comply with postoperative care following
tenodesis

24. Biceps tenodesis

25. Biceps tenodesis – Pros
• Goal is to maintain the length-tension relationship of the
biceps
• May prevent post operative muscle atrophy
• May prevent fatigue cramping
• Helps to maintain normal contour and appearance

26. Biceps tenodesis - Cons
• More technical
• Longer anaesthetic
• More risks – additional wound, humeral #
• More expensive
• Longer post operative rehabilitation

27. Biceps tenodesis
• My choice in:
• Younger, active patients
• Thinner arms
• Those not wanting cosmetic deformity
• Manual jobs
• Those willing to partake in rehabilitation

28. Method of tenodesis
• Multiple options
• Can be performed proximally with tendon in the groove or
distally, with the tendon out of the groove
• Proximal:
• Can be done arthroscopically
• Distal:
• Allows excision of diseased tendon from the groove which can
cause postoperative pain secondary to residual tenosynovitis

29. Arthroscopic tenodesis

30. Subpectoral open tenodesis

31. Subpectoral open tenodesis

32. Subpectoral open tenodesis

33. Rehab post tenodesis
• Sling 4 weeks
• No active elbow flexion or supination exercises for 4 weeks
• Strengthening from 8 weeks
• Unrestricted activity at 3-4 months post op

34. Thank you

35. Orthopaedic Upper Limb Surgeons
Mr. Devinder Garewal – Shoulder Surgeon
Mr. Matthan Mammen – Elbow, Wrist & Hand Surgeon
Warringal & North Park Private Hospitals
Referrals: 1300 ARM CLINIC | 1300 276 254
Online referrals & information: melbournearmclinic.com