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    Proximal Biceps

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    Prabath Chinthaka
    The document discusses the anatomy, examination, imaging, and management of proximal biceps tendon disorders. Key points include: 1) The proximal biceps tendon attaches to the superior labrum and has four anatomical variants of attachment. It has intra-articular and extra-articular zones within the bicipital groove. 2) Clinical examination involves tests like Speed's test, dynamic and static instability tests, and Yergason's test. Imaging studies like ultrasound and MRI can detect tendinopathy, instability, and rupture. 3) Non-operative management includes NSAIDs, steroid injections, regenerative injection therapies, and rehabilitation. Operative options include tenotomy or tenodes

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    Download as PPTX, PDF, TXT or read online from Scribd

    Proximal Biceps

    Uploaded by

    Prabath Chinthaka
    45 views23 pages
    The document discusses the anatomy, examination, imaging, and management of proximal biceps tendon disorders. Key points include: 1) The proximal biceps tendon attaches to the superior labrum and has four anatomical variants of attachment. It has intra-articular and extra-articular zones within the bicipital groove. 2) Clinical examination involves tests like Speed's test, dynamic and static instability tests, and Yergason's test. Imaging studies like ultrasound and MRI can detect tendinopathy, instability, and rupture. 3) Non-operative management includes NSAIDs, steroid injections, regenerative injection therapies, and rehabilitation. Operative options include tenotomy or tenodes

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    The document discusses the anatomy, examination, imaging, and management of proximal biceps tendon disorders. Key points include: 1) The proximal biceps tendon attaches to the superior labrum and has four anatomical variants of attachment. It has intra-articular and extra-articular zones within the bicipital groove. 2) Clinical examination involves tests like Speed's test, dynamic and static instability tests, and Yergason's test. Imaging studies like ultrasound and MRI can detect tendinopathy, instability, and rupture. 3) Non-operative management includes NSAIDs, steroid injections, regenerative injection therapies, and rehabilitation. Operative options include tenotomy or tenodes

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    45 views23 pages

    Proximal Biceps

    Uploaded by

    Prabath Chinthaka
    The document discusses the anatomy, examination, imaging, and management of proximal biceps tendon disorders. Key points include: 1) The proximal biceps tendon attaches to the superior labrum and has four anatomical variants of attachment. It has intra-articular and extra-articular zones within the bicipital groove. 2) Clinical examination involves tests like Speed's test, dynamic and static instability tests, and Yergason's test. Imaging studies like ultrasound and MRI can detect tendinopathy, instability, and rupture. 3) Non-operative management includes NSAIDs, steroid injections, regenerative injection therapies, and rehabilitation. Operative options include tenotomy or tenodes

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 23

    PROXIMAL BICEPS TENDON

    ANATOMY
    • Biceps Labral Complex (BLC) - Superior
    labrum + LHBT
    • BLC – Three zones; Inside, Junction,
    Tunnel
    • Inside – Sup. Labruum + Biceps anchor
    • Junction – Intra articular LHBT + Pulleys
    • Tunnel – Extra articular LHBT + Bicipital
    tunnel (fibro – osseous)
    • Superior labrum – histologically distinct
    from inferior labrum
    • Posterior labrum – closely resembles
    LHBT

    (Clin Sports Med 2016;35(1):01-18)


    ANATOMY
    Biceps Anchor
    • LHBT directly attaches to supraglenoid tubercle –
    50%
    • Closely associated with sup. Labrum – 50%
    • Four anatomical variants of attachment described
    • Type I – entirely post. Labrum
    • Type II – predominantly posterior
    • Type III – equally anterior & posterior
    • Type IV – mostly anterior

    (Clin Sports Med 2016;35(1):01-18)


    ANATOMY
    Intra-articular LHBT
    • Average length – 99 – 138 mm
    • Needs 19 mm excursion for normal ROM
    • Blood supply – sup. labral tributaries proximally &
    ascending branches of ant. circumflex
    • LHBT has nocioceptive neural elements
    (Musculocutaneous nerve)
    • Intra articular delivery of LHBT – gold standard
    diagnostic modality for pathologic lesions
    ANATOMY
    Biceps Reflexion Pulley
    • Capsulo – ligamentous complex
    • Stabelizes LHBT within zone I of bicipital groove
    • Contribution – CHL, SGHL, Subscapularis &
    Supraspinatus tendons
    • Arthroscopically – anteromedial and posterolateral
    biceps reflection pulleys
    • Pulleys are vulnerable to injury due to repeated
    shear forces

    (Clin Sports Med 2016;35(1):01-18)


    ANATOMY
    Bicipital Tunnel
    • Fibro-osseous enclosure of extra-articular LHBT
    • Often conceal hidden lesions
    • Divided in to 3 anatomic zones

    Function
    • Source of debate & controversy
    • EMG – show relative inactivity during isolated shoulder mvt
    • Cadaver studies – mainly depressor, important for anterior/ posterior &
    inferior stability
    • Most clinically relevant study by Giphart et. al. – little effect on gleno-
    humeral kinamatics
    (J Shoulder Elbow Surg 2015;24(4):215 -24)
    EXAMINATION
    • Popeye deformity (do not miss a SOL) • Biceps Tenderness – hallmark of biceps
    • Ludington Test – complete tear disorders
    • Elbow flexed & arm 10 IR
    EXAMINATION
    Biceps Instability tests Yergason’s Test
    • Dynamic – tendon subluxate in & out of • Used to diagnose degenerative &
    the groove with mvt inflammatory conditions
    • Static – typically seen with pulley injury or • Reliability is controversial
    Ssc tendon tear
    EXAMINATION
    Speed’s Test Other Tests
    • Main clinical utility for biceps pathology • Lift - off Test
    • Also positive for SLAP, Cuff tears & OA • Biceps Entrapment Test
    • Dynamic Shear Test
    • Active Compression Test – O’Brien
    PROXIMAL BICEPS DISORDERS
    Inflammatory Instability
    Primary Tendonitis • Subluxation/ dislocation of LHBT
    • Inflammation in the groove without • Rotator interval injury, pulley rupture, SSC
    tendon injury, SLAP injuries
    associated pathology
    • Overuse
    Rupture
    • Partial split/ fraying/ complete rupture
    Secondary Tendonitis
    • secondary to: overuse, attrition,
    • Chronic inflammation with associated
    impingement, chronic inflammation,
    shoulder pathology
    instability
    SYMPTOMS OF BICEPS DISORDERS
    Tendonitis Instability
    • Anterior shoulder pain • Snapping or clicking
    • Along bicipital groove • Anterior shoulder pain
    • Made worse by activity
    • Worse at night Rupture
    • Unable to sleep on the affected shoulder • Sudden audible pop
    • Radiates down the arm • Sudden onset severe sharp pain
    • Biceps cramps
    • Anterior arm bruising
    • weakness
    • Popeye sign
    IMAGING STUDIES - USS
    Cheap but highly operator dependent Instability
    Tendinopathy • USS can not assess pulley injuries
    • Tendon thickening • “chondral Print” indirect US sign due to
    • Synovial hypertrophy chondral erosion
    • Fluid around the tendon in the groove
    • Accuracy – 50% - 96%
    IMAGING STUDIES - USS
    • Rupture
    Instability
    • Absence of LHBT in the groove & cranially
    • USS shows excellent accuracy to detect – “empty groove”
    LHBT subluxation/ dislocation
    • Retracted tendon stump
    • Dynamic studies can be done
    • +/- upper SSC tendon injury
    IMAGING STUDIES - MRI
    • Preferred imaging modality with/without
    contrast
    • Visualisation relies on sequences on the
    proper plane

    Degeneration Subluxation/ Dislocation


    IMAGING STUDIES - MRI
    Tendonitis Rupture
    MANAGEMENT – NON OPERATIVE
    NSAIDS Other Modalities
    • Beneficial in short term to control pain &
    swelling • Topical Nitro-glycerine
    • Little benefit in treating chronic tendon • Iontophoresis
    injuries
    • Phonophoresis
    (Am Fam Physician 2013;87(7):486)
    • Theraputic US therapy
    Steroids
    • Extracorporeal shock wave therapy
    • Provide short term anti inflammatory effect
    • Low - level laser therapy
    • Can be US guided injection
    (Am Fam Physician 2013;87(7):486)
    • Risk of LHBT rupture
    • Preferred LA – Ropivacain (less chondrotoxic)
    (J bone Joint Surg Am 2008;90(5):986-91)
    MANAGEMENT – NON OPERATIVE
    Regenerative Injection Therapy Rehab Programmes
    • US guided • Acute Phase
    • Important role in non surgical Mx • Pain control, restore muscle balance, baseline
    dynamic stability
    • Induce an inflammatory response to regenerate
    damaged tissue • Intermediate phase
    • strengthening, increasing flexibility, Improving ROM,
    - Dextrose enhancing neuro muscular control
    - PRP • Advanced strengthening Phase
    - WBC • Aggressive strengthening, restore muscular endurance & power,
    prepare to return to activity
    - RBC
    • Return to activity phase
    - Stem cells
    (Phys Med Rehabil Clin N Am 2010;21(3):585 – 605) (Clin Sports Med 2016;35(1):75-92)
    MANAGEMENT - OPERATIVE
    Indications Tenotomy vs. Tenodesis
    • LHBT injury/ tear (25% - 50% OF tendon • Several variables need to be considered
    diameter)
    - Age
    • Instability
    - Functional demand
    • Tenosynovitis
    - Cosmesis
    • Bicipital groove pain (usu. due to poor gliding
    IIry to longitudinal tear) - Body Habitus
    • Failed conservative treatment - Operative time
    • SLAP tear - Workers compensation
    • Subscap tear with LHBT subluxation - Patient compliance with rehab
    MANAGEMENT – OPERATIVE; TENOTOMY
    Tenotomy – Surgical options
    Arthroscopic Tenotomy
    • Quick & technically simple
    • Posterior viewing portal & antero superior
    working portal
    • LHBT retracts in to the groove
    • Stump is trimmed

    Looped Tenotomy
    • Described by Goubier et. al.
    • LHBT is looped on itself to prevent retraction
    (Arthrosc Tech 2014;3(4):e427-30)
    MANAGEMENT – OPERATIVE; TENODESIS
    Several techniques have been described Surgical options
    • Open/ Arthroscopic • A’copic soft tissue tenodesis
    • Fixation – interference screw/ suture anchor/ • A’copic suture anchor tenodesis
    sutureless anchor • A’copic knotless anchor tenodesis
    • Level – sub • Mini-open suture anchor subpectoral
    • Intra osseous/ extra osseous tenodesis
    • Mini-open interference screw subpectoral
    • Some prefer mini open subpectoral tenodesis tenodesis
    – remove pain generators from whole groove • Mini-open key hole tenodesis
    • Mini-open bone tunnel tenodesis
    MANAGEMENT – OPERATIVE; TENODESIS
    MANAGEMENT – OPERATIVE; TENOTOMY VS.
    TENODESIS
    Tenotomy Tenodesis
    Pros • Technically easier • Lower incidence of Popeye deformity
    • Fewer post op restrictions • Maintenance of length – tension relationship
    • Quicker recovery • Retaining good supination strength
    • Shorter operative time

    Cons • Higher chance of Popeye deformity • More post op restrictions


    • Muscle cramping/ fatigue • Longer recovery
    • Longer operative time

    (Clin Sports Med 2016;35(1):93-111)


    THANK YOU!

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