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Biceps Tendonitis

The long head of biceps tendon (LHB) attaches to the glenoid rim at its anchor on the superior aspect. The tendon is an intra-articular structure at this point, passing along the rotator interval until it enters the bicipital groove.

This tendon is a useful land mark in shoulder arthroscopy. The tendon is stabilised in the groove by a pulley anteriorly and supraspinatus insertion posteriorly.

Biceps tendonitis may be caused by direct injury, impingement with an acromial spur and instability of the tendon (associated with rotator cuff tears.

The pain is anterior and radiates down the arm. It is worse with elbow flexion and overhead activities. Clinical tests include the Speed and Yergason tests. MRI or USS can be used for investigations.

If untreated, this can lead to complete rupture of the tendon. Once this happens, the tendon is retracted down the arm leading to the popeye sign. If this occurs in the elderly with rotator cuff tear then it is best treated conservatively. If it occurs in the young (associated with heavy lifting and weights) then a tenodesis may be indicated.

Conservative management includes rest, activity modification, NSAIDs and physiotherapy. Steroid injections also play a role here. In the experienced hands, these can be carried out in the outpatient department, but more often are referred to radiologists for ultrasound guided injections.

Surgery is predominantly arthroscopic. Biceps tenodesis is the treatment of choice for the more active patients. It preserves biceps strength and avoids the popeye sign which is of concern cosmetically. The procedure is however technically challenging. The tenodesis can be intra-articular or extra-articular. With the intra-articular technique, the biceps groove is roughened using the arthroscopic shaver. An anchor with double sutures is inserted at the groove. The 2 sutures are passed through the biceps tendon. The tendon is then detached close to its anchor and allowed to slide slightly before tying the sutures. The extra-articular technique involves cutting the tendon arthroscopically and delivering it through a small anterior skin incision. A special interference screw is used to secure the tendon to the anterior shaft of the humerus. Both of these procedures will include a period of restriction in movement afterwards. (link to rehab)

Biceps tenotomy is a simpler and quicker procedure but results in weakness and popeye sign. It may also be associated with biceps pain. It is performed arthroscopically and the patient is mobilised immediately afterwards.

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