Download Long Head of Biceps: More than a starting point?

Long Head of
Biceps: More than a
starting point?
Stuart Wildman MSc BSc MMACP MCSP HCPC,
October 2013
Extended Scope Physiotherapist
Aims
¤  Justification for topic choice
¤  Anatomy of the Long Head of Biceps
¤  Consideration of the physical examination
¤  Benefits of ultrasound
¤  Ultrasound technique
¤  Pathology encountered
¤  How useful is ultrasound?
¤  Limitations to the judgements in research?
¤  Implications for clinical practice
Why this topic?
¤  It’s the first thing we scan on the shoulder!
¤  Anterior shoulder pain is a commonly encountered complaint in
ESP clinics
¤  Shoulder pain is the 3rd most common MSK condition (Mitchell
et al, 2005)
¤  Difficult to diagnose a specific pain source with shoulder pain
(Park et al, 2005).
¤  Physical examination is unreliable in the diagnosis of LHB tendon
pathology (Khazzam et al, 2012)
Long head of biceps
• 
LHB arises from glenoid labrum and
supraglenoid tubercle
• 
Lies on medial aspect of biciptal groove
• 
LHB is intra-articular but extra-synovial
• 
9cm long and 5-6mm in diameter (Ahrens &
Boileau, 2007)
• 
Superior glenohumeral ligament and
coracohumeral ligament act as a ‘biceps
pulley’ mechanism. Subscapularis aponeurosis
also provides stability (Brasseur, 2012)
• 
Function of LHB is controversial (Khazzam et al,
2012)…humeral head depressor and stabiliser
of an unstable joint
Figure 1. Long head of Biceps Anatomy
Physical Examination:
¤  Physical examination is unreliable (Khazzam et al, 2012) and rarely
dictates diagnosis.
¤  Individual tests have poor clinical quality in shoulder disorders
(Kibler et al, 2009; Ditsios et al, 2012)
¤  Biciptal groove tenderness most common finding (Churgay,2009)
¤  Yergasons/Speeds - Specificity 79%, 75% and sensitivity 43% and
32% (Holtby & Razmjou,2004)
¤  Combination of tests is the best approach (Kibler et al, 2009)
Advantages of Ultrasound
• 
Real time
• 
No radiation
• 
Correlation with site of pain
• 
Relatively cheap
• 
Comparison with contralateral side
• 
Good patient tolerance
• 
Fewer contra-indications
than MRI eg metal work,
pace maker
(Smith and Finoff, 2009)
Transverse LHB
Figure 2: Normal Transverse LHB
Figure 3: Positioning for transverse
view
Longitudinal LHB
Figure 4: Normal longitudinal LHB
Figure 5: Position for longitudinal image
Classification of LHB pathology
¤  Classification system proposed by Chen et al (2012)
¤  Type 1: LHB tendinitis (tenosynovitis/tendinopathy)
¤  Type 2: Subluxation of the LHB
¤  Type 3: Dislocation of the LHB
¤  Subluxation: Partial/ transient loss of contact between the tendon or
groove (Ahrens & Boileau, 2007)
¤  Disclocation: Complete and permanent loss of contact between the
tendon and groove (Ahrens & Boileau, 2007)
¤  Type 4: Partial LHB tendon tears
¤  Type 5: Rupture LHB tendon
¤  Type 6: SLAP lesions
LHB tendinopathy
¤  Increased cross-sectional area (Ahmad
et al, 2007).
¤  ‘Hourglass biceps’ when
hypertrophied and becomes
entrapped blocking final 10 degrees
of elevation (Ahrens and Boileau,2007)
Figure 6: Thickened LHB
(www.ultrasoundcases.org)
¤  Associated stenosis of the bicipital
groove (Ahmad et al, 2007)
¤  Increase vascularity and effusion in
the synovial sheath (Ahrens and Boileau,
2007)
Figure 7: Increased vascularity
LHB (www.ultrasoundcases.org)
Medial instability…
¤  Medial instability of the long head of biceps
¤  Occurs in 20% of RC tears (Chen et al, 2012)
¤  Angluation of the tendon predisposes it to
medial subluxation (Brasseur,2012)
¤  Patient with large RC tears (>5cm) were
more likely to have LHB pathology (Chen et
al, 2012)
Figure 8: Medially subluxed LHB
¤  Rupture of the coracohumeral ligament
can lead to subluxation of the LHB on the
anterior side of subscapularis tendon
(Brasseur, 2012)
¤  Hypoechoic triangle – point of reference
(Brasseur, 2012)
Figure 9 : Normal transverse LHB
Lateral instability…and rupture
¤  Lateral instability of the long head of
biceps
¤  Associated with supraspinatus tear
¤  Spontaneous rupture –
¤  Occurs in hypovascular zone
1.2cm-3cm from tendon origin
(Cheng et al, 2010)
¤  Popeye sign
Figure 10 :Biceps rupture
longitudinal view
(www.ultrasoundcases.info)
Other considerations
¤  Fluid in LHB sheath with 90% of RC tears and LHB pathology occurs in 82% of
shoulders with RC tears (Chen et al, 2012)
¤  Also indicative of intra-articular, peritendinous effusion, however….also
bicipital tendinopathy (but not always!)…potential for red herring!
Figure 11: Transverse LHB effusion
Figure 12: Longitudinal LHB effusion
How useful is Ultrasound?
¤  Limited research in comparison to rotator cuff pathology (Skendzel et
al, 2012)
¤  90% concordance rate between arthroscopy and ultrasound for
sonographically normal tendons (Skendzel et al, 2012)
¤  Ultrasound has poor sensitivity and specificity for detecting partial
thickness tears (Armstrong et al, 2006;)
¤  Ultrasound has a high sensitivity and specificity for biceps tendon
rupture (;Skendzel et al, 2012)
¤  High sensitivity and specificity for tendon dislocation (Armstrong et al,
2006)
Limitations to the judgements of
research….?
¤  Comparison between arthroscopy and ultrasound for ‘non tear’
conditions is difficult…ultrasound can see within the tendon bulk
whereas arthroscopy cannot..
¤  Ultrasound cannot visualise the anchor of the long head of biceps
to the labrum..potentially missing pathology as it cannot be
visualised..
¤  Difficult to conclude on the quality of imaging devices used, and
the experience level of clinicians.
Summary and Clinical Implications
¤  Clinical examination for long head of biceps pathology is not useful in
isolation (Holtby and Razmjou, 2004)
¤  Ultrasound can assist with diagnosing ruptures and dislocation.
(Armstrong et al, 2006).
¤  Ultrasound can assist in providing information on tendon thickness,
neovascularisation, quality and effusion.
¤  LHB effusion can indicate local tendinopathic changes but also other
rotator cuff tears and joint pathology.
¤  Merging clinical examination findings and ultrasound findings can
enhance diagnosis of long head of biceps tendinopathy.
References
¤ 
Ahmad, C.S., DiSipio, C., Lester, J., Gardner, T.R., Levine, W.N., & Bigliani, L.U. (2007) ‘Factors affecting dropped biceps
deformity after tenotomy of the long head of biceps tendon’, Arthroscopy, 23:5, pp. 537-541.
¤ 
Ahrens, P.M. & Boileau, P (2007) ‘The long head of biceps and associated tendinopathy’, Journal of Bone and Joint
Surgery, 89:8, pp. 1001-1009.
¤ 
Armstrong A, Teefey SA, Wu T, Clark AM, Middleton WD, Yamaguchi K, et al. (2006) ’The efficacy of ultrasound in the
diagnosis of long head of the biceps tendon pathology’. Journal of Shoulder and Elbow Surgery,15, pp. 7–11.
¤ 
Brasseur, J.L. (2012) ‘The biceps tendons: From the top and from the bottom’, Journal of Ultrasound, 15, pp. 29-38.
¤ 
Chen,C-H., Chen,C-H., Chnag, C-H.,Su, C-I., Wang, K-C., Wang, I-C., Liu, H-T., Yu, C-M. & Hsu, K-Y. (2012) ‘Classification
and Analysis of Pathology of the Long Head of Biceps Tendon in Complete Rotator Cuff Tears’ , Chang Gung Medical
Journal, 35:3, pp. 263-270.
¤ 
Churgay, C.A. (2009)’ Diagnosis and treatment of biceps tendinitis and tendinosis’, American Family Physician, 80, pp.
470–476.
¤ 
Ditsios, K., Agathangelidis, F., Boutsiadis, A., Karataglis, D & Padadouppoulos, P (2012) ‘Long Head of Biceps Pathology
Combined With Rotator Cuff Tears’, Advances in Orthopaedics, pp. 1-6.
References
¤ 
Holtby R, Razmjou H. (2004) ‘Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions:
Comparison with arthroscopic findings’ , Arthroscopy, 20, pp. 231–236.
¤ 
Khazzam, M., Kuhn, J.E., Mulligan, E., Abboud, J.A., Baumgarten, K.M., Brophy, R.H., Jones, G.L., Miller, B., Smith. & Wright, R.W.
(2012) ‘Magnetic Resonance Imaging Identification of Rotator Cuff Retears After Repair: Interobserver and Intraobserver
Agreement’, American Journal of Sports Medicine, 40(8), pp. 1722-1727.
¤ 
Kibler, B.W., Sciascia, A.D., Hester,P., Dome, D. & Jacobs, C. (2009) ’Clinical Utility of Traditional and New Tests in the Diagnosis of
Biceps Tendon Injuries and Superior Labrum Anterior and Posterior Lesions in the Shoulder’, American Journal of Sports Medicine,
37:9, pp. 1840-1847
¤ 
Park, H.B., Atsushi, Y., Harpreet, G.S., El Rassi, G.,McFarland ,E.G. (2005) ‘Diagnostic Accuracy of Clinical Tests for the Different
Diagnoses of Subacromial Impingement Syndrome, American Journal of Bone and Joint Surgery, 87 (7), pp1446-1455.
¤ 
Skendzell, J.G., Jacobson, J.A., Carpenter, J.E. & Miller, B.S. (2012) ‘Long Head of Biceps Brachii Tendon Evaluation: Accuracy of
Preoperative Ultrasound’, American Journal of Roentgenology, 197, pp 942-948.
¤ 
Smiff, J & Finnoff, J.T. (2009) Diagnostic and Interventional musculoskeletal ultrasound part 1: Fundamentals, PM & R: The Journal
of Injury, function and rehbailitation, 1(1), pp. 64-75.
¤ 
www.theultrasoundsite.org