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Case Report
http://dx.doi.org/10.14517/aosm14003
pISSN 2289-005X·eISSN 2289-0068
Extra-articular origin of long head of biceps brachii that is
attached to the rotator cuff
Woo-Jin Yi, Jin-Hyoung Son
Department of Orthopaedic Surgery, Seoul Red-Cross Hospital, Seoul, Korea
The long head of biceps brachii contributes to the stability of glenohumeral joints. Its pathologic changes can cause
pain in the shoulders independent of or in combination with other structures. Various anatomical variations of the long
head of biceps brachii have been reported, but an extra-articular origin of the long head of biceps brachii has rarely been
reported. Here, we report a case of an extra-articular origin of the long head of biceps brachii that was firmly attached to
the rotator cuff.
Keywords: Shoulder; Long head of biceps brachii; Anatomic variant; Arthroscopy
INTRODUCTION
Long head of biceps brachii (LHBB) is an anatomical
site in which a lot of anatomical variants exist - the most
common being a third head LHBB. Conversely, an extraarticular origin of LHBB has rarely been reported [1-5].
The clinical importance or relevance of these variants are
yet unclear [1-4]. Thus, without more knowledge of these
anatomical variants it is difficult to accurately diagnose
lesions of the biceps through magnetic resonance imaging
(MRI) [5]. We found and treated a case of an extra-articular
origin of the LHBB that was attached firmly to the rotator
cuff with laminated tear.
CASE REPORT
A 57-year-old woman presented with spontaneous
pain and weakness in the left shoulder 8 months prior
to the hospital visit. The symptoms aggravated 3 weeks
prior to the visit when she fell on her left hand. Physical
examination showed tenderness on the lateral aspect
and on the bicipital groove of the shoulder joint. Range of
passive motion was normal, whereas, active flexion and
Arthroscopy and
Orthopedic Sports Medicine
AOSM
abduction motions were decreased from normal. The
patient showed positive scores for the Neer’s impingement
test, Hawkin’s impingement test, empty can test, and full
can test, and negative scores for the Speed test, Yergason
test, and instability test.
Simple X-ray films showed no abnormal findings;
therefore further radiological checks were made through
MRI. MRI revealed a 20 × 19 mm sized full thickness
rotator cuff tear that crossed from the rotator interval to
the infraspinatus tendon including the supraspinatus
tendon. The LHBB could be traced along the bicipital
groove, but not in the intra-articular area. The origin of the
LHBB was absent on the superior labrum (Fig. 1).
The patient was diagnosed with a full thickness rotator
cuff tear. During the arthroscopic operation, we found
that the gleno-humeral joint com­municated into the
subacromial space through a large rotator cuff tear. The
torn rotator cuff was laminated and the upper tissue of
the laminated rotator cuff was retracted more medially
than the lower tissue. We found that the LHBB did not
originate from the superior labrum but panned out at its
end to merge with the inferior aspect of the lower tissue
of the torn supraspinatus tendon, which was assumed
Received January 16, 2014; Revised February 18, 2014; Accepted February 26, 2014
Correspondence to: Woo-Jin Yi , Department of Orthopaedic Surgery, Seoul Red-Cross Hospital, 9 Saemunan-ro, Jongno-gu, Seoul
110-747, Korea. Tel: +82-2-2002-8390, Fax: +82-2-2002-8398, E-mail: [email protected]
Copyright © 2014 Korean Arthroscopy Society and Korean Orthopedic Society for Sports Medicine. All rights reserved.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Arthrosc Orthop Sports Med 2014;1(2):129-133
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Woo-Jin Yi, Jin-Hyoung Son. Extra-articular origin of the long head of biceps brachii
Fig. 1. (A) A oblique coronal view of a pre­
operative magnetic resonance imaging
(MRI) shows a full thickness rotator cuff
tear (black arrow). And an absence of the
long head of biceps brachii (LHBB) in the
intra-articular space and in the superior
labrum (white arrow). (B) Another oblique
coronal view of a preoperative MRI shows
a normal intact LHBB (arrowheads) in the
bicipital groove.
Fig. 2. (A) The arthroscopic view from the
posterior portal shows the upper tissue
(arrows) and the lower tissue (arrowheads)
of laminated rotator cuff tear that is
firmly attached to the long head of biceps
brachii (LHBB). (B) When the LHBB is
pushed down, the panning out of the
LHBB is clearly seen. The lateral margin
of the lower tissue of the rotator cuff
(arrowheads) can be distinguished from
the LHBB.
LHBB glided. There was no pathologic abnormality on the
superior labrum except for the absence of the origin of
LHBB (Figs. 2, 3).
We performed acromioplasty and then tenodesis of
the LHBB to the upper end of the bicipital groove. Lastly,
we repaired the lower tissue of the rotator cuff on the
footprint just lateral to the articular surface, and then
repaired the upper tissue on the lateral area of the repaired
lower tissue using a double row suture bridge technique.
DISCUSSION
Fig. 3. The arthroscopic view from posterior portal shows the nonintra-articular origin of the long head of biceps brachii on the superior
labrum (arrow). SSc, subscapularis tendon; G, glenoid surface.
to be the capsule. The attachment of the LHBB to the
lower tissue of the torn rotator cuff was so firm that the
torn rotator cuff moved together with the LHBB when the
130
The LHBB has many kinds of anatomical variants, but
the attachment between LHBB and the rotator cuff is not
commonly encountered in daily practice. Normally, the
LHBB originates from the posterior part of the superior
labrum and the supraglenoid tubercle. From its origin, it
travels to the intra-articular space over the humeral head,
passes out of the joint capsule, and runs down along the
bicipital groove.
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Woo-Jin Yi, Jin-Hyoung Son. Extra-articular origin of the long head of biceps brachii
Functionally, the LHBB contributes to the stability of
shoulder joints. Clinically, the pathologic changes in
LHBB may cause pain with or without collateral patho­
logic changes in other structures. Further, during an
arthroscopic operation, understanding the anatomical
structure and anatomic variants of LHBB may aid surgeons
to distinguish between an actual pathology and a rare
anatomical property. Thus, the need for a set of standards
to differentiate between pathologic changes and anatomic
variants of the LHBBs is very important [4,6,7].
Although some investigators suggest that LHBB does not
have any specific function in shoulder joints, it is generally
accepted that LHBB contributes to the stability of the
glenohumeral joint by pushing down the humeral head
and placing it on the glenoid surface [4,6,8,9]. In fact, many
investigators emphasize the correlation between LHBB
and anterior instability. Based on the studies that anterior
instabilities are commonly found in the patients with
LHBB variants, and other studies that electrical activities
of the LHBs on electromyography tests are increased in the
pitchers with anterior instabilities.
Numerous anatomic variants of LHBBs have been
previously reported. Two seminal studies have syste­
matically classified intra-articular variants of LHBBs by
reviewing many cases. Dierickx et al. [1] classified variants
of the intra-articular LHBBs into 4 major families and into
12 subgroups by analyzing 3,000 arthroscopic findings
from retrospective reviews. Kanatli et al. [7] classified
variants of intra-articular LHBBs into 7 types by analyzing
671 arthroscopic findings.
But with regard to our case, the classification of Kanatli
et al. [7] suggests only one type, the complete synovial
tunnel, for the cases that LHBBs are not observed in the
intra-articular spaces. Therefore, it doesn’t include absence
of the LHBB or the extra-articular origin from joint capsule
or rotator cuff as in our case. The classification of Dierickx
et al. [1] does not differentiate the extra-articular origin of
LHBB, originating from the joint capsule or rotator cuff,
from the complete synovial tunnel, which is described by
Kanatli et al. [7] and reported by Hammond and Bryant
[10].
The characteristic of synovila tunnel making distinction
from our case is that a pristine LHBB of the intra-articular
space is completely encased by a a synovial envelope,
and thus it is not the true BARC (biceps adhesion to the
rotator cuff) complex. So taking this distinction into con­
sideration, we reviewed the cases where the LHBBs did
not originate from the superior labrums or supraglenoid
tubercles and were not observed in the intra-articular
spaces, and then classified them using the classification
of Dierickx et al. [1]. In order to exclude complete synovial
tunnel, we included only the cases in which the firm
attachments of LHBB to the rotator cuffs were identified.
According to our literature review, 5 cases of ADHCO (completely attached to the supraspinatus, but not
attached to the labrum) were reported [1-5], and in these,
2 cases were identified as having a firm attachment to
the rotator cuff [1,4]. The other 2 cases were excluded
because there was no clear evidence of a firm attachment
to the rotator cuff and therefore, possibilities of complete
synovial tunnel existed [2,5]. Whereas in the last case, the
LHBB were tapered and merged to the rotator interval [3].
Our case is quite similar to the ADH-CO case reported by
Dierickx et al. [1], except for the laminated appearance of
the rotator cuff tear. The above two cases can be thought
to be caused by the secondary adhesion of LHBB to the
Fig. 4. (A) The oblique coronal view of
magnetic resonance imaging of the nonsymptomatic right shoulder shows a
non-labral origin (white arrow) and nonintra-articular origin of the long head
of biceps brachii (LHBB). (B) The extraarticular portion of the LHBB of the nonsymptomatic right shoulder is identified.
An intact rotator cuff (arrowheads) can
be seen.
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Woo-Jin Yi, Jin-Hyoung Son. Extra-articular origin of the long head of biceps brachii
rotator cuff after both are torn. However, the likelihood
of this seems to be low in our case for three reasons.
First, the remaining portion of LHBB appears completely
normal without any inflammatory changes or adhesion
to other tissues. Second, the LHBB pans out at its end
and smoothly merges with the joint capsule and rotator
cuff (Fig. 2B). Lastly, the MRI of the non-symptomatic
contralateral shoulder of the same patient also shows
absence of an intra-articular portion of the LHBB but an
intact rotator cuff (Fig. 4).
In laminated rotator cuff tears, the lower tissues are
usually retracted more medially than the upper tissues,
but in our case, the lower tissue was unusually retracted
less medially than the upper tissue. This unusual retraction
of the lower tissue may have come under constrain by the
tension from strong attachment with the LHBB.
During embryonic development, the LHBB is formed
from the mesoderm of the arm bud at around the 7th or
8th week [6]. In the past, the LHBB was thought to first
develop in the extra-articular, extra-capsular space and
then migrate into the intra-articular space. But now the
site of development and occurrence of the transmigration
is under dispute [1,7]. Audenaert et al. [11] proposed
that the LHBB develops between the fibrous capsule
and synovial layer, and the staged migration occurs into
intra-articular position. Egea et al. [3] and Parikh et al. [9]
proposed that this migration may be interrupted, and
this may explain the variations in LHBB. But histological
findings by Yeh et al. [12] in their case showed that the
tendon fibers dispersed and mixed with the connective
tissue of the superior joint capsule after it merged
with the capsule, and they stated that the incomplete
differentiation of the LHBB and the rotator cuff can
explain these variants, a hypothesis to which Gaskin et al.
[5] agreed.
Although the variations of LHBBs have been thought
to have no relations with pathology, a lot of opinions
have been suggested that the possibility of the shoulder
instability increases when accompanied with the
variation of LHBB [2,3,5]. The relation with the rotator cuff
tear was also suggested [1,3,7]. Dierickx et al. [1] believe
that the rotator cuff tears can be induced by a complete
adherence or a solid fusion between the rotator cuff and
the LHBB. Egea et al. [3] suggested a correlation between a
rotator cuff tear and an absence of the LHBB in the intraarticular space. In agreement to these previous findings,
our case of abnormal LHBB was also accompanied with
a full thickness rotator cuff tear. We believe the rotator
cuff tear may have been caused by the stress on the
rotator cuff insertion during biceps contraction because
of its firm attachment to the biceps tendons. But further
investigation is required to prove this assumption.
As variants of intra-articular LHBBs are difficult to
diagnose accurately with MRI or other examinations,
it is easy to misinterpret them as pathologic changes.
Therefore, increasing the knowledge and awareness of the
variants of LHBBs is a way to improve the rate of accurate
interpretations at preoperative examinations. This will help
avoid unnecessary operations and decrease the possibility
of treatment failures. In an effort to contribute to this, we
report a case of an extra-articular origin of a LHBB firmly
attached to the rotator cuff that has a laminated tear.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was
reported.
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