Anatomy, examina-on and imaging of the biceps Klaus Bak, MD
Disclosures Klaus Bak, MD I
Leadership posi6on/advisory role for: none Stockholder in: Teres Medical Group Patents and royal6es from: none Honoraria（lecture fee) from: none Honoraria(manuscript fee) from: none Grant/Research funding from: none Other remunera6on from: Arthrex Employee of: Teres Hospital Parken, Copenhagen, Denmark
None of the disclosures are related to this talk
Proximal Biceps Anatomy • SHB – Coracoid process – Muscular & aponeuroCc origin – Rarely related to pathology
• LHB Supra-‐glenoid tubercle – Unique to primates – Long intra & extra arCcular course – Hypovascular zone 1-‐3cm from origin – Prone to pathology
Biomechanics -‐ funcCon • Controversial – not fully understood
• StaCc and dynamic – – – – – –
Restricts anterior and posterior translaCon Increased acCvity in LHB with glenohumeral instability Reduce tension in anterior band of IGHL Depressor funcCon in the cocking posiCon Dynamic restraint in maximal ER minimal EMG acCvity with the elbow immobilized
• French school – The only funcCon of the LHB is to give rise to pain
ClassificaCon Systems • Burkhead; Lafosse; Habermeyer • Important features: – Associated injuries – Degree of LHB damage – Stable or unstable
Anterior and posterior instability of the LHB tendon in rotator cuff tears: a new classification based on arthroscopic observations, LaFosse et al Arthroscopy 2007
LAFOSSEs CLASSIFICATION
LBH-TENDON
Instability (direction)
No
Anterior/posterior
Anterior-posterior
Instability (severity)
no
Subluxed
dislocated
I
II
III
A
B
C
Subscapularis
No
Superior 1/3 tear
Complete tear
Supraspinatus
No
Partial tear
Full-thickness tear
Lesion (macroscopic)
ROTATOR CUFF
Lesions of the LHB in paCents with shoulder pain. Mahirogullari, Chloros, Ferguson, Weisler, Poehling (ESSKA 2008)
1622 shoulder arthroscopies -‐ Habermeyer-‐Walch classificaCon, N=264 (16 %) LHB pathology • Group 1 (16%) – isolated LHB pathology: – Isolated LHB-‐tendiniCs – Isolated LHB-‐rupture
31 13
– LHB tendoniCs – LHB rupture
118 90
12
• Group 2 – cuff tears (83%): • Group 3
– FTT Subscap and dislocaCon of LHB
Long head of biceps pathology Bak & Malta Hansen (DSSAK 2009, SECEC 2009)
Arthroscopic findings -‐ 196 shoulder pain • 41 had LHB-‐pathology (21 %) • Group 1 (7 = 17%): – Isolated LHB-‐tendiniCs – Isolated LHB-‐rupture
6 1
– LHB tendoniCs – LHB rupture
19 15
• Group 2 cuff tears (34 = 83%): • Group 3
– FTT Subscap and dislocaCon of LHB 0
LHB Stability • Bicipital Groove – Between tuberosiCes
• Stabilisers – Superficial • Transverse ligament
– Deep • Biceps Pulley – SGHL & CHHL – Subscapularis – Supraspinatus
Tendinopathy • Thickening & stenosis – hourglass biceps – Painful locking & catching – Akin to Trigger finger – Abrades humeral head
Clinical examinaCon • Pain and tenderness by palpaCon of the bicipital groove • ProvocaCon tests – Speed’s test • Resisted Forward Flexion of Arm – Yergason’s Test • Resisted SupinaCon of Forearm – Biceps instabilitets test • Tendon MigraCon with Internal and External RotaCon – Upper cut test (Kibler) – Gerber’s LiN Off Test • Subscapularis – Cuff strength • CosmeCc deformity – Popeye
DiagnosCc accuracy • Speed’s test – SensiCvity 76% – Specificity 66 %
• PreoperaCve O'Brien and Speed tests did not correlate with intraoperaCve observed LHB pathology
LaFosse et al Arthroscopy 2007
Accuracy of clinical tests Kibler et al, AJSM 2009: Clinical u6lity of tradi6onal and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder • The bear hug and upper cut were most sensiCve (0.79 and 0.73) • The belly press and Speed's test were most specific (0.85 and 0.81) • The upper cut was most accurate (0.77) and produced the highest posiCve likelihood raCo (3.38)
Accuracy of clinical tests Holtby and Razmjou, Arthroscopy 2004: Accuracy of the Speed's and Yergason's tests in detec6ng biceps pathology and SLAP lesions: comparison with arthroscopic findings: ”Although Speed's and Yergason's tests are moderately specific, they do not generate a large change in the post-‐test probability and are unlikely to make a significant change in the pretest diagnosis”
InvesCgaCons • X Ray
– Axilliary view -‐ Osteophytes in bicipital groove
• Ultrasound
– Dynamic stability – SynoviCs – SensiCve & specific for rupture or dislocaCon
• MRI
– Instability – Associated cuff lesions
Ultrasound Fluid in the bicipital sheath Biceps
Courtesy of Michel Court-Payen
Courtesy of Michel Court-Payen
Tendinosis and partial rupture
Tendinosis
Partial rupture
Biceps Medial
Subluxation Empty Groove
Courtesy of Michel Court-Payen
Dislocation
Ultrasound The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology -‐ JSES 2006 Armstrong A, Teefey SA, Wu T, Clark AM, Middleton WD, Yamaguchi K, Galatz LM.
• Overall, ultrasound diagnosed 35 of 36 normal biceps tendons (specificity, 97%) and 17 of 35 abnormal biceps tendons (sensiCvity, 49%) • Superior in diagnosing instability compared to clinical examinaCon and MRI
Arthroscopy • Dry Arthroscopy • Assess other pathology • Anchor • Pulley • Subscap • Hook Tendon
CONCLUSION • The Long Head of Biceps tendon has a long course and is surrounded by a number of important anatomical structures which reflects the complexity of the pathology • Clinical examinaCon and ultrasound are easy and precise diagnosCc tools • MRI is needed to assess associated pathology
