Is the biceps long head a pain generator? How would we know? Are we keepers or killers?

The long head tendon  of the biceps (LHTB) is a component of normal shoulder structure and function. There are billions of people walking the earth with intact biceps tendons who are not in pain, so it cannot be called a "pain generator". 

In the normal shoulder the (LHTB) provides a secure anchor for half of the biceps and stability for the shoulder - both through its contribution to concavity compression and also by the "monorail" mechanism in which the transverse humeral ligament and intertuberular groove glide along the biceps monorail providing increasing stability against anterior and posterior translation as the humerus is elevated as shown in this nice diagram by Steve Lippitt.

While Speed-s and Yergason's tests are often used to detect pathology of the LHTB, we have found that the saw test is more sensitive and specific. In this test the elbow is held at 90 degrees of flexion holding a weight as shown in the video below.

Out of respect for the stabilizing function of the long head tendon of the biceps we are biceps keepers rather than biceps killers when we perform shoulder arthroplasty.  We will only sacrifice the biceps if it is seriously frayed or unstable in the groove.

In 50 years of doing shoulder arthroplasty, we've never had to take a patient back to the OR for postoperative biceps issues. There is one patient who had biceps symptoms when she played golf and a positive saw test. Her symptoms responded to a single injection of her biceps sheath.

We always appreciate feedback and commentary on the blog. Jed Kuhn, immediate past president of the American Shoulder and Elbow Surgeons and consummate educator, after reading the post gave us a 'biceps reading list', which is included here:

Throwing, the Shoulder, and Human Evolution

Adaptive pathology: new insights into the physical examination and imaging of the thrower’s shoulder and elbow

Evidence of sympathetic innervation and a1-adrenergic receptors of the long head of the biceps brachii tendon

Sympathetic and Sensory Neural Elements in the Tendon of the Long Head of the Biceps

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link). 

Massive, irreparable cuff tears: what options does the patient have?

By definition, "massive, irreparable rotator cuff tears" are not reparable. Chronic, massive, irreparable cuff tears are common and can range from being asymptomatic to disabling.

It is recognized that for many patients, non-operative management can substantially improve the comfort and function of the shoulder with a chronic massive tear (see Nonoperative treatment of chronic, massive irreparable rotator cuff tears: a systematic review with synthesis of a standardized rehabilitation protocol). For patients with painful massive, irreparable rotator cuff tears having retained active elevation of the arm, a conservative procedure, the "smooth and move" (see this link),  can provide significant benefit and prompt return to activities without the complexity or the risks associated with more aggressive surgeries 

Some surgeons advocate attempting partial repair of the massive cuff defect. The authors of Massive and irreparable rotator cuff tears treated by arthroscopic partial repair with long head of the biceps tendon augmentation provides better healing and functional results than partial repair only suggested that partial repair with augmentation using the long head of the biceps would result in a better quality of tendon to bone healing and improved clinical, functional and radiological outcomes for patients with chronic, massive and irreparable rotator cuff tears involving both the supraspinatus and infraspinatus tendons. Irreparability was defined intraoperatively as the inability to achieve sustainable repair of the supraspinatus after complete release,

The augmented group consisted of 30 patients whose biceps long head tendon was intact (only minimal redness, fraying and stable proximal attachment) on intraoperative assessment.

The non-augmented group consisted of 30 patients with poor biceps tendon quality, tendon dislocation or absence of the tendon.

As assessed by MRI at one year after surgery, the retear rate for was 43.3% for the augmented group and 73.3% for the non-augmented group. 

In spite of these imaging findings, there were no significant differences between the groups in patients' postoperative shoulder range of motion, strength, Hamada classification, Simple Shoulder Test (SST) scores and postoperative Goutallier scales. The Constant score (CMS) averaged 76.2±0.9 for the augmented group and 70.9±11.5 for the non-augmented group, but this difference failed to reach clinical significance ( the minimal clinically important difference is >10 for the CMS (see Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery)).

Of note, the augmented and non-augmented groups were not comparable. For example, two thirds of the augmented patients were male, whereas less than half of the non-augmented patients were male. The pathologies were different: the augmented patients had intact biceps tendons while the non-augmented patients did not; the size and retraction of the rotator cuff tendons are not reported. Data are not presented on the preoperative strength or range of motion.

Comment:  If we are to be able to discuss management options for our patients with these tears, we will need comparative clinical studies of patients that are similar before treatment is begun. Only in this way will we have the basis for understanding the relative effectiveness of physical therapy, smooth and move, subacromial balloon catheters, superior capsular reconstruction, partial cuff repairs (without and with augmentation) and reverse total shoulder arthroplasty. The need for controlled studies can be seen in this article: Subacromial Balloon Spacer - what is the evidence supporting the value of this innovation to patients with irreparable cuff tears?

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter (X): https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

The long head biceps - a shoulder stabilizer.

The Role of the Long Head of the Biceps Tendon in Posterior Shoulder Stabilization during Forward Flexion

These authors used a cadaver model to help understand role the long head of the biceps tendon (LHBT) in glenohumeral stability.

They found that loading the biceps tendon at 30 and 60 degrees of forward flexion increased glenohumeral stability when posteriorly directed loads were applied. 

Comment: The stabilizing effect of the biceps tendon is demonstrated by one of the common mechanisms for a SLAP injury in which posterior force applied to the joint avulses the origin of the long head from the glenoid.

We find it helpful to consider the analogy of a monorail in which the train is stabilized by sliding along a fixed track

The biceps "rail" is secured to the superior glenoid rim.

The humerus is secured on the rail by the biceps sheath and the transverse humeral ligament as shown in this arthroscopic view

and in this illustration from our late colleagues John Clark and Doug Harryman's classic "Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy"

The biceps sheath and the transverse humeral ligament keep the humerus riding along the rail of the biceps tendon - the stabilizing effect of which becomes greater as the shoulder is elevated, bringing the transverse humeral ligament closer to the supraglenoid tubercle.

The role of the biceps tendon in stabilizing the shoulder is not only important for understanding the SLAP tear, but also in glenohumeral arthroplasty. For this reason, we preserve the long head tendon of the biceps in performing the ream and run (see this link  or anatomic total shoulder (see this link)  unless it is severely frayed or dislocated. While some surgeons (self-declared "biceps killers") routinely sacrifice the tendon at arthroplasty, in our experience the incidence of problems with a preserved biceps post arthroplasty is very low.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).