Biceps Sheath Research Articles

The long head of biceps at the shoulder: a scoping review

BackgroundThis review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions.MethodsPubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English.Results214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep’s role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy’s limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation.ConclusionsThe scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required.Pre-registrationOSF: https://osf.io/erh9m

Arthroscopic management of synovial chondromatosis of the shoulder: A case report

Synovial chondromatosis of the shoulder is a rare entity that is generally mono-articular and uncommon in diarthrodial joints. Treatment of synovial chondromatosis of the shoulder includes open arthrotomy retrieval of loose bodies and synovectomy. With advances in arthroscopy, the same could be achieved using arthroscopic techniques. This case report describes a case report of a 35-year-old male patient who presented with complaints of pain and restriction of movement for 6 months. The MRI of the patient was suggestive of multiple loose bodies in the shoulder joint, in the subdeltoid region, and subscapularis muscle with subacromial bursitis. Arthroscopically more than 100 loose bodies were retrieved with subacromial decompression. Shoulder synovial chondromatosis has been rarely reported in the literature. The malignant transformation although rare, but it is still a possibility. The recurrence rate varies from 3.2% to 22.3%. Open arthrotomy, synovectomy, and retrieval of loose bodies cause delayed recovery and more morbidity with high chances of subscapularis insufficiency due to the need of subscapularis tenotomy. Arthroscopic treatment although have limitations such as limited visualization, limited synovectomy, and difficult interventions around the axillary recess or biceps sheath, but provides with the advantage of lesser morbidity and early rehabilitation. Synovial chondromatosis can be successfully treated arthroscopically as it provides intra-articular and extra articular access with early rehabilitation, lesser morbidity, and early recovery.

Ultrasound-Guided Biceps Tendon Sheath Injections Frequently Extravasate Into the Glenohumeral Joint

To evaluate the frequency of glenohumeral joint extravasation of ultrasound (US)-guided biceps tendon sheath injections. Fifty shoulders with a clinical diagnosis of bicipital tenosynovitis pain received a US-guided biceps sheath injection with anesthetic, steroid, and contrast (5.0 mL mixture) followed immediately by orthogonal radiographs to localize the anatomic distribution of the injection. Radiographic evaluation of contrast localization was determined and interobserver reliability calculated. All 50 postinjection radiographs (100%) demonstrated contrast within the biceps tendon sheath. In addition, 30 of 50 (60%) radiographs also revealed contrast in the glenohumeral joint. Interobserver reliability for determination of intraarticular contrast was good (kappa value 0.87). US-guided bicipital sheath injections reproducibly result in intrasheath placement of injection fluid. Bicipital sheath injections performed with 5 mL of volume result in partial extravasation into the joint 60% of the time. These data may be useful for surgeons who use the results of diagnostic biceps injections for diagnosis and surgical decision-making. III, prospective cohort study, diagnosis.

Transosseous Suture–Based Arthroscopic Suprapectoral Biceps Tenodesis

Biceps tenodesis is a well-accepted surgical treatment to relieve pain and dysfunction about the shoulder. Multiple locations and methods of tenodesis have been described, with similar outcomes. Transosseous cuff repairs and tendon repairs have been used for decades as a tried and true fixation method. This technique describes an arthroscopic transosseous technique for biceps tenodesis in the suprapectoral location that is technically simple, fast, eliminates the cost of implants, avoids an incision in the axillae which may be prone to dehiscence or infection, and releases the biceps sheath, which may be related to pain generation. Moreover, the biceps length tension relationship is easily recapitulated using anatomical landmarks.

Biceps sheath fluid on shoulder ultrasound as a predictor of rotator cuff tear: analysis of a consecutive cohort

Ultrasound provides evaluation of rotator cuff disease with accuracy comparable to that of magnetic resonance imaging. Fluid in the sheath of the long head of the biceps tendon (LHB), identified on ultrasound scan, has been associated with disease of the rotator cuff, LHB, and glenohumeral joint. Prior literature has compared ultrasound findings only with arthrography, and results have been conflicting. Arthroscopy remains the reference standard in assessing accuracy of imaging modalities. We present the first study investigating the significance of fluid in the LHB on ultrasound in predicting subsequent rotator cuff disease identified on arthroscopy. Records were reviewed of 175 patients undergoing ultrasound and subsequent arthroscopy under 1 shoulder surgeon. Experienced musculoskeletal radiologists and sonographers performed ultrasound. Ultrasound examination and operating records were collected and analyzed. Data were analyzed using descriptive statistics, correlation, and logistic regression modeling. Highly significant correlation (P < .001; ρ = 0.354) was found between fluid in the LHB sheath and rotator cuff tears on arthroscopy. Statistically significant but weak correlation (P < .05; rho = 0.187) was found between fluid in the LHB sheath and both biceps tendon disease and glenohumeral joint disease. Fluid around the LHB was shown to increase the likelihood of having rotator cuff tear (odds ratio, 2.641; 95% confidence interval, 1.229-5.674) and biceps tendon disease (odds ratio, 2.698; 95% confidence interval, 1.216-5.987). This is the first report identifying significant correlation between fluid in the LHB sheath identified on ultrasound and subsequent rotator cuff disease identified at arthroscopy. We recommend routine reporting of fluid in the LHB sheath as it is likely to improve the accuracy of detecting rotator cuff and biceps tendon diseases.

Septic Arthritis of the Pediatric Shoulder: From Infancy to Adolescence.

Background. Septic arthritis of the glenohumeral joint in the pediatric population (<18 yo) is not commonly described in the literature. There is a corresponding paucity of information regarding its presentation and treatment. Methods. An IRB approved review of patients treated with irrigation and debridement by the Orthopaedic Department was completed. This retrospective study includes four patients, presenting from 2005 to 2015, with septic arthritis of the shoulder. Results. The mean age (M age) at presentation was 5 years, with a range of 1 month to 15 years. Patients presented on average after 7 days with pain and a mean temperature of 39°C, erythrocyte sedimentation rate of 66 mm/hr, a C-reactive protein level of 11.17 g/dL, and a white blood cell count of 20.2 × 103/mcL. Staphylococcus aureus, Candida albicans, and Pseudomonas aeruginosa were cultured from the wounds. All cases were treated operatively with irrigation and debridement and with antimicrobial therapy. Patients received antibiotics for an average of 6 weeks. Conclusion. Septic arthritis of the shoulder occurs in all pediatric ages. Successful treatment of septic arthritis of the shoulder was accomplished in four cases without division of the biceps sheath, with an average follow-up of 8 months.

Arthroscopic Keyhole Proximal Biceps Tenodesis: A Technical Note

We describe an arthroscopic keyhole technique for proximal biceps tenodesis. The technique is safe, easy to reproduce, cost-effective, and less time consuming. It does not need any special instrumentation and is suitable especially for use in the developing countries. It enables examination of the biceps sheath and distal biceps tendon for unidentified tears, synovitis, and fibrosis.

Clinical success of biceps tenodesis with and without release of the transverse humeral ligament

Multiple methods for biceps tenodesis exist, but long-term studies have demonstrated high failure rates. We hypothesized that tenodesis techniques that do not release the biceps sheath are associated with a higher surgical revision rate than those that do. A retrospective study was conducted of 127 biceps surgeries over a 2-year period. The mean follow-up post surgery was 22 months (range, 6-59). Clinical failure was defined as ongoing pain localized in the biceps groove, severe enough to warrant revision surgery. When all techniques that released the biceps sheath (6.8%, 4/59) were compared to those that did not release the biceps sheath (20.6%, 14/68), a statistically significant difference was found, P = .026 (chi-square). Proximal arthroscopic techniques were revised at a significantly higher rate than distal tenodesis techniques (P = .005). Biceps tenodesis techniques which do not release the biceps sheath or remove the tendon from the sheath have increased revision rates, compared to techniques that do. This may be supportive evidence for the theory that residual pain generating elements in the biceps groove is a cause of failure of proximal tenodesis methods.

Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians

BackgroundVariations in corticosteroid/anesthetic doses for injecting shoulder conditions were examined among orthopaedic surgeons, rheumatologists, and primary-care sports medicine (PCSMs) and physical medicine and rehabilitation (PMRs) physicians to provide data needed for documenting inter-group differences for establishing uniform injection guidelines.Methods264 surveys, sent to these physicians in our tri-state area of the western United States, addressed corticosteroid/anesthetic doses and types used for subacromial impingement, degenerative glenohumeral and acromioclavicular arthritis, biceps tendinitis, and peri-scapular trigger points. They were asked about preferences regarding: 1) fluorinated vs. non-fluorinated corticosteroids, 2) acetate vs. phosphate types, 3) patient age, and 4) adjustments for special considerations including young athletes and diabetics.Results169 (64% response rate, RR) surveys were returned: 105/163 orthopaedic surgeons (64%RR), 44/77 PCSMs/PMRs (57%RR), 20/24 rheumatologists (83%RR). Although corticosteroid doses do not differ significantly between specialties (p > 0.3), anesthetic volumes show broad variations, with surgeons using larger volumes. Although 29% of PCSMs/PMRs, 44% rheumatologists, and 41% surgeons exceed "recommended" doses for the acromioclavicular joint, >98% were within recommendations for the subacromial bursa and glenohumeral joint. Depo-Medrol® (methylprednisolone acetate) and Kenalog® (triamcinolone acetonide) are most commonly used. More rheumatologists (80%) were aware that there are acetate and phosphate types of corticosteroids as compared to PCSMs/PMRs (76%) and orthopaedists (60%). However, relatively fewer rheumatologists (25%) than PCSMs/PMRs (32%) or orthopaedists (32%) knew that phosphate types are more soluble. Fluorinated corticosteroids, which can be deleterious to soft tissues, were used with these frequencies for the biceps sheath: 17% rheumatologists, 8% PCSMs/PMRs, 37% orthopaedists. Nearly 85% use the same non-fluorinated corticosteroid for all injections; <10% make adjustments for diabetic patients.ConclusionVariations between specialists in anesthetic doses suggest that surgeons (who use significantly larger volumes) emphasize determining the percentage of pain attributable to the injected region. Alternatively, this might reflect a more profound knowledge that non-surgeons specialists have of the potentially adverse cardiovascular effects of these agents. Variations between these specialists in corticosteroid/anesthetic doses and/or types, and their use in some special situations (e.g., diabetics), bespeak the need for additional investigations aimed at establishing uniform injection guidelines, and for identifying knowledge deficiencies that warrant advanced education.

Ultrasound assessment of large joint amyloidosis in haemodialysis

SUMMARY:Dialysis‐related amyloidosis (DRA), associated with beta‐2 microglobulin deposition, is a common cause of morbidity in patients with renal failure undergoing chronic dialysis. The non‐invasive diagnosis of DRA in its early stages is difficult. High resolution ultrasound (US) was used to examine the shoulder, hip and knee joints of 25 chronic haemodialysis patients, and features distinctive of DRA were determined. Distinctive US features were associated with increased total duration of dialysis (15 ± 5 vs 4 ± 2 years), carpal tunnel syndrome (9/10 cases) and shoulder joint discomfort (19 vs three joints). These features include altered rotator cuff echogenicity (hyperechoic and hypoechoic areas; 20/48 joints), hypoechoic material in the biceps sheath (16/48), erosions of bone (15/48) and reduced biceps tendon fibril echogenicity (12/48). These changes are unique in the experience of the current authors, but histological proof that they are definitely the result of DRA has not yet been possible. Tears of the rotator cuff tendons (14/50) were not consistently associated with symptoms (7/14). Tendon thickness was also increased (as has been described previously). The hip capsule thickness was increased in patients with signs of DRA in the shoulder, but no specific changes in texture were seen. Asymptomatic knee joint effusions were present in 40/50 joints (80%). These features detectable on high resolution US allow the non‐invasive early detection of DRA and are useful in the diagnosis and management of this condition.

Shoulder arthrography in rheumatoid arthritis.

Arthrograms of the shoulder were evaluated in 10 patients with rheumatoid arthritis. The arthrographic findings common to all joints consisted of nodular filling defects, irregular capsular attachments, bursal filling defects and visualized lymphatic drainage. Findings unique to the shoulder joint consisted of rotator cuff tear, frozen shoulder, and biceps sheath dilatation. Since the agents used to treat patients with rheumatoid arthritis have profound side effects, it is important to exclude an associated rotator cuff tear and/or confirm the presence of glenohumeral rheumatoid involvement.