The Management of Biceps Pathology: A Clinical Guide from the Shoulder to the Elbow

Description

The biceps tendon is one of the most challenging anatomic structures to completely understand. Its precise role for shoulder function has yet to be completely defined, and pathologic conditions exist at both its proximal and distal ends. In recent years, the biceps labral complex has been recognized as a common cause of shoulder pain among patients. Accurate diagnosis, utilizing both physical examination and imaging, is crucial to decision-making regarding the most effective treatment. Many controversies exist surrounding the management of biceps pathology with a myriad of potential solutions to consider.  This practical text breaks down the biceps into succinct, digestible portions with expert tips and tricks to help manage bicipital problems in a wide array of patients. Sensibly divided into three thematic sections, it encompasses all aspects of the biceps tendon, including relevant anatomy, diagnosis, imaging, and non-operative management (including rehabilitation and biologic treatments). Surgical management strategies as they pertain to both proximal and distal biceps tendon pathologies will be covered, including both arthroscopic and open tenodesis, transfer, and inlay and onlay fixation methods. A review of associated complications and how to avoid them is likewise described in detail, along with post-surgical rehabilitation techniques to maximize return to play. Ideal for orthopedic surgeons and sports medicine specialists at all levels, The Management of Biceps Pathology will be a unique resource for all clinicians facing challenges treating the active patient with shoulder and elbow pain. Preface Contents Contributors Part I: Anatomy, Imaging and Function of the Biceps Tendon 1: Anatomy of the Biceps Tendon: From Origin to Insertion Introduction Proximal Biceps Tendon Inside Superior Glenoid Labrum Biceps Anchor Junction Intra-articular Long Head of the Biceps Tendon Biceps Pulley Bicipital Tunnel Zone 1 Zone 2 Zone 3 Vincula and Other Accessory Structures Neurovascular Anatomy Function Distal Biceps Tendon Structure and Function Zone 1: Pre-aponeurosis Zone 2: Aponeurosis or Lacertus Fibrosus Zone 3: Post-aponeurosis Vascular Supply Neurovascular Anatomy Conclusion References 2: How to Diagnose Biceps Tendon Pathology Introduction History Proximal Biceps Specific History Distal Biceps Specific History Physical Exam Proximal Biceps Physical Exam Distal Biceps Physical Exam Conclusion References 3: Imaging the Biceps Tendon at Both the Shoulder and Elbow: What to Look Out for Background Proximal Biceps Tendon and Biceps-Labral Complex (BLC) Anatomy Imaging MRI Technique Is It a SLAP or Normal Variant? Summary: Proximal Biceps Tendon “What to Look Out For” Biceps in Groove and Biceps Pulley Anatomy Classification of Biceps Pulley Lesions Imaging MRI Ultrasound Summary: Biceps in Groove “What to Look Out For” Subgroove and Mid-Biceps Tendon Distal Biceps Tendon Anatomy Distal Biceps Tendon Rupture and Classification Imaging MRI Ultrasound Summary: Distal Biceps Tendon “What to Look Out For” Postoperative BT Proximal Biceps Distal Biceps Summary References 4: Ultrasound and the Biceps Tendon: Diagnostic and Therapeutic Benefits Introduction Anatomy of the Biceps Brachii Basics of Musculoskeletal Sonography Sonographic Evaluation of the Biceps Brachii Proximal Attachment at the Superior Glenoid Upper Pole of Humeral Head Rotator Interval Bicipital Groove Distal Attachment at the Radial Tuberosity Diagnostic Sonography for Biceps Pathology Proximal Biceps Anchor Lesions Proximal Biceps Instability Proximal Biceps Tendinopathy Distal Biceps Tendinopathy Distal Biceps Tendon Rupture Ultrasound-Guided Treatments for Biceps Pathology Long Head of Biceps Peritendinous Injection Long Head of Biceps Percutaneous Tenotomy Distal Biceps Tendon Injection Conclusion References 5: Role of the Biceps Tendon as a Humeral Head Depressor Introduction Anatomy Biomechanical Characteristics of the LHBT LHBT as a Humeral Head Depressor Biomechanical Studies In Vivo Studies Conclusion References 6: The Role of the Biceps Tendon in the Overhead Athlete Introduction Anatomy Biomechanics Pathology History Examination Diagnostic Studies Nonoperative Treatment Surgical Treatment Author’s Preferred Surgical Technique Outcomes Complications References Part II: Proximal Biceps Tendon Conditions 7: Biceps Tendinopathy: Causes and Solutions to This Problem Introduction Anatomy Causes Pathophysiology Associated Pathology Diagnosis Imaging Nonsurgical Management Surgical Management Outcomes Conclusions References 8: Nonsurgical Management of Proximal Biceps Pathology Introduction Anatomy Pathology Clinical Presentation Musculoskeletal Ultrasound (MSK-US) Evaluation Illustrative Case Musculoskeletal Ultrasound (MSK-US)-Guided Injection Illustrative Case Magnetic Resonance Imaging Nonoperative Algorithm Non-steroidal Anti-inflammatory Drugs (NSAIDs) Physical Therapy Corticosteroid Injection Other Modalities Orthobiologic Injections Treatment Follow-Up Summary References 9: SLAP Tear Diagnosis and Management Introduction Anatomy Pathogenesis Classification Clinical Evaluation Imaging Treatment Nonsurgical Treatment Surgical Management Rehabilitation Outcomes Lessons Learned References 10: The Incarcerating Biceps Tendon Introduction LHBT Stabilizing Anatomy Clinical Presentation MRI Findings Arthroscopic Evaluation Medial Biceps Chondromalacia Surgical Management Conclusion References 11: Anterior Shoulder Pain in the Throwing Athlete: SLAP Repair vs. Biceps Tenodesis? Or Both Proximal Biceps–Labral Anatomy Mechanism of Injury in Throwing Athletes Clinical Presentation and Examination Diagnostic Imaging Arthroscopic Assessment Surgical Treatment Options SLAP Tear Repair Technique SLAP Repair Outcomes Primary Biceps Tenodesis Technique Primary Biceps Tenodesis in Overhead Throwing Athletes Implications of Biceps Tenodesis Clinical Outcomes of Biceps Tenodesis Complications Management of Failed SLAP Repair Author’s Preferred Surgical Technique References 12: Injuries to the Biceps Pulley Introduction Classification Clinical Findings Imaging Surgical Management Authors’ Preferred Technique for Biceps Tenodesis [28] Outcomes Subpectoral Biceps Tenodesis Summary References 13: Managing Biceps Pathology with Rotator Cuff Tears Introduction Anatomy and Function Diagnosis Management Nonoperative Operative Rehabilitation Outcomes Complications References 14: Managing Biceps/SLAP Pathology with Associated Shoulder Instability Introduction Anterior Glenohumeral Stability Superior Labral and Biceps Complex History Physical Examination Imaging Treatment Outcomes Conclusion References 15: Arthroscopic Versus Open Tenodesis: Which Patients Need Which? Introduction Anatomy of the Long Head of the Biceps Tendon Indications for Biceps Tenodesis Tendon Ruptures Tendon Instability SLAP Lesions Biceps Tendinitis Biceps Tenodesis Techniques Proximal (Arthroscopic) Fixation Distal (Open) Fixation Which Patients Need Arthroscopic Versus Open Tenodesis? Arthroscopic Biceps Tenodesis Advantages Disadvantages Which Patients to Consider for Arthroscopic Biceps Tenodesis Open Biceps Tenodesis Advantages Disadvantages Which Patients to Consider for Open Biceps Tenodesis Outcomes Following Arthroscopic Versus Open Biceps Tenodesis Conclusions References 16: Inlay Versus Onlay Fixation Methods for Proximal Biceps Tenodesis Introduction Arthroscopic vs. Open Techniques Onlay and Inlay Fixation Devices Outcomes Management Diagnosis and Nonoperative Management Operative Management Arthroscopic Evaluation Tenotomy Open Sub-pectoral Tenodesis General Approach Inlay Technique with Interference Screw Onlay Technique with Suture Anchor Arthroscopic Tenodesis Postoperative Rehabilitation Protocol Summary References 17: The Arthroscopic Subdeltoid Biceps Transfer to the Conjoint Tendon: A Different Perspective on Treatment Introduction Biceps Anatomy Pathophysiology Surgical Technique Arthroscopic Examination and Exposure in the Subdeltoid Space LHBT Preparation LHBT Transfer to the Conjoint Tendon Bicipital Tunnel Decompression Postoperative Management Pearls and Pitfalls Outcomes Advantages and Disadvantages Conclusion References 18: Complications Following Proximal Biceps Tenodesis Introduction Infection and Wound Complications Neurovascular Complications Hardware Complications Rare Complications Postoperative Outcomes Conclusions References 19: Post-operative Rehabilitation: Biceps Tenodesis Introduction Phase 1: Protective Phase (Weeks 0–2) Phase 2: Controlled Strength (Weeks 3–5) Phase 3: Advanced Strengthening (Weeks 6–11) Phase 4: Return to Participation (Weeks 12+) References Part III: Distal Biceps Tendon Conditions 20: Management of Partial-Thickness Distal Biceps Tears Introduction Anatomy Anatomical Variations Functional Anatomy and Biomechanics Supination of the Forearm Weak Flexion of the Elbow Dynamic Stability of the Glenohumeral Joint Clinical Evaluation Patient History and Common Injury Mechanism/Reporting Physical Exam of the Elbow Hook Test Bicipital Crease Interval Test Passive Forearm Pronation Test Advanced Imaging Techniques and Radiographs MRI Sequences Flexion Abduction Supination MRI Sonography Non-operative and Operative Management Conservative Treatment Conservative Protocol Complications Results and Outcomes Surgical Surgical Approach Single-Incision Technique Author’s Preferred Technique Dual-Incision Technique Results and Outcomes References 21: Complete Distal Biceps Ruptures Introduction Anatomy History and Physical Examination Imaging Treatment Surgical Approach Surgical Fixation Techniques Two-Incision Technique: Transosseous Tunnel Fixation (Fig. 21.6a, b) Single-Incision Techniques: Suture Anchor, Interference Screw, and/or Cortical Button Fixation (Figs. 21.7a, b, 21.8a, b, and 21.9a, b) Authors’ Preferred Technique and Rehabilitation Outcomes Complications Conclusion References 22: Methods of Fixation for Distal Biceps Repair: What Does the Evidence Show? Distal Biceps Anatomy Clinical Presentation and Workup Surgical Approach Single-Incision Approach Dual-Incision Approach Single- vs. Dual-Incision Technique Fixation Techniques Transosseous Suture Fixation Interference Screw Fixation Suture Anchor Fixation Suture Button Fixation Biomechanical Studies Clinical Outcome Studies Anatomic Considerations Author’s Preferred Technique for Repair of Acute Distal Biceps Rupture References 23: Chronic and Revision Distal Biceps Reconstruction Introduction Presentation Anatomy Nonoperative Treatment Operative Treatment Approach Direct Repair Grafts Fixation Techniques Graft Interposition for Chronic Tears Graft Interposition for Revision Reconstruction Clinical Outcomes Outcomes for Direct Repair Outcomes for Graft in Chronic Setting Outcomes for Graft in Revision Setting Postoperative Management Conclusion References 24: Complications of Distal Biceps Tendon Repair Background Operative Treatment Overall Complication Risk Timing of Surgical Intervention Single- vs. Two-Incision Complications Fixation-Specific Complications Minimizing Fixation-Specific Complications Neurologic Complications Lateral Antebrachial Cutaneous Nerve Posterior Interosseous Nerve Superficial Radial Nerve Median Nerve Ulnar Nerve Minimizing Neurologic Complications Heterotopic Ossification/Synostosis Minimizing Heterotopic Ossification Complications Rerupture Vascular Complications Wound Complications Fracture Conclusion References 25: Rehabilitation Following Distal Biceps Repair Literature Review Operative Technique for Distal Biceps Repair ASMI Technique Rehabilitation Program Phase I: Immediate Postoperative Phase (Weeks 1–2) Phase II: Early Controlled Mobility Phase (Weeks 3–6) Phase III: Late Controlled Mobility Phase (Weeks 7–12) Phase IV: Intermediate Phase (Weeks 12–16) Phase V: Advanced Strengthening Phase (Weeks 16–20) Phase VI: Return to Activity Phase (Week 20>) References Index