An expert roundtable moderated by Jeffrey S. Abrams, MD
The biceps continues to be a “pain generator” for many shoulders, and a variety of techniques are used to address anterior shoulder pain that is often combined with other pathology. Jeffrey S. Abrams, MD, asked a group of international experts—including Richard K. N. Ryu, MD; Nikhil N. Verma, MD; and Gilles Walch, MD—how they would evaluate and treat patients with ailments that are commonly seen in an orthopaedic practice.
A worker’s comp case
Dr. Abrams: Let’s start with a 53-year-old man, who was referred with anterolateral shoulder pain 2 months following a worker’s compensation injury. The physical exam finds loss of active and passive movement, and the patient reports that a steroid injection and physical therapy haven’t helped. An arthroscopic evaluation finds articular changes indicating inflammation, but no tears (Fig. 1). What physical or arthroscopic findings would direct further surgical treatment?
Dr. Ryu: The difficulty in this case is the worker’s compensation status and its influence on shoulder pain and treatment outcomes. I would caution against aggressive treatment of any shoulder disorder without fairly conclusive evidence that the pathology warrants an intervention.
The diagnosis by history is most consistent with an adhesive capsulitis. Pain that localizes to the bicipital groove suggests possible biceps involvement. Selective injections in the subacromial space and the bicipital groove would be helpful although not conclusive.
I would also recommend that the proximal biceps be pulled into the joint on every shoulder arthroscopy to evaluate the biceps component within the groove and to rule out any hidden lesions. If physical and imaging findings confirm a biceps component in addition to the adhesive capsulitis and conservative measures continue to be ineffective, a tenodesis could be combined with a capsular release, or the procedures could be staged to maximize early shoulder range of motion.
Dr. Verma: Anterior shoulder pain is much like anterior knee pain in that many overlapping diagnoses are possible. This appears to be most consistent with a post-traumatic capsulitis. During arthroscopy, motion loss associated with diffuse capsulitis is often accompanied by biceps tenosynovitis. In this situation, I do not routinely release the biceps and have found a minimal incidence of persistent biceps pain once motion has recovered.
Arthroscopic findings that may influence my decision to perform a biceps procedure include compromise of the biceps anchor or bicipital groove restraints or a partial tear. It is critical to use a probe to displace the biceps into the joint and evaluate as much of the groove portion of the tendon as possible.
An overhead athlete
Dr. Abrams: What about a 35-year-old overhead athlete with anterior shoulder pain? If arthroscopy confirms a superior labral tear and partial articular rotator cuff scuffing (Fig. 2), what treatment would you suggest?
Dr. Walch: In this age group, I would first consider treating the cuff problem with débridement or, if the cuff lesion is significant based on MRI, with repair and biceps tenodesis. I would not repair the superior labrum anterior-posterior (SLAP) lesion in this age group. I would be more aggressive in treating any internal impingement pathology of the glenoid—by débridement of the posterior bone spurring in a younger athlete.
Dr. Ryu: In this case, internal impingement precipitated by a glenohumeral internal rotation deficit is the most likely pathology. Evaluating internal rotation loss with the sleeper stretch exercise compared with the contralateral side is imperative. If a loss is present and unresponsive to stretching, I’d perform a posterior capsular release.
Dr. Verma: Like Dr. Walch, I would have significant reservations about performing primary SLAP repair in this patient for two reasons: age and labral degeneration. In our experience, age is associated with higher failure rates, and labral degeneration may compromise healing. My preference would be a subpectoral biceps tenodesis with interference screw fixation combined with arthroscopic labral débridement. In revision situations, I prefer biceps tenodesis for patients with persistent pain following primary SLAP repair.
Tenotomy or tenodesis?
Dr. Abrams: What would you say to this 58-year-old man with shoulder pain (Fig. 3A,B)? Would the best treatment be biceps tenotomy or biceps tenodesis?
Dr. Ryu: The images suggest biceps disease that begins proximally and extends into the bicipital groove, with significant inflammatory fluid within the sheath. If this pathology is isolated, and the patient is a low-demand individual who is overweight and fleshy, a biceps tenotomy would be reasonable. In a higher-functioning individual with cosmesis concerns, a tenodesis above or below the bicipital groove would be appropriate, with the decision predicated on disease within the groove and physical findings.
Dr. Walch: The status of the rotator cuff is important. In the case of cuff tear, I would repair the cuff and treat the biceps according to the patient’s age. If the patient is younger than 60 years of age, I perform a tenodesis; older than 60, my choice would be tenotomy.
Dr. Verma: Again, we are in agreement—tenodesis in younger, active patients, particularly those who would be unsatisfied with a cosmetic deformity, and tenotomy for older, more sedentary patients with low risk for fatigue discomfort and for patients tolerant of cosmetic asymmetry.
The professional athlete
Dr. Abrams: In a professional athlete with a small rotator cuff tear (Fig. 4), which technique for biceps tenodesis would you choose? When would you begin resistive exercises in therapy? When would you allow a return to collision sports?
Dr. Verma: My preference is a subpectoral approach with fixation using an interference screw technique, which offers the strongest biomechanical fixation for both construct stiffness and ultimate load to failure. I would initiate resistive exercises in therapy at 8 weeks postoperatively and allow unrestricted return to sports, including contact sports, at 12 weeks.
Dr. Ryu: I would perform an arthroscopic cuff repair, watching for associated pathologies. I would treat biceps disease with a suture anchor tenodesis above or below the bicipital groove, depending on the extent of the biceps involvement. An arthroscopic suprapectoral tenodesis would be an alternative if groove involvement is noted and intervention is limited to an all-arthroscopic approach.
Rehabilitation for the biceps tenodesis would be subservient to the rotator cuff repair protocol. Resistance training begins at 3 months postoperatively, with a return to full participation at 6 months in most cases.
Dr. Walch: In this age group, I prefer tenodesis to the pectoralis major tendon, combined with repair of the rotator cuff tear. Resistive exercise can begin at 3 months. I would anticipate return to throwing in 6 months.
Going “below” the groove
Dr. Abrams: What if you have a patient with painful range of motion and you find tenderness along the anterior biceps groove? Would this alter your surgical evaluation or treatment? When is it necessary to tenodese “below” the groove?
Dr. Ryu: Tenderness along the bicipital groove suggests that the pathology extends beyond the intra-articular component. If arthroscopic treatment is planned, the biceps must be carefully inspected, including the portion within the groove. If disease does extend into the groove, tenodesis below the groove would be preferable to proximal treatment.
Dr.Walch: I am not influenced by tenderness in the groove. In throwing athletes, I prefer to perform a subpectoral tenodesis and not violate the subacromial space.
Dr. Verma: The extra-articular portion of the biceps may commonly be involved in pathologic disease states and may be a potential cause of anterior shoulder pain. If the clinical exam indicates biceps symptoms, my preference is to perform a biceps tenotomy or tenodesis even if the intra-articular portion of the tendon appears normal at the time of arthroscopy.
I prefer to perform a distal tenodesis in all patients, eliminating the biceps as a potential source for any residual anterior shoulder pain.
The “Popeye” bulge
Dr. Abrams: A 62-year-old builder underwent partial-thickness cuff débridement and biceps tenodesis. Six months after surgery deformity and shoulder pain developed (Fig. 5). How would you evaluate and treat?
Dr. Walch: First, I would consider the repair of the rotator cuff tear. Regarding the bump in the arm, I would perform an open tenodesis for patients with severe cramping or a major cosmetic concern.
Dr. Verma: What exactly are the patient’s complaints? If the pain is located proximally around the shoulder or lateral deltoid, it’s more likely from glenohumeral or rotator cuff pathology. If the patient is experiencing muscle cramping or fatigue discomfort, or is unhappy with the cosmetic appearance, I would recommend surgical resuspension of the tendon.
Dr. Ryu: If clinical examination suggests a rotator cuff tear, I’d advise further diagnostic testing. A subpectoral tenodesis would address cosmetic and functional concerns. In most cases, however, benign neglect and counseling on the “Popeye” deformity and occasional cramping with vigorous activities is appropriate.
The weight lifter
Dr. Abrams: A 50-year-old weight lifter who had a rotator cuff repair a year ago and returned to physical activities now complains of anterior pain with biceps radiation (Fig. 6). During the initial surgery, the biceps appeared normal. How would you treat?
Dr. Ryu: I’d have a frank discussion about expectations. The appearance of a high-grade partial biceps tear so quickly should raise the issue of a missed or escalating subscapularis tear. I would also carefully evaluate the subacromial space for potential recurrent or persistent spurring and mechanical impingement. This individual is a prime candidate for a biceps tenodesis, above or below the groove, depending on the extent of the disease.
Dr. Walch: I would check the cuff with an MRI to confirm healing. If the repair failed, I would perform another repair combined with biceps tenodesis. If it healed, I would perform a tenodesis of the biceps.
Dr. Verma: Anterior pain with radiation into the biceps has been a strong predictor of long head biceps pathology. If the diagnosis is unclear, an ultrasound-guided injection of local anesthetic into the biceps tendon sheath can help establish the diagnosis and potentially initiate treatment.
For persistent symptoms, I would recommend shoulder arthroscopy with biceps tenodesis. For a weight lifter, tenodesis is better than tenotomy for cosmetic appearance, avoidance of fatigue or cramping biceps pain, and maintenance of the normal length-tension relationship of the muscle.
Jeffrey S. Abrams, MD, is a shoulder and sports medicine specialist in Princeton, N.J. He can be reached at firstname.lastname@example.org
Participants report the following disclosures:
Dr. Abrams: CONMED Linvatec; Arthrocare; Mitek; Wright Medical Technology, Inc.; Cayenne Medical; KFxMedical; Ingen Medical; Springer; Orthopaedic Learning Center Board of Directors; Arthroscopy Association of North America (AANA) Continuing Education Committee, American Shoulder and Elbow Surgeons (ASES)
Dr. Ryu: Miteck; medbridge; AANA; Sport Medicine and Arthroscopy Review
Dr. Verma: Arthroscopy Journal of Knee Surgery Vindico Medical; Smith & Nephew; DJ Orthopaedics; Arthrex, Inc.; Ossure; Omeros
Dr. Walch: Société Française de Chirurgie Orthopédique; European Society of Shoulder and Elbow Surgery; Société Française d'Arthroscopie; ASES corresponding member; Journal of Shoulder and Elbow Surgery; Tornier