Lynne S. Steinbach, M.D. Professor of Radiology and Orthopaedic Surgery Department of Radiology University of California San Francisco
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1 The Long Head of the Biceps Tendon: Normal Anatomy and Pathology on MRI Lynne S. Steinbach, M.D. Professor of Radiology and Orthopaedic Surgery Department of Radiology University of California San Francisco
2 Biceps Muscles and Tendons Long Head Short Head Distal Tendon Bicipital Aponeurosis (Lacertus Fibrosis)
3 Long Head of the Biceps Tendon Anatomy Function Pathology Variants Treatment (LHBT)
4 Origin Superior labrum and/or supraglenoid tubercle Intracapsular, extrasynovial Extends laterally in the rotator interval which is composed of: Capsule Coracohumeral lig (CHL) Superior glenohumeral lig (SGHL) Supraspinatus(SS) Subscapularis (Subs)
5 Originates from the supraglenoid tubercle and superior labrum LHBT Origin
6 LHBT Intra-articular articular Portion from Anchor to Pulley Sagittal Plane
7 LHBT Intra-articular articular Portion from Anchor to Pulley Axial Plane
8 LHBT Origin Axial Plane Glenoid origin is variable between individuals Anterior origin Posterior origin
9 Normal LHBT, SGHL, CHL in Rotator Interval Axial Plane SGHL CHL B
10 Pulley is junction between intra- and extra-articular articular biceps Curves degrees into extra-articular articular groove Notice the Subs tendon extending over the pulley to the greater tuberosity
11 LHBT Pulley Surrounds biceps in rotator interval and proximal biceps groove Ligamentous sling Superficial-CHL Deep-SGHL Contributions from SS and Sub tendons called fasciculus obliquus Sagittal plane
12 LHBT Pulley Pulley Biceps Notice the split in the biceps Sagittal plane
13 LHBT Pulley Extra-articular articular BT lies in intertubercular sulcus between LT and GT Stabilized by pulley CHL superficial SGHL deep Pulley reinforced by Subs and SS tendon fibers Attach to LT and GT Subscapularis Axial plane SS
14 LHBT Synovial Reflection in Intertubercular Groove
15 LHBT Synovial Reflection in Intertubercular Groove
16 Humeral head depressor Stabilizer GHJ Posterior translation of flexed or abducted externally rotated shoulder Biceps is fixed between glenoid and humerus Superior excursion 4cm from flexion to extension LHBT Function
17 Occur with repetitive load and abrasive wear Less commonly acute Diagnosis and treatment of biceps injuries is a clinical challenge LHBT Sports Injuries
18 LHBT Pathology By Location Intra-capsular Origin Tendon and labral (SLAP) lesions Rotator interval Impingement (external and internal) Subluxation and dislocation Tendinosis Hourglass biceps Tears Extra-capsular Biceps groove Tenosynovitis Tendinosis Tears Most biceps tendon abnormalities are accompanied by other internal derangement
19 Causes of LHBT Dislocation and Subluxation Trauma and impingement (ASI) Forcefully stopped overhead throw Repetitive forceful internal rotation above the horizontal plane Fall Outstretched arm internal or external rotation Backward on hand or elbow Biceps groove anomalies and dysplasia Degeneration of biceps tendon Tears subscapularis and supraspinatus tendons
20 Anterior Superior Impingement Internal impingement caused by repetitive overhead motion Internal rotation and adduction Biceps instability and tears Anterior translation and superior migration humeral head Tears Pulley lesions SGHL and CHL SS and Subscap tendons Peter Habermeyer, J Shoulder and Elbow Surg 2004;13:5-12
21 Phases of Baseball Pitching Cocking Follow-through Phases of baseball pitching
22 Biceps in Throwing Athletes Phases of baseball pitching Vector forces on LHBT Cocking External rotation Medial force Follow-through Internal rotation Lateral force EMG activity increased with follow-through and shoulder instability
23 Biceps Subluxation & Dislocation Modified Habermayer Classification EXTRA-ARTICULAR ARTICULAR Subluxation I and II Dislocation III and IV INTRA-ARTICULAR ARTICULAR Dislocation V and VI Subscapularis SS
24 Type I Biceps Subluxation Subscapularis Tendon Tear with Intact Pulley Intact pulley Subscapularis tendon partial intrasubstance or anterior tear Medial biceps shift or minor subluxation Subscapularis SS
25 Type II Biceps Subluxation Medial Pulley Tear with Intact Subscap Tendon Subscapularis SS Biceps shift or subluxation more exaggerated than Type I
26 Isolated Pulley Lesion SGHL Tear/Biceps Tendinitis
27 partial subscap tear.jpg Type IIIA Extra-articular articular Biceps Dislocation Medial Pulley and Intrasubstance Subscapularis Tendon Tears ubscapularis SS
28 Type IIIB Extra-articular articular Biceps Dislocation Medial Pulley and Anterior Subscapularis Tendon Tears Subscapularis SS
29 Type IV Extra-articular articular Biceps Dislocation Lateral Pulley with Supraspinatus Tears SS Tear
30 Type V Intra-articular articular Biceps Dislocation Medial and Lateral Limbs of Pulley and Full Thickness Subscapularis Tendon Tears Subscapularis SS
31 Type VI Intra-articular articular Biceps Dislocation Medial Pulley and Subscap tendon Detachment from LT ubscapularis SS
32 Type VI Intra-articular articular Biceps Dislocation Medial Pulley and Subscap tendon Detachment from LT Armstrong A, et al. J Shoulder Elbow Surg 2006;15:7-11
33 Split Tear Biceps Tendon with Med Subluxation & Subscap Tear
34 LHBT Tendinosis
35 BT tendinosis just proximal to bicipital groove with tendon unable to slide into groove Inhibits passive and active elevation and causes pain Usually seen with RCT Hourglass Biceps psha O, et al., Eur J Radiol 2008;68:36-56 oileau P, et al. J Shoulder Elbow Surg 2004;13: *Chung C and Steinbach L., eds. MRI of the Upper Extremity. LWW, 2009
36 Hourglass Biceps Sagittal T2W Coronal T2W
37 Biceps Entrapment Hourglass Biceps
38 Partial Tear LHBT SS Tendon Tear SLAP Lesion
39 Partial Tears LHBT Partial tear biceps
40 Complete Tear LHBT Near Origin at Supraglenoid Tubercle in a Bodybuilder
41 Posterior Dislocation of LHBT with Posterior Incarceration
42 Incarcerated LHBT in GT Fx
43 Incarcerated Biceps in Greater Tuberosity Fracture
44 Extra-articular articular LHBT Primary Repetitive overhead movement in sports Secondary Rotator cuff tears and external impingement Tenosynovitis
45 Criteria for Extra-articular articular Biceps Fluid out of proportion to that in the joint Several bands in tendon sheath Tendon adherence to one side Tenosynovitis
46 Extra-articular articular Biceps Tendon Evaluation During Arthroscopy Extra-capsular portion not seen during arthroscopy Preoperative knowledge of pathology leads surgeon to probe the tendon Pulling on intracapsular tendon improves visualization of extra- capsular portion
47 Longitudinal Biceps Tear and Normal Variant in the Groove Partial Tear Normal variant-accessory Head
48 - Split Biceps Tendon? Copyright 2010 by the American Roentgen Ray Society
49 - Accessory Head of LHBT Prevalence of supernumerary head % More common in Asians Less common in Caucasians Gheno, R. et al. Am. J. Roentgenol. 2010;194:W80-W83 Copyright 2010 by the American Roentgen Ray Society
50 LHBT Variants Accessory heads 3-77 heads have been reported Congenital absence Intracapsular origin
51 - Accessory Head of LHBT Prevalence of supernumerary heads 9-22% More common in Asians Less common in Caucasians Gheno, R. et al. Am. J. Roentgenol. 2010;194:W80-W83 Copyright 2010 by the American Roentgen Ray Society
52 Osseous Body in Tendon Sheath Can Mimic Accessory Tendon
53 Congenital Absence of the LHBT Seven cases reported 4/7 associated with other anomalies including Spina bifida occulta Congenital inguinal hernia Right undescended testicle Insult in 6 th and 7 th week of gestation Underdeveloped biceps groove
54 Intracapsular Origin LHBT Incomplete differentiation of the joint capsule Biceps merges with capsule
55 Conservative Debridement Partial tears and tendinosis Tenodesis or tenotomy Large partial or full thickness tear or subluxation Repair of adjacent rotator cuff tear LHBT Pathology Treatment
56 Biceps Tenodesis
57 Injuries of the Long Head of the Biceps Tendon Biceps tendon disease is associated with overhead sports as well as rotator cuff disease and SLAP lesions The pulley, supraspinatus and subscapularis tendons are often abnormal with displacement and tears of the biceps tendon Intra-articular articular tendinosis is common Extra-articular articular biceps abnormalities as well as normal variants are well seen with MR and US
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