The Long Head of the Biceps Tendon Has Minimal Effect on In Vivo Glenohumeral Kinematics

Authors:

J Erik Giphart, Florian Elser, Christopher B Dewing, Michael R Torry, Peter J Millett

Abstract:

The in vivo stabilizing role of the long head of the biceps tendon (LHB) is poorly understood. However, its role as a pain generator in the shoulder was described in 1948 by Hitchcock and Bechtol, who were also among the first to advocate biceps tenodesis. Tenodesis or tenotomy of the LHB has been reported to be an effective pain-relieving treatment option for recalcitrant biceps tendinitis and tendinopathy with low complication rates. However, the LHB has been reported in several in vitro studies to have the mechanical ability to stabilize the glenohumeral joint. Therefore, tenodesis or tenotomy could theoretically alter glenohumeral joint kinematics, creating a subsequent concern for potential pathological changes in patients after these procedures. These concerns have sparked significant debate about the best indications for biceps tenodesis or tenotomy and for which patient populations the procedure is suitable. Moreover, the importance of investigating the stabilizing role of the LHB in vivo is emphasized by these debates.

Evidence of the ability of the LHB to constrain glenohumeral motion is based primarily on cadaveric studies, which reported that the LHB has stabilizing effects on the glenohumeral joint anteriorly, posteriorly, superiorly, and inferiorly, suggesting concavity compression as its primary mechanism for providing glenohumeral stability. Others have suggested a pivotal role of the LHB in preventing superior humeral head migration. In vitro biomechanical investigations have also reported that the LHB significantly constrains rotational range of motion. Overall, cadaveric models have suggested that without the stabilizing presence of the LHB, increased glenohumeral translations of between 5 and 25 mm can occur in the superior-inferior and anterior-posterior planes.

To date, however, translations of this magnitude have not been demonstrated in vivo. In the shoulders of patients with isolated ruptures of the LHB, when compared with their contralateral healthy shoulders, average superior position differences of the humeral head of 2.2 mm (maxi- mum difference of 6 mm) at 45°, 90°, and 120° of abduction were measured by Warner and McMahon using serial, static radiographs. The authors theorized this amount of superior translation could contribute to an iatrogenic impingement syndrome. However, in the clinical literature, the stabilizing role of the LHB has not been as evident. For instance, the distance between the acromion and the humeral head in static radiographs was not altered after tenotomy. Similarly, Boileau et al4 have further questioned the stabilizing role of the LHB, showing no clinical evidence of instability or proximal humeral migration in patients who were treated with tenodesis compared with those treated by superior labral anterior posterior (SLAP) repair. Moreover, significantly more patients were able to return to their previous level of sports participation when compared with SLAP repair in this study.

Clearly, surgeons still face a confusing and contradictory body of evidence surrounding the biomechanical function of the LHB. While cadaveric studies show a stabilizing effect of the LHB, clinical data suggest that there is no clinically demonstrable increased humeral head motion after LHB tenodesis or tenotomy. Therefore, the purpose of this study was to investigate the effects of the LHB on glenohumeral kinematics in vivo using highly sensitive and accurate 3-dimensional imaging. To do this, we used a biplane fluoroscopy system to compare shoulders in patients who had undergone an isolated LHB tenodesis with their healthy contralateral shoulder during abduction, a simulated late cocking phase of a throw, and a simulated lifting task (loaded forward flexion). Our hypothesis was that there would be no differences in glenohumeral translations greater than 1.0 mm between the shoulders.

For the complete study: The Long Head of the Biceps Tendon Has Minimal Effect on In Vivo Glenohumeral Kinematics

Peter Millett, MD

Average rating:

39 reviews

Alexandra Thompson

Mar 23, 2024

by Alexandra Thompson on Peter Millett, MD

110%

Dr. Millett and his team did a SLAP tear repair and bicep tenodesis on my left shoulder. I use my arms as an artist, and love to swim in the ocean, surf, paddle, and telemark ski. So regaining full use of my shoulder and keeping my bicep attached was very important to me. Now, over two years later, my shoulder has the equivalent range of motion as my other arm and as before the injury, and no pain. After the first three months it felt so good and was so strong that - to my horror - I completely forgot my six-month follow-up.

Not only did Dr. Millett and his team make my arm as good as new, but having had the experience of such kindness and expertise throughout the process of surgery and recovery is like an added shoulder superpower.

Thank you Rita, Brooke, Jason, Sarah, Camille, Olivia, Dr. Millett and everyone! And see you soon when my husband comes in for his knee...

Jeff Chandler

Jan 31, 2022

by Jeff Chandler on Peter Millett, MD

Flawless procedure, Easy recovery

Dr. Millet's repaired my knee and tibia, following a botched operation by a different surgeon. That procedure was virtually pain free and I was weight bearing within a few days. That was 18 years ago and the knee is still strong. A few years after the knee incident, Dr Millet repaired my shoulder. My insurance company approved me for 3 months of disability following that surgery. I was off pain medication in 2 days and had 90% range of motion within a week. I withdrew my disability claim and returned to work within two weeks of surgery. I’m not a famous athlete—just a regular guy. Nonetheless, I was treated like an NFL at the Steadman clinic. Most notable was the time for recovery. Other surgeons perform their hour-long task in the OR and don’t involve themselves in the other functions. Peter and his team manages the entire process from diagnosis, anesthesia, nursing care, and therapy. He takes a holistic approach to patient care and doesn’t skip any steps.

Jenn West

Jul 2, 2021

by Jenn West on Peter Millett, MD

Saved My Life

I went to Dr. Millett after 7 knee surgeries (6 on my right and 1 on my left) and had seen 11 different surgeons who all refused to remove femur metal from my right leg. I am highly allergic to metal and the chronic pain was leaving me bedridden for 3.5wks out of a month. He personally wrote me back on my inquiry, listened to my concerns, scheduled my surgery within a week (due to insurance issues) and personally followed up with my recovery. The level of patient care from Dr. Millett and his ENTIRE team is above any care I have ever received in my 20 years of dealing with orthopedic surgeons. There are not enough words to describe the level of care, dedication and professionalism you receive from Dr. Millett and his staff.
My only disappointment is that I did not find him sooner!!!

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