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The Long Head of the Biceps The Long Head of the Biceps Tendon:Tendon:Normal Anatomy and Normal Anatomy and Pathology on MRIPathology on MRI

Lynne S. Steinbach, M.D.

Professor of Radiology and Orthopaedic SurgeryDepartment of RadiologyUniversity of California San Francisco

Bicipital Aponeurosis(Lacertus Fibrosis)

Biceps Muscles and Tendons

Long Head Short Head

Distal Tendon

Long Head of the Biceps TendonLong Head of the Biceps Tendon(LHBT)(LHBT)

•• AnatomyAnatomy•• FunctionFunction•• Pathology Pathology •• VariantsVariants•• TreatmentTreatment

•• OriginOrigin–– Superior labrum and/or Superior labrum and/or

supraglenoid tuberclesupraglenoid tubercle

•• Intracapsular, extrasynovialIntracapsular, extrasynovial•• Extends laterally in the Extends laterally in the

rotator interval which is rotator interval which is composed of:composed of:–– CapsuleCapsule–– Coracohumeral lig (CHL)Coracohumeral lig (CHL)–– Superior glenohumeral lig Superior glenohumeral lig

(SGHL)(SGHL)–– Supraspinatus(SS)Supraspinatus(SS)–– Subscapularis (Subs)Subscapularis (Subs)

LHBTLHBTOriginOrigin

•• Originates from the Originates from the supraglenoid tubercle supraglenoid tubercle and superior labrumand superior labrum

LHBT IntraLHBT Intra--articulararticular Portion from Portion from Anchor to PulleyAnchor to Pulley

SagittalSagittal PlanePlane

LHBT IntraLHBT Intra--articulararticular Portion from Portion from Anchor to PulleyAnchor to Pulley

Axial PlaneAxial Plane

LHBT OriginLHBT OriginAxial PlaneAxial Plane

•• Glenoid origin is variable between individualsGlenoid origin is variable between individuals

Anterior origin Posterior origin

Normal LHBT, SGHL, CHL in Normal LHBT, SGHL, CHL in Rotator IntervalRotator Interval

Axial PlaneAxial Plane

B

SGH

L CHL

•• Pulley is junction Pulley is junction between intrabetween intra-- and and extraextra--articulararticular bicepsbiceps

•• Curves 30Curves 30--45 degrees 45 degrees into extrainto extra--articulararticulargroovegroove

•• Notice the Subs tendon Notice the Subs tendon extending over the extending over the pulley to the greater pulley to the greater tuberositytuberosity

LHBTLHBTPulleyPulley

•• Surrounds biceps in Surrounds biceps in rotator interval and rotator interval and proximal biceps grooveproximal biceps groove

•• Ligamentous slingLigamentous sling–– SuperficialSuperficial--CHLCHL–– DeepDeep--SGHLSGHL

•• Contributions from SS Contributions from SS and Sub tendons called and Sub tendons called fasciculus obliquusfasciculus obliquus

Sagittal plane

LHBTLHBTPulleyPulley

Sagittal plane

BicepsPulley

Notice the split in the biceps

LHBTLHBTPulleyPulley

•• ExtraExtra--articular BT lies articular BT lies in intertubercular sulcus in intertubercular sulcus between LT and GTbetween LT and GT

•• Stabilized by pulleyStabilized by pulley–– CHL superficialCHL superficial–– SGHL deepSGHL deep

•• Pulley reinforced by Pulley reinforced by Subs and SS tendon Subs and SS tendon fibersfibers–– Attach to LT and GTAttach to LT and GT

Axial plane

SubscapularisSS

LHBTLHBTSynovial Reflection in Synovial Reflection in

IntertubercularIntertubercular Groove Groove

LHBTLHBTSynovial Reflection in Synovial Reflection in

IntertubercularIntertubercular Groove Groove

LHBTLHBTFunctionFunction

•• Humeral head Humeral head depressordepressor

•• Stabilizer GHJStabilizer GHJ–– Posterior translation of Posterior translation of

flexed or abducted flexed or abducted externally rotated externally rotated shouldershoulder

•• Biceps is fixed between Biceps is fixed between glenoid and humerus glenoid and humerus –– Superior excursion 4cm Superior excursion 4cm

from flexion to extensionfrom flexion to extension

LHBTLHBTSports InjuriesSports Injuries

•• Occur with repetitive Occur with repetitive load and abrasive wearload and abrasive wear

•• Less commonly acuteLess commonly acute•• Diagnosis and Diagnosis and

treatment of biceps treatment of biceps injuries is a clinical injuries is a clinical challengechallenge

LHBTLHBTPathology By LocationPathology By Location

•• IntraIntra--capsularcapsular–– OriginOrigin

•• Tendon and labral (SLAP) lesionsTendon and labral (SLAP) lesions–– Rotator intervalRotator interval

•• Impingement (external and internal)Impingement (external and internal)•• Subluxation and dislocationSubluxation and dislocation•• TendinosisTendinosis

–– Hourglass bicepsHourglass biceps•• TearsTears

•• ExtraExtra--capsularcapsular–– Biceps grooveBiceps groove

•• TenosynovitisTenosynovitis•• TendinosisTendinosis•• TearsTears

Most biceps tendon abnormalities are accompanied by other internal derangement

•• Trauma and impingement (ASI)Trauma and impingement (ASI)–– Forcefully stopped overhead throwForcefully stopped overhead throw–– Repetitive forceful internal rotation above the Repetitive forceful internal rotation above the

horizontal planehorizontal plane–– Fall Fall

•• Outstretched arm internal or external rotationOutstretched arm internal or external rotation•• Backward on hand or elbowBackward on hand or elbow

•• Biceps groove anomalies and dysplasiaBiceps groove anomalies and dysplasia•• Degeneration of biceps tendonDegeneration of biceps tendon•• Tears subscapularis and supraspinatus tendonsTears subscapularis and supraspinatus tendons

Causes of LHBT Dislocation and Causes of LHBT Dislocation and SubluxationSubluxation

Anterior Superior ImpingementAnterior Superior Impingement• Internal impingement caused

by repetitive overhead motion• Internal rotation and adduction•• Biceps instability and tearsBiceps instability and tears•• Anterior translation and Anterior translation and

superior migration humeral superior migration humeral headhead

• Tears – Pulley lesions SGHL and

CHL– SS and Subscap tendons Peter Habermeyer, J Shoulder and Elbow Surg

2004;13:5-12

Phases of Baseball PitchingPhases of Baseball Pitching

Phases of baseball pitching

Cocking

Follow-through

Biceps in Throwing AthletesBiceps in Throwing Athletes•• Vector forces on LHBTVector forces on LHBT

–– CockingCocking•• External rotationExternal rotation•• Medial forceMedial force

–– FollowFollow--throughthrough•• Internal rotationInternal rotation•• Lateral forceLateral force

•• EMG activity increased EMG activity increased with followwith follow--through and through and shoulder instability shoulder instability

Phases of baseball pitching

Biceps Subluxation & DislocationBiceps Subluxation & DislocationModified Habermayer ClassificationModified Habermayer Classification

•• EXTRAEXTRA--ARTICULARARTICULAR–– SubluxationSubluxation

•• I and III and II–– DislocationDislocation

•• III and IVIII and IV•• INTRAINTRA--ARTICULARARTICULAR

–– DislocationDislocation•• V and VIV and VI

Subscapularis

SS

Type I Type I Biceps SubluxationBiceps Subluxation

Subscapularis Tendon Tear with Intact PulleySubscapularis Tendon Tear with Intact Pulley

•• Intact pulleyIntact pulley•• Subscapularis tendon Subscapularis tendon

partial intrasubstance partial intrasubstance or anterior tearor anterior tear

•• Medial biceps shift or Medial biceps shift or minor subluxationminor subluxation

Subscapularis

SS

Type II Type II Biceps SubluxationBiceps Subluxation

Medial Pulley Tear with Intact Subscap Medial Pulley Tear with Intact Subscap TendonTendon

Biceps shift or subluxation more exaggerated than Type I

Subscapularis

SS

Isolated Pulley LesionIsolated Pulley LesionSGHL Tear/Biceps TendinitisSGHL Tear/Biceps Tendinitis

Type IIIA Type IIIA ExtraExtra--articular Biceps Dislocationarticular Biceps Dislocation

Medial Pulley and Intrasubstance Medial Pulley and Intrasubstance Subscapularis Tendon TearsSubscapularis Tendon Tears

SubscapularisSS

partial subscap tear.jpg

Type IIIB Type IIIB ExtraExtra--articular Biceps Dislocationarticular Biceps Dislocation

Medial Pulley and Anterior Subscapularis Medial Pulley and Anterior Subscapularis Tendon TearsTendon Tears

Subscapularis SS

Type IV Type IV ExtraExtra--articular Biceps Dislocationarticular Biceps Dislocation

Lateral Pulley with Supraspinatus TearsLateral Pulley with Supraspinatus Tears

SSTear

Type V Type V IntraIntra--articulararticular Biceps DislocationBiceps DislocationMedial and Lateral Limbs of Pulley and Full Medial and Lateral Limbs of Pulley and Full

Thickness Thickness SubscapularisSubscapularis Tendon TearsTendon Tears

Subscapularis

SS

Type VI Type VI IntraIntra--articular Biceps Dislocationarticular Biceps Dislocation

Medial Pulley and Subscap tendon Medial Pulley and Subscap tendon Detachment from LTDetachment from LT

Subscapularis SS

Type VI Type VI IntraIntra--articular Biceps Dislocationarticular Biceps Dislocation

Medial Pulley and Subscap tendon Medial Pulley and Subscap tendon Detachment from LTDetachment from LT

Armstrong A, et al. J Shoulder Elbow Surg 2006;15:7-11

Split Tear Biceps Tendon with Split Tear Biceps Tendon with Med Subluxation & Subscap TearMed Subluxation & Subscap Tear

LHBT TendinosisLHBT Tendinosis

Hourglass BicepsHourglass Biceps•• BT tendinosis just BT tendinosis just

proximal to bicipital proximal to bicipital groove with tendon groove with tendon unable to slide into unable to slide into groovegroove

•• Inhibits passive and Inhibits passive and active elevation and active elevation and causes paincauses pain

•• Usually seen with RCTUsually seen with RCT

Opsha O, et al., Eur J Radiol 2008;68:36-56Boileau P, et al. J Shoulder Elbow Surg 2004;13:249-257

*Chung C and Steinbach L., eds. MRI of the Upper Extremity. LWW, 2009

Hourglass BicepsHourglass Biceps

Sagittal T2W Coronal T2W

Biceps Entrapment Biceps Entrapment ““Hourglass BicepsHourglass Biceps””

Partial Tear LHBTPartial Tear LHBTSS Tendon Tear SS Tendon Tear

SLAP LesionSLAP Lesion

Partial Tears LHBTPartial Tears LHBT

Partial tear biceps

Complete Tear LHBT Near Complete Tear LHBT Near Origin at Supraglenoid Tubercle Origin at Supraglenoid Tubercle

in a Bodybuilderin a Bodybuilder

Posterior Dislocation of LHBT Posterior Dislocation of LHBT with Posterior Incarcerationwith Posterior Incarceration

Incarcerated LHBT in GT FxIncarcerated LHBT in GT Fx

Incarcerated Biceps in Greater Incarcerated Biceps in Greater Tuberosity FractureTuberosity Fracture

ExtraExtra--articulararticular LHBTLHBTTenosynovitisTenosynovitis

•• PrimaryPrimary–– Repetitive overhead Repetitive overhead

movement in sportsmovement in sports•• SecondarySecondary

–– Rotator cuff tears Rotator cuff tears and external and external impingementimpingement

Criteria for ExtraCriteria for Extra--articular Biceps articular Biceps TenosynovitisTenosynovitis

•• Fluid out of proportion Fluid out of proportion to that in the jointto that in the joint

•• Several bands in Several bands in tendon sheathtendon sheath

•• Tendon adherence to Tendon adherence to one sideone side

ExtraExtra--articular Biceps Tendon articular Biceps Tendon Evaluation During ArthroscopyEvaluation During Arthroscopy

•• ExtraExtra--capsular portion not capsular portion not seen during arthroscopyseen during arthroscopy

•• Preoperative knowledge of Preoperative knowledge of pathology leads surgeon to pathology leads surgeon to probe the tendonprobe the tendon–– Pulling on intracapsular Pulling on intracapsular

tendon improves tendon improves visualization of extravisualization of extra--capsular portioncapsular portion

Longitudinal Biceps Tear and Longitudinal Biceps Tear and Normal Variant in the GrooveNormal Variant in the Groove

Partial Tear Normal variant-Accessory Head

Copyright © 2010 by the American Roentgen Ray Society

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Split Biceps Tendon?Split Biceps Tendon?

Copyright © 2010 by the American Roentgen Ray Society

Gheno, R. et al. Am. J. Roentgenol. 2010;194:W80-W83

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Accessory Head of LHBTAccessory Head of LHBT

•• Prevalence of Prevalence of supernumerary head 9supernumerary head 9--22%22%

•• More common in More common in AsiansAsians

•• Less common in Less common in CaucasiansCaucasians

LHBT VariantsLHBT Variants

•• Accessory headsAccessory heads–– 33--7 heads have been reported7 heads have been reported

•• Congenital absenceCongenital absence

•• IntracapsularIntracapsular originorigin

Copyright © 2010 by the American Roentgen Ray Society

Gheno, R. et al. Am. J. Roentgenol. 2010;194:W80-W83

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Accessory Head of LHBTAccessory Head of LHBT

•• Prevalence of Prevalence of supernumerary heads supernumerary heads 99--22%22%

•• More common in More common in AsiansAsians

•• Less common in Less common in CaucasiansCaucasians

Osseous Body in Tendon SheathOsseous Body in Tendon SheathCan Mimic Accessory TendonCan Mimic Accessory Tendon

Congenital Absence of the LHBTCongenital Absence of the LHBT

•• Seven cases reportedSeven cases reported–– 4/7 associated with 4/7 associated with

other anomalies other anomalies includingincluding

•• SpinaSpina bifida bifida occultaocculta•• Congenital inguinal herniaCongenital inguinal hernia•• Right Right undescendedundescended

testicletesticle

•• Insult in 6Insult in 6thth and 7and 7thth

week of gestationweek of gestation•• Underdeveloped biceps Underdeveloped biceps

groovegroove

IntracapsularIntracapsular Origin LHBTOrigin LHBT

•• Incomplete Incomplete differentiation of differentiation of the joint capsulethe joint capsule

•• Biceps merges Biceps merges with capsulewith capsule

LHBT PathologyLHBT PathologyTreatmentTreatment

•• ConservativeConservative•• Debridement Debridement

–– Partial tears and Partial tears and tendinosistendinosis

•• Tenodesis or tenotomyTenodesis or tenotomy–– Large partial or full Large partial or full

thickness tear or thickness tear or subluxationsubluxation

•• Repair of adjacent Repair of adjacent rotator cuff tearrotator cuff tear

Biceps TenodesisBiceps Tenodesis

Injuries of the Long Head of the Injuries of the Long Head of the Biceps TendonBiceps Tendon

•• Biceps tendon disease is associated with overhead Biceps tendon disease is associated with overhead sports as well as rotator cuff disease and SLAP sports as well as rotator cuff disease and SLAP lesionslesions

•• The pulley, supraspinatus and subscapularis The pulley, supraspinatus and subscapularis tendons are often abnormal with displacement and tendons are often abnormal with displacement and tears of the biceps tendontears of the biceps tendon

•• IntraIntra--articular tendinosis is common articular tendinosis is common •• ExtraExtra--articular biceps abnormalities as well as articular biceps abnormalities as well as

normal variants are well seen with MR and USnormal variants are well seen with MR and US