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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
-
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
-
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
-
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