Descriptive Analysis of the Long Head of the Biceps Abnormalities in Distal Isolated Supraspinatus Tears Based on Video Records: A Study From the SFA Biceps Study Group Using the “Biceps Box” Concept

Abstract

Background:

Considering the long head of biceps (LHB) management, important cultural differences exist among the surgeons around the world, especially when repairing small isolated distal supraspinatus tears under arthroscopy. In the perspective of an international survey to analyze our practice regarding biceps management in small rotator cuff tears, the aim is to collect all the possible LHB abnormalities according to literature review, before considering that the LHB could be normal or pathologic.

Indications:

The SFA (Société Francophone d’Arthroscopie) behind its research biceps group summarized these abnormalities in a description analysis called the “biceps box” concept, which was validated with a strong inter-rater reliability. The aim is to present the description analysis using a common language with short video records for each abnormality described to reproduce “intraoperatively” the different possible scenarios the surgeon has to encounter during arthroscopic evaluation.

Technique Description:

The description of the “biceps box” concept classifies lesions of the LHB, with so-called intrinsic lesions, for which the LHB should be considered pathological: partial rupture or delamination, fissuring, lateral or medial instability or subluxation, hypertrophy with an hourglass figure; and so-called extrinsic lesions, for which the LHB should be considered healthy: damage to the pulley without bicipital instability, exposure of the articular portion of the biceps by rupture of the supraspinatus tendon, inflammation of the superficial surface of the tendon, presence of type 1 or 2 superior labral anterior to posterior (SLAP) lesions, or a chondral print.

Results:

We present the 10 possible scenarios with video records according to our description analysis.

Discussion/Conclusion:

The LHB could be considered as a pain generator in certain situations which are still not completely clear. The indication of biceps tenotomy or tenodesis depends on the interpretation of the surgeon of these abnormalities as a pathologic or a normal condition. The next step is to use these videos in an international survey to assess cultural differences regarding the management and eventually find a consensus regarding treatment options for each abnormality.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

In December 2022, during the annual meeting in Toulouse of the SFA (Société Francophone d’Arthroscopie), we had a symposium to deal with the question “Is the long head of the biceps to be preserved in grade 1 isolated tears of the supraspinatus.” A SFA biceps study group was constituted under the direction of Prof Julien Berhouet and Dr Christophe Charousset.

In the perspective of an international survey to analyze our practice regarding long head of the biceps (LHB) management in small rotator cuff tears, the aim is first to collect all the possible LHB abnormalities according to literature review, before considering that any description of abnormalities of the LHB could be normal or pathologic.

Regarding the disclosure, the study is sponsored by the SFA.

The Biceps study group of SFA has no conflict of interest regarding this topic.

Considering the LHB management, important cultural differences exist among the surgeons around the world, especially when repairing small isolated distal supraspinatus tears under arthroscopy. The French are worldly well known as biceps killers behind their leader Gilles Walch. The first arthroscopic LHB tenotomy was performed by Gilles Walch in 1989, because he was disappointed by saving and stabilizing the biceps in its groove that left pain sequelae. He also observed the pain relief after proximal rupture of the LHB and suspected that this latter could be a pain generator. The first time he talked about it was during the seventh congress of the European Society for Surgery of the Shoulder and the Elbow in 1993, and the first publication was in French in 1992. ¹¹

Several publications from Pascal Boileau and SFA symposia confirmed that the LHB could be a pain generator.^4,5 However, there are variable macroscopic abnormalities of the LHB described in the literature and it is still difficult to know which ones are pathological. Therefore, we decided to start with a descriptive analysis of all these abnormalities with a need of a common language.

A systematic review of the literature allows us to bring the concept of the “biceps box.” The rotator interval can be likened to a parallelepiped so-called “the biceps box” with 6 sides: the posterior side with the supraspinatus, the superior side with the coracohumeral ligament, the anterior side with the subscapularis, the lateral side with the biceps pulley, the inferior side with the cephalic cartilage, and the medial side with the superior labrum. ⁸ From this model, we defined the sides of the box as the extrinsic structures and the LHB as the intrinsic structure.

Therefore, the description of the “biceps box” concept classifies lesions of the LHB, with so-called intrinsic lesions, for which the LHB should be considered pathological: partial rupture or delamination, fissuring, lateral or medial instability or subluxation, hypertrophy with an hourglass figure; and so-called extrinsic lesions, for which the LHB should be considered healthy: damage to the pulley without bicipital instability, exposure of the articular portion of the biceps by rupture of the supraspinatus tendon, inflammation of the superficial surface of the tendon, presence of type 1 or 2 superior labral anterior to posterior (SLAP) lesions, or a chondral print. The application of a precise protocol for the exploration of the LHB, associated with this previously defined lesion classification, made it possible to obtain a high rate of agreement for the arthroscopic diagnostic analysis of the LHB. ⁷

We finally individualized 10 different possible scenarios of LHB abnormalities observed during an isolated distal supraspinatus tear summarized in this table.

All the arthroscopies are performed in beach chair. Let's have a view on the intrinsic abnormalities, for which the LHB should be considered pathological.

First, the partial rupture of the biceps is also called “delamination.” It is a right shoulder with a posterior viewing portal. In this case, the biceps appear almost ruptured.

The second abnormality could be the presence of fissuring in the LHB tendon. It is a right shoulder with a posterior viewing portal.

A medial instability of the biceps could occur if the medial pulley is damaged. It is a left shoulder with a posterior viewing portal. The soft tissue components of the biceps pulley system include fibers from the subscapularis, the supraspinatus, the coracohumeral ligament, and the superior glenohumeral ligament. When the upper fibers of the subscapularis are torn, medial instability of the LHB could appear.

Laurent Lafosse also described a possible lateral instability of the biceps in case of supraspinatus tears. ⁹ It is a right shoulder with a posterior viewing portal. There is an anterior cable tear of the supraspinatus responsible for a lateral instability of the LHB.

Pascal Boileau described the hourglass biceps in 2004. ³ It is a left shoulder with a posterior viewing portal. The LHB appears hypertrophic in its intra-articular portion that leads to entrapment within the joint on elevation of the arm. The hypertrophy of the intra-articular tendon leads to a disproportion between the tendon and the cross-sectional size of the bicipital groove, preventing sliding of the tendon into the groove and leading to its entrapment.

Analyzing the extrinsic abnormalities, for which the LHB should be considered healthy, we could also define 5 patterns:

First, an isolated medial pulley lesion without instability of the LHB could sometimes be observed. This is a right shoulder with a posterior viewing portal. Note that there is no subscapularis tear and therefore no medial instability of the LHB in this case.

This is a left shoulder with a lateral subacromial viewing portal. In case of rupture of the supraspinatus tendon, the LHB could be completely exposed in the subacromial space and being impinged between the acromion and the humerus without the protection of the superior cuff.

This is a left shoulder with a posterior viewing portal. Hypervascularization of the superficial surface of the tendon or inflammation of the synovitis surrounding the LHB environment could be present. Sometimes, the inflamed portion may not be visible unless the tendon is manually retracted.

This is a right shoulder with a posterior viewing portal. Analyzing the superior labrum insertion with a probe, a SLAP 1 or 2 lesion according to Snyder classification could be observed. ¹⁰

This is a right shoulder with a posterior viewing portal. The chondral print sign is a chondral change on the humeral head underneath the LHB tendon. According to Peter Domos, it does not seem to be a reliable sign of LHB instability or of other LHB pathology. ⁶

The main benefit of this description analysis behind the “biceps box” concept is to find a common language regarding the description of LHB abnormalities depicted when repairing small isolated distal supraspinatus tears under arthroscopy.

We defined 5 intrinsic lesions with a pathological appearance of the biceps and 5 extrinsic lesions with a healthy appearance of the biceps, with a strong inter-rater reliability. ⁷ The next step is an international survey using these 10 videos to assess biceps management among the world.

The main limitation is that there is only an arthroscopic description analysis without additional clinical and paraclinical factors that could influence the decision making regarding the biceps management.^1,2 Moreover, there is no consensus regarding the pathologic aspect of these lesions. If some of these lesions are clearly pathologic, such as a delaminated biceps, and therefore certainly a pain generator, some others such as chondral print seem to have no pathologic expressions. For the other lesions, debates still exist among the shoulder community explaining different approaches regarding biceps treatment.

Further studies are needed to understand in which condition the biceps should be considered as a pain generator to justify a biceps tenotomy or tenodesis.