BICEPS, TENDON TEARS, AND
SLAP LESIONS
The classic “Popeye” deformity of the biceps
muscle is associated with rupture of the long head of the biceps muscle
proximally in the shoulder at the level of the bicipital groove. When the
tendon retracts from its origin, the muscle shortens, resulting in a “bunching
up” of the muscle belly. This is a common condition often associated with
rotator cuff tears or impingement syndrome (see Plate 1-41). In many cases,
persistent shoulder symptoms after biceps tendon rupture are related to the
associated rotator cuff pathologic process rather than symptoms associated with
the biceps tendon tear. If shoulder symptoms persist after long head of the
biceps tendon rupture, then evaluation of the rotator cuff with magnetic
resonance imaging (MRI) or ultra- sonography of the shoulder is warranted. In
some patients, although uncommon, isolated tear of the long head of the biceps
can result in aching discomfort or cramping of the biceps for forceful elbow
flexion or supination of the forearm, both of which are functions of the biceps
muscle. Most isolated tears of the long head of the biceps are asymptomatic,
and for this reason most are not treated by surgical repair, particularly in
the older or more sedentary patient. Isolated acute tears in the younger and
active patient in some cases should be considered for surgical repair. When
surgically repaired, the torn end of the long head of the biceps tendon is
sutured within the biceps groove using a suture anchor. Alternatively, the
tendon can be sutured to local soft tissues such as the pectoralis major tendon
or the short head of the biceps. This procedure is called a biceps tenodesis
and is most often performed by arthroscopic means when the tendon is released
from its origin at the time of surgery when performed electively for treatment
of a biceps tendon lesion or a lesion of the superior labrum from anterior to
posterior (SLAP lesion) involving the long head of the biceps.
When a tenodesis is performed for
management of an acute rupture, the repair is more often performed by open
surgery through a small deltopectoral or subpectoral incision. In cases in
which a biceps or superior labrum pathologic process involving the biceps is
found at the time of surgery for an isolated biceps pathologic process or when
it is associated with rotator cuff pathology in an older or more sedentary
patient, the long head of the biceps tendon is released at the site of its
origin and allowed to retract without repair. Although this will result in a
“Popeye” deformity, the patient is most often asymptomatic and the pain that
was preoperatively associated with the long head of the biceps is relieved. The
biceps tendon is attached to the superior labrum both anteriorly and
posteriorly. Type I SLAP lesions are common and often associated with the
normal aging process and as such are not often associated with sig- nificant
pathology or symptoms. Similarly, when type II lesions are typically seen in
the older age population they are often asymptomatic. Type II SLAP lesions can
be symptomatic when they are acute and traumatic. They are often seen after a
fall onto an outstretched arm or in the overhead-throwing athlete as related to
repetitive trauma and may warrant a surgical repair. Type III lesions involve a
bucket-handle tear of the labrum with mechanical symptoms without biceps tendon
involvement and are amenable to surgical treat- ment specifically to remove
that portion of the labrum that is detached. Type IV SLAP lesions involve both
the superior labrum and the long head of the biceps tendon. These lesions are
often symptomatic and are generally treated by removal of the labral tissue and
with tenodesis of the biceps. Alternatively, the biceps tendon and type IV SLAP
lesion can be repaired if tendon quality is good and the lesion is relatively small.
Less common types of SLAP lesions are associated with tears extending into the
anterior inferior labrum (Bankart-type labrum tears) and are associated with
glenohumeral instability. In these cases, when symptomatic, both lesions are
repaired at the time of surgery, most commonly with arthroscopic techniques.
Diagnosis of SLAP lesions is performed
with a variety of maneuvers, including the O’Brien sign. The O’Brien sign is
performed with a series of three maneuvers as shown and described in Plate 1-35.
A positive test for a SLAP lesion results in pain in the anterior aspects of
the shoulder with a resisted forward elevation. These symptoms are less so with
the arm in external rotation and also not significantly present with the arm in
internal rotation but in the plane of the scapula.
