CHAPTER 47 • SHOULDER SUPERIOR LABRUM BICEPS AND PEC TEARS 285- The impingement test is not specific, but can be sen-
sitive to biceps pathology. Localized tenderness along
the groove can help distinguish this from supraspina-
tus tendinosis.
•A Speed’s test is performed by an examiner applying
resistance to arm flexion while the arm is supinated. A
Yergason sign reproduces pain while palpating the
tendon while applying resistance against supinating a
flexed forearm. Pain and weakness caused by pain can
be reproduced with these maneuvers (Burkhead et al,
1998; Curtis and Snyder, 1993). - Muscular biceps examination is done with elbow flex-
ion and the arm in neutral and supination. Additional
testing can be performed with resistive elbow flexion
or supination while the shoulder is in the overhead
throwing position (Bell and Noble, 1996). - Disruptions of the long head of the biceps may pro-
duce a “biceps Popeye muscle” if the tendon retracts
distally beyond the transverse ligament. A tear at the
muscle tendon junction can create a similar deformity.
This appears as a bulging muscle located distal to the
contralateral side. There is often ecchymosis initially
and it is commonly associated with a rotator cuff tear
(Neer, Bigliani, and Hawkins, 1977). - Biceps imaging can be best accomplished with MRI
without enhancement. The sagittal views can demon-
strate the articular portion, and the transverse cuts
demonstrate the extra-articular portions. Rotator cuff
tears in the coronal view may raise suspicion of asso-
ciated pathology. Transverse cuts may demonstrate
the biceps medial to the bicipital groove. An impor-
tant coexistent pathology is disruption of the sub-
scapularis insertion.
BICEPS TENDON TEARS TREATMENT
- Biceps pathology is often coexistent with rotator cuff
problems. Tendinosis and impingement can coexist
with supraspinatus tears. Biceps instability following
trauma can be associated with a subscapularis tear.
Rotator cuff deficiency is important in determining
treatment options.
•Traditionally treatment has been divided into biceps
tears involving 50% of tendon or greater (Curtis and
Snyder, 1993). More mild tears are debrided and
larger tears are considered for tenotomy or tenodesis.
This concept is controversial, and sports physicians
have individualized treatment rather than degree of
tendon involvement (Gill et al, 2001). - Biceps tendon debridement can be done arthroscopi-
cally or through an open approach. The articular part
of the tendon can be easily debrided arthroscopically.
To visualize the extra-articular portion, the tendon
needs to be drawn into the articular viewing area or
has to be visualized on the bursal side after the sup-
porting capsule has been divided.- Current controversy exists between cutting the dam-
aged biceps tendon (tenotomy) (Gill et al, 2001)
versus reattachment of the biceps tendon in a different
location (tenodesis) (Curtis and Snyder, 1993).
Generally, older individuals who are less active are
comfortable with tenotomy supported by a minimal
postoperative recovery. Younger and high-demand
individuals may wish to avoid a possible biceps
muscle deformity that may be created by completing
the tear of the biceps and prefer a tenodesis.
Functional deficits from a long head rupture or iatro-
genic division of the long head of the biceps are usu-
ally temporary (Mariani, Cofield, and Askew, 1988).
Patients’ concerns and options should be discussed
preoperatively. - Biceps tenodesis can be performed after completing
the tear adjacent to the superior labrum. The stump
can be fastened to the proximal humerus or to adja-
cent soft tissue. Bone repairs can be performed with
suture anchors, bone tunnels, or interference screw
fixation. Soft tissue repairs can be maintained with
sutures, tendon to tendon, or tendon to ligament.
•Patients can be categorized as rotator cuff intact with
biceps tear or coexistent cuff and biceps tears. In the
latter, the arthroscopic or open suture anchor repair
can be used to create a secure tendon-to-bone repair of
both the cuff and the biceps. Patients with an intact
cuff may have tenodesis performed, but will need
postoperative activity restriction during the initial
healing period to protect the biceps attachment.
Resistive exercises are generally started at 8 weeks
postoperatively. - Subpectoral open tenodesis repairs have been popu-
larized when extensive tendon involvement includes
the extra-articular portion. This allows for excision of
the diseased portion prior to tendon-to-humerus reat-
tachment. The muscle tendon junction is aligned
along the inferior border of the pectoralis major
tendon.
PECTORALIS MAJOR- The pectoralis major is a large muscle responsible for
arm flexion, internal rotation, and adduction. - Pectoralis tears were considered uncommon but have
been recognized with increasing frequency due to
weight lifting, contact sports, anabolic steroids, and
MRI diagnosis (Noble and Bell, 1996). - Chest strengthening has always placed a large empha-
sis on the pectoralis. Supine and seated flysand bench