Research Review by Dr. Shawn Thistle©

Date:

Sept. 2007

Study Title:

Physical examination for partial tears of the biceps tendon

Authors:

Gill HS et al.

Publication Information:

American Journal of Sports Medicine 2007; 35(8):1334-1340.

Summary:

There are many potential pain generators in the shoulder, one of which is the biceps tendon. There have been recent advances in the surgical treatment for injuries to this tendon, and a number of studies describing tests used to establish a diagnosis during physical examination. Unfortunately, not many of these studies have examined the sensitivity, specificity, positive/negative predictive value, or likelihood ratios for most of these tests.

Further, when the creator of the test performs the study, the high clinical value reported must be called into question.

The aim of this study was to establish characteristics of partial tears of the long head of the biceps tendon using a large cohort of consecutive patients, and analyze the diagnostic value of two clinical tests for diagnosing injuries to this structure. Below is a review of the anatomy, function and pathology of the long head of the biceps tendon, followed by analysis of the study.

Biceps Tendon Anatomy and Function (* from additional reference below)
  • the long head of the biceps tendon (LHBT) attaches to the labrum and supraglenoid tubercle of the scapula, and is approximately 9cm long
  • the LHBT is intra-articular yet extrasynovial, and widest at its origin – tapering progressively as it exits the bicipital groove
  • the proximal third of the tendon is the most densely innervated, and contains high levels of calcitonin gene-related peptides and substance P (indicating a rich sympathetic nerve network)
  • the tendon receives its blood supply from the anterior circumflex humeral artery
  • the LHBT passes posterior to the coracohumeral ligament and underneath the transverse humeral ligament as it travels distally
  • the LHBT exits the shoulder at roughly a 30 degree angle, with the passive structures acting as a pulley system
  • the rotator interval (consisting of capsuloligamentous structures including the coracohumeral and superior glenohumeral ligaments) are responsible for keeping the tendon in its proper location as it passes into the bicipital groove
  • the more distal transverse humeral ligament is not thought to play a primary role in stabilizing the tendon as was once believed
  • Function - remains controversial: thought to be at least partly responsible for anteriorly stabilizing the shoulder (passively and perhaps even actively) – this role may depend on the position of the elbow, and requires further study
Pathology Involving the Biceps Tendon
  • general classifications include: trauma, inflammation, and instability
  • tendinopathy and tenosynovitis are closely associated with glenohumeral impingement (primary or secondary) – as the LHBT is subject to the same mechanical stresses as the rotator cuff
  • due to the continuity with the shoulder joint, intra-articular shoulder problems can affect the LHBT as well
  • medial subluxation or dislocation can occur acutely, or due to repetitive trauma (especially overhead athletics)
  • Biceps Tendinopathy - can be isolated along the biceps tendon (primary) or in conjunction with inflammation and fibrosis of surrounding structures (secondary); long term damage can lead to medial subluxation/dislocation; may mimic impingement syndrome with point tenderness in bicipital groove
  • Biceps Tendon Instability - progressive or acute disruption of the pulley system (coracohumeral and superior glenohumeral ligaments) allows subluxation of the tendon; often associated with articular surface supraspinatus or subscapularis tears
  • SLAP Lesions - the glenoid labrum provides the attachment point for the LHBT – pathology of the labrum and SLAP lesion classification will be covered elsewhere in the RRS database
Study Summary

This study began with a cohort of 847 consecutive patients, all of whom underwent arthroscopic surgery on a variety of shoulder conditions. A smaller group of 40 patients was found to have partial biceps tendon tears, and hence formed the study group for this paper. Each patient underwent a standardized preoperative physical examination including a battery of orthopedic tests to evaluate their clinical utility for identifying lesions to the LHBT. The two tests or specific focus in this study were:
  1. Biceps Tendon Palpation - performed in the bicipital groove 3-6cm below the anterior acromion with the arm in 10° of internal rotation – a positive test was defined as pain elicited with palpation on the affected side versus no pain on the uninvolved side
  2. Speed’s Test - performed with the patient standing, elbow extended and forearm supinated, and the arm elevated to 90° and slightly extended horizontally – the patient then resisted a downward force applied by the examiner – this test was considered positive if pain was reported specifically in the bicipital groove

Pertinent Results:

  • of the 40 patients with partial biceps tendon tears, there were 24 men and 16 women with an average age of 59 (range 18-83)
  • the most common conditions associated with LHBT tears (as determined by arthroscopy) were: rotator cuff tears (85%) and anterior instability (7.5%)
  • 33/40 tears were intra-articular, and occurred within 1.5-2cm from the origin of the LHBT
  • 7/30 tears were located in the pulley system, extending into the intertubercular region
  • Speed’s test had a sensitivity of only 50%, specificity of 67%, an accuracy of 66%, and a likelihood ratio of 1.51 for partial biceps tendon tears
  • tenderness with biceps tendon palpation had a sensitivity of only 53%, specificity of 54%, an accuracy of 54%, and a likelihood ratio of 1.13
  • combined positives on both tests yielded a sensitivity of 68%, specificity of only 49%, an accuracy of 59%, and a likelihood ratio of 1.31
  • none of the tests in the battery used for SLAP lesions, or other conditions, were effective for identifying biceps tendon tears

Conclusions & Practical Application:

This small study suggests that no one clinical test can accurately and reliably identify the presence of a partial tear of the biceps tendon. Even those previously thought to be useful for this condition were not able discriminate those with tears from those without tears. Even direct palpation of the structure did not produce satisfactory clinical utility! Differential diagnosis of shoulder problems can be challenging, and injury to the biceps tendon should always be considered.

Therefore, as clinicians, we are left to utilize the tests at our disposal, despite their shortcomings. To date, the literature on assessing the LHBT is not conclusive for a number of factors including: referred pain patterns from the biceps tendon, clinical tests to identify lesions to this structure, and conservative methods that are most effective for treating it.

Although the cohort in this study was relatively small, the condition in question is quite specific, making a large cohort difficult to obtain. The results regarding the clinical utility of the two tests should be interpreted with caution based on this factor, but at a glance they were still quite disappointing. This is in accordance with previous literature, as similar studies investigating orthopedic tests for other shoulder conditions (particularly SLAP lesions) have also indicated that physical tests are not very useful for obtaining a specific diagnosis.

What this study does highlight for manual therapists is that patients with rotator cuff pathology may also have damage to the biceps tendon, as they often coexist. In patients who are not responding to conservative care, or when a definitive diagnosis cannot be obtained, referral for advanced imaging or arthroscopy should be considered.

Additional Reference:

Barber FA, Field LD & Ryu RKN. Biceps tendon and superior labrum injuries: decision-making. Journal of Bone & Joint Surgery 2007; 89-A(8): 1844-1855.