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Revue de Chirurgie Orthopédique et Traumatologique
Vol 89, N° 8  - décembre 2003
pp. 672-682
Doi : RCOE-12-2003-89-8-0035-1040-101019-ART2
Entrapment of the long head of the biceps: the "hourglass biceps".
Another cause of pain and locking of the shoulder
 

P. Boileau [1], P.-M. Ahrens [1], C. Trojani [1], J.-S. Coste [1], B. Cordéro [1], P. Rousseau [1]
[1] Service de Chirurgie Orthopédique et Traumatologie du Sport, Hôpital de L'Archet, CHU de Nice, 151, route de Saint-Antoine de Ginestière, 06202 Nice.

Tirés à part : P. BoileauE-mail : boileau.p@chu-nice.fr

Abstract
Entrapment of the long head of the biceps: the “hourglass biceps”. Another cause of pain and locking of the shoulder
Purpose of the study

We describe a mechanical condition affecting the long head of the biceps tendon (LHBT) causing potentially unrecognized entrapment within the joint and subsequent pain and locking. This is caused by a hypertrophic intra-articular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm.

Materials and methods

Twenty one patients were identified, during open (14 cases) or arthroscopic (7 cases) surgery, with a so called “hourglass biceps” i.e., hypertrophic intraarticular portion of the LHBT and incarceration of the tendon during elevation. All cases occurred in conjunction with a rotator cuff rupture except one who had a partial deep tear. All patients were treated by excision of the biceps, after tenodesis or bipolar tenotomy, and appropriate treatment of the concomitant lesions.

Results

All patients presented with anterior shoulder pain and loss of passive elevation averaging 10-20°. A dynamic intraoperative test involving forward elevation with the elbow extended demonstrated entrapment of the tendon within the joint in each case. This test creates a characteristic “buckling” of the tendon and “squeezing” of the tendon between the humeral head and the glenoid (“hourglass test”). Excision of the tendon allowed immediate restoration of complete elvation. Mean Constant score increased from 38 points to 76 points postoperatively.

Discussion

The “hourglass biceps” is caused by a hypertrophic intraarticular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm. Loss of 10-20° of passive elevation, bicipital groove tenderness, and radiographic findings of a hypertrophied tendon can aid in diagnosis. The “hourglass biceps” should not be misdiagnosed for a frozen shoulder. Definitive diagnosis is made at surgery with the “hourglass test”: incarceration and squeezing of the tendon within the joint during forward elevation of the arm with the elbow extended. Simple tenotomy cannot resolve this mechanical block. Either tenotomy with excision of the intraarticular portion of the LHBT or tenodesis must be performed. The “Hourglass” biceps is an addition to the familiar pathologies of the long head of the biceps tendon (tenosynovitis, prerupture, rupture, instability), and should be considered in any case of chronic anterior shoulder pain associated with a loss of shoulder elevation.

Keywords: Biceps tendon , locking , tenotomy , tenodesis


INTRODUCTION

The role of the long head of the biceps in shoulder motion, stability, and pain continues to be an issue of discussion despite more than 100 years of debate, practically since the princeps description of periarthritis by Duplay ( [1]) in 1872. The association of shoulder pain with a long biceps disorder, whether isolated or associated with cuff tears, is however a commonly accepted notion which can correspond to inflammation (tenosynovitis), or an early-stage tear or instability of the tendon in the bicipital groove (subluxation or overt dislocation) [Berleman and Bayley ( [2]), Boileau and Walch ( [3]), Burkhead ( [4]), De Plama ( [5]), Goldfarb and Yamaguchi ( [6]), Hitchcock and Bechtol ( [7]), Meyer ( [8]), Peterson ( [9]), Post and Benca ( [10]), Walch et al. ( [11]), Warren ( [12])].

We report here a mechanical intraarticular problem involving the long head of the biceps. We have dubbed it the "hourglass" long biceps. The problem corresponds to hypertrophy of the intraarticular portion of the long head of the biceps tendon (LHBT) which can then no longer glide in the bicipital groove during forward flexion or abduction of the arm (fig. 1). We first identified this type of dysfunction intraoperatively during arthroscopic procedures or open repairs of the rotator cuff: the hypertrophic LHBT was entrapped in the glenohumeral joint space when the arm was raised. The hourglass long biceps, which could also be termed entrapped LHBT, constitutes a new pathological entity comparable to entrapped finger tendons observed in the hand. There is a disproportion between the containing element (narrow bicipital groove) and the contained element (hypertropic tendon). This pathological entity can sometimes be found in association with rotator cuff tears. Clinical expression includes pain and locked shoulder due to loss of the last degrees of elevation.

The purpose of this work was to report this new pathological entity. The clinical expression, possible diagnostic methods using physical examination and imaging techniques, as well as surgical treatment modalities and expected outcome are detailed.

MATERIAL AND METHODS

Following our initial observations, we conducted a prospective study of patients with the pathological entity, recognized preoperatively and proven intraoperatively. Hourglass long biceps was defined as hypertrophy of the intraarticular portion of the LHBT associated with mechanical blockage of the shoulder.

Between June 2000 and April 2002, a cohort of 21 patients was identified with a clinical diagnosis of hourglass long biceps confirmed intraoperatively. The cohort included seven women and fourteen men, mean age 62 years (range 47-69). The dominant arm was involved in 18 patients. Eleven patients were manual laborers who regularly performed or had regularly performed activities requiring use of the arm above the horizontal plane (painters, masons, carpenters).

Clinical data

All of the patients complained of chronic shoulder pain, generally localized in the anterior part of the shoulder (16 patients). Pain radiated to the elbow in ten patients and to the cervical spine in eight. Fourteen patients described pain worsening during active elevation of the arm above the horizontal plane. The patients had suffered chronic shoulder pain for 13.2 months on average (range 1 - 36 months) before consulting. Medical treatment was given for six months in all patients (rest, nonsteroidal anti-inflammatory drugs, rehabilitation, corticosteroid injections). On average the patients had received 2.6 (range 0 - 12) corticosteroid injections in the bursa or the glenohumeral joint space.

Physical examination revealed pain at palpation of the bicipital groove in 15 patients. The Speed test was positive in ten and the Jobe test was positive in 17. A remarkable sign was the 10° to 20° deficit in passive forward flexion. This limitation of passive motion was more easily demonstrated when the patient was in the reclining position (fig. 2). Attempts to force the passive elevation of the arm were unsuccessful and triggered significant shoulder pain.

Radiological data

A complete radiological work-up of the shoulder was obtained preoperatively and included anteroposterior views in neutral rotation, external rotation and internal rotation, a lateral view of the scapula (Lamy view) and an axillary lateral view. For nine patients, the films showed indirect signs of rotator cuff tears or pre-tears: nine patients had an aggressive osteophytic acromion (type 3); the acromiohumeral distance was narrowed measuring 6.4 mm on average. Hypertrophy of the LHBT could not be demonstrated preoperatively in six patients. Computed tomography, coupled with arthrography demonstrated hypertrophy of the LHBT in three patients and subluxation associated with hypertrophy in six. Magnetic resonance imaging was performed in four patients and did not reveal signs in favor of tendon hypertrophy.

Inclusion criteria

Patients with shoulder pain were included in this study if they also presented the following criteria:

  • hypertrophy of the intraarticular portion of the LHBT
  • incarceration of the intraarticular portion of the LHBT during arm elevation, demonstrated intraoperatively or during the "hourglass" test (described below) causing mechanical blockage of the shoulder.

Exclusion criteria

Patients with shoulder pain or stiff shoulder related to other pathological conditions were excluded, specifically:

  • glenohumeral conditions: osteoarthritis, inflammatory arthritis, history of humerus or glenoid fracture, glenohumeral instability, retractile capulitis,
  • other long biceps conditions: disinsertion of the proximal tendons (SLAP), dislocation of the LHBT, full thickness tendon tear;
  • long biceps conditions affecting the LHBT in the bicipital groove: synovitis with adherences or calcifications in the bicipital groove.

Conversely, tenosynovitis, delamination, partial tears or subluxation associated with hypertrophy of the LHBT were not exclusion criteria as long as there was an intraarticular incarceration of the tendon and mechanical blockage of the shoulder during forward flexion.

Surgical exploration

Surgical or arthroscopic exploration and treatment was performed by a senior operator (PB) or by another operator under his supervision. General anesthesia was used in all cases for both open and arthroscopic procedures. Patients were in a semi-reclining position. Arm traction was not used during arthroscopic procedures, performed via a posterior portal in all cases. The "hourglass" test (described below) was performed after open or arthroscopic exploration. For arthroscopy, a palpator was introduced via an anterior portal to pull the extraarticular portion of the LHBT into the articulation for inspection and verification that no adherence retained the tendon in the bicipital groove.

Postoperative follow-up

Patients were followed regularly at consultations at 3, 6, 9, 12 and 24 months. The Constant and Murlay function score ( [13]) was determined at each consultation.

RÉSULTS

Epidemiological data of the cohort are summarized in tableau I.

Operative observations

A hypertrophic hourglass LHBT was identified as the cause of pain and joint blockage in 21 patients: 14 during open surgery and seven during arthroscopic surgery. Mean diameter of the intraarticular portion of the LHBT measured intraoperatively was 12 +/- 3 mm versus 6 +/- 3 mm for the extraarticular portion. In addition to tendon hypertrophy, the intraarticular portion of the tendon exhibited tenosynovitis in eleven patients, tendon delamination in fourteen and subluxation in six.

All patients had a wide tear of the rotator cuff except one patient who had a partial tear on the deep aspect of the supraspinatus tendon and three patients who had a small tear of the supraspinatus tendon associated with retraction to the trochiter (stage I). Rotator cuff lesions are detailed in tableau I..

The "hourglass" diagnostic test

In order to prove that the hypertrophy of the LHBT was indeed the cause of the mechanical blockage, we developed a diagnostic test called the "hourglass test". The test, performed during open or arthroscopic surgery, consists in raising the arm passively in the plane of the scapula holding the elbow extended and the forearm in neutral rotation. The intraarticular portion of the LHBT is observed (fig. 4a). The hourglass test is positive if the tendon cannot glide in the bicipital groove when the arm is raised. This is visualized by a buckle which forms in the hypertrophic tendon (fig. 4b) or by incarceration of the tendon in the joint space (Figure 4c) where the tendon becomes entrapped between the humeral head and the glenoid cavity. When performed during an arthroscopic procedure, the test can be conducted "in air" after injection of 10 cc of air into the joint space, then after injection of saline solution.

Before considering that the hourglass test is definitively positive, we always rule out any other possible pathological condition of the biceps tendon in the bicipital groove. We therefore systematically checking whether the extraarticular portion of the tendon is healthy searching for any macroscopic lesion and verifying that it glides easily when pulled into the joint space. Extraarticular blockage of the tendon (adherences in the groove for example) could induce a false positive test. During the test, the elbow must be maintained in full extension. Flexion of the elbow would release the LHBT and thus could be another source of false positive tests, the tendon buckling in the articulation even in the absence of hypertrophy of the intraarticular portion.

Our observations clearly demonstrated that incarceration of the LHBT within the joint space is the cause of limited passive forward flexion of the arm. When attempting to raise the arm to full elevation, we perceived a resistance which occurred when the tendon became incarcerated between the humeral head and the glenoid cavity. The limitation of passive forward flexion could not be overcome under general anesthesia.

Failure of "conventional" unipolar tenotomy

A highly significant observation was the fact that "conventional" tenotomy of the LHBT by proximal section at the level of the supraglenoid tuberosity was not followed by slippage of the tendon into the bicipital groove as is classically described. Because the (mobile) tendon stump remains in the articulation, proximal tenotomy does not alleviate the mechanical block. The stump of a hypertrophic tendon is mobile but remains entrapped between the humeral head and the glenoid or between the humeral head and the acromion. The hourglass test thus remained positive after proximal tenotomy due to persistence of defective passive forward flexion.

Surgical treatment: resection of the intraarticular portion of the LHBT after biopolar tenotomy or tenodesis

The patients were treated by resection of the intraarticular portion of the LHBT after bipolar tenotomy (two patients) or tenodesis (nineteen patients). Concomitant lesions of the cuff were also repaired (tableau I). Choice between tenotomy and tenodesis depended on the surgical possibilities, but we preferred tenodesis.

Bipolar tenotomy was performed in two patients. The procedure consisted in resection of the intraarticular portion of the LHBT after sectioning the tendon at its entry into the bicipital groove then at its glenoid insertion. In nineteen patients, we performed tenodesis using the technique described earlier [Boileau et al. ( [14])] where the tendon is positioned in a bony groove fashioned at the upper end of the bicipital goove and fixed with a resorbable interferential screw. Briefly, once the proximal tenotomy was completed, the tendon was maintained on a traction suture after being folded back on itself and sutured together. The doubled tendon was then calibrated to 8 or 9 mm, which required in certain cases longitudinal stripping of the hypertrophic portion. A bony groove, also measuring 8-9 mm in diameter and 25 mm in length was drilled 1 cm above the upper end of the bicipital groove. The tendon was fixed in the bony groove with a resorbable interferential screw (Tenoscrew®, Phusis, Saint-Ismier, France) measuring 9 mm or 9.5 mm in diameter and 20 mm long (fig. 5 et 6).

Rotator cuff repair was performed in sixteen patients during the same operative time: fourteen during open procedures and two during arthroscopic procedures. The patient with a partial tear of the deep aspect of the supraspinatus tendon underwent arthroscopic debridement. Acromioplasty was also performed in 14 of the patients who had cuff repair. Acromioplasty was also performed in 2 other patients whose rotator cuff lesions could not be repaired.

Outcome of surgical treatment

Resection of the intraarticular portion of the LHBT provided complete and immediate (intraoperative) recovery of full passive forward flexion. This result confirmed that the restriction of passive motion was related to hypertrophy of the hourglass tendon entrapped in the joint space where it was unable to glide into the tendon groove during forward flexion.

Early results after surgical treatment have been evaluated in 14 patients at a minimum six months. Active forward flexion improved from 120° preoperatively to 160° postoperatively. External rotation improved from 38° to 52°. The Constant score improved from 38 points preoperatively to 76 points postoperatively. The pain score improved from 4 points preoperatively to 13 points at last follow-up.

DISCUSSION

We report a new pathological entity affecting the long head of the biceps tendon at the shoulder level where tendon becomes entrapped in the humeroglenoid space during forward flexion causing shoulder pain and dysfunction (locked shoulder). Our description of the "hourglass" tendon corresponds to a mechanical problem resulting from hypertrophy of the intraarticular portion of the LHBT preventing the tendon from gliding in the bicipital groove during forward flexion of the arm (fig. 1). This pathological entity occurs preferentially in patients with a wide rotator cuff tear, although we did have two patients with an hourglass tendon associated with a partial tear of the supraspinatus retracted to the trochiter (stage I) and one patient who had a partial lesion of the deep aspect of the supraspinatus tendon. Deficient passive forward flexion (10°-20°), pain localized in the bicipital groove, or tendon hypertrophy visualized on the arthroscan or MRI are suggestive of the diagnosis of hourglass tendon fig. 2 et 3). The definitive diagnosis is established at surgery (conventional or arthroscopy): the intraarticular portion of the hypertrophic tendon is trapped in the joint space when the arm is elevated, elbow extended (positive hourglass test). Prior verification that the LHBT is healthy and glides well in the bicipital groove is necessary. Simple unipolary tenotomy does not resolve the mechanical blockage of the shoulder because the mobile stump of the hypertrophic tendon does not retract into the bicipital groove but remains entrapped in the articulation. The only solutions are to resect the intraarticular portion of the tendon after bipolar tenotomy or to perform tenodesis which allows restoration of complete symmetrical forward flexion.

Although hypertrophy of the LHBT is well known, it has basically been described in patients with rotator cuff tears [Dines et al. ( [15]), Leffert and Rowe ( [16]), Meyer ( [8]), Murthi et al. ( [17]), Neer ( [18]), Neviaser ( [19]), Sethi et al. ( [20])]. To our knowledge, there have been no reports describing entrapment of the LHBT in the joint space during forward flexion causing pain and shoulder dysfunction (locking). Our purpose was to alert clinicians against misdiagnosis of this new pathological entity which can be confused with other causes of shoulder pain or stiffness. We also wanted to know whether there is a specific surgical treatment: simple tenotomy does not resolve the mechanical problem because the hypertrophic (but mobile) tendon persists and can still be trapped in the glenohumeral joint.

There are many causes of hypertrophy of the LHBT [Dinet et al. ( [15]), Leffert and Rowe ( [16]), Meyer ( [8]), Murthi et al. ( [17]), Neer ( [18]), Neviaser ( [19]), Sethi et al. ( [20])]. Leffert and Rowe ( [16]) have observed possible increase in the size of the biceps in case of degenerative rotator cuff tears. For these authors, this hypertrophy is a secondary functional compensation for the absence of the rotator cuff. Neer ( [18]) also emphasized that the long biceps has a decompression effect on the humeral head and that the intraarticular portion of the tendon can become hypertrophied in the event of cuff tears. Goldfarb and Yamaguchi ( [6]) provided another possible explanation of LHBT hypertrophy. They noted that the tendon is situated in the anterior part of the shoulder at the level where conflicts with the acromion occur so that a thickened tendon, observed in patients with chronic rotator cuff tears, could be secondary to chronic inflammation resulting from an anterosuperior conflict. These two mechanisms (functional compensation due to cuff insufficiency and/or repeated microtrauma due to the anterosuperior conflict) probably contribute to the hypetrophy of the long biceps. This hypothesis is also supported by recent histological data showing inflammatory remodeling of the LHBT [Murthi et al. ( [17]), Sethi et al. (20]. Although certain electrophysiological and anatomic publications question the lowering role of the humeral head [Gowan et al. ( [21]), Hitchcock and Rechtol ( [7]), Levy et al. ( [22])], it is reasonable that ascension of the humeral head secondary to a wide cuff tear could cause excessive stress on the LHBT and provoke hypertrophy.

While hypertrophy of the intraarticular portion of the LHBT can probably be explained in patients with rotator cuff tears, the reason for this hypertrophy is less obvious when observed in patients with a small tear of the supraspinatus or with a healthy cuff (three patients in our series). An "external" or extra-articular (anterosuperior) conflict is certainly not the only explanation. There might also be an "internal" intra-articular conflict resulting from repeated friction on the tendon as it enters the bicipital groove causing tendon inflammation similar to the pathological process observed in finger tendon entrapment [Sampson et al. ( [23])]. Physiological movement of the long biceps during anterior flexion corresponds in reality to movement of the groove over a stationary tendon [De Palma ( [5]), Hitchcock and Bechtol ( [7]), Meyer ( [8])]. Possible stenosis of the bicipital groove (Ozaki et al. ( [24]), Pfahler et al ( [25])] and the form of the bicipital groove might participate in provoking tendon hypertrophy as it enters the bicipital groove [Creenshaw and Kilgore ( [26]), Hitchcock and Bechtol ( [7]), Meyer ( [8])]. A narrow groove, which could be congenital or acquired (oseophytes), could be a predisposing factor of "hourglass" hypertrophy of the LHBT, but our study did not provide information to elucidate this hypothesis.

In summary, our hypothesis is that "hourglass" hypertrophy of the LHBT results from multiple factors:

  • functional hypertrophy secondary to cuff deficiency,
  • an inflammatory process secondary to an extraarticular conflict (anterosuperior with the acromial vault),
  • an inflammatory process secondary to an intraarticular conflict due to repeated friction of the tendon in a narrow groove.

Hitchcock and Bechtol ( [7]) suggested that inflammation within the bicipital groove could lead to adhesions hindering smooth movement of the tendon. They recommended tenodesis with resection of the intraarticular portion of the tendon to avoid buckling. More recently, decompression and synovectomy have been proposed for localized tendonitis in the bicipital groove [Murthi et al. ( [17])]. Cases of long biceps tendonitis in the bicipital groove, preventing the tendon from gliding in the bicipital groove, were specifically excluded from our study because this pathological entity can produce a similar clinical presentation. In all patients in our study, the absence of movement of the tendon in the groove was directly related to the oversized diameter of the bicipital portion of the long biceps tendon since we were always able to pull it into the joint and check its macroscopic appearance. Symptoms caused by the "hourglass" tendon are difficult to differentiate from those related to associated cuff disease. All the patients in our series presented chronic shoulder pain. The pain increased with active and passive elevation of the arm above the horizontal. There is probably more than one cause for "hourglass" tendon shoulder pain: reasonably, reactional synovitis and/or tendon delamination, which is sometimes present, could both generate pain. Tendon entrapment in the joint resulting from the impossibility to glide in the groove during elevation or abduction, certainly also participates in generating pain. Furthermore, this incarceration of the hypertropic tendon within the joint also creates a mechanical block, limiting active and passive forward flexion. Limitation of passive anterior flexion is in our experience the most pertinent clinical sign for suspecting "hourglass" LHBT; Shoulder blockage observed in patients with "hourglass" LHBT produces permanent shoulder flexion which can be compared with permanent knee flexion in subjects with a bucket-handle meniscal lesion. Retractile capsulitis is the main differential diagnosis, but in this pathology, joint motion is limited in all directions, including rotation. Clinicians should be consider the possibility of an "hourglass" tendon because unlike "frozen shoulder" where first-intention medical treatment is indicated, surgery is the solution for "hourglass" tendon. Preoperative rehabilitation is ineffective. It is useless to try to recover passive shoulder motion because the shoulder is locked mechanically and motion cannot be recovered. Besides certain failure, rehabilitation could cause unnecessary pain. Medical treatment and rehabilitation are not indicated here because the problem is a mechanical one. In other words, surgery should not be postponed; a mechanical solution is required to resolve this purely mechanical problem.

Preoperative diagnosis of "hourglass" LHBT is difficult; it is based on demonstration of intraarticular hypertrophy of the tendon. An anterior arthrogram in internal rotation may provide objective evidence (fig. 3). But arthrography cannot differentiate between a hypertrophic tendon and an "hourglass" tendon trapped in the joint. In the future, dynamic ultrasound or MRI will undoubtedly be able to provide evidence for the preoperative diagnosis of "hourglass" tendon. This pathological association (hypertrophic LHBT, trapped in the joint, with subluxation) was found in six patients in our series (fig. 7). The hypertrophic LHBT behaved like a "dilatation bougie" when raising the arm, opening then tearing the pulley system at the entry of the bicipital groove; the upper part of the subcapular "opened like a book", leaving the LHBT slip over the medial border of the bicipital groove.

The "hourglass test" which we propose was conducted during open or arthroscopic surgery and enabled certain diagnosis (fig. 4). This test is performed by raising the patient's arm above the horizontal with the elbow extended. The operator observes that the LHBT remains trapped within the joint instead of gliding into the bicipital groove and that forward flexion is limited by the irreducible blockage. The intra-articular portion of the tendon presents a characteristic Z-shaped buckle (fig. 4). Complete elevation is impossible because of the tendon entrapment. The "hourglass test" can be performed easily during an arthroscopic procedure with the patient in a semi-sitting position totally avoiding traction. The test can be performed in the lateral reclining condition if traction is prevented during the test.

The "hourglass" LHBT is a new pathological entity of the shoulder comparable to entrapped finger tendons. There is a conflict between the content (the hypertrophic tendon) and the containing element (the overly narrow bicipital groove) preventing the tendon from gliding normally. However, unlike entrapped finger tendons, where the treatment consists in widening the containing element by sectioning the reflection pulley, such a solution is not possible at the shoulder level: section of the coracohumeral ligament and the transverse ligament would provoke tendon dislocation in front of the subscapularis and cause persistent pain and a pseudoparalytic shoulder. We found that reducing tendon thickness and/or tubulization of the intra-articular portion of the tendon would not provide certain cure and allow the tendon to glide normally in the bicipital groove. The only logical treatment was to resect the portion of the tendon after bipolar tenotomy or tenodesis. Removing the intra-articular portion of the LHBT is particularly warranted because the cause of the hypertrophy of this portion of the tendon remains to be fully elucidated, particularly in patients with a normal cuff. When tenotomy is performed arthroscopically, one must be careful to resect the intra-articular portion of the tendon and not leave the tendon incarcerated in the joint, which would lead to persistent symptoms. There are several techniques for tenodesis of the long biceps [Berleman and Bayley ( [2]), Burkhead ( [4]), Creenshaw and Kilgore ( [26]), Dines et al. ( [15]), Walch et al. ( [11]) ( [27])]. We retained our technique of tenodesis using a resorbable interferential screw because it can be performed arthroscopically or during open surgery in patients with torn or intact cuffs [Boileau et al. ( [14])]. Furthermore, this technique allows removal of the intra-articular portion of the tendon while preserving tension on the muscle.

In conclusion, the present study demonstrated that:

  • the long head of the biceps tendon can become trapped in the glenohumeral joint when the arm is raised over the horizontal when the intraarticular portion of the tendon is hypertrophied;
  • this hypertrophy of the long head of the biceps tendon or "hourglass" tendon, causes shoulder pain and locking, with deficient passive elevation when the tendon is trapped in the joint; this entity must not be misdiagnosed as retractile capuslitis;
  • the "hourglass test" confirms the diagnosis intra-operatively, demonstrating objectively the tendon fold and incarceration in the joint during passive elevation of the arm with the elbow in extension;
  • isolated tenotomy does not resolve the mechanical block because the tendon cannot retract into the bicipital groove, remaining trapped in the joint. Resection of the intra-articular portion of the long head of the biceps tendon, after bipolar tenotomy or tenodesis, enables total recovery of passive elevation.

The "hourglass" LHBT should be added to the already long list of tendon pathologies (tenosynovitis, pretears, subluxation, dislocation) and should be searched for in patients with persistent unexplained anterior shoulder pain with loss of the last degrees of passive forward flexion, even when the rotator cuff is intact.

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The owners of this website hereby guarantee to respect the legal confidentiality conditions, applicable in France, and not to disclose this data to third parties.
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