Stabilizing function of the long head

of the biceps in the hanging

arm position
Eiji Itoi, MD, Neil E. Motzkin, MD, Bernard F. Morrey, MD, and
Kai-Nan An, PhD, Rochester, Minn.

The contribution of the long head of the biceps (LHB) to shoulder stability was
studied. Nine fresh-frozen cadaveric shoulders were tested in the hanging arm
position. The muscle belly of the long head of the biceps was removed and
replaced with a spring device to apply load to the long head of the biceps. An
electromagnetic tracking device was used to record the positions of the humeral
head (7) without load and with loads of 7.5 kg and 3 kg on the long head of the
biceps, (2) with 7.5 kg of force to the proximal humerus in three diHerent
directions, and (3) in three diHerent rotations of the arm. Displacement in the
anterior and posterior directions was significantly decreased by long head of the
biceps loading and was less significant in internal rotation. Inferior displacement
in external rotation was significantly decreased by long head of the biceps
loading. It is concluded that in the hanging arm position, the long head of the
biceps could, if contracted, provide some stabilizing function to the humeral
head in all directions, and more importantly, in anterior/posterior directions.
Furthermore, the stabilizing function of the LHB is influenced by rotation of the
arm. (J SHOULDER ELBOW SURG 7994;3: 735-42.)

The function of the biceps at the elbow has during biceps contraction. Glousman et al. 6
been well described, and there is general were the first to provide objective evidence to
agreement that the biceps brachii is a strong the longtime clinical speculation of the LHB as
supinator of the forearm and a weak flexor at a possible anterior stabilizer. They observed
the elbow." 3, 20 Debate continues, however, on that the electromyographic activity of the biceps
the exact function of the long head of the biceps during throwing motion increased in patients
(LHB) at the shoulder joint. As a mover, it is a with chronic anterior instability of the shoulder
flexor," 4, 7, 8,13 an obductor," 8, IS, 20 or an internal compared with those without instability. The
rototor.': 13 As a stabilizer it has been considered LHB is an intraarticular, extrasynovial structure
a depressor of the humeral head. IS. 18 Recently, on the surface of the humeral head and courses
Kumar et ol." demonstrated from a cadaveric into the intertubercular groove. From this ana-
study that the function of the LHB was to sta- tomic consideration and from the report by
bilize the humeral head in the glenoid and to Glousman et a 1.,6 our initial hypothesis was that
suppress superior migration of the humerus the LHB, if contracted, might stabilize the hu-
meral head not only in the superior direction
but also in the anterior/posterior and inferior
From the Biomechanics Laboratory, Department of Ortho- directions. Furthermore, rotation of the arm
pedics, Mayo Clinic/Mayo Foundation, Rochester. changes the relation of the LHB to the humeral
Presented at the Eighth Open Meeting of the American
Shoulder and Elbow Surgeons, Washington, D.C., Feb-
head. The intraarticular length of the LHB is the
ruary 23, 1992. greatest when the arm is in the hanging and
Reprint requests: Kai-Nan An, PhD, Biomechanics Labora- externally rotated position." Habermeyer et ol."
tory, Department of Orthopedics, Mayo Clinic, Rochester, thought that it was in this position that the ten-
MN 55905.
Copyright © 1994 by Journal of Shoulder and Elbow Surgery
sion of the LHB became maximum and that the
Board of Trustees. effectiveness of the LHB was greatest. Recently,
0273/8481/94/$3.00 + 0 32/1154277 Rodosky et ol." reported that the LHB increases

135
136 Itoi et 01. 1. Shoulder Elbow Surg.
Mayl June 7994

putations with interscapulothoracic amputation

proximally and midhumeral transection distally.
At the time of transection, the distance between
the cut end of the specimen and the medial epi-
condyle of the humerus was recorded . The ori-
entation of the cut end of the specimen was
recorded with particular attention paid to the
rotation of the humerus in reference to the fore-
arm. In this manner the rotation of the proximal
humerus could be accurately determined at the
time of experimentation. The specimens were
thawed for preparation. A fiberglass rod (9.6
mm or 12.6 mm in diameter, according to the
size of the humerus) was inserted into the med-
ullary canal of the proximal humerus and ce-
mented into place. An anterior / posterior fiber-
glass pin (6.3 mm in diameter) on which to hang
a weight during loading was inserted just prox-
imal to deltoid insertion. It was also used to
maintain proper rotation during the stress tests.
A second fiberglass pin was inserted perpen-
dicular to the first pin, the medial/lateral di-
rection, at the level of the latissimus dorsi in-
sertion . This second pin was used to apply an-
terior or posterior loads to the proximal
Figure 1 Experimental setup. Spring was attached humerus (Figure 1).
to cut end of LHB by nylon thread fixed to tendon by All muscles except the rotator cuff were re-
Bunnell's method . Other end of spring was attached
moved. The specimens with complete thickness
to device on intramedullary rod . By pulling down de-
vice, either 1.S-kg or 3-kg load was appl ied to LHB. tears of the rotator cuff were excluded from the
study . The LHB was cut at the level of the prox-
imal musculotendinous junction, and a spring
was attached between the cut end of the biceps
the torsional rigidity of the shoulder. Judging tendon and a sliding device on the intramedul-
from these reports, the contribution of the LHB lary rod so that a load could be determined
to shoulder stability may change with rotation and applied to the biceps tendon from the force-
of the arm. Our second hypothesis, therefore, length relationship of the spring. The joint cap-
was that rotation of the humerus affects the sta- sule, ligaments, and intraarticular pressure
bilizing function of the LHB. None of the pre- were kept intact; this was also confirmed after
vious studies, however, revealed the stabilizing the experiments were performed. The scapula
function of the LHB in the different directions was mounted to a polycast acrylic (Polycast
and various rotations. The purpose of this study Technology Corporation, Stanford, Connecti-
was to determine (1) the stabilizing function of cut) fixator. The inferior tip of the intramedul-
the LHB, if contracted, with the arm in the hang- lary rod was placed through a small fixed hole
ing position, and (2) the influence of arm ro- to prevent any abduction / adduction and flex-
tation on the stabilizing function of the LHB. ion/ extension of the arm and not to disturb any
anterior / posterior or superior / inferior move-
MATERIAL AND METHODS ment of the humeral head during the experiment
Specimen preparation. Nine fresh- (Figure 1).
frozen cadaveric shoulders with an average Experimental conditions. In humans the
age of 58 years (range 29 to 77 years), without scapula is anteriorly rotated by 30° with refer-
radiographic evidence of glenohumeral arthri- ence to the coronal plene." In this study arm
tis, were obtained for experimentation. The rotation was described in reference to the co-
specimens were prepared as forequarter am- ronal plane. All 36 permutations of the follow-
J. Shoulder Elbow Surg. Itoi et 01. 137
Volume 3, Number 3

o LHBOkg
t--b-t
• LHB 1.5 kg
IR ~ LHB3kg
I . I
•
I
I p<O.OOOl

I---Q---4
NR I
• I p<O.OOOl

"
I I

ER
Post. +-- +
... t-Q-t
p=0.0141

---+ Ant.
-1.5 -1.0 -0.5 0.0 0.5 1.0
Position of Humeral Head (em)
Figure 2 Passive change of humeral head pos ition in anterior/posterior
direction with LHB loading . Without translation force , head shifted poste-
riorly with loading of LHB. This was highly stat istically significant in interna l
and neutral rotations (p < 0.0001) . In external rotation posterior shift was
less significant (p = 0.0141) .

ing conditions were measured : (1) with no force fining the midpoint of the vertical axis of the
and with 1.5 kg of translation force appl ied to glenoid (the longest longitudinal line passing
the humeral head anteriorly, posteriorly, and through the middle of the LHB origin). The z-
inferiorly, (2) in 30° internal, neutral, and 30° axis was defined as a line passing through the
external rotation, and (3) with no load and with origin parallel to a line along the medial border
1.5 kg and 3 kg of load applied to the LHB. All of the scapula (i.e., the superior/inferior axis).
nine shoulders were measured in 30° internal This latter line was defined by digitizing two
and external rotation, and five of these shoul- points: (1) the inferior angle of the scapula, and
ders were measured in neutral rotation as well. (2) the intersection of the medial border of the
Data collection. The three-dimensional scapula and the scapular spine. The x-axis was
kinematics of the humerus and the scapula was defined as a line passing through the origin and
monitored by an electromagnetic tracking de- perpendicular to the line along the medial bor-
vice, 3Space Tracker System (Polhemus Navi- der of the scapula (i.e., the medial/lateral axis).
gation Sciences Division, McDonnell Douglas The y-axis was defined as a line through the
Electronics Company, Colchester, Vt.) . This sys- origin and perpendicular to both the x-axis and
tem allows measurement of the three-dimen- z-oxis (i.e., the anterior / posterior axis).
sional position and orientation of a sensor in The center of the humeral head was calcu-
relation to a source with six degrees of freedom. lated and defined in two ways, as previously
The accuracy of this system is proven to be quite described." Both the geometric center and the
high.I.9. 10. 19 kinematic center were similar. In this study the
After the experiments the glenohumeral joint kinematic center was used to represent the cen-
was disarticulated,.and several anatomic land- ter of the humeral head.
marks on the humerus and scapula were digi- The y-axis values of the center of the humeral
tized . A coordinate system was established with head were used in anterior or posterior trans-
the data such that the point defining the origin lation test analyses, and the z-axis values were
of the coordinate system was at the center of used in inferior translation test analyses.
the glenoid. This center was determined by de- Statistical analysis. Because the same
138 Itoi et 01. J. Shoulder Elbow Surg.
May/June 7994

-. 1.0
S
U
Sup. o LHBOkg
t
• LHB 1.5 kg
'-'"
A
--g LHB3kg

a.>
::r: 0.5 p=O.OO73
c;J p=O.OO57
J-c NS
S 1 +
:E
~
0
0.0 . . .l . .t... .!.. . . . .J. .:....... . .~. . .t. . . ±.. ..
s
.....
.........
CZl
~
0
c, -0.5 Inf.
IR NR ER
Flgu.re 3 Passive change of humeral head position in inferior direction
with LHB loading . Position of humeral head before applying inferior trans-
lation force moved superiorly with LHB loading. Superior translation was
significant in neutral (p = 0.0073) and external rotation (p = 0.0057) but
not in internal rotation .

specimens were tested multiple times under dif- rotations (p = 0.0057); the 1.5-kg and 3-kg
ferent conditions, a repeated measures analysis loaded positions were sign ificantly higher than
of variance was used to determine which design without loading in the neutral pos ition, and the
variances were significant. The Student-New- 3-kg loaded position was significantly higher
man-Keuls multiple comparisons procedure than that w ithout loading in external rotation.
was used to determine which individual mean There was no significant difference in internal
values were significantly different. Statistical rotation.
significance was set at the 5% level. Anterior displacement was defined as the dis-
tance the center of the humeral head moved
RESULTS along the y-axis after the application of 1.5 kg
The center of the humeral head in the ante- of anterior translation force to the humerus. In
rior / posterior direction before the application neutral rotation application of 1.5 kg and 3 kg
of translation force is shown in Figure 2. With of load to the LHB significantly decreased an-
increased loading of the LHB, the humeral head terior- displacement (p = 0.0012, Figure 4). In
moved posteriorly. This posterior shift has high external rotation each displacement was sig-
statistical significance in internal (p < 0.0001) nificantly different from one another (p <
and neutral rotation (p < 0.0001), with each po- 0.0001). In internal rotation displacements
sition differing significantly from the other. In without LHB loading and with 1.5 kg of load
external rotation the posterior shift was also sig- were not significantly different, whereas dis-
nificant (p = 0.0141), but there was no signifi- placement with a 3-kg load was significantly
cant difference between the 1.5-kg loaded po- smaller than the other two (p = 0.0025).
sition and the 3-kg loaded position. The load imparted to the LHB significantly re-
The position of the head in the superior / in- duced posterior displacement in all rotations
ferior direction before the application of trans - (Figure 5). With internal and external rotations,
lation force is shown in Figure 3. With increased 1.5 kg of load to the LHB significantly decreased
loading of the LHB, the humeral head translated displacements (p = 0.0005 and p = 0.0002, re-
superiorly in every rotation of the arm. This was spectively), but there were no significant differ-
significant in neutral (p = 0.0073) and external ences between the 1.5-kg and 3-kg loads. In
J. Shoulder Elbow Surg. Itoi et 01. 139
Volume 3, Number 3

o LHBO kg
p=0.0012
I:J LHB 1.5 kg
• LHB 3 kg

p<O.OOO I

p=0.OO25

IR NR ER
Figure 4 Resistance to anterior displacement of humeral head by LHB
loading. LHB loading of 1.5 kg significantly reduced anterior displacement
caused by l.5-kg translation force in neutral and external rotations but not
in internal rotation. Application of 3-kg weight to LHB significantly reduced
anterior displacement in all rotations.

,..-.., 1.0 o LHBOkg

S
U
I:J LH B 1.5 kg
'--' • LHB 3 kg p<O.OOO l
.....
5 p=O.OOO2
s
~
p=0.OOO5

~
~ 0.5
... .
r/J

o I-;

..o. .
I-;
~
.....
r/J
o
0.. 0.0 4'--'--"-'-''''''''
IR NR ER
Figure 5 Resistance to posterior displacement of humeral head by LHB
loading. Posterior displacements caused by 1.S-kg translation force were
Significantly decreased by LHB loading of 1.5 kg in all rotations.

neutral rotation displacements under the var- ments (Figure 6). The only significant decrease
ious loading conditions of the LHB differed sig- in displacement was with 3 kg of load to the
nificantly (p < 0.0001). LHB in external rotation (p = 0.0227).
Inferior displacements were much smaller The decrease in displacement after the ap-
compared with anterior and posterior displace- plication of a 3-kg load on the LHB was termed
140 Itoi et 01. J. Shoulder Elbow Surg.
Moy/ June 7994

---E 0.6 0 uta 0 kg

I:J UlB 1.5 kg
U
<:»
....c • LHB 3 kg

(l.)
E
(l.)
0.4
p=O.0227
o NS
ro
......
0..
..en. .
a 1-<
0.2
.....1-<
0

~
~ = 0.0
IR NR ER
Figure 6 Resistance to inferio r displacement of humeral head by LHB
loading . Displacement values were smaller than anterior or posterior d is-
placement values . LHB loading of 3 kg significantly reduced inferio r dis-
placement caused by 1.S-kg translation force in external rotat ion . There
were no signif icant differences in other rotations .

a decrease ratio. In the anterior translation test der function in a coordinated fashion . It is un-
the decrease ratio was 0.65 with the arm in ex- likely that a single muscle is active while all the
ternal rotation and 0.64 with the arm in neutral other muscles are silent. Furthermore, activities
rotation, whereas it was 0.33 with the arm of the rotator cuff and the deltoid may be of
in internal rotation, which was significantly such magnitude to overshadow the potential ef-
smaller than the two former ratios (p = 0.0041). fect of the LHB observed in this study.
In the posterior and inferior directions there The restricting effect of the LHB to the trans-
were no significant differences between the de- lation of the humeral head was moderately in-
crease ratios. fluenced by the relatively small amount of hu-
meral rotations. This influence may be ex-
DISCUSSION plained by the change of anatomic relationship
In this study we observed that the passive ten- between the LHB and the humeral head (Figure
sion of the LHB restricted the translation of the 7). In internal rotation the LHB is located an-
humeral head in all directions tested, especially terior to the humeral head, thus the compressive
in anterior/posterior directions. It must be em- force is less efficiently transmitted to the hu-
phasized that this investigation conducted in the meral head. In addition to this anatomic rela-
laboratory cannot be directly translated into the tionship, the joint laxity itself changed signifi-
clinical setting. However, interpretation of our cantly with the humeral rotation; it was minimal
results might suggest that active contraction of in internal rotation because 30 0 of internal ro-
the biceps restricts the forced movement of the tation was close to the maximum in most spec-
humeral head. Application of this result to in imens. Decreased laxity seemed to make the
vivo dynamic stabilization is difficult because of restricting effect of the LHB less conspicuous in
the following reasons . (1) The most common internal rotation.
type of instab ility is anterior instability, and it When the LHB was loaded, the humeral head
usually occurs with the arm in abduction and shifted superiorly, but the inferior translation of
external rotation. This study was performed with the humeral head was restricted concomitantly.
the arm at the side, which is less clinically rel- This phenomenon can be explained as follows.
evant. (2) In vivo, all muscles around the shoul- With the arm at the side, the head had already
J. Shoulder Elbow Surg. Itoi et 01. 141
Volume 3, Number 3

Figure 7 Relation between humeral head and LHB in var ious rotations
(seen from above) . A, In 30 0 internal rota tion , or B, neutra l rotat ion , LHB
is located anterolateral to humeral head , whereas C in 30 0 external rotat ion ,
it runs almos t perpendicular to glenoid surface . All figures are views from
above: arrow ind icates anterio r direction , and asterisk indicates LHB. G,
Glenoid; H, humeral head.

been shifted slightly to the inferior direction be- orientation, joint configuration, balance of mus-
cause of the weight of the arm and loss of mus- cle tension, and direction and amount of exter-
cle tone, although the negative intraarticular nally imposed loading. Our data suggest the
pressure, an important inferior stobilizer."" was possibility that the LHB can potentially function
intact. The passive tension of the LHB was trans- as a dynamic stabilizer and is consistent with
mitted both to the glenoid and the humerus some observations in the literoture." To further
through the intramedullary rod, which might clarify the roles, however, development of a
push the humerus upward. This superior shift more sophisticated model with all the muscles
seemed to bring the head into a more stable balanced and clinical evidence such as hyper-
position, because the inferior translation was trophy of the biceps in unstable shoulders or
restricted in this upward-shifted position. This increased EMG activity of the biceps in unstable
observation, therefore, does not contradict the shoulders are necessary. Such information
idea that the LHB is a head depressor. In fact, should assist in the interpretation of the role of
when superior translation force was applied, stabilizing function of the LHB as presented
superior translation of the humeral head would here.
also be limited by the LHB loading.
As mentioned previously this is a simpl ified REFERENCES
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May/June 1994

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