Professional Documents
Culture Documents
Long Head of Biceps
Long Head of Biceps
Abstract
Background This review aimed to explore the available literature to update our understanding of the long head of
biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform
future research and management directions.
Methods PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st
December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in
English.
Results 214 articles were included in the final analysis, and results were categorised into six emergent themes: (1)
Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and
an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly
reported theme. (2) Function - Bicep’s role in glenohumeral elevation and stability in healthy shoulders is minimal.
In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with
rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff
disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with
symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited
diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of
magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was
moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy’s
limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into
the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of
injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management
- For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis
and tenotomy report similar improvements in pain without any significant adverse effect on strength or function.
Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain,
with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with
adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in
isolation.
*Correspondence:
Brendan Diplock
[email protected]
Full list of author information is available at the end of the article
© Crown 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the
article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need
to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 2 of 19
Conclusions The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and
suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals
with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting
a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established;
however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The
diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations
of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-
surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain.
Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients
undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff
tear progression to failure and long-term shoulder function is unknown, and further research is required.
Pre-registration OSF: https://osf.io/erh9m
Keywords Anatomy, Assessment, Function, Long head of biceps, Management, Scoping review, Shoulder
publications (Table 1). Studies were categorised into stability in the bicipital groove, as detailed in Supplemen-
emergent themes; (a) anatomy, (b) function, d) pathol- tary Table 3.
ogy, e) assessment and f ) management. Emergent themes
were further dichotomised into sub-themes and by the Impact of variation
level of evidence (Table 2). Of the twenty individual case studies in Supplementary
Tables 2, fourteen reported shoulder pain associated
Anatomy with the anatomical variation, an association between
The normal origin of the Long Head of the Biceps (LHB) pain and aberrant origins in nine studies and pain and
has traditionally been from the supraglenoid tubercle and LHBT absence in five studies. In four case studies, three
superior labrum, with its proximal tendon tracking dis- articles reported shoulder instability associated with an
tally through the rotator cuff interval where the biceps absence of the LHBT and shoulder instability and weak-
pulley envelops it and houses within the biceps groove. ness in one case study. Shoulder instability and pain were
Upon exiting the biceps pulley, it travels under the trans- reported in five articles, associated with aberrant origins
verse humeral ligament, where it joins the short head of in two case studies and LHBT absence in three case stud-
the biceps to form the biceps brachii muscle belly, shar- ies. Two articles observed a single aberrant origin and
ing a common distal tendon attachment onto the radial absent LHBT associated with shoulder pain and restric-
tuberosity ligament [19]. Thirty-six articles in Supple- tion of movement in two case studies. A solitary case
mentary Table 2 include normal anatomical variations study observed a Partial Articular-sided Supraspinatus
of the biceps brachii and the impact of aberrant origins, Tendon Avulsion (PASTA) in two patients with an anom-
supernumerary accessory heads and a congenital absence alous origin of the LHBT from the Supraspinatus. Two
of the LHBT on shoulder pain and function. Supplemen- large case series studies and a single systematic review
tary Table 3 includes three studies on the normal anat- reported a positive correlation between (a) observed
omy of the transverse humeral ligament. anatomical variances of the LHBT origin and the pres-
ence of anterosuperior labral fraying (odds ratio, 3.58;
Anatomical variation p = 0.000), abnormal superior glenohumeral ligament
Of the thirty-nine articles on biceps brachii anatomy (odds ratio, 3.69; p = 0.012) [57], and (b) LHBT absence
found, thirty-six papers reported anatomical variations and the presence of shoulder pain (85.7%) and instability
from normal. Supplementary Table 2 details the reported (37.1%) [167]. Whilst shoulder joint instability was more
variants by type and number. The most common prevalent in biceps variations in the mesotenon; it did
observed anatomical variations pooled across all 36 stud- not reach significance (27.6%: 14.9%, p = 0.305) [163].
ies included a) aberrant origins (n = 136), supernumerary
accessory heads (n = 98) and LHBT absence (n = 48). The Function
most common aberrant origin of the LHB at the shoul- In this section of LHB function at the shoulder, forty-
der was the presence of a bifurcate tendon origin in seven seven articles were categorised under the subthemes of
articles and an anomalous LHBT origin from the supra- (a) biceps electromyography, (b) shoulder biomechanics
spinatus in six articles. A trifurcate origin of the LHBT (Supplementary Table 4), (c) shoulder stability in vivo
was seen in three studies, with a solitary case of Chon- (Supplementary Table 5), (d) glenohumeral joint arthro-
droepitrochlearis and an LHBT traversing through a bifid kinematics in vitro (Supplementary Table 6), and (e)
Subscapularis found in one paper. Nine studies reported shoulder proprioception as detailed in Supplementary
the presence of a third supernumerary head in forty-nine Table 7.
shoulders, and two reported a four-headed biceps vari-
ant in nine shoulders. The overall reported prevalence Electromyography (EMG)
of anatomical variations of the biceps brachii in the case Twenty-seven studies used electromyography (EMG) to
study series ranged from 2.2 to 70% [28, 34, 36, 57, 58, investigate the activity of the biceps brachii, as detailed
86, 113, 163], as detailed in Supplementary Table 2. Three in Supplementary Table 4. Thirteen studies differentiated
studies reported no distinct anatomical structure of the long head vs. short head of biceps activity. Sixteen studies
transverse humeral ligament to support a role in LHBT used surface electromyography (sEMG) to record biceps
Table 2 Characteristics of included studies by themes and level brachii activity during functional tasks of the shoulder
of evidence [21, 29, 42, 44, 70, 83, 84, 103, 112, 114, 116, 117, 121,
Themes Level of evidence (LOE) 159, 190, 213]. Four studies used fine wire electromyog-
Anatomy Level 1 Level 2 Level 3 Level 4 Level 5
raphy (fwEMG) to record biceps brachii muscle activity
(n = 39) (n = 0) (n = 1) (n = 1) (n = 27) (n = 10)
[20, 23, 25, 51]. Seven studies used a combination of both
Reference - [57] [163] [8, 34, 39, 54, [28,
number(s) 56, 58, 63, 33, 36, sEMG and fwEMG for recording activity of the biceps
68, 74, 79, 69, 76, brachii and other shoulder muscles, such as the rotator
82, 105, 109, 80, 86, cuff and deltoid muscles [40, 46, 52, 101, 102, 120, 228].
123, 125, 113,
129, 141, 138,
Biomechanics
144, 167, 219]
171, 173, Thirteen articles detailed in Supplementary Table 4
184, 185, investigated the role of the LHB in healthy shoulders.
189, 207, Six studies demonstrated LHB muscle activity during
209, 212] shoulder elevation [20, 21, 44, 70, 103, 116]. Three stud-
Function Level 1 Level 2 Level 3 Level 4 Level 5 ies validated LHB activity during overhead throwing and
(n = 47) (n = 1) (n = 3) (n = 16) (n = 14) (n = 13)
bowling [23, 84, 114]. In contrast, four studies supported
Reference [193] [99, 120, [20, 25, 37, [21, 23, 29, [27,
no significant LHB activity during shoulder elevation
number(s) 130] 42, 47, 51, 65, 40, 44, 46, 30–32,
83, 102, 103, 52, 70, 78, 35, 38, [40, 52, 101, 121]. Studies using an elbow brace or elbow
114, 116, 84, 101, 112, 50, 85, flexor fatigue protocol to minimise biceps function at the
121, 190, 117, 159] 88, 94, elbow confirmed an active role of the LHB during shoul-
213, 228] 100, der elevation in two studies [44, 116].
106,
In contrast, three studies found no significant or mini-
153]
Pathology Level 1 Level 2 Level 3 Level 4 Level 5
mal activity of the LHB during shoulder elevation [40, 52,
(n = 37) (n = 2) (n = 4) (n = 18) (n = 10) (n = 3) 121]. Two studies of biceps brachii activity during com-
Reference [178, [48, 89, [53, 55, 61, [22, 45, 59, [24, 64, mon therapeutic shoulder exercises demonstrated the
number(s) 196] 158, 198] 62, 87, 98, 75, 77, 111, 96] highest biceps activity in the sagittal plane, during unsup-
148, 152, 124, 137, ported elbow flexion and supination, from an extended
157, 161, 172, 195] position (e.g., shoulder extension) or during high-veloc-
177, 179,
191, 197,
ity explosive exercises such as underarm throwing [117,
203, 205, 159]. Two studies reported more significant activity and
217, 227] strength production of biceps brachii during biceps curl
Assess- Level 1 Level 2 Level 3 Level 4 Level 5 variations in shoulder elevation [83, 112]. One study
ment (n = 10) (n = 20) (n = 8) (n = 9) (n = 3) reported more significant biceps brachii activity dur-
(n = 50) ing isometric shoulder external rotation in sitting than
Reference [43, 95, [41, 60, [122, 134, [49, 66, 72, [119,
supine. One study supported a pre-activation and a pre-
number(s) 107, 67, 73, 81, 155, 156, 135, 140, 151,
108, 90, 104, 160, 162, 144, 164, 220] setting role of the LHB and rotator cuff during shoulder
118, 110, 115, 199, 206] 176, 180] rotation at 45° scaption in normal asymptomatic subjects
128, 132, 139, [46].
150, 149, 165,
183, 166, 168,
Shoulder stability
188, 169, 175,
221] 181, 187, Six in vivo studies examined the role of the biceps bra-
214] chii in shoulder stability, as detailed in Supplementary
Manage- Level 1 Level 2 Level 3 Level 4 Level 5 Table 5. Five studies support a role in glenohumeral joint
ment (n = 7) (n = 7) (n = 18) (n = 7) (n = 2) stability and humeral head depression [37, 47, 56, 65,
(n = 41) 78] and a single study reported a minor role in shoul-
Reference [97, [91, 114, [19, 26, 71, [133, 143, [186, der stability [99]. Active humeral head depression at the
number(s) 131, 126, 182, 92, 93, 136, 145, 147, 225]
shoulder by the biceps brachii in patients with rotator
142, 210, 226, 146, 154, 202, 218,
201, 229] 170, 174, 224] cuff lesions was observed under radiology assessment
215, 192, 194, in one study [47]. A large study by Walch, Edwards [65]
230, 200, 204, of 291 patients undergoing LHB tenotomy for irrepa-
231] 208, 216, rable full thickness tears of the rotator cuff demon-
222, 223]
strated a significant superior migration of the head of
Totals Level 1 Level 2 Level 3 Level 4 Level 5
(n = 214) (n = 20) (n = 35) (n = 61) (n = 67) (n = 31)
the humerus following tenotomy. A single case report
of incidental arthroscopy findings of LHBT absence
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 6 of 19
reported an association with shoulder instability which to the contralateral uninjured shoulders and controls, as
improved after thermal capsulorraphy [56]. A study of detailed in Supplementary Table 7.
seven patients with an LHBT absence under arthroscopy/
MRI demonstrated superior glenohumeral translation in Pathology
shoulders compared to intact shoulders [37]. One study Thirty-five diagnostic studies in Supplementary
of thirty asymptomatic volunteers showed a dynamic Tables 8 and eight EMG studies, as detailed in Supple-
role of the LHB in glenohumeral joint stability during mentary Tables 9, were categorised under the sub-
low angles of shoulder elevation < 30° [78]. In contrast, themes of LHBT pathology, rotator cuff pathology and
a study of five patients undergoing biceps tenodesis for compensation.
chronic biceps tenosynovitis demonstrated no significant
alterations in glenohumeral joint position or activity after Long head of biceps pathology
LHB tenotomy compared to healthy shoulders [99]. As detailed in Supplementary Tables 8, common LHBT
pathologies include tendon instability, tendinopathy (rup-
Glenohumeral joint arthrokinematics tures, tears, lesions, tendinitis, sheath effusions), bicep
Thirteen in vitro cadaver studies detailed in Supplemen- pulley lesions, bicipital groove dysplasia, labral variants/
tary Table 6 examined the role of the LHB in intact shoul- SLAP lesions and an absence of LHBT. Observed biceps
ders and six articles with simulated shoulder injuries, pathology associated with the LHB’s anatomical varia-
including rotator cuff tears, Bankart and superior labral tions involved anterosuperior labrum variants, a Buford
lesions [30–32, 35, 88, 94]. Ten studies demonstrated complex, SLAP lesions, and biceps instability [53, 77,
a shoulder stability role for the LHB [30–32, 35, 38, 85, 205, 227]. Other pathological associations included; (a)
88, 94, 106, 153]. Six studies demonstrated a humeral LHBT pulley lesions and degenerative LHB tendinopathy
head depressor role [27, 38, 50, 88, 106, 153]. One study with biceps instability and degenerative glenohumeral
demonstrated a glenohumeral joint compressor role joint disease [111], (b) LHB tendinitis and pro-inflam-
[100]. The observed and often stated limitations of the matory mediators, neovascularisation, and gene expres-
cadaver studies found included rationales to determine sion [191], (c) absent LHBT and shoulder pain [179], (d)
appropriate biceps forces in vitro that accurately repre- LHBT rupture, instability with shoulder pain and perma-
sent the normal physiological loads of the LHB in vivo. nent elbow/forearm strength and endurance loss [62],
Three studies used a biceps load of 55-N force, predicted and LHBT tears with occult distal biceps lesions extend-
from the Physiological Cross-Sectional Area (PCSA) ing beyond the biceps groove (Supplementary Table 15)
of the biceps brachii [35, 38, 88]. Two studies used pro- [135].
gressive biceps loads of 10, 20 and 40-N based on previ-
ously published PCSA values [100, 153]. A single study Rotator cuff pathology
used %PCSA (55-N) to determine a passive 5 N (10%) Concomitant rotator cuff pathology associated with LHB
and active 25 N (50%) biceps preload [94]. A single study tendinopathy includes rotator cuff tears, Supraspina-
used PCSA to determine physiological biceps loads tus and Subscapularis tears, Supraspinatus tendinopa-
with no reported values stated [50]. Two studies used a thy and rotator cuff tendinopathy. A high association
biceps load of 1.5 and 3 kg [30] and 1.5 kg [31], propor- was observed between LHBT instability and rotator cuff
tional to PCSA. Two studies used a 3 kg [27] and a 20-N pathology in twelve articles, inclusive of Subscapularis
[106] simulated biceps load with no reported rationale. tears in eight articles [61, 98, 137, 152, 178, 195, 196, 203],
Two studies calculated physiological biceps loads using isolated Supraspinatus tears and Subscapularis tears in
a combination of PCSA and EMG percentage of a maxi- two studies [24, 227] and rotator cuff tears in two studies
mal voluntary contraction during a functional task, e.g., [45, 75]. A lower association was observed between the
throwing [32, 85]. incidence of biceps pulley lesions and rotator cuff tears,
SLAP lesions, anterosuperior impingement and increas-
Shoulder proprioception ing age [89]. Absence of the LHBT with rotator cuff tears
No direct evidence for or against the role of the LHB in [217]. Biceps groove morphology with LHBT instability
proprioception at the shoulder was found. Two system- and Subscapularis tendinopathy [157, 158]. LHBT sheath
atic reviews on proprioception and shoulder pain/pathol- effusion and rotator cuff tears [148] and increased cross-
ogy were found. Ager, Borms [193] reported moderate sectional area of LHBT with rotator cuff tears [64] as
evidence for an affected sense of kinaesthesia and insuf- detailed in Supplementary Table 8.
ficient evidence for an impaired sense of force amongst
painful shoulders. Fyhr, Gustavsson [130] reported defi- Compensation
cits in movement sense and passive joint reposition sense Eight EMG studies were found directly supporting
following post-traumatic shoulder instability compared increased muscle activation of the biceps brachii in the
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 7 of 19
presence of rotator cuff pathology and shoulder insta- was yet to be established. The other more recent study
bility, as detailed in Supplementary Table 9. Two stud- [175] reported moderate inter-rater reliability but found
ies demonstrated significant hyperactivity of the biceps the association between within-session and between-ses-
brachii compared to control groups in the presence of sion changes in pain regarding treatment efficacy for the
rotator cuff tears during reaching and shoulder elevation Shoulder Symptom Modification Procedure (SSMP) to be
tasks [42, 102]. A single study reported a significant delay insufficient. The authors consequently concluded that the
in anticipatory muscle activation in subjects with rota- Shoulder Symptom Modification Procedure (SSMP) was
tor cuff tears during a ball drop task [213]. A recent study not reliable or valid for managing shoulder pain. A single
demonstrated both hyperactivity and pre-activation of study of a symptom modification test cluster for shoulder
the biceps brachii in patients with rotator cuff tears dur- instability reported a significant, meaningful relationship
ing reaching tests [228]. In support of biceps activity between GIRD - glenohumeral internal rotation deficit
during throwing, two studies reported significant hyper- and an impingement GIRD apprehension-relocation test
activity of the biceps brachii during simulated pitching cluster [206].
and cocking phases of throwing in subjects with anterior Several systematic reviews and diagnostic studies
shoulder instability vs. controls [25, 51]. In contrast to examined the validity of traditional and contemporary
the observed changes in muscle activity with rotator cuff Orthopaedic special tests for LHBT pathology with con-
pathology, two studies reported no significant differences siderable variability found, whilst two studies showed
in (a) biceps brachii activity with the elbow immobilised a limited diagnostic yield of bicipital groove tenderness
in a brace during shoulder range of motion in patients for LHB tendinopathy [73, 169], as detailed in Supple-
with rotator cuff tears vs. controls [40] and (b) in activity mentary Table 11. Three high levels of evidence studies
or fatigue of the biceps brachii during a gripping task in supported the use of test clusters to improve their diag-
patients with rotator cuff tears [120]. nostic yield (biceps groove palpation, Speed’s, Yergason’s
and Uppercut test) with higher diagnostic utility demon-
Assessment strated when performed in combination with diagnostic
Assessing the LHBT in the clinical examination can be ultrasound (Supplementary Table 12) [81, 169, 183].
completed in several ways. Fifty articles investigating the
assessment of the LHBT pathology at the shoulder were Magnetic resonance imaging and arthrography
categorised into several sub-themes, including (a) screen- Eighteen studies were found investigating the validity
ing questionnaires and (b) clinical examination (Supple- of Magnetic Resonance Imaging (MRI) and Arthrog-
mentary Tables 10, 11 and 12), (c) diagnostic imaging raphy (MRA), compared with arthroscopic surgery in
such as magnetic resonance imaging/arthrography seventeen of the eighteen studies found diagnosing
(Supplementary Table 13) and ultrasound, (d) diagnostic proximal LHBT pathology at the shoulder, exclusive of
injections (Supplementary Table 14) and (e) arthroscopy SLAP lesions and labral pathology as detailed in Supple-
(Supplementary Table 15). mentary Table 13. Overall diagnostic accuracy, speci-
ficity, and sensitivity values for MRA were superior to
Screening questionnaires MRI for LHBT pathology, though, the difference was
As detailed in Supplementary Tables 10, a single article negligible. Both diagnostic utilities varied considerably
reported limited validity for using postoperative screen- for LHB tendinopathy, including tears, tendinitis, tendi-
ing questionnaires to assess pre-operative LHBT pathol- nosis, instability, and pulley lesions. There was an over-
ogy [149]. all trend for low sensitivity and high diagnostic accuracy
and specificity values for the exclusion and detection of
Clinical examination full thickness and complete tears of the LHBT for both
As detailed in Supplementary Tables 10, a single study MRI and MRA, respectively, compared with low specific-
established a clinical examination algorithm for the ity and sensitivity values to rule in and out partial thick-
standardisation of shoulder assessment, including the ness tears of the LHBT [60, 90, 118, 139, 150, 155, 180,
differential diagnosis of biceps pathology [220]. Three 188]. LHBT instability demonstrated variable specificity,
studies examined the clinical utility of a symptom modi- and sensitivity values with a trend for higher specificity
fication approach to diagnosing and managing shoul- values to rule in dislocation of the LHBT compared with
der musculoskeletal conditions, including Rotator cuff subluxation, whilst the sensitivity values in many of the
and LHB-related shoulder pain. Of two studies on the studies identifying LHBT instability were poor [60, 90,
Shoulder Symptom Modification Procedure (SSMP), one 118, 134, 139, 150, 155, 165, 180, 188]. In a single system-
[151] found high inter-rater reliability. Yet, the authors atic comparison of MRI and MRA, MRA demonstrated
acknowledged that the efficacy of the Shoulder Symptom higher specificity for detecting LHBT appearance and
Modification Procedure (SSMP) in treating shoulder pain position than MRI [221]. A single study of biceps pulley
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 8 of 19
lesions on MRA compared with arthroscopy reported used in most diagnostic and imaging studies, as detailed
high accuracy, sensitivity, and specificity values for MRA in Supplementary Tables 11, 12, 13, and 14. In Supple-
[104]. Contrary to clinical intuition, a single study of mentary Tables 15, the limitations of arthroscopy to fully
the impact of Body Mass Index (BMI) on MRI accuracy evaluate the proximal intra-articular LHBT-labral com-
demonstrated significantly higher diagnostic accuracy of plex and identify occult extra-articular bicipital tunnel
MRI for the detection of Bankart lesions in both over- lesions were reported in four articles [119, 132, 140, 164].
weight and obese patients when compared with patients
with a healthy Body Mass Index (BMI) (Supplementary Management
Table 10) [214]. In this section of Management, forty-one articles
were categorised under non-surgical (Supplementary
Diagnostic ultrasound Tables 16 and 17) and surgical management. Surgical
Ten studies examined the validity of diagnostic ultra- management was further dichotomised into operative
sound in detecting LHBT pathology compared with intervention for (a) LHBT-related shoulder pathology
arthroscopy in four studies, arthroscopy/open surgery (Supplementary Table 18), (b) rotator cuff-related shoul-
in two, arthroscopy/arthrotomy in one and MRI in two der pathology (Supplementary Table 19) and (c) rotator
studies, as detailed in Supplementary Table 14. Two cuff and LHBT-related shoulder pathology, as detailed in
articles reported high specificity and sensitivity values Supplementary Table 20.
for ruling in and out full-thickness tears. In comparison,
there was an observed trend for lower sensitivity values Non-surgical management
to rule out partial thickness tears of the LHBT [67, 95]. Supplementary Table 16 details our limited findings of
Two studies demonstrated variable specificity and sensi- four articles reporting on the non-surgical management
tivity for complete tears [128, 181]. Two studies showed of LHB-related shoulder pain. A single paper presented
high specificity for LHBT rupture [49, 181]. Biceps a care pathway for shoulder pain management, includ-
instability demonstrated an overall trend for increased ing LHBT management in primary care [220]. Two EMG
specificity and sensitivity values for ruling in and out dis- studies demonstrated a progression of biceps-targeted
location > subluxation of the LHBT [43, 49, 67, 128, 181]. activity from least active to most active during common
The specificity of diagnostic ultrasound to rule in tendini- shoulder rehabilitation exercises in healthy subjects [117,
tis was high, and its sensitivity to rule out tendinitis was 159]. A single study by McDevitt, Snodgrass [202] dem-
low [43, 110]. A single cross-sectional study comparing onstrated support for including dry needling, eccentric,
the diagnostic accuracy of ultrasound vs. MRI in detect- concentric exercise, and biceps brachii stretching for
ing LHBT pathology to arthroscopy showed a trend for managing chronic LHB tendinopathy.
higher specificity for MRI compared to diagnostic ultra- Seven studies investigated the injection of dye, local
sound for identifying proximal LHBT pathology. Sensi- anaesthetic, and corticosteroid into the LHBT sheath
tivity values for both remained poor [162]. (Supplementary Table 17). None compared injection
with no injection or placebo. Six reported greater accu-
Diagnostic injection racy and pain relief when injections were guided by ultra-
A single study on diagnostic injections for LHBT sound or fluoroscopy than unguided injections [91, 93,
pathology reported high specificity but low sensitivity 97, 126, 210, 232]. One cadaver study found a high rate
to exclude LHBT pathology [169]. A cadaver study by of dye migration into the glenohumeral joint capsule and
Gofeld, Hurdle [186] demonstrated the spread of injec- the potential for wanted or unwanted deposition of injec-
tate from the biceps sheath into the glenohumeral joint tate into the intra-articular glenohumeral joint [186].
and cartilage in 92% of specimens suggesting the lim- One article compared non-surgical care versus tenode-
ited diagnostic utility of injections for LHB pathology as sis for LHBT ruptures. Patients managed non-surgically
detailed in Supplementary Table 14. tend to return to work quicker but at lesser capacity and
with less elbow flexion and forearm supination strength
Arthroscopic surgery than patients who underwent biceps tenodesis [26]. One
Supplementary Table 15 detailed four clinical studies systematic review reported common surgical indications
that presented findings of LHBT pathology (lipstick sign, for tenodesis, including LHBT tears, instability, and teno-
sentinel sign, chondral print, and the ramp test). One synovitis [145].
study reported the presence of a detour sign on MRI as
a useful clinical indicator of LHBT subluxation, occult Surgical management
Subscapularis, and Supraspinatus rotator cuff pathology In total, thirty-five articles compared postoperative out-
[166]. Arthroscopic surgery as a standard gold reference comes in patients undergoing LHB tenodesis versus
for confirmation of LHBT pathology at the shoulder was tenotomy, with tenodesis the most common procedure
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 9 of 19
reported (n = 9983) vs. tenotomy (n = 6855). Twenty-two Result findings are medium-term and likely to represent
articles examined LHB tenodesis and tenotomy outcomes post-surgical outcomes over time.
in subjects with LHBT-related shoulder pathology in iso-
lation (Supplementary Table 18). Six articles investigated Adjunctive surgery on a healthy LHBT for rotator cuff
the effects of adjunctive LHBT surgery in subjects with pathology
rotator cuff-related shoulder pathology (Supplemen- Of the six articles reporting outcomes of adjunctive
tary Table 19), and seven articles reported tenodesis and biceps surgery for repairable and irreparable rotator cuff
tenotomy outcomes in subjects with concomitant rotator tears, similar levels of patient satisfaction and PROMS
cuff and LHBT-related shoulder pathology, as detailed in were observed across all studies, as detailed in Supple-
Supplementary Table 20. mentary Table 19. Two articles comparing post-operative
clinical outcomes of patients undertaking either tenode-
Surgery for LHBT pathology sis or tenotomy for irreparable rotator cuff tears without
For subjects undergoing tenodesis vs. tenotomy for rotator cuff repair reported high levels of patient satisfac-
LHBT-related shoulder pathology, the overall postop- tion and PROMS [65, 71]. Of the four articles investigat-
erative Patient Reported Outcome Measures (PROMS) ing adjunctive tenodesis or tenotomy with rotator cuff
were similar for both tenodesis and tenotomy, across repair, higher surgical costs were reported in patients
the twenty-two articles found, with a minor trend for who underwent (a) rotator cuff repair with adjunctive
improved constant scores in favour of tenodesis in three tenodesis compared with adjunctive tenotomy or rota-
articles [131, 194, 224]. A higher prevalence of Popeye tor cuff repair in isolation and (b) arthroscopic tenode-
deformity in fourteen articles and cramping arm pain in sis compared with open biceps surgery [218, 222]. There
six were observed in patients who undertook tenotomy was a trend for a higher incidence of Popeye deformity
vs. tenodesis, as detailed in Supplementary Table 18. in three articles [71, 133, 154] and cramping arm pain in
Decreased post-operative narcotic use and quicker pain one article [154] for patients who underwent tenotomy.
relief was observed in one article for patients follow- An article by Meraner, Sternberg [154] reported greater
ing biceps tenotomy [182], with longer surgical times postoperative shoulder abduction strength in patients
observed in patients post-tenodesis [131]. Three studies who underwent rotator cuff repair with adjunctive teno-
that dichotomised their results by patient demograph- desis compared with tenotomy. In addition to the six
ics showed a greater incidence of Popeye deformity in articles discussed, one clinical trial by Godenèche, Kempf
male patients [92], with less satisfaction in younger male [174], Supplementary Table 20 compared clinical out-
patients following tenotomy compared with tenode- comes following tenodesis or tenotomy in subjects with
sis [229]. Male gender, younger age, and active worker’s Supraspinatus rotator cuff tears and no LHBT pathology
compensation were associated with increased complica- (normal) vs. Supraspinatus rotator cuff tears with LHBT
tions following tenotomy [204]. For articles comparing pathology over a 10-year follow-up period. For patients
LHB tenodesis vs. tenotomy for LHBT or SLAP pathol- with a healthy LHBT, similar constant scores were
ogy, similar trends were observed, with no significant reported between Supraspinatus repair in isolation and
differences in postoperative PROMS for pain, function, Supraspinatus repair with either adjunctive tenodesis or
and strength [197, 215, 216]. However, a more signifi- tenotomy. The authors concluded that adjunctive LHBT
cant trend was observed for increased shoulder flexion surgery with Supraspinatus repairs should be avoided
range of motion (ROM) and less postoperative stiff- intraoperatively in patients with a normal LHBT. In the
ness in patients who undertook open compared with seven articles, post-surgical follow-up times ranged from
arthroscopic tenodesis [216]. One article by Horan, 12 months to 10 years. Except for one 10-year study,
Dekker [197] comparing SLAP repair vs. biceps tenode- most studies reported a mean follow-up time of ≤ 3 years.
sis in young overhead-throwing athletes demonstrated Result findings were, therefore, medium to long-term
PROMS with a high rate of return to overhead-throw- and likely represented stable post-surgical outcomes over
ing sports. Similar strength scores were reported across time.
all studies, apart from two articles reporting subjective
biceps weakness at the elbow following tenotomy [92, Surgery for rotator cuff and LHBT pathology
204]. A comparison of arthroscopic vs. open tenode- As detailed in Supplementary Tables 20, seven arti-
sis reported greater postoperative shoulder flexion for cles reported postoperative outcomes in subjects with
patients who underwent open tenodesis [146]. Post- concomitant rotator cuff and LHBT-related shoulder
surgical follow-up in the twenty-two articles was highly pathology. Five articles reported similar post-operative
variable, ranging from 3 months to 13 years, with many clinical results in subjects who undertook routine rota-
studies reporting a mean follow-up time ≥ two years. tor cuff repair and adjunctive tenodesis or tenotomy,
with a trend for higher constant scores in patients who
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 10 of 19
undertook tenodesis [19, 142, 147, 170, 225]. Again, there found an established humeral head depressor function
was a trend for a higher incidence of Popeye deformity at the shoulder in (a) subjects with rotator cuff tears and
in three articles [147, 170, 225] and cramping arm pain shoulder instability, (b) in patients following adjunc-
in two papers [147, 225] in patients who underwent tive LHB tenotomy for irreparable rotator cuff tears, (c)
tenotomy with similar rotator cuff repair rates observed. in patients with an absent LHBT and (d) during physio-
Shorter operative times were observed in patients who logical loading of the biceps brachii in cadaver shoulders
underwent rotator cuff repair in isolation compared with with simulated rotator cuff and labral lesions. The role of
patients who underwent rotator cuff repair and adjunc- the LHB in proprioception at the shoulder was under-
tive tenodesis [142]. For subjects with a concomitant determined. Our scoping review found that both sEMG
Supraspinatus tear and confirmed intraoperative LHBT and fwEMG can be used effectively to investigate biceps
pathology, Godenèche, Kempf [174] reported higher con- brachii and LHB activity. Chalmers, Cip [116] established
stant scores for function and strength in patients who that both the long and short heads of the biceps brachii
underwent Supraspinatus repair with either adjunctive have separate muscular fibres and can be studied effec-
LHB tenodesis or tenotomy, compared with patients who tively through sEMG. Marri and Swaminathan [236]
underwent isolated Supraspinatus repair. Similar higher confirmed the usefulness of sEMG analysis of the biceps
PROMS in subjects undergoing rotator cuff repair and brachii in training and rehabilitation programs.
adjunctive tenodesis or tenotomy compared with rotator
cuff repair in isolation were observed in another article Pathology
[19]. A study of patients with concomitant rotator cuff There was an established association between LHB ten-
tears and SLAP lesions reported similar clinical out- dinopathy and rotator cuff pathology and LHBT instabil-
comes in PROMS and shoulder ROM for patients who ity and occult Subscapularis tears in our scoping review,
undertook rotator cuff repair with SLAP repair vs. sub- with EMG studies demonstrating hyperactivity of LHB in
jects who undertook rotator cuff repair with adjunctive the presence of rotator cuff tears and shoulder instability,
tenodesis [200]. Post-surgical follow-ups ranged from 1 suggesting a compensation role of the LHB in pathologi-
month to 10 years, with most studies reporting a mean cal shoulders. Similar changes in muscle activation of the
follow-up time ≤ to 4 years. Pooled result findings are deep abdominal muscles have been established in people
medium-term and highly likely to represent post-surgical with chronic low back pain [237–239]. Our conclusions
outcomes over time. agree with Khandare, Arce [240] and Kaar [241] that fur-
ther research is required to determine if the LHB mus-
Discussion cle compensates for rotator cuff pathology and shoulder
Anatomy instability. We hypothesise that the increased biceps
Our scoping review observed considerable anatomical activity observed in patients with rotator cuff deficiency
variation of the LHB from double or triple tendon aber- may explain the high prevalence of concomitant LHBT
rant origins and supernumerary third and fourth acces- pathology with rotator cuff disease severity as it attempts
sory heads to a congenital absence of the LHBT. These to compensate for rotator cuff deficiency at the shoulder.
observed variations were associated with higher shoulder Occult Subscapularis tears typically occur when biceps
pain and instability prevalence. Morris, Guettler [233] sling integrity is compromised, displacing the unstable
and Kanatli, Ozturk [234] reported similar observations, LHBT anteromedially into the Subscapularis tendon,
concluding that anatomical variations of the LHB are not leading to subsequent tearing [242–244]. Other potential
always benign. The role of the transverse humeral liga- mechanisms of LHB tendinopathy include mechanical
ment in LHBT stability was unclear, with the literature constriction and irritation from a bottleneck narrowing
invalidating the transverse humeral ligament as a distinct of the biceps groove [245].
anatomical structure. The growing consensus in the liter-
ature supports the biceps pulley as the primary stabiliser Assessment
of the LHBT in the bicipital groove [235]. The limited diagnostic utility of screening questionnaires,
special orthopaedic tests, and palpation in the differential
Function diagnosis of LHBT pathology was a consistent theme in
The role of the biceps brachii at the elbow joint and its our scoping review. Due to the variable diagnostic utility
contribution to elbow flexion and forearm supination is of special orthopaedic tests of the shoulder [3, 246–255],
well documented and understood in the literature [19]. it was not surprising that the diagnostic accuracy of spe-
Our scoping review found a lack of consensus for an cial orthopaedic tests to identify LHBT pathology was
active role of LHB at the shoulder during shoulder eleva- also highly variable, with the use of test clusters improv-
tion and throwing activities, with a minor role in shoul- ing test accuracy. The use of a symptom modification
der stability in normal healthy shoulders. In contrast, we approach during the physical examination of the shoulder
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 11 of 19
is contemporary [256]. Our study findings agree with a systematic review by Castro, Corrêa [259] reported low
the conclusions drawn by Lehman [257] that the defini- to very-low-quality evidence to support the conservative
tive mechanisms underpinning the symptom modifica- management of rotator cuff and biceps tendinopathy-
tion approach are yet to be fully understood, and more related shoulder pain. Generic rehabilitation principles
research is required to validate its use in shoulder pain. for tendinopathy typically include progressive muscle
Proximal LHBT tenderness at the bicipital groove seems strengthening for tendon remodelling and adaption to
to have little utility for diagnosing LHBT pathology. load [260, 261]. From the anecdotal research we found
The American College of Radiology Appropriateness on biceps activity during common shoulder rehabilitation
Criteria for Atraumatic Shoulder Pain recommends MRI exercises, a potential LHB rehabilitation exercise pro-
or diagnostic ultrasound be performed when LHBT gram may include a progression of biceps curls into ele-
pathology is suspected, and initial radiographs are nor- vation, shoulder front raises in external rotation, elbow
mal or inconclusive. Our scoping review findings support extension and supination, and a sport-specific program
using MRA over MRI to diagnose LHBT appearance, of overhead to underarm throwing drills. Similar authors
position, and biceps pulley lesions for LHBT pathology. have inferred the need for research validating the use
Most MRI and MRA studies reported a high utility for of LHB strengthening exercises for rotator cuff-related
detecting full thickness and complete tears of the LHBT; shoulder pain, shoulder impingement and instability [30–
however, the utility for MR imaging to detect and exclude 32, 38, 50, 85, 88].
partial thickness tears of the LHBT was low. Overall MR This review found no studies that compared LHB
imaging to detect LHBT instability was found to be vari- injection with no injection, indicating that the current
able; though, there was an observed trend for higher literature does not provide guidance on the efficacy of
specificity to rule in LHBT dislocation compared with injection for LHBT pathology. In contrast, a prior review
subluxation. MRI and MRA sensitivity values were lower reported that it might give temporary pain relief for
than the reported specificity values. inflammatory conditions of the LHBT [262]. If a clini-
Similar to our MR findings, several studies reported cal decision is made to use LHBT sheath injection, our
the higher diagnostic utility of ultrasound for biceps results consistently indicate that image-guided proce-
dislocation greater than subluxation and the detection dures are more accurate and should be preferred over
of full-thickness tears of the LHBT. However, its abil- unguided techniques. Injected substances can migrate
ity to identify partial-thickness tears of the LHBT was from the sheath into the communicating glenohumeral
less accurate. Similar findings were found for diagnos- joint capsule, exposing the joint to a variety of potential
ing biceps tendinopathy. Study comparisons between corticosteroid adverse effects, including known cata-
diagnostic ultrasound and MRI reported high specific- bolic effects on the tendon, ligament, adipose and carti-
ity values for MRI greater than diagnostic ultrasound lage tissue [262–264]. In addition, high concentrations
for proximal LHBT pathology, but sensitivity values for of commonly used local anaesthetics such as lidocaine
both were overall poor. A recent literature review by and bupivacaine are chondrotoxic [265–267]. These risks
Ostrowski, Beaumont [258] found similar results with a must be weighed against pain-induced morbidity and
reported high accuracy of musculoskeletal ultrasound progressive shoulder dysfunction associated with LHBT
to diagnose LHBT dislocation, subluxation, and full- pathology. Until further research clarifies the efficacy of
thickness tears, and less accuracy in diagnosing partial- injection compared with other treatment options, clini-
thickness tears and tendonitis. Arthroscopy was the gold cians must continue to make clinical decisions based on
reference standard in most diagnostic tests and imag- the individual patient’s circumstances.
ing studies. The reported limitations of arthroscopy to
fully visualise the proximal LHBT at the glenohumeral Surgical management
joint in our scoping review findings may underestimate For the surgical management of long head of biceps
their reported accuracy and sensitivity values, and more pathology with or without rotator cuff pathology, our
research is required to validate their use in the diagnosis scoping review found similar improvements in patient-
of LHB-related shoulder pain and tendon pathology. reported outcomes for pain and function post-opera-
tively for tenodesis or tenotomy, with tenodesis trending
Non-surgical management towards higher constant scores and tenotomy trending
There were limited result findings for the conserva- to be more cost and time effective. At the same time,
tive management of LHBT pathology due to the lack of patients undergoing tenodesis were less likely to have
articles found, with subjects managed non-surgically post-surgical complications of Popeye deformity and
trending to return to work quicker but at lesser capac- cramping arm pain. A similar trend was observed in
ity and with less elbow/forearm strength than subjects a recent systematic review by Aldon-Villegas, Perez-
undergoing LHB tenodesis. Similar to our observations, Cabezas [268], with fewer Popeye signs and cramping
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 12 of 19
arm pain following tenodesis compared with tenotomy. biceps sling in LHBT stability with minimal support for
A slight trend was observed for reduced operative time, the transverse humeral ligament as a separate, distinct
narcotic use and quicker pain relief in patients undergo- anatomical structure. (b) Function - the minimal role of
ing tenotomy. In studies that dichotomised their results the LHB in shoulder elevation and glenohumeral stability
by age, less satisfaction was observed in younger male in healthy shoulders. In pathological shoulders, proximal
patients following tenotomy compared with tenodesis. humeral migration, and hyperactivity of the LHB sug-
The systematic inclusion of adjunctive LHB tenotomy gest a potential compensation function in individuals
or tenodesis on a healthy normal LHBT with rotator cuff with symptomatic rotator cuff tears or shoulder instabil-
repair has been reported as an increasing trend in the ity. However, changes in LHB muscle activity in subjects
literature [269]. Our findings support avoiding adjunc- with asymptomatic rotator cuff pathology are undeter-
tive LHBT surgery with rotator cuff repairs in subjects mined. Further research is required in both asymptom-
with a normal LHBT because similar clinical outcomes atic and symptomatic rotator cuff tear populations to
following Supraspinatus repair in isolation vs. Supraspi- determine whether there is a compensation role of the
natus repair with adjunctive biceps tenodesis/tenotomy LHB at the shoulder. (c) Pathology - The prevalence of
were found. Similar patient-reported outcome measures concomitant LHBT pathology with rotator cuff tears is
(PROMS) in subjects undergoing rotator cuff repair and well established; however, the cause-and-effect relation-
adjunctive tenodesis or tenotomy compared with rotator ship between LHBT pathology and rotator cuff disease is
cuff repair in isolation were observed by Watson, Robbins undetermined. Further research is required to establish if
[19]. Whether to include routine biceps tenodesis/tenot- the LHBT becomes overloaded and, in turn, pathologi-
omy with rotator cuff repair presents a surgical conun- cal as it tries to compensate for the loss of function of a
drum similar to the standard inclusion of bursectomy torn rotator cuff or is a secondary effect of degenerative
with subacromial decompression surgery for subacromial shoulder pathology, pain, and weakness. (d) Assessment
pain syndrome when evidence supports identical clinical - The diagnostic utility of both clinical orthopaedic tests
outcomes for bursectomy vs. bursectomy with acromio- and diagnostic imaging to exclude LHBT pathology may
plasty [270]. The question of whether LHB tenodesis or be understated due to the inherent limitations of arthros-
tenotomy should be routinely performed in arthroscopic copy as the standard gold reference to visualise the
rotator cuff repairs was recently discussed by Moorthy proximal LHBT at the glenohumeral joint fully. (e) Non-
and Tan [271], concluding that whilst there is a role for surgical management - Conservative rehabilitation pro-
biceps surgery in rotator cuff repair, further higher-level grams of the shoulder that include biceps strengthening
studies are needed to determine if tenodesis and tenot- protocols are understudied, and the evidence to support
omy should be performed routinely instead of selectively the inclusion of LHB rehabilitation in the management of
in rotator cuff tears. Goldfarb and Yamaguchi [6] advo- rotator cuff and biceps-related shoulder pain is lacking.
cated that routine tenodesis be avoided during operative Further research is required to understand how a biceps-
treatment for rotator cuff tears as LHB tendinopathy may focused rehabilitation program may improve shoulder
be reversible. pain and functional outcomes in patients with symp-
tomatic rotator cuff tears and b) prevent or reduce the
Limitations likelihood of an asymptomatic rotator cuff tear becom-
This scoping review was limited to English publications, ing symptomatic and progressing to failure. (f) Surgical
excluding full-text articles published in other languages. management - Similar post-surgical clinical outcomes
Previous narrative reviews and grey literature were are observed for tenodesis and tenotomy for biceps and
excluded, including conference abstracts and thesis dis- concomitant rotator cuff-related shoulder pain, with
sertations. The lead author (BD) independently performed subjects undergoing biceps tenodesis less likely to have
the screening, inclusion, exclusion, and data extrac- cramping arm pain and a Popeye deformity compared to
tion. Whilst the level of evidence for each article was patients undergoing biceps tenotomy. The significance
assessed, the methodological quality of the studies was of routine surgical removal of the LHBT and sequelae
not appraised critically as per guidelines for complet- on rotator cuff tear progression to failure and long-term
ing scoping reviews. Articles biased towards rotator cuff shoulder function is unknown, and further research is
pathology and intra-articular SLAP or labral pathology required.
were excluded from this scoping review.
Abbreviations
ABS Absence of LHB
Conclusions and recommendations BB Biceps Brachii
The scoping review highlights; (a) Anatomy – Common DUS Diagnostic Ultrasound
F Female
anatomical variations of the biceps brachii, associated N Force
with shoulder pain and instability, a potential role for the GHJ Glenohumeral Joint
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 13 of 19
14. Peters MDJ, Marnie C, Tricco AC, Pollock D, Munn Z, Alexander L, et al. 37. Warner JJP, McMahon PJ. The role of the long head of the biceps brachii
Updated methodological guidance for the conduct of scoping reviews. JBI in superior stability of the glenohumeral joint. J Bone Joint Surg - Ser A.
Evid Synth. 2020;18(10):2119–26. 1995;77(3):366–72.
15. Clark JM, Sanders S, Carter M, Honeyman D, Cleo G, Auld Y, et al. Improving 38. Pagnani MJ, Deng XH, Warren RF, Torzilli PA, O’Brien SJ. Role of the long head
the translation of search strategies using the polyglot search translator: a of the biceps brachii in glenohumeral stability: a biomechanical study in
randomized controlled trial. J Med Libr Assoc. 2020;108(2):195–207. cadavera. J Shoulder Elbow Surg. 1996;5(4):255–62.
16. Morrison A, Polisena J, Husereau D, Moulton K, Clark M, Fiander M, et al. The 39. Mariani PP, Bellelli A, Botticella C. Arthroscopic absence of the long head of
effect of English-language restriction on systematic review-based meta- the biceps tendon. Arthroscopy: the journal of arthroscopic & related surgery
analyses: a systematic review of empirical studies. Int J Technol Assess Health : official publication of the Arthroscopy Association of North America and the
Care. 2012;28(2):138–44. International Arthroscopy Association. 1997;13(4):499–501.
17. Sucharew H, Macaluso M. Progress Notes: methods for Research evidence 40. Yamaguchi K, Riew KD, Galatz LM, Syme JA, Neviaser RJ, Yamaguchi K, et al.
synthesis: the Scoping Review Approach. J Hosp Med. 2019;14(7):416–8. Biceps activity during shoulder motion: an electromyographic analysis. Clin
18. The Joanna Briggs Institute Levels of Evidence and Grades of Recommenda- Orthop Relat Res. 1997;336:122–9.
tion Working Party*. Supporting Document for the Joanna Briggs Institute 41. Bennett WF. Specificity of the speed’s test: arthroscopic technique for
Levels of Evidence and Grades of Recommendation.The Joanna Briggs Insti- evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy.
tute. 2014. [Available from: (Microsoft Word - JBI-Levels-of-evidence_2014. 1998;14(8):789–96.
doc.docx). 42. Kido T, Itoi E, Konno N, Sano A, Urayama M, Sato K. Electromyographic activi-
19. Gray H, Williams PL, Bannister LH. Gray’s anatomy : the anatomical basis ties of the biceps during arm elevation in shoulders with rotator cuff tears.
of medicine and surgery. 38th / chairman of the editorial board, Peter L. Acta Orthop Scand. 1998;69(6):575–9.
Williams ; editorial board, Lawrence H. Bannister … [et al.] ed. New York: 43. Read JW, Perko M. Shoulder ultrasound: diagnostic accuracy for impinge-
Churchill Livingstone; 1995. ment syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder
20. Basmajian JV, Latif A. Integrated actions and functions of the chief flexors Elbow Surg. 1998;7(3):264–71.
of the elbow: a detailed electromyographic analysis. J bone joint Surg Am 44. Sakurai G, Ozaki J, Tomita Y, Nishimoto K, Tamai S. Electromyographic analysis
volume. 1957;39–A(5):1106–18. of shoulder joint function of the biceps brachii muscle during isometric
21. Furlani J. Electromyographic study of the m. biceps brachii in movements at contraction.Clinical Orthopaedics and Related Research. 1998(354):123–31.
the glenohumeral joint. Acta Anat. 1976;96(2):270–84. 45. Walch G, Nové-Josserand L, Boileau P, Levigne C. Subluxations and disloca-
22. Neviaser TJ, Neviaser RJ, Neviaser JS, Neviaser JS. The four-in-one arthroplasty tions of the tendon of the long head of the biceps. J Shoulder Elbow Surg.
for the painful arc syndrome. Clin Orthop Relat Res. 1982;163(163):107–12. 1998;7(2):100–8.
23. Jobe F, Moynes D, Tibone J, Perry J. An EMG analysis of the shoulder in pitch- 46. David G, Magarey ME, Jones MA, Dvir Z, Türker KS, Sharpe M. EMG and
ing. Am J Sports Med. 1984;12(3):218–20. strength correlates of selected shoulder muscles during rotations of the
24. Petersson CJ. Spontaneous medial dislocation of the tendon of the long glenohumeral joint. Clin Biomech (Bristol Avon). 2000;15(2):95–102.
biceps brachii. An anatomic study of prevalence and pathomechanics.Clinical 47. Kido T, Itoi E, Konno N, Sano A, Urayama M, Sato K. The depressor function of
orthopaedics and related research. 1986(211):224–7. biceps on the head of the humerus in shoulders with tears of the rotator cuff.
25. Glousman R, Jobe F, Tibone J, Moynes D, Antonelli D, Perry J. Dynamic J Bone Joint Surgery-British Volume. 2000;82B(3):416–9.
electromyographic analysis of the throwing shoulder with glenohumeral 48. Murthi AM, Vosburgh CL, Neviaser TJ. The incidence of pathologic changes of
instability. J bone joint Surg Am volume. 1988;70(2):220–6. the long head of the biceps tendon. J Shoulder Elbow Surg. 2000;9(5):382–5.
26. Mariani EM, Cofield RH, Askew LJ, Li G, Chao EYS. Rupture of the tendon of 49. Teefey SA, Hasan SA, Middleton WD, Patel M, Wright RW, Yamaguchi K.
the long head of the biceps brachii. Surgical versus nonsurgical treatment. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and
Clin Orthop Relat Res. 1988;228(228):233–9. arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg
27. Kumar VP, Satku K, Balasubramaniam P. The role of the long head of biceps Am. 2000;82(4):498–504.
brachii in the stabilization of the head of the humerus.Clin Orthop Relat Res. 50. Halder AM, Zhao KD, O’Driscoll SW, Morrey BF, An KN. Dynamic contributions
1989(244):172–5. to superior shoulder stability. J Orthop Res. 2001;19(2):206–12.
28. Kosugi K, Shibata S, Yamashita H. Supernumerary head of biceps brachii and 51. Kim SH, Ha KI, Kim HS, Kim SW. Electromyographic activity of the biceps
branching pattern of the musculocutaneus nerve in japanese. Surg Radiol brachii muscle in shoulders with anterior instability. Arthroscopy-the J
Anat. 1992;14(2):175–85. Arthroscopic Relat Surg. 2001;17(8):864–8.
29. Brown JM, Solomon C, Paton M. Further evidence of functional differentiation 52. Levy AS, Kelly BT, Lintner SA, Osbahr DC, Speer KP. Function of the long head
within biceps brachii. Electromyogr Clin Neurophysiol. 1993;33(5):301–9. of the biceps at the shoulder: electromyographic analysis. J Shoulder Elbow
30. Itoi E, Kuechle DK, Newman SR, Morrey BF, An KN. Stabilising function Surg. 2001;10(3):250–5.
of the biceps in stable and unstable shoulders. J Bone Joint Surg Br. 53. Ilahi OA, Labbe MR, Cosculluela P. Variants of the anterosuperior glenoid
1993;75(4):546–50. labrum and associated pathology. Arthroscopy: The Journal of Arthroscopic
31. Itoi E, Newman SR, Kuechle DK, Morrey BF, An KN. Dynamic anterior stabilisers and Related Surgery. 2002;18(8):882–6.
of the shoulder with the arm in abduction. J bone joint Surg Br volume. 54. Smith EL, Matzkin EG, Kim DH, Harpstrite JK, Kan DM. Congenital absence
1994;76(5):834–6. of the long head of the biceps brachii tendon as a VATER association. Am J
32. Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps Orthop (Belle Mead NJ). 2002;31(8):452–4.
muscle and superior glenoid labrum in anterior stability of the shoulder. Am J 55. Beall DP, Williamson EE, Ly JQ, Adkins MC, Emery RL, Jones TP, et al. Associa-
Sports Med. 1994;22(1):121–30. tion of biceps tendon tears with rotator cuff abnormalities: degree of correla-
33. Vangsness CT Jr, Jorgenson SS, Watson T, Johnson DL. The origin of the long tion with tears of the anterior and superior portions of the rotator cuff. AJR
head of the biceps from the scapula and glenoid labrum. An anatomical Am J Roentgenol. 2003;180(3):633–9.
study of 100 shoulders. J Bone Joint Surg - Ser B. 1994;76(6):951–4. 56. Glueck DA, Mair SD, Johnson DL. Shoulder instability with absence of the
34. Williams MM, Snyder SJ, Buford D. Jr. The Buford complex–the “cord-like” long head of the biceps tendon. Arthroscopy: the journal of arthroscopic &
middle glenohumeral ligament and absent anterosuperior labrum com- related surgery : official publication of the Arthroscopy Association of North
plex: a normal anatomic capsulolabral variant. Arthroscopy: the journal America and the International Arthroscopy Association. 2003;19(7):787–9.
of arthroscopic & related surgery : official publication of the Arthroscopy 57. Rao AG, Kim TK, Chronopoulos E, McFarland EG. Anatomical variants in the
Association of North America and the International Arthroscopy Association. Anterosuperior aspect of the Glenoid Labrum. J Bone Joint Surg Am Volume.
1994;10(3):241–7. 2003;85(4):653.
35. Pagnani MJ, Deng XH, Warren RF, Torzilli PA, Altchek DW. Effect of lesions of 58. Enad JG. Bifurcate origin of the long head of the biceps tendon. Arthroscopy.
the superior portion of the glenoid labrum on glenohumeral translation. J 2004;20(10):1081–3.
bone joint Surg Am volume. 1995;77(7):1003–10. 59. Habermeyer P, Magosch P, Pritsch M, Scheibel MT, Lichtenberg S. Anterosupe-
36. Refior HJ, Sowa D. Long tendon of the biceps brachii: Sites of predilection for rior impingement of the shoulder as a result of pulley lesions: a prospective
degenerative lesions. J Shoulder Elbow Surg. 1995;4(6):436–40. arthroscopic study. J Shoulder Elbow Surg. 2004;13(1):5–12.
60. Mohtadi NG, Vellet AD, Clark ML, Hollinshead RM, Sasyniuk TM, Fick GH, et
al. A prospective, double-blind comparison of magnetic resonance imaging
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 15 of 19
and arthroscopy in the evaluation of patients presenting with shoulder pain. 84. Rojas IL, Provencher MT, Bhatia S, Foucher KC, Bach BR Jr, Romeo AA, et al.
J Shoulder Elbow Surg. 2004;13(3):258–65. Biceps activity during windmill softball pitching: injury implications and
61. Chen CH, Hsu KY, Chen WJ, Shih CH. Incidence and severity of biceps long comparison with overhand throwing. Am J Sports Med. 2009;37(3):558–65.
head tendon lesion in patients with complete rotator cuff tears. J Trauma. 85. Youm T, ElAttrache NS, Tibone JE, McGarry MH, Lee TQ. The effect of the long
2005;58(6):1189–93. head of the biceps on glenohumeral kinematics. J Shoulder Elbow Surg.
62. Deutch SR, Gelineck J, Johannsen HV, Sneppen O. Permanent disabilities in 2009;18(1):122–9.
the displaced muscle from rupture of the long head tendon of the biceps. 86. Gheno R, Zoner CS, Buck FM, Nico MAC, Haghighi P, Trudell DJ, et al. Acces-
Scand J Med Sci Sports. 2005;15(3):159–62. sory head of biceps brachii muscle: anatomy, histology, and MRI in cadavers.
63. Franco JC, Knapp TP, Mandelbaum BR, Franco JC, Knapp TP, Mandelbaum BR. Am J Roentgenol. 2010;194(1):W80–W3.
Congenital absence of the long head of the biceps tendon. A case report. 87. Lakemeier S, Reichelt JJ, Timmesfeld N, Fuchs-Winkelmann S, Paletta JR,
Journal of Bone & Joint Surgery, American Volume. 2005;87(7):1584-6. Schofer MD. The relevance of long head biceps degeneration in the presence
64. Toshiaki A, Itoi E, Minagawa H, Yamamoto N, Tuoheti Y, Seki N, et al. Cross- of rotator cuff tears. BMC Musculoskelet Disord. 2010;11:191.
sectional area of the tendon and the muscle of the biceps brachii in shoul- 88. Su WR, Budoff JE, Luo ZP, Su W-R, Budoff JE, Luo Z-P. The effect of pos-
ders with rotator cuff tears: a study of 14 cadaveric shoulders. Acta Orthop. terosuperior rotator cuff tears and biceps loading on glenohumeral
2005;76(4):509–12. translation. Arthroscopy: The Journal of Arthroscopy & Related Surgery.
65. Walch G, Edwards TB, Boulahia A, Nove-Josserand L, Neyton L, Szabo I. 2010;26(5):578–86.
Arthroscopic tenotomy of the long head of the biceps in the treatment 89. Braun S, Horan MP, Elser F, Millett PJ. Lesions of the biceps pulley. Am J Sports
of rotator cuff tears: Clinical and radiographic results of 307 cases. 2005. Med. 2011;39(4):790–5.
p.238–46. 90. De Maeseneer M, Boulet C, Pouliart N, Kichouh M, Buls N, Verhelle F, et al.
66. Ardic F, Kahraman Y, Kacar M, Kahraman MC, Findikoglu G, Yorgancioglu ZR. Assessment of the long head of the biceps tendon of the shoulder with
Shoulder impingement syndrome: relationships between clinical, functional, 3T magnetic resonance arthrography and CT arthrography. Eur J Radiol.
and radiologic findings. Am J Phys Med Rehabil. 2006;85(1):53–60. 2011;81(5):934–9.
67. Armstrong A, Teefey SA, Wu T, Clark AM, Middleton WD, Yamaguchi K, et al. 91. Hashiuchi T, Sakurai G, Morimoto M, Komei T, Takakura Y, Tanaka Y.
The efficacy of ultrasound in the diagnosis of long head of the biceps tendon Accuracy of the biceps tendon sheath injection: ultrasound-guided or
pathology. J Shoulder Elbow Surg. 2006;15(1):7–11. unguided injection? A randomized controlled trial. J Shoulder Elbow Surg.
68. Gleason PD, Beall DP, Sanders TG, Bond JL, Ly JQ, Holland LL, et al. The 2011;20(7):1069–73.
transverse humeral ligament: a separate anatomical structure or a continu- 92. Lim TK, Moon ES, Koh KH, Yoo JC. Patient-related factors and complications
ation of the osseous attachment of the rotator cuff? Am J Sports Med. after arthroscopic tenotomy of the long head of the biceps tendon. Am J
2006;34(1):72–7. Sports Med. 2011;39(4):783–9.
69. Schoenleber SJ, Spinner RJ. An unusual variant of the biceps brachii. Clin 93. Mitra R, Nguyen A, Stevens KJ. Fluoroscopically guided supraglenoid tubercle
Anat. 2006;19(8):702–3. steroid injections for the management of biceps tendonitis. Pain Pract.
70. Swaringen JC, Mell AG, Langenderfer J, LaScalza S, Hughes RE, Kuhn JE. 2011;11(4):392–6.
Electromyographic analysis of physical examination tests for type II superior 94. Patzer T, Habermeyer P, Hurschler C, Bobrowitsch E, Paletta JR, Fuchs-Winkel-
labrum anterior-posterior lesions. J Shoulder Elbow Surg. 2006;15(5):576–9. mann S, et al. Increased glenohumeral translation and biceps load after SLAP
71. Boileau P, Baqué F, Valerio L, Ahrens P, Chuinard C, Trojani C. Isolated lesions with potential influence on glenohumeral chondral lesions: a biome-
arthroscopic biceps tenotomy or Tenodesis improves symptoms in patients chanical study on human cadavers. Knee Surg Sports Traumatol Arthrosc.
with massive irreparable rotator cuff tears. J bone joint Surg Am volume. 2011;19(10):1780–7.
2007;89(4):747–57. 95. Skendzel JG, Jacobson JA, Carpenter JE, Miller BS. Long head of biceps brachii
72. Castagna A, Mouhsine E, Conti M, Vinci E, Borroni M, Giardella A, et al. tendon evaluation: accuracy of preoperative ultrasound. AJR Am J Roent-
Chondral print on humeral head: an indirect sign of long head biceps tendon genol. 2011;197(4):942–8.
instability. Knee Surg Sports Traumatol Arthrosc. 2007;15(5):645–8. 96. Uzel AP, Bertino R, Boileau P. Bilateral spontaneous tenodesis of the long
73. Gill HS, El Rassi G, Bahk MS, Castillo RC, McFarland EG. Physical examination head of the biceps at the bicipital groove with massive rotator cuff tear on a
for partial tears of the biceps tendon. Am J Sports Med. 2007;35(8):1334–40. 103-year-old female cadaver: the natural evolution of the human shoulder?
74. Kim KC, Rhee KJ, Shin HD, Kim YM. Biceps long head tendon revisited: a case Musculoskelet Surg. 2011;95(S1):79–82.
report of split tendon arising from single origin. Arch Orthop Trauma Surg. 97. Zhang J, Ebraheim N, Lause GE. Ultrasound-guided injection for the
2007;128(5):495–8. biceps brachii tendinitis: results and experience. Ultrasound Med Biol.
75. Lafosse LMD, Reiland YMD, Baier GPMD, Toussaint BMD, Jost BMD. Anterior 2011;37(5):729–33.
and posterior instability of the long head of the Biceps Tendon in Rotator 98. Chen CH, Chen CH, Chang CH, Su CI, Wang KC, Wang IC, et al. Classification
Cuff tears: a new classification based on arthroscopic observations. Arthros- and analysis of pathology of the long head of the biceps tendon in complete
copy. 2007;23(1):73–80. rotator cuff tears. Chang Gung Med J. 2012;35(3):263–70.
76. MacDonald K, Bridger J, Cash C, Parkin I. Transverse humeral ligament: does it 99. Giphart JE, Elser F, Dewing CB, Torry MR, Millett PJ. The long head of the
exist? Clin Anat. 2007;20(6):663–7. biceps tendon has minimal effect on in vivo glenohumeral kinematics: a
77. Ilahi OA, Cosculluela PE, Ho DM. Classification of anterosuperior glenoid biplane fluoroscopy study. Am J Sports Med. 2012;40(1):202–12.
labrum variants and their association with shoulder pathology. Orthopedics. 100. Hanypsiak B, Nguyen M, McGarry M, Morgan C, Gupta R, Lee TQ. The role of
2008;31(3):226. the biceps brachii in overhead throwing: a biomechanical study. Arthrosc - J
78. Landin D, Myers J, Thompson M, Castle R, Porter J. The role of the biceps Arthroscopic Relat Surg. 2012;28(6):e4.
brachii in shoulder elevation. J Electromyogr Kinesiol. 2008;18(2):270–5. 101. Hawkes DH, Alizadehkhaiyat O, Fisher AC, Kemp GJ, Roebuck MM, Frostick SP.
79. Sayeed SA, Shah JP, Collins MS, Dahm DL. Absence of the long head of the Normal shoulder muscular activation and co-ordination during a shoulder
biceps tendon associated with glenoid dysplasia and posterior labral tear. elevation task based on activities of daily living: an electromyographic study.
Clin Anat. 2008;21(7):728–32. J Orthop Res. 2012;30(1):53–60.
80. Vijayabhaskar P, Baral P, Vaishya R, Shrestha RN. Supernumerary head of 102. Hawkes DH, Alizadehkhaiyat O, Kemp GJ, Fisher AC, Roebuck MM, Frostick SP.
biceps brachii: a rare occurrence in the nepalese population. Kathmandu Shoulder muscle activation and coordination in patients with a massive rota-
Univ Med J (KUMJ). 2008;6(2):225–7. tor cuff tear: an electromyographic study. J Orthop Res. 2012;30(7):1140–6.
81. Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of tradi- 103. Nejat N, Mathieu PA, Bertrand M. Investigation on muscle compartments in
tional and new tests in the diagnosis of biceps tendon injuries and superior the Biceps Brachii. J Med Biol Eng. 2012;32(4):251–7.
labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 104. Schaeffeler C, Waldt S, Holzapfel K, Kirchhoff C, Jungmann PM, Wolf P, et al.
2009;37(9):1840–7. Lesions of the biceps pulley: diagnostic accuracy of MR arthrography of the
82. Koplas MC, Winalski CS, Ulmer WH Jr, Recht M. Bilateral congenital absence of shoulder and evaluation of previously described and new diagnostic signs.
the long head of the biceps tendon. Skeletal Radiol. 2009;38(7):715–9. Radiology. 2012;264(2):504–13.
83. Oliveira LF, Matta TT, Alves DS, Garcia MAC, Vieira TMM. Effect of the shoulder 105. Wittstein JMD, Lassiter TMD, Taylor DMD. Aberrant origin of the long head of
position on the biceps brachii EMG in different dumbbell curls. J Sports Sci the biceps: a case series. J Shoulder Elbow Surg. 2012;21(3):356–60.
Med. 2009;8(1):24–9.
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 16 of 19
106. Alexander S, Southgate DF, Bull AM, Wallace AL. The role of negative intraar- 131. Ge H, Zhang Q, Sun Y, Li J, Sun L, Cheng B. Tenotomy or tenodesis for the long
ticular pressure and the long head of biceps tendon on passive stability of head of biceps lesions in shoulders: a systematic review and meta-analysis.
the glenohumeral joint. J Shoulder Elbow Surg. 2013;22(1):94–101. PLoS ONE. 2015;10(3):e0121286.
107. Biederwolf NE. A proposed evidence-based shoulder special testing exami- 132. Gilmer BB, DeMers AM, Guerrero D, Reid JB 3rd, Lubowitz JH, Guttmann
nation algorithm: clinical utility based on a systematic review of the literature. D. Arthroscopic versus open comparison of long head of biceps tendon
Int J Sports Phys Ther. 2013;8(4):427–40. visualization and pathology in patients requiring tenodesis. Arthroscopy.
108. Genovese E, Spanò E, Castagna A, Leonardi A, Angeretti MG, Callegari L, et 2015;31(1):29–34.
al. MR-arthrography in superior instability of the shoulder: correlation with 133. Leroux T, Chahal J, Wasserstein D, Verma NN, Romeo AA. A systematic review
arthroscopy. Radiologia Med. 2013;118(6):1022–33. and Meta-analysis comparing clinical outcomes after concurrent Rotator
109. Gillardin P, Vanhoenacker FM, Wauters T, De Backer AI. Congenital absence of Cuff Repair and Long Head Biceps Tenodesis or Tenotomy. Sports Health.
long head of the biceps tendon. J Belg Soc Radiol. 2013;96(5):320. 2015;7(4):303–7.
110. Huang S-W, Wang W-T. Quantitative diagnostic method for Biceps Long Head 134. Malavolta EA, Assunção JH, Guglielmetti CLB, de Souza FF, Gracitelli MEC,
Tendinitis by using Ultrasound. TheScientificWorld. 2013;2013:948323–7. Ferreira Neto AA. Accuracy of preoperative MRI in the diagnosis of disorders
111. Mazzocca AD, McCarthy MB, Ledgard FA, Chowaniec DM, McKinnon WJ Jr, of the long head of the biceps tendon. Eur J Radiol. 2015;84(11):2250–4.
Delaronde S, et al. Histomorphologic changes of the long head of the biceps 135. Moon SC, Cho NS, Rhee YG. Analysis of “hidden lesions” of the extra-articular
tendon in common shoulder pathologies. Arthroscopy. 2013;29(6):972–81. biceps after subpectoral biceps tenodesis: the subpectoral portion as the
112. Moon J, Shin I, Kang M, Kim Y, Lee K, Park J, et al. The effect of shoulder flexion optimal tenodesis site. Am J Sports Med. 2015;43(1):63–8.
angles on the recruitment of Upper-extremity muscles during isometric 136. Petscavage-Thomas J, Gustas C. Comparison of ultrasound-guided to
contraction. J Phys Ther Sci. 2013;25(10):1299–301. fluoroscopy-guided biceps tendon sheath injection. Ultrasound Med Biol.
113. Nasr AY, Hussein AM. Morphology and clinical implication of the extra-head 2015;41(4):89.
of biceps brachii muscle. Folia Morphol (Warsz). 2013;72(4):349–56. 137. Shi LL, Mullen MG, Freehill MT, Lin A, Warner JJ, Higgins LD. Accuracy of long
114. Ahamed NU, Sundaraj K, Ahmad B, Rahman M, Ali MA, Islam MA. Surface head of the biceps subluxation as a predictor for subscapularis tears. Arthros-
electromyographic analysis of the biceps brachii muscle of cricket bowlers copy. 2015;31(4):615–9.
during bowling. Australas Phys Eng Sci Med. 2014;37(1):83–95. 138. Singh R, Singla M, Tubbs RS. Macro/micro observational studies of fibres
115. Arrigoni P, Ragone V, D’Ambrosi R, Denard P, Randelli F, Banfi G, et al. Improv- maintaining the biceps brachii tendon in the bicipital groove: application to
ing the accuracy of the preoperative diagnosis of long head of the biceps surgery, pathology and kinesiology. Folia Morphol (Warsz). 2015;74(4):439–46.
pathology: the biceps resisted flexion test. Joints. 2014;2(2):54–8. 139. Tadros AS, Huang BK, Wymore L, Hoenecke H, Fronek J, Chang EY. Long head
116. Chalmers PN, Cip J, Trombley R, Cole BJ, Wimmer MA, Romeo AA, et al. Gle- of the biceps brachii tendon: unenhanced MRI versus direct MR arthrogra-
nohumeral function of the long head of the Biceps muscle: an Electromyo- phy. Skeletal Radiol. 2015;44(9):1263–72.
graphic Analysis. Orthop J Sports Med. 2014;2(2):2325967114523902. 140. Taylor SAMD, Khair MMMD, Gulotta LVMD, Pearle ADMD, Baret NJ, Newman
117. Cools AM, Borms D, Cottens S, Himpe M, Meersdom S, Cagnie B. Rehabilita- AMBS, et al. Diagnostic glenohumeral arthroscopy fails to fully evaluate the
tion exercises for athletes with Biceps Disorders and SLAP Lesions: a con- Biceps-Labral Complex. Arthroscopy. 2015;31(2):215–24.
tinuum of exercises with increasing loads on the biceps. Am J Sports Med. 141. Yershov D, Hudák R. Unusual variation of the Biceps Brachii with possible
2014;42(6):1315–22. median nerve entrapment. Prague Med Rep. 2015;116(2):167–72.
118. Dubrow SA, Streit JJ, Shishani Y, Robbin MR, Gobezie R. Diagnostic accuracy 142. Zhang Q, Zhou J, Ge H, Cheng B. Tenotomy or tenodesis for long head
in detecting tears in the proximal biceps tendon using standard nonenhanc- biceps lesions in shoulders with reparable rotator cuff tears: a prospective
ing shoulder MRI. Open Access J Sports Med. 2014;5:81–7. randomised trial. Knee Surg Sports Traumatol Arthrosc. 2015;23(2):464–9.
119. Festa A, Allert J, Issa K, Tasto JP, Myer JJ. Visualization of the extra-articular 143. Abraham VT, Tan BH, Kumar VP. Systematic review of Biceps Tenodesis:
portion of the long head of the biceps tendon during intra-articular shoulder arthroscopic Versus Open. Arthroscopy. 2016;32(2):365–71.
arthroscopy. Arthroscopy. 2014;30(11):1413–7. 144. Banerjee M, Müller-Hübenthal J, Grimme S, Balke M, Bouillon B, Lefering R et
120. Hawkes DH, Alizadehkhaiyat O, Kemp GJ, Fisher AC, Roebuck MM, Frostick SP. al. Moderate value of non-contrast magnetic resonance imaging after non-
Electromyographic assessment of muscle fatigue in massive rotator cuff tear. dislocating shoulder trauma. Knee surgery, sports traumatology, arthroscopy:
J Electromyogr Kinesiol. 2014;25(1):93–9. official journal of the ESSKA. 2016;24(6):1888–95.
121. Lisowski JK, Oyama S, Hibberd EE, Myers JB, Prentice WE, Creighton RA. Biceps 145. Creech MJ, Yeung M, Denkers M, Simunovic N, Athwal GS, Ayeni OR. Surgical
Brachii does not play an active role in Humeral Movement. Athletic Train indications for long head biceps tenodesis: a systematic review. Knee Surg
Sports Health Care: J Practicing Clinician. 2014;6(4):179–88. Sports Traumatol Arthrosc. 2016;24(7):2156–66.
122. Nourissat G, Tribot-Laspiere Q, Aim F, Radier C. Contribution of MRI and CT 146. Duchman KR, DeMik DE, Uribe B, Wolf BR, Bollier M. Open Versus arthroscopic
arthrography to the diagnosis of intra-articular tendinopathy of the long biceps tenodesis: a comparison of functional outcomes. Iowa Orthop J.
head of the biceps. Orthop Traumatol Surg Res. 2014;100(8 Suppl):391–4. 2016;36:79–87.
123. Pandey V, van Laarhoven SN, Arora G, Rao S. Bifurcated intraarticular long 147. Gurnani N, van Deurzen DF, Janmaat VT, van den Bekerom MP. Tenotomy or
head of biceps tendon. Indian J Orthop. 2014;48(4):432–4. tenodesis for pathology of the long head of the biceps brachii: a sys-
124. Redondo-Alonso L, Chamorro-Moriana G, Jiménez-Rejano JJ, López-Tarrida P, tematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc.
Ridao-Fernández C. Relationship between chronic pathologies of the supra- 2016;24(12):3765–71.
spinatus tendon and the long head of the biceps tendon: systematic review. 148. Hanusch BC, Makaram N, Utrillas-Compaired A, Lawson-Smith MJ, Rangan A.
BMC Musculoskelet Disord. 2014;15:377. Biceps sheath fluid on shoulder ultrasound as a predictor of rotator cuff tear:
125. Zhang AL, Gates CH, Link TM, Ma CB. Abnormal origins of the long head of analysis of a consecutive cohort. J Shoulder Elbow Surg. 2016;25(10):1661–7.
the biceps tendon can lead to rotator cuff pathology: a report of two cases. 149. Kerschbaum M, Arndt L, Bartsch M, Chen J, Gerhardt C, Scheibel M. Using the
Skeletal Radiol. 2014;43(11):1621–6. LHB score for assessment of LHB pathologies and LHB surgery: a prospective
126. Aly A-R, Rajasekaran S, Ashworth N. Ultrasound-guided shoulder girdle injec- study. Arch Orthop Trauma Surg. 2016;136(4):469–75.
tions are more accurate and more effective than landmark-guided injections: 150. Lee R, Choi S-J, Lee M, Ahn J, Shin D, Kang C, et al. Diagnostic accuracy of 3T
a systematic review and meta-analysis. Br J Sports Med. 2015;49(16):1042–9. conventional shoulder MRI in the detection of the long head of the biceps
127. Banerjee S, Patel VR. Anomalous biceps origin from the rotator cuff. Indian J tendon tears associated with rotator cuff tendon tears. Skeletal Radiol.
Orthop. 2015;49(1):105–8. 2016;45(12):1705–15.
128. Fischer CA, Weber M-A, Neubecker C, Bruckner T, Tanner M, Zeifang F. Ultra- 151. Lewis JS, McCreesh K, Barratt E, Hegedus EJ, Sim J. Inter-rater reliability of the
sound vs. MRI in the assessment of rotator cuff structure prior to shoulder shoulder Symptom Modification Procedure in people with shoulder pain.
arthroplasty. J Orthop. 2015;12(1):23–30. BMJ Open Sport Exerc Med. 2016;2(1):e000181.
129. Fraser PR, Howard LW, Rosales AA, Guttmann GD. Bilateral symmetrical super- 152. Malavolta EA, Assunção JH, Guglielmetti CL, de Souza FF, Gracitelli ME,
numerary heads of biceps brachii with rare pectoralis major insertion. Surg Bordalo-Rodrigues M, et al. Accuracy of preoperative MRI in the diagnosis of
Radiol Anat. 2015;37(3):299–302. subscapularis tears. Arch Orthop Trauma Surg. 2016;136(10):1425–30.
130. Fyhr C, Gustavsson L, Wassinger C, Sole G. The effects of shoulder injury 153. McGarry MH, Nguyen ML, Quigley RJ, Hanypsiak B, Gupta R, Lee TQ. The effect
on kinaesthesia: a systematic review and meta-analysis. Man Therap. of long and short head biceps loading on glenohumeral joint rotational
2015;20(1):28–37.
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 17 of 19
range of motion and humeral head position. KNEE Surg SPORTS Traumatol 175. Meakins A, May S, Littlewood C. Reliability of the shoulder Symptom
Arthrosc. 2016;24(6):1979–87. Modification Procedure and association of within-session and between-
154. Meraner D, Sternberg C, Vega J, Hahne J, Kleine M, Leuzinger J. Arthroscopic session changes with functional outcomes. BMJ Open Sport Exerc Med.
tenodesis versus tenotomy of the long head of biceps tendon in simultane- 2018;4(1):e000342.
ous rotator cuff repair. Arch Orthop Trauma Surg. 2016;136(1):101–6. 176. Motley GS, Guengerich B, Schuller T, Turbyfill A. The Ramp Test: an
155. Razmjou H, Fournier-Gosselin S, Christakis M, Pennings A, ElMaraghy A, arthroscopic technique for confirming intra-articular subluxation and insta-
Holtby R. Accuracy of magnetic resonance imaging in detecting biceps bility of the long head of the Biceps Tendon within the shoulder. Arthrosc
pathology in patients with rotator cuff disorders: comparison with arthros- Tech. 2018;7(4):e327–e30.
copy. J Shoulder Elbow Surg. 2016;25(1):38–44. 177. Vestermark GL, Van Doren BA, Connor PM, Fleischli JE, Piasecki DP, Hamid N.
156. Sahu D, Fullick R, Giannakos A, Lafosse L. Sentinel sign: a sign of biceps The prevalence of rotator cuff pathology in the setting of acute proximal
tendon which indicates the presence of subscapularis tendon rupture. Knee biceps tendon rupture. J Shoulder Elbow Surg. 2018;27(7):1258–62.
Surg Sports Traumatol Arthrosc. 2016;24(12):3745–9. 178. Yoon JS, Kim SJ, Choi YR, Lee W, Kim SH, Chun YM. Medial subluxation or
157. Shah SH, Small KM, Sinz NJ, Higgins LD. Morphology of the lesser tuberos- dislocation of the biceps on magnetic resonance arthrography is reliably
ity and intertubercular groove in patients with arthroscopically confirmed correlated with concurrent Subscapularis full-thickness tears confirmed
Subscapularis and Biceps Tendon Pathology. Arthroscopy: The Journal of arthroscopically. Biomed Res Int. 2018;2018:2674061.
Arthroscopy & Related Surgery. 2016;32(6):968–75. 179. Zabrzyński J, Paczesny Ł, Łapaj Ł, Grzanka D, Szukalski J, Zabrzyński J, et al.
158. Urita A, Funakoshi T, Amano T, Matsui Y, Kawamura D, Kameda Y, et al. Process of neovascularisation compared with pain intensity in tendinopathy
Predictive factors of long head of the biceps tendon disorders-the bicipital of the long head of the biceps brachii tendon associated with concomitant
groove morphology and subscapularis tendon tear. J Shoulder Elbow Surg. shoulder disorders, after arthroscopic treatment. Microscopic evaluation
2016;25(3):384–9. supported by immunohistochemical markers of the endothelial cells. Folia
159. Borms D, Ackerman I, Smets P, Van den Berge G, Cools AM. Biceps Disorder Morphol. 2018;77(2):378–85.
Rehabilitation for the Athlete. Am J Sports Med. 2017;45(3):642–50. 180. Baptista E, Malavolta EA, Gracitelli MEC, Alvarenga D, Bordalo-Rodrigues M,
160. Grassbaugh JA, Bean BR, Greenhouse AR, Yu HH, Arrington ED, Friedman RJ, Ferreira Neto AA, et al. Diagnostic accuracy of MRI for detection of tears and
et al. Refuting the lipstick sign. J Shoulder Elbow Surg. 2017;26(8):1416–22. instability of proximal long head of biceps tendon: an evaluation of 100
161. Hawi N, Liodakis E, Garving C, Habermeyer P, Tauber M. Pulley lesions in shoulders compared with arthroscopy. Skeletal Radiol. 2019;48(11):1723–33.
rotator cuff tears: prevalence, etiology, and concomitant pathologies. Arch 181. Bélanger V, Dupuis F, Leblond J, Roy JS. Accuracy of examination of the long
Orthop Trauma Surg. 2017;137(8):1097–105. head of the biceps tendon in the clinical setting: a systematic review. J Reha-
162. Huguet D, Darrieutort-Laffite C, Le Goff B. Comparison of ultrasound and MRI bil Med. 2019;51(7):479–91.
in the diagnosis of proximal and distal biceps tendon pathology. Ann Rheum 182. Belay ES, Wittstein JR, Garrigues GE, Lassiter TE, Scribani M, Goldner RD, et
Dis. 2017;76:731. al. Biceps tenotomy has earlier pain relief compared to biceps tenodesis:
163. Jeung Yeol J, Seung Min P, Young Eun P, Jae Chul Y, Jeong JY, Park SM, et a randomized prospective study. Knee Surg Sports Traumatol Arthrosc.
al. Morphological classification of anatomical variants of the intra-articular 2019;27(12):4032–7.
portion of the long head of the biceps brachii tendon and analysis of the 183. Cardoso A, Amaro P, Barbosa L, Coelho AM, Alonso R, Pires L. Diagnostic
incidence and the relationship with shoulder disease for each subtype. J accuracy of clinical tests directed to the long head of biceps tendon in a
Orthop Surg (10225536). 2017;25(3):1–6. surgical population: a combination of old and new tests. J Shoulder Elbow
164. Jordan RW, Saithna A. Physical examination tests and imaging studies based Surg. 2019;28(12):2272–8.
on arthroscopic assessment of the long head of biceps tendon are invalid. 184. Carroll MA, Lebron EM, Jensen TE, Cooperman TJ. Chondroepitrochlearis and
Knee Surg Sports Traumatol Arthrosc. 2017;25(10):3229–36. a supernumerary head of the biceps brachii. Anat Sci Int. 2019;94(4):330–4.
165. Kang Y, Lee JW, Ahn JM, Lee E, Kang HS. Instability of the long head of the 185. El Abiad JM, Faddoul DG, Baydoun H. Case report: broad insertion of a large
biceps tendon in patients with rotator cuff tear: evaluation on magnetic reso- subscapularis tendon in association with congenital absence of the long
nance arthrography of the shoulder with arthroscopic correlation. Skeletal head of the biceps tendon. Skeletal Radiol. 2019;48(1):159–62.
Radiol. 2017;46(10):1335–42. 186. Gofeld M, Hurdle MF, Agur A. Biceps Tendon Sheath Injection: An Anatomical
166. Khil EK, Cha JG, Yi JS, Kim H-J, Min KD, Yoon YC, et al. Detour sign in the diag- Conundrum. Pain medicine (Malden, Mass). 2019;20(1):138 – 42.
nosis of subluxation of the long head of the biceps tendon with arthroscopic 187. Kim JY, Rhee SM, Rhee YG. Accuracy of MRI in diagnosing intra-articular
correlation. Br J Radiol. 2017;90(1070):20160375. pathology of the long head of the biceps tendon: results with a large cohort
167. Kumar CD, Rakesh J, Tungish B, Singh DM. Congenital absence of the long of patients. BMC Musculoskelet Disord. 2019;20(1):270.
head of biceps tendon & its clinical implications: a systematic review of the 188. Loock E, Michelet A, D’Utruy A, Molinazzi P, Hannink G, Bertiaux S, et al. Mag-
literature. Muscles Ligaments & Tendons Journal (MLTJ). 2017;7(3):562–9. netic resonance arthrography is insufficiently accurate to diagnose biceps
168. Nascimento AT, Claudio GK. Magnetic resonance imaging without contrast as lesions prior to rotator cuff repair. Knee Surg Sports Traumatol Arthrosc.
a diagnostic method for partial injury of the long head of the biceps tendon. 2019;27(12):3970–8.
Rev Bras Ortop. 2017;52(1):40–5. 189. Sabzevari S, Khalilipour Roudi M, Kalawadia J, Lin A. Chronic long head biceps
169. Rosas S, Krill MK, Amoo-Achampong K, Kwon K, Nwachukwu BU, McCormick Tendinitis secondary to Anomalous Origins in Young Patients: a Case Series.
F. A practical, evidence-based, comprehensive (PEC) physical examination for Arch Bone Jt Surg. 2019;7(6):493–7.
diagnosing pathology of the long head of the biceps. J Shoulder Elbow Surg. 190. Sasaki S, Kenmoku T, Otera A, Miyajima G, Nagura N, Nakawaki M, et al. Elec-
2017;26(8):1484–92. tromyographic analysis of infraspinatus and scapular muscles during external
170. Shang X, Chen J, Chen S. A meta-analysis comparing tenotomy and teno- shoulder rotation with different weight loads and positions. J Orthop Sci.
desis for treating rotator cuff tears combined with long head of the biceps 2019;24(1):75–80.
tendon lesions. PLoS ONE. 2017;12(10):e0185788. 191. Schmalzl J, Plumhoff P, Gilbert F, Gohlke F, Konrads C, Brunner U et al. The
171. Winston BA, Robinson K, Crawford D. Monocept”: a brief report of congenital inflamed biceps tendon as a pain generator in the shoulder: A histological
absence of the long head of the Biceps Tendon and Literature Review. Case and biomolecular analysis.Journal of Orthopaedic Surgery. 2019;27(1).
Rep Orthop. 2017;2017:1090245. 192. Aflatooni JO, Meeks BD, Froehle AW, Bonner KF. Biceps tenotomy versus
172. Zabrzyński J, Paczesny Ł, Łapaj Ł, Grzanka D, Szukalski J. Is the inflammation tenodesis: patient-reported outcomes and satisfaction. J Orthop Surg Res.
process absolutely absent in tendinopathy of the long head of the biceps 2020;15(1):56.
tendon? Histopathologic study of the long head of the biceps tendon after 193. Ager AL, Borms D, Deschepper L, Dhooghe R, Dijkhuis J, Roy J-S, et al. Pro-
arthroscopic treatment. Pol J Pathol. 2017;68(4):318–25. prioception: how is it affected by shoulder pain? A systematic review. J Hand
173. Cutler HS, Tao MA, O’Brien SJ, Taylor SA. Trifurcate Origin of Long Head of Ther. 2020;33(4):507–16.
Biceps Brachii: a Case Report and Literature Review. J Orthop Case Rep. 194. Anil U, Hurley ET, Kingery MT, Pauzenberger L, Mullett H, Strauss EJ. Surgical
2018;8(4):70–3. treatment for long head of the biceps tendinopathy: a network meta-analy-
174. Godenèche A, Kempf JF, Nové-Josserand L, Michelet A, Saffarini M, Hannink sis. J Shoulder Elbow Surg. 2020;29(6):1289–95.
G, et al. Tenodesis renders better results than tenotomy in repairs of 195. Chae SH, Jung TW, Lee SH, Kim MJ, Park SM, Jung JY, et al. Hidden long head
isolated supraspinatus tears with pathologic biceps. J Shoulder Elbow Surg. of the Biceps Tendon instability and concealed intratendinous Subscapularis
2018;27(11):1939–45. tears. Orthop J Sports Med. 2020;8(1):2325967119898123.
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 18 of 19
196. Dirkx G, Pouliart N. How reliable are imaging protocols in the diagnosis of 216. Belk JW, Thon SG, Hart J, McCarty EC Jr, McCarty EC. Subpectoral versus
subscapularis tears? Acta Orthop Belg. 2020;86(4):706–10. suprapectoral biceps tenodesis yields similar clinical outcomes: a systematic
197. Horan M, Dekker T, Goldenberg B, Dornan G, Peebles L, Provencher M et al. review.J isakos. 2021.
Superior labrum anterior-posterior (SLAP) repair versus subpectoral biceps 217. Candela V, Preziosi Standoli J, Carbone S, Rionero M, Gumina S. Shoulder long
tenodesis for isolated slap II lesions in overhead athletes aged younger 35 head biceps Tendon Pathology is Associated with increasing Rotator Cuff tear
years: A comparison of minimum two-year outcomes.Orthopaedic Journal of size. Arthrosc Sports Med Rehabil. 2021;3(5):e1517–e23.
Sports Medicine. 2020;8(7 SUPPL 6). 218. DeFroda SF, Li L, Milner J, Bokshan SL, Owens BD. Cost comparison of
198. Kim BR, Lee J, Ahn JM, Kang Y, Lee E, Lee JW et al. Predicting the clinically arthroscopic rotator cuff repair with arthroscopic vs. open biceps tenodesis. J
significant subscapularis tendon tear: malposition and tear of the long head Shoulder Elbow Surg. 2021;30(2):340–5.
of the biceps tendon on shoulder magnetic resonance imaging.Acta Radiol. 219. Enix D, Scali F, Sudkamp K, Keating R. Supernumerary head of the Biceps
2020:284185120980017. Brachii muscle: an anatomic variant with clinical implications. J Chiropr Med.
199. Li D, Wang W, Liu Y, Ma X, Huang S, Qu Z. The backward traction test: a new 2021;20(1):37–42.
and effective test for diagnosis of biceps and pulley lesions. J Shoulder Elbow 220. Eubank BHF, Lackey SW, Slomp M, Werle JR, Kuntze C, Sheps DM. Consensus
Surg. 2020;29(2):e37–e44. for a primary care clinical decision-making tool for assessing, diagnosing, and
200. Lim S, Kim SK, Kim YS. Comparison between SLAP repair and biceps managing shoulder pain in Alberta, Canada. BMC Fam Pract. 2021;22(1):201.
tenodesis with concomitant rotator cuff repair in patients older than 45 221. Groarke P, Jagernauth S, Peters SE, Manzanero S, O’Connell P, Cowderoy G et
years: Minimum 2-Year Clinical and Imaging Outcomes. Clin Orthop Surg. al. Correlation of magnetic resonance and arthroscopy in the diagnosis of
2020;12(3):364–70. shoulder injury.ANZ J Surg. 2021.
201. MacDonald P, Verhulst F, McRae S, Old J, Stranges G, Dubberley J, et al. Biceps 222. Hughes JD, Gibbs CM, Drummond M, Vaswani R, Ayinon C, Fongod E, et al.
Tenodesis Versus Tenotomy in the treatment of lesions of the long head of Failure rates and clinical outcomes after treatment for long-head biceps
the Biceps Tendon in Patients undergoing arthroscopic shoulder surgery: a brachii tendon pathology: a comparison of three treatment types. JSES Int.
prospective double-blinded Randomized Controlled Trial. Am J Sports Med. 2021;5(4):630–5.
2020;48(6):1439–49. 223. Kooistra B, Gurnani N, Weening A, van Deurzen D, van den Bekerom M.
202. McDevitt AW, Snodgrass SJ, Cleland JA, Leibold MBR, Krause LA, Mintken PE. Tenotomy or Tenodesis for Tendinopathy of the long head of the Biceps
Treatment of individuals with chronic bicipital tendinopathy using dry nee- Brachii: an updated systematic review and Meta-analysis. Arthrosc Sports
dling, eccentric-concentric exercise and stretching; a case series. Physiother Med Rehabil. 2021;3(4):e1199–e209.
Theory Pract. 2020;36(3):397–407. 224. Liu H, Song X, Liu P, Yu H, Zhang Q, Guo W. Clinical outcomes of arthroscopic
203. Mehta SK, Teefey SA, Middleton W, Steger-May K, Sefko JA, Keener JD. tenodesis Versus Tenotomy for Long Head of the Biceps Tendon Lesions: a
Prevalence and risk factors for development of subscapularis and biceps systematic review and Meta-analysis of Randomized clinical trials and Cohort
pathology in shoulders with degenerative rotator cuff disease: a prospective Studies. Orthop J Sports Med. 2021;9(4):2325967121993805.
cohort evaluation. J Shoulder Elbow Surg. 2020;29(3):451–8. 225. Patel BH, Agarwalla A, Lu Y, Ouillette RJ, Forsythe B, Amin NH et al. Isolated
204. Mirzayan R, McCrum C, Butler RK, Alluri RK. Risk factors and complications Biceps Tenodesis and Tenotomy: A Systematic Review of Indications and
following arthroscopic tenotomy of the long head of the Biceps Tendon. Patient Satisfaction. Orthopedics. 2021:1–8.
Orthop J Sports Med. 2020;8(2):2325967120904361. 226. Pozzetti Daou J, Nagaya DY, Matsunaga FT, Sugawara Tamaoki MJ. Does
205. Özer M, Kaptan AY, Ataoglu MB, Cetinkaya M, Ayanoglu T, Ince B et al. The Biceps Tenotomy or Tenodesis have better results after surgery? A systematic
Buford complex: prevalence and relationship with labral pathologies.Journal review and Meta-analysis. Clin Orthop Relat Res. 2021;479(7):1561–73.
of Shoulder and Elbow Surgery. 2020. 227. Ulucakoy C, Kaptan AY, Yapar A, Orhan O, Ozer M, Kanatli U. The effect of
206. Riley SP, Grimes JK, Apeldoorn AT, de Vet R. Agreement and reliability of a bicipital groove morphology on the stability of the biceps long head tendon.
symptom modification test cluster for patients with subacromial pain syn- Arch Orthop Trauma Surg. 2021;141(8):1325–30.
drome. Physiother Res Int. 2020;25(3):e1842. 228. Veen EJD, Koorevaar CT, Verdonschot KHM, Sluijter TE, de Groot T, van der
207. Traverso A, Piasecki K, Gallusser N, Farron A. Agenesis of the long head of Hoeven JH, et al. Compensatory Movement patterns are based on abnormal
the biceps brachii tendon: ignored variations of the anatomy and the next activity of the Biceps Brachii and posterior deltoid muscles in patients with
tendon to disappear?BMJ Case Rep. 2020;13(5). symptomatic rotator cuff tears. Clin Orthop Relat Res. 2021;479(2):378–88.
208. van Deurzen DFP, Gurnani N, Alta TDW, Willems JH, Onstenk R, van den 229. Woodmass JM, McRae SMB, Lapner PL, Sasyniuk T, Old J, Stranges G, et al.
Bekerom MPJ. Suprapectoral versus subpectoral tenodesis for long head Effect of age, gender, and body mass index on incidence and satisfaction of a
biceps Brachii tendinopathy: a systematic review and meta-analysis. Orthop Popeye deformity following biceps tenotomy or tenodesis: secondary analy-
Traumatol Surg Res. 2020;106(4):693–700. sis of a randomized clinical trial. J Shoulder Elbow Surg. 2021;30(8):1733–40.
209. Wade R, Shah SS, B SS, Shah KA, Raj A. A rare anatomical variation in the origin 230. Zhou P, Liu J, Deng X, Li Z. Biceps tenotomy versus tenodesis for lesions of
of the Tendon of Long Head of Biceps in a 30-Year-old male: a Case Report the long head of the biceps tendon: a systematic review and meta-analysis of
and Review of Literature. J Orthop Case Rep. 2020;9(6):94–7. randomized controlled trials. Med (Baltim). 2021;100(3):e23993.
210. Yiannakopoulos CK, Megaloikonomos PD, Foufa K, Gliatis J. Ultrasound- 231. Zhu XM, Leroux T, Ben-David E, Dennis B, Gohal C, Kirsch JM, et al. A
guided versus palpation-guided corticosteroid injections for tendinosis meta-analysis of level I evidence comparing tenotomy vs tenodesis in the
of the long head of the biceps: a randomized comparative study. Skeletal management of long head of biceps pathology. J Shoulder Elbow Surg.
Radiol. 2020;49(4):585–91. 2021;30(5):961–8.
211. Ahmed AF, Toubasi A, Mahmoud S, Ahmed GO, Al Ateeq Al Dosari M, Zikria 232. Petscavage-Thomas J, Gustas C. Comparison of Ultrasound-Guided to Fluo-
BA. Long head of biceps tenotomy versus tenodesis: a systematic review roscopy-Guided Biceps Tendon Sheath Therapeutic Injection. J Ultrasound
and meta-analysis of randomized controlled trials. Shoulder & Elbow. Med. 2016;35(10):2217–21.
2021;13(6):583–91. 233. Morris D, Guettler J, Morris S. Bilateral Superior Labrum anterior to posterior
212. Ayoubi R, Darwish M, Nassour N, Aouad D, Maalouly J, Kanj V, et al. A rare (SLAP) tears with abnormal anatomy of biceps Tendon. Am J Orthop (Belle
case of an anatomical variation of bilateral long head of the biceps brachii Mead NJ). 2015;44(8):E275–7.
tendons identified within the substance of bifid subscapularis tendons. Asia 234. Kanatli U, Ozturk BY, Bolukbasi S. Anatomical variations of the anterosuperior
Pac J Sports Med Arthrosc Rehabil Technol. 2021;23:18–21. labrum: prevalence and association with type II superior labrum anterior-
213. Baek S, Ki SY, Chung SW, Lee SJ, Cho YC, Oh KS. Delayed anticipatory posterior (SLAP) lesions. J Shoulder Elbow Surg. 2010;19(8):1199–203.
muscle activation in Rotator Cuff Tendinopathy. Orthop J Sports Med. 235. Nakata W, Katou S, Fujita A, Nakata M, Lefor AT, Sugimoto H. Biceps pulley:
2021;9(7):23259671211019360. normal anatomy and associated lesions at MR arthrography. Radiographics.
214. Beer Y, Gilat R, Ner EB, Shohat N, Atoun E, Lindner D, et al. Impact of body 2011;31(3):791–810.
Mass Index on the Accuracy of Physical Examination and MRI of the shoulder. 236. Marri K, Swaminathan R. Analysis of concentric and eccentric contractions
Orthop J Sports Med. 2021;9(2):2325967120985643. in biceps brachii muscles using surface electromyography signals and mul-
215. Belk JW, Kraeutler MJ, Houck DA, Chrisman AN, Scillia AJ, McCarty EC. Biceps tifractal analysis. Proceedings of the Institution of Mechanical Engineers Part
tenodesis versus tenotomy: a systematic review and meta-analysis of level I H-Journal of Engineering in Medicine. 2016;230(9):829 – 39.
randomized controlled trials. J Shoulder Elbow Surg. 2021;30(5):951–60.
Diplock et al. BMC Musculoskeletal Disorders (2023) 24:232 Page 19 of 19
237. Knox MF, Chipchase LS, Schabrun SM, Romero RJ, Marshall PWM. Anticipatory 255. Sandrey MA. Special physical examination tests for superior labrum anterior-
and compensatory postural adjustments in people with low back pain: a posterior shoulder tears: an examination of clinical usefulness. J Athl Train.
systematic review and meta-analysis. Spine J. 2018;18(10):1934–49. 2013;48(6):856–8.
238. Hodges PW, Richardson CA. Delayed postural contraction of transversus 256. Lewis J, McCreesh K, Roy JS, Ginn K. Rotator Cuff Tendinopathy: navigat-
abdominis in low back pain associated with movement of the lower limb. J ing the diagnosis-management conundrum. J Orthop Sports Phys Ther.
Spinal Disord. 1998;11(1):46–56. 2015;45(11):923–37.
239. Massé-Alarie H, Flamand VH, Moffet H, Schneider C. Corticomotor control of 257. Lehman GJ. The role and value of Symptom-Modification Approaches in
deep abdominal muscles in chronic low back pain and anticipatory postural Musculoskeletal Practice. J Orthop Sports Phys Ther. 2018;48(6):430–5.
adjustments. Exp Brain Res. 2012;218(1):99–109. 258. Ostrowski JL, Beaumont A, Dochterman E. Diagnostic Accuracy of Musculo-
240. Khandare S, Arce RA, Vidt ME. Muscle compensation strategies to maintain skeletal Ultrasound on Long Head Biceps Tendon Pathologies.J Sport Rehabil.
glenohumeral joint stability with increased rotator cuff tear severity: A simu- 2021:1–4.
lation study.Journal of Electromyography and Kinesiology. 2019. 259. Castro BKC, Corrêa FG, Maia LB, Oliveira VC. Effectiveness of conservative
241. Kaar SG. CORR Insights®: Compensatory Movement patterns are based on therapy in tendinopathy-related shoulder pain: a systematic review of ran-
abnormal activity of the Biceps Brachii and posterior deltoid muscles in domized controlled trials. Phys Ther Sport. 2021;49:15–20.
patients with symptomatic rotator cuff tears. Clin Orthop Relat Research®. 260. Ainsworth R. Physiotherapy rehabilitation in patients with massive, irrepa-
2021;479(2):389–91. rable rotator cuff tears. Musculoskelet Care. 2006;4(3):140–51.
242. Eakin CL, Faber KJ, Hawkins RJ, Hovis WD. Biceps tendon disorders in athletes. 261. Pogorzelski J, Fritz EM, Godin JA, Imhoff AB, Millett PJ. Nonoperative treat-
J Am Acad Orthop Surg. 1999;7(5):300–10. ment of five common shoulder injuries: a critical analysis. Obere Extrem.
243. Gerber C, Sebesta A. Impingement of the deep surface of the subscapularis 2018;13(2):89–97.
tendon and the reflection pulley on the anterosuperior glenoid rim: a pre- 262. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the shoulder
liminary report. J Shoulder Elbow Surg. 2000;9(6):483–90. region. Am Fam Physician. 2003;67(6):1271–8.
244. Odonoghue DH, SUBLUXING BICEPS TENDON IN, THE ATHLETE.Clinical Ortho- 263. Gleich J, Milz S, Ockert B. [Principles of tendon healing at the shoulder and
paedics and Related Research. 1982(164):26–9. consequences for their treatment: importance of platelet-rich plasma and
245. Deurzen DFP, Garssen FL, Kerkhoffs GMMJ, Bleys RLAW, Have I, Bekerom regenerative medicine]. Unfallchirurg. 2021;124(2):89–95.
MPJ. Clinical relevance of the anatomy of the long head bicipital groove, an 264. Fadale PD, Wiggins ME. Corticosteroid injections: their use and abuse. J Am
evidence-based review. Clin Anat. 2021;34(2):199–208. Acad Orthop Surg. 1994;2(3):133–40.
246. Calvert E, Chambers GK, Regan W, Hawkins RH, Leith JM. Special physical 265. Allen GM. The diagnosis and management of shoulder pain. J Ultrason.
examination tests for superior labrum anterior posterior shoulder tears are 2018;18(74):234–9.
clinically limited and invalid: a diagnostic systematic review. J Clin Epidemiol. 266. Kreuz PC, Steinwachs M, Angele P. Single-dose local anesthetics exhibit a
2009;62(5):558–63. type-, dose-, and time-dependent chondrotoxic effect on chondrocytes and
247. Gismervik S, Drogset JO, Granviken F, Rø M, Leivseth G. Physical examination cartilage: a systematic review of the current literature. Knee surgery, sports
tests of the shoulder: A systematic review and meta-analysis of diagnostic traumatology, arthroscopy: official journal of the ESSKA. 2018;26(3):819–30.
test performance.BMC Musculoskeletal Disorders. 2017;18(1). 267. Piper SL, Kim HT. Comparison of Ropivacaine and Bupivacaine toxic-
248. Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3, et ity in human articular chondrocytes. J bone joint Surg Am volume.
al. Physical examination tests of the shoulder: a systematic review with meta- 2008;90(5):986–91.
analysis of individual tests. Br J Sports Med. 2008;42(2):80–92. discussion. 268. Aldon-Villegas R, Perez-Cabezas V, Chamorro-Moriana G. Efficacy of manage-
249. Innocenti T, Ristori D, Miele S, Testa M. The management of shoulder ment of associated dysfunctions on rotator cuff and long head of the biceps:
impingement and related disorders: a systematic review on diagnostic systematic review. J Orthop Surg Res. 2021;16(1):501.
accuracy of physical tests and manual therapy efficacy. J Bodyw Mov Ther. 269. Kim YS, Jeong JY, Lee HJ. Arthroscopic tenodesis of the long head of the
2019;23(3):604–18. Biceps Tendon. JBJS Essent Surg Tech. 2017;7(3):e19.
250. Dessaur WA, Magarey ME. Diagnostic accuracy of clinical tests for superior 270. Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, de Ruiter T, et al.
labral anterior posterior lesions: a systematic review. J Orthop Sports Phys Guideline for diagnosis and treatment of subacromial pain syndrome: a
Therapy. 2008;38(6):341–52. multidisciplinary review by the dutch Orthopaedic Association. Acta Orthop.
251. Munro W, Healy R. The validity and accuracy of clinical tests used to 2014;85(3):314–22.
detect labral pathology of the shoulder–a systematic review. Man Ther. 271. Moorthy V, Tan AHC. Should long head of biceps tenodesis or tenotomy
2009;14(2):119–30. be routinely performed in arthroscopic rotator cuff repairs? J Orthop.
252. Mirkovic M, Green R, Taylor N, Perrott M, ACCURACY OF CLINICAL TESTS, TO 2020;21:161–5.
DIAGNOSE SUPERIOR LABRAL ANTERIOR AND POSTERIOR (SLAP) LESIONS.
Phys Therapy Reviews. 2005;10(1):5–14.
253. Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test Publisher’s note
utility for assessing superior labral anterior posterior lesions. Am J Sports Springer Nature remains neutral with regard to jurisdictional claims in
Med. 2009;37(11):2252–8. published maps and institutional affiliations.
254. Powell JW, Huijbregts PA, Jensen R. Diagnostic utility of clinical tests for
SLAP lesions: a systematic literature review. J Man Manipulative Therapy.
2008;16(3):58E–79E.