The long head of the biceps (LHB) tendon has been a known source of shoulder pain and problems for many years. It is a unique anatomic structure that enters the glenohumeral joint via the confines of a very complex pulley system consisting of soft tissue and bone. In the last 25 years, we have gained considerable knowledge with regards to the anatomy, pathophysiology, evaluation, and surgical treatment of the LHB tendon.

The LHB tendon originates from the supraglenoid tubercle at the top of the glenoid rim and travels through the glenohumeral joint toward the mouth of the intertubercular groove where it exits the joint at a 35° angle anteriorly. The intertubercular groove is formed by the junction of the lateral edge of the lesser tuberosity and the anterior edge of the greater tuberosity. The tendon glides within the confines of the groove and is held there by the soft tissue constraints of the pulley system.¹

The proximal portion of the biceps groove pulley system consists of four soft tissue structures that form the mouth: the superior glenohumeral ligament (SGHL), the subscapularis tendon, the coracohumeral ligament (CHL), and the supraspinatus tendon. They combine to form a funnel that directs the LHB tendon into the groove. The floor of this funnel-shaped entrance consists of the SGHL. It arises from the anterosuperior labrum immediately anterior to the supraglenoid tubercle and crosses in a lateral direction, inserting beneath the LHB tendon at the floor of the biceps groove.² It is reinforced by the subscapularis tendon below. The proximal roof of the pulley system consists of the CHL, which is made up of two bands that traverse laterally from their origin at the coracoid process. The roof is formed by the CHL, which arises from the coracoid process to form two bands that traverse laterally. The more anterior band inserts into the superior border of subscapularis tendon, the transverse humeral ligament, and the lesser tuberosity. The most posterior band inserts into the greater tuberosity and is reinforced by the tendinous portion of the supraspinatus.¹ The funnel is completed by the union of the anteroinferior SGHL with the posterosuperior CHL and is termed the reflection pulley.³

The distal part of the groove is stabilized by the transverse humeral ligament, which forms the roof of the bony groove. This ligament is a continuation of the interval tissue from the superior aspect, the supraspinatus tendon from the posterolateral aspect, and the subscapularis tendon from the anteromedial aspect.^1,4

Accordingly, the soft tissue components of the proximal and distal portions of the biceps pulley system form a strong hood over the bicipital groove, which is also known as the biceps sheath. The LHB tendon is enveloped by synovium within the groove and is innervated by sensory fibers, which are thought to play a role in the pathogenesis of shoulder pain.⁵

The pathophysiology of LHB tendon pain can be separated into three groups: inflammatory, traumatic (macro and repetitive micro), and instability. The causes of these various types of pathology are intimately related to the surrounding anatomy of the pulley system, and the three subtypes often overlap with resultant demise of the tendon. As described in the classical article by the Neviaser family, the majority of the tendonous changes are seen in the portion of the tendon that sits in the bony groove with the arm at rest.⁶

Multiple biomechanical studies have shown that the LHB tendon plays a role in the function and stability of the glenohumeral joint.^{7, 8, 9, 10, 11, 12, 13 and 14} The overall importance of the LHB tendon remains somewhat controversial. Regardless, most shoulder specialists would agree that the LHB tendon is not very active when it becomes painful or is unstable as a result of various pathologies and may actually play a negative role when diseased.¹

The most common form of biceps instability is an anteroinferior subluxation of the tendon as a result of a tear in the reflection pulley. This most often primarily involves the SGHL insertion at the anteroinferior portion of the mouth of the groove. When this happens, the biceps tendon can subluxate in an anteroinferior direction, toward the upper portion of the subscapularis tendon insertion into the lesser tuberosity. This can eventually lead to tearing of the subscapularis tendon, with the biceps tendon sliding into or under the tendon as it tears.¹

When pathology of the LHB tendon results in debilitating pain and/or dysfunction of the shoulder and when the subscapularis tendon is at risk, most shoulder surgeons recommend biceps tenodesis or tenotomy to eliminate pain, improve shoulder function, prevent LHB tendon complete rupture, and/or prevent subscapularis tendon from further injury.

Arthroscopic LHB tenotomy is the preferred choice of treatment of LHB tendon pathology by some surgeons as it is quick and easy and has outcomes comparable with those of tenodesis. However, many patients do not like the resultant “Popeye” deformity and cramping that often results, especially in males. For that reason, most surgeons currently prefer treating LHB tendon pathology with a tenodesis procedure.

Tenodesis procedures have been performed with open techniques for many decades and include both bone and soft tissue techniques. The “keyhole” technique in which a knotted LHB tendon was placed into a keyhole in the proximal humerus was one of the first techniques and was quite common in the 1970s and 1980s. It created a stress riser and was abandoned because of a risk for humeral fracture with postoperative trauma. Open soft tissue tenodesis remains quite common in shoulder arthroplasty with the biceps being sown to the pectoralis major tendon.

With the advent of shoulder arthroscopy starting primarily in the mid to late 1980s, arthroscopic and/or arthroscopic-assisted techniques have largely replaced open techniques. The all-arthroscopic techniques are performed in a higher position, either at the mouth of the biceps groove or more distally toward the bottom of the biceps groove, immediately above the pectoralis major tendon. More distal techniques, beneath the pectoralis major tendon, must be performed with an open but arthroscopic-assisted technique.

In 1993, Weber was the first to describe the arthroscopic-assisted mini open subpectoral approach to biceps tenodesis.¹⁵ This technique was largely abandoned when proximal all-arthroscopic techniques were introduced as first described by Gartsman et al in 2000 with the implementation of suture anchors.¹⁶ Soon after, Boileau introduced the use of interference screws and Rodosky reported on the use of a novel soft tissue technique with sutures passed percutaneously across the transverse humeral ligament/anterior interval tissue capturing the LHB at the bicipital groove.^17,18

In 2012, Warner et al reported that proximal arthroscopic techniques failed at a higher rate than distal techniques due to pain coming from the bicipital groove.¹⁹ After his report, many surgeons reverted to the subpectoral approach as described by Weber.¹⁵ However, Weber discontinued his use of the subpectoral approach as multiple studies including a large multicenter study by Burkhart et al, with over 1000 cases, showed highly satisfactory results with proximal techniques.²⁰ In 2015, Weber published a comparison study of his proximal arthroscopic tenodesis group with 10-year follow-up versus his previous subpectoral tenodesis group showing no difference in clinical outcome and concluding that concerns about pain related to the retention of the biceps within the bicipital groove appear unfounded.²¹ An earlier biomechanical study by Rodosky et al in 2010 indicated that the
quality of the biceps tendon is the rate limiting factor in determining the success or failure of proximal techniques.²² Those patients with unreliable proximal tissue would be better candidates for a more distal approach where the tissue is less likely to be diseased. The more distal approaches would include the subpectoral approach as mentioned earlier or the arthroscopic suprapectoral approach performed low in the bicipital groove as described by David et al.²³