The preoperative preparation of a patient with LHB tendinopathy involves appropriate evaluation of a patient’s signs and symptoms of LHB tendinopathy, which is often associated with anterior shoulder pain, often localized to the bicipital groove.⁴ The pain often occurs at night and may radiate down the arm into the biceps muscle and is exacerbated by overhead activities.⁴

Many special tests have been used in the evaluation of LHB tendinopathy, including Speed, Yergason, bicipital groove tenderness, uppercut, bear hug, belly press, anesthetic injection, and O’Brien, all with varying degrees of sensitivity and specificity. In a systematic review of the literature by Rosas et al⁵ the sensitivities and specificities of the most common special tests in determining the presence of LHB tendinopathy were investigated and compared with the gold standard of diagnostic arthroscopy or arthrotomy. Bear hug, uppercut, and anesthetic injection were the most sensitive with 79%, 73%, and 66% sensitivity, respectively.⁵ Anesthetic injection, belly press, and O’Brien were the most specific with 87.5%, 85%, and 84% specificity, respectively.⁵

Varying imaging modalities often used in the evaluation of LHBT include radiography, ultrasonography, magnetic resonance imaging (MRI), and computed tomography (CT) arthrography. Radiography is often initially used, which helps to identify potential calcification or osteophytes within the bicipital groove⁴ or other pathology implicated in anterior shoulder pain such as fractures, rotator cuff arthropathy, acromioclavicular arthritis, and/or glenohumeral arthritis. Ultrasonography involves the dynamic evaluation of the biceps tendon and can be used to diagnose a biceps rupture, subluxation, or dislocation of the biceps tendon.⁴ Nourissat et al⁶ investigated the specificity and sensitivity of MRI (1.5 T) and CT arthrogram compared with the gold standard of diagnostic arthroscopy in the diagnosis of intra-articular tendinopathy of the long head of the biceps tendon. For the MRI examination, tendon pathology was defined as an abnormal signal in one of the expired segments, or at its insertion, and CT arthrography tendon pathology was defined as evidence of remodeling, fissuring, or degeneration.⁶ MRI was found to have a sensitivity of 42.84% and specificity of 75%, and CT arthrogram had a sensitivity of 71.3% and a specificity of 100%.⁶

We believe that a diagnostic/therapeutic cortisone injection of the biceps sheath to be a crucial aspect of both evaluation and preoperative planning for a Loop ‘N’ Tack tenodesis when the procedure will be performed in isolation (ie, not as a part of another surgery, such as a rotator cuff repair). It is expected that the patient will have excellent relief of the symptoms related to their biceps pathology, even if it is short lived. We would caution against performing the Loop ‘N’ Tack procedure in anyone who does not get significant relief following this injection as their pain will most likely not be due to any pathology of the biceps.

The patient is placed in the beach chair or lateral decubitus position, based on surgeon preference for shoulder arthroscopy. Diagnostic arthroscopy through the posterior portal is completed with a 30° scope ( Video 27-1). An 18-gauge spinal needle is used via the outside-in technique of the anterior portal within the rotator interval, directly centered on the biceps tendon. Anterior portal positioning is essential to ensure instruments can easily access above and below the biceps tendon, as well as ease of access to the intra-articular groove, just proximal to the subscapularis tendon. A cannula is used through the anterior portal for suture management.

With the use of a ring suture grasper, a suture with a looped end is inserted through the anterior portal (FiberLink SutureTape; Arthrex, Naples, FL). The looped end of the suture is first passed superior to biceps tendon (Figure 27-1), released, and retrieved inferior to the biceps. The loop of the suture is withdrawn through the anterior cannula and a looped hitch (“luggage-tag”) knot is created by having the free end of the suture through the loop and pulling to tighten the luggage-tag around the biceps firmly (Figure 27-2).

The tension on the eventual tenodesis can be set by adjusting the location of the luggage-tag. The tenodesis will be eventually anchored at the superior border of the subscapularis and anterior margin of the supraspinatus tendon, at the most distally visualized portion of the intra-articular bicipital groove. If the surgeon desires to replicate the native tension on the biceps, the luggage-tag should be placed more distal on the biceps.

We recommend taking the biceps slightly off tension to minimize the load seen on the biceps. In such cases, the luggage-tag should be tightened around the biceps approximately 15 mm distal to its insertion on the superior labrum. It is important to not place the suture too close to the superior labrum insertion of the biceps to make sure the loop does not slip off the end of the biceps once it is cut. Once the luggage-tag has been placed in the desired position, the free end of the suture is placed through the cannula with a grasping suture retriever inferior to the biceps tendon (Figure 27-3). A tissue penetrator is inserted through the cannula to pierce through the midportion of the biceps distal to the luggage-tag knot (Figure 27-4). With the tissue penetrator, the free end of the suture is grasped and pulled through the biceps tendon and withdrawn from the cannula (Figure 27-5).