Fluoroscopically guided supraglenoid tubercle steroid injections for the management of biceps tendonitis

The long head of biceps at the shoulder: a scoping review

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.

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

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Comparison of Ultrasound-Guided to Fluoroscopy-Guided Biceps Tendon Sheath Therapeutic Injection

OBJECTIVES

Biceps tendinitis is a source of anterior shoulder pain and is amenable to therapeutic injection. Studies have shown greater accuracy with image-guided compared to unguided injection of the biceps tendon sheath. There is no literature comparing ultrasound-guided to fluoroscopy-guided biceps tendon sheath injection. The purpose of this study was to compare clinical outcomes, complication rates, procedure success rates, and financial costs of the two imaging-guided methods.

METHODS

A 10-year retrospective review of the picture archiving and communication system was performed to identify patients who underwent image-guided proximal biceps tendon sheath injection. Two radiologists reviewed the picture archiving and communication system and clinical notes to record pain relief, complications, fluoroscopy time, first-pass success rate (defined as injection into the sheath on the first needle pass), final success rate (needle placement in the tendon sheath on the final needle pass), and average costs.

RESULTS

Fifty fluoroscopy-guided and 53 ultrasound-guided cases were identified. There was no statistically significant difference in pain relief or complications. The first-pass success rate was 90.6% for ultrasound compared to 74.0% for fluoroscopy. The final-pass success rate was 98.2% for ultrasound versus 92.0% for fluoroscopy. The mean fluoroscopy time was 57.6 seconds. Ultrasound showed preinjection abnormalities of the biceps tendon in 47.5% of cases.

CONCLUSIONS

Compared to fluoroscopy-guided biceps tendon sheath injection, ultrasound had higher initial- and final-pass success rates, visualized abnormalities before injection, and had similar pain relief and complication rates. Ultrasound is more accurate and has greater diagnostic benefits than unguided or fluoroscopy-guided biceps tendon sheath injection.