1. Long Head of Biceps Pathology Tendinopathy and Instability

2. Normal Anatomy Long Head of Biceps Tendon (LHBT) attached to superior labrum and glenoid Tendon is surrounded by synovial sheath Surrounded by a sling of soft tissue

3. Normal Anatomy

4. Pathophysiology LHBT can undergo the following – Tendinopathy – Instability – SLAP Lesions – Rupture

5. Tendinopathy Inflammation of tendon rare Inflammation of tendon synovial sheath more common (Tenosynovitis) Degeneration of tendon structure also occurs Tendinopathy refers to any tendon disorder with pain, swelling and impaired performance

6. Tendinopathy Repetitive traction and friction causes tendon to initial swell Continued irritation causes tendon to become thicker Adhesions form to surrounding structures Often occurs with other rotator cuff disease (Secondary Biceps Tendinopathy) Can occur in isolation (Primary Biceps Tendinopathy)

7. Tendinopathy

8. Instability Medially directed force displaces the tendon into subscapularis insertion Medial force increased with repetitive throwing in abduction external rotation Due to soft tissue sling, instability occurs with other soft tissue disease, most commonly subscapularis disruption

9. Associated Pathologies Anterior Instability Internal Impingement Rotator Cuff Pathology, External Impingement, Bursitis

10. Subjective Tendinopathy Usually insidious onset Localized anterior shoulder pain over bicipital groove Vague symptoms History of repeated overhead movements or sports Instability Acute Trauma Clicking and popping of anterior shoulder Audible snap with throwing motions Signs of adjacent rotator cuff disease

11. Objective Tendinopathy Pain on palpation of the bicipital groove Reduced internal rotation Instability Tenderness and painful clicking with full abduction and external rotation

12. Special Tests Tendinopathy Yergasson’s Speed’s Instability Apprehension

13. Further Investigation MRI with Arthrogram Arthroscopic Surgery

14. Management Tendinopathy Conservative always considered first Injections and Surgery can be used if conservative management fails Instability Conservative usually unsuccessful Treatment focussed on associated pathology first Surgery usually considered

15. Tendinopathy Conservative Management Rest from aggravating activities Stage 1 – Restore Normal Mobility Stage 2- Restore Normal Motor Control and Strength Stage 3 – Dynamic Stability Stage 4- Return to Sport Rehabilitation

16. Surgical Management Tendinopathy LHBT Decompression Subacromial Decompression LHBT Debridement LHBT Tenotomy LHBT Tenodesis LHBT Transfer Instability LHBT Tenotomy LHBT Tenodesis Subscapularis Repair

17. Post Operative Rehabilitation Varies between surgeons and types of surgery See the reading list for examples of post operative rehabilitation programmes