6.1 Variants of the origin of the long head of the biceps from the scapula and glenoid labrum according to Vangsness et al. [131]*
One hundred fresh-frozen shoulders were studied. Each specimen was dissected to expose the intact shoulder capsule. The authors then photo- graphed the tendon attachment to the supraglenoid tubercle, recording the percentage of fibres arising from the tubercle, the anterior labrum, and the posterior labrum.
Four types of attachment could be distinguished:
n Type I: All of the labral part of the attachment was to the posterior labrum, with none to the anterior labrum (Fig. 16a)
n Type II: Most was to the posterior labrum, but with a small contri- bution to the anterior labrum (Fig. 16b)
n Type III: Equal contributions to anterior and posterior labrum (Fig. 16c)
n Type IV: Most attached to the anterior labrum, with a small contri- bution to the posterior labrum (Fig. 16d)
Classifications of pathology
of long head of the biceps tendon 6
Fig. 16a±d. a Type I. The labral attachment is entirely posterior, with no contribution to the anterior labrum. b Type II. Most of the labral contribution is posterior
a b
6.2 Classification of SLAP-Lesions
(superior labrum, anterior to posterior lesion) according to Snyder [122, 123]*
A SLAP lesion is defined as an injury of the superior labrum from ante- rior to posterior in relation to the biceps tendon anchor.
n Type 1: fraying and fragmentation of the free edge of the superior la- brum.
± 21% of SLAP lesions.
± This is often a relatively minor problem that is commonly encoun- tered during routine arthroscopy in middle-aged and older pa- tients (Fig. 17a).
n Type 2: the biceps anchor is significantly detached from the superior glenoid tubercle.
± Usually associated with fraying of the edge of the labrum.
± The middle glenohumeral ligament my be rendered unstable when it has a high attachment of the superior labrum and must be eval- uated for security.
± 55% of SLAP lesions (Fig. 17b).
Fig. 16. c Type III. There are equal contributions to both the anterior and the posteri- or parts of the labrum. d Type IV. Most of the labral contribution is anterior, with a small contribution to the posterior labrum
c d
n Type 3: bucket-handle tear of a meniscoid superior labrum with an otherwise normal biceps tendon attachment.
± The fragment of labrum is usually mobile like a bucket-handle tear of a meniscus in the knee, but it may be split in two, leaving a stub of labral tissue on either end.
± Rarely, the middle glenohumeral ligament may be confluent with the free fragment of labrum and consequently rendered unstable.
± 9% of SLAP lesions (Fig. 17c).
n Type 4: type 3 lesion with the tear extending into the biceps tendon.
± The tendon split may be minimal or quite significant.
± 10% of SLAP lesions (Fig. 17d).
a 6.2 Classification of SLAP-Lesions 37
Fig. 17. a Type-1superior labrum, anterior to posterior (SLAP) Lesion. b Type-2 SLAP Lesion. c Type-3 SLAP Lesion. d Type-4 SLAP Lesion
a b
c d
Combined or complex SLAP lesions: Most often, these are type 3 or 4 lesions combined with a significantly detached biceps anchor, or type 2 lesion. When this is encountered, it has to be classified as a complex SLAP type 2 and 3 or type 2 and 4 lesion.
6.3 Classification of SLAP lesion according to Maffet et al. [82]*
The authors performed a diagnostic arthroscopy in 63 patients. Of these, 62% had lesions that fit within the classifications system of Sny- der [122, 123]. Thirty-eight percent in this study had significant biceps tendon-superior labrum injury that did not fit into the classification system proposed by Snyder [122, 123]. The authors defined three addi- tional types of SLAP lesions:
n Type I±IV: are equivalent to Snyder's classification
n Type V: an anterior-inferior Bankart lesion continues superiorly to include separation of the biceps tendon (Fig. 18a)
n Type VI: an unstable flap tear of the labrum is present in addition to biceps tendon separation (Fig. 18b)
n Type VII: the superior labrum-biceps tendon separation extends anteriorly beneath the middle glenohumeral ligament (Fig. 18c)
Fig. 18. a Type-V SLAP lesion (Maffet). b Type-VI lesion (Maffet). c Type-VII lesion (Maffet)
a b c
6.4 Subtypes of SLAP II lesions according to Morgan [88]*
The type II SLAP lesion as originally described by Snyder [122, 123] in- volved a detachment of the biceps anchor and the adjacent labrum from bone with an anterosuperior location.
The authors have observed three types of type II SLAP lesions by anatomic location:
n Anterior SLAP lesion: anterosuperior type II SLAP lesion (Fig. 19a)
n Posterior SLAP lesion: posterosuperior type II SLAP lesion (Fig. 19b)
n Combined SLAP lesion: combined anterior and posterior type II SLAP lesion (Fig. 19c)
a 6.4 Subtypes of SLAP II lesions according to Morgan 39
Fig. 19. Subtypes of type-II SLAP lesions by anatomic location. a Anterior. b Posterior. c Combined anterior and posterior
a b
c
6.5 Topographic classification of LHB-lesions [58]
(Table 3)
n Zone 1: origin
n Zone 2: intraarticular course
n Zone 3: bicipital groove
n Zone 4: lesions below the bicipital groove
Table 3. Topographical classification of LHB lesions
Lesion Zone Pathology
Lesions of the origin of the LHB I SLAP lesions I±IV Andrews lesions
Supratubercular lesions II Isolated tendinosis/tendinitis (Partial) tears of LHB
(Partial) tears of LHB in Rotator cuff lesions
Supratubercular instability (Walch I)
Sulcus associated lesions III Subluxation/dislocation out of the bicipital groove (Walch II) without lesions of postero- superior rotator cuff but where applicable accompanied with a lesion of the subscapularis tendon (and capsule) Lesions below the bicipital groove IV Peripheral of proximal LHB
(e.g., at tendon±muscle transition zone)
6.6 Classification of biceps tendon disorders according to Yamaguchi and Bindra [140]
The various disorders of the long head of the biceps tendon were classi- fied into inflammatory, unstable, or traumatic, on the basis of the origi- nal initiating event. It must be stressed that the distinction is not always clear; the degenerated and inflamed tendon is more prone to trauma and, conversely, repeated trauma may result in changes in the tendon indistinguishable from those of inflammation. Nevertheless, this classifi- cation can help with the organization of the pathogenesis of these disor- ders and formulation of protocols for appropriate management.
I. Inflammatory
1. Biceps tendinitis concurrent with rotator cuff disease 2. Primary bicipital tendinitis
II. Instability 1. Subluxation
n Type I: superior subluxation
n Type II: unstable at proximal portion of groove
n Type III: subluxation following melanin or nonunion of lesser tuber- osity
2. Dislocation
n Type I: extraarticular, combined with partial tear of subscapularis
n Type II: intraarticular, combined with full-thickness tear of subscapu- laris
III. Traumatic 1. Traumatic rupture
n Type I: partial
n Type II: complete
2. Superior labral tears (SLAP lesion)
n Type I: significant fraying
n Type II: complete detachment of biceps tendon and superior labrum from glenoid
n Type III: ªbucket-handleº tear of superior labrum
n Type IV: central superior labrum tear with extension into the biceps
a 6.6 Classification of biceps tendon disorders 41
6.7 Histological changes of the long head
of the biceps tendon according to Murthi et al. [92]*
n Normal
n Chronic inflammation
n Fibrosis
n Mucinous degeneration
n Vascular congestion
n Dystrophic calcification
n Acute inflammation
6.8 Classification of subluxation of the long head of the biceps tendon according to Walch [54]*
Habermeyer and Walch define subluxation of the long biceps tendon as a partial and/or transient incomplete loss of contact between the tendon and its bony groove. Three different types of biceps tendon subluxation were recognized:
n Superior subluxation (type I):
The circular sling of the superior glenohumeral and coracohumeral liga- ments (i.e., rotator interval sling) is partially or completely torn, result- ing in loss of restraint of the long head of the biceps tendon above the entrance to the groove. The subscapularis tendon, which attaches to the lesser tubercle just below the superior glenohumeral ligament, is largely intact; otherwise a true dislocation is present. The lesion above the en- trance to the groove is sometimes marked by an accompanying partial lesion of the supraspinatus tendon on the articular side, directly at the lateral groove entrance, where it forms the roof for the biceps tendon.
The pathologic substrate of the type I subluxation is discontinuity in the tendo-ligamentous rotator interval sling surrounding the long biceps tendon (i.e., lesions of the coracohumeral and superior glenohumeral li- gament and a partial rupture of the supraspinatus and/or subscapularis tendon above the entrance to the groove).
n Subluxation at the groove (type II):
The lesion responsible for the subluxation is located below the entrance to the bony groove. With this type of lesion, the tendon slips over the medial rim of the bony groove and ªridesº on the border of the lesser tuberosity. The causal lesion is a detachment of the outermost fibres of the subscapularis tendon. Tearing of the superficial (outer) portions that line the floor of the groove and help anchor the long biceps tendon al- lows the tendon to displace to a medially subluxated position. The prin- cipal criterion for a type II biceps tendon subluxation is a partial rup- ture of the outer, superficial tendinous portions of the subscapularis muscle, allowing the biceps tendon to ride over the bone of the lesser tuberosity. The type II lesion may be confined to the superior half of the groove or may involve its entire length.
n Malunion and nonunion of the lessertuberosity (type III):
A fracture-dislocation of the lesser tuberosity can progress to a mal- union or nonunion that compromises the medial bony restraint of the long biceps tendon, allowing the tendon to subluxate. The patient com- plains of painful internal rotation of the humerus.
6.9 Classification of dislocation of the long head of the biceps tendon according to Walch [54]*
Habermeyer and Walch [54] have proposed a classification based upon the pathomorphologic features of the biceps tendon dislocation.
n Type I
± Extraarticular dislocation combined with a partial tear of the subscapularis tendon
In this type the long biceps tendon is completely dislocated to a point over the lesser tuberosity. The deeper portions of the subscapu- laris tendon still insert into the lesser tuberosity, separating the bi- ceps tendon from the joint space. Invariably there is a rupture of the common attachment of the superior glenohumeral ligament and cor- acohumeral ligament. The biceps tendon, then, is displaced over the anterior wall of the groove and slips or glides medially over the torn fibres of the subscapularis tendon. The clavipectoral fascia covers this a 6.9 Classification of dislocation of the long head of the biceps tendon 43
lesion externally, and this might give the impression that the supsca- pularis tendon is intact over its full-thickness. It has been shown, however, that the outer attachment of the supscapularis tendon is al- ways torn. This type of dislocation corresponds in its evolution to a type II subluxation but represents a more advanced stage.
Besides the superficial lesion of the subscapularis tendon, there is frequently an associated tear of the rotator cuff. Only systematic ex- ploration of the rotator cuff interval can ensure that the dislocation of the long biceps tendon is missed.
± Extraarticular dislocation with an intact subscapularis tendon Dislocation of the long biceps tendon over a completely intact sub- scapularis tendon is very rare. In a series of 70 patients with sub- luxation and dislocations of the long biceps tendon, only 2 patients (3%) were found to manifest this condition.
n Type II
± Intraarticular dislocation of the long biceps tendon combined with a complete tearof the subscapularis tendon
The biceps tendon is widened and flattened as a result of its contact with the lesser tuberosity. It is shown as a diversity of substance le- sion, ranging from erosion to prerupture. The subscapularis tendon is torn from its attachment on the lesser tuberosity, and the long bi- ceps tendon is interposed into the joint space and displaced infero- medially. On the articular side, the biceps tendon is apposed to the glenoid labrum. Entrapment of the tendon in the anterior joint space occurs with each internal rotational movement of the humerus.
Usually the proximal two-thirds of the subscapularis tendon is rup- tured; rarely is the distal, purely muscular insertion of the subscapu- laris tendon torn as well. We credit Gerber [144] with drawing atten- tion to the problem of an isolated rupture of the subscapularis ten- don and its consequences.
The intraarticular dislocation is often associated with extensive tearing of the rotator cuff. Approximately half of these dislocations have a traumatic etiology.
6.10 Classification of ªhiddenº rotator interval lesions according to Bennett [8]*
Various lesions of the rotator interval are illustrated in Fig. 20. These in- clude subscapularis tear or intraarticular subscapularis (IASS) without involvement of the SGHL/MCHL complex, Fig. 20a; tears of the SGHL/
MCHL complex without subscapularis (IASS) involvement, Fig. 20b; and subscapularis (IASS) tears with involvement of the SGHL/MCHL com- a 6.10 Classification of ªhiddenº rotator interval lesions according to Bennett 45
Fig. 20. Arthroscopic classification of ªhiddenº rotator interval lesions. The various le- sions found in rotator interval. Arrows indicate potential direction and area of abnor- mal biceps motion. a Intraarticular subscapularis (IASS) lesion. b Middle coracohu- meral ligament lesion (MCHL). c MCHL/IASS lesion. d Lower coracohumeral ligament lesion. (From Bennett [8])
a b
c d
plex, Fig. 20c. While the lateral wall of the bicipital sheath is not truly in the rotator interval a lesion of the LCHL is also illustrated, Fig. 20d.
6.11 Classification of pulley lesions according to Habermeyer et al. [52]*
n Group 1: isolated lesion of the superior glenohumeral ligament (Fig. 21a)
n Group 2: lesion of the superior glenohumeral ligament and partial articular-side lesion of the supraspinatus tendon (Fig. 21b)
Fig. 21. Classification of Pulley lesions. (From Habermeyer et al. [52]). a Group 1:
(SGHL) lesion only. b Group 2: SGHL lesion and partial articular-side supraspinatus tendon tear (SSP#). c Group 3: SGHL lesion and partial articular-side subscapularis tendon tear (SSC#). d Group 4: SGHL lesion with partial articular-side supraspinatus (SSP#) and subscapularis tendon tear (SSC#)
a b
c d
n Group 3: combination of a lesion of the superior glenohumeral liga- ment and a deep surface tear of the subscapularis tendon (Fig. 21c)
n Group 4: combination of a lesion of the superior glenohumeral liga- ment and a deep surface tear of the supraspinatus and the subscapu- laris tendon (Fig. 21d)
a 6.11 Classification of pulley lesions according to Habermeyer et al. 47
