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Hi, my name's Jo Gibson. I'm a clinical physiotherapy specialist working at the Liverpool Upper Limb Unit, in Liverpool in the UK. If you've been following these Facebook Lives, essentially over the last few weeks, we've been talking about diagnosis of some common shoulder conditions and maybe over the last couple of weeks some not so common things.

I've been lucky enough to specialise in treatment of the shoulder since 1995 and during that time, I've worked in an orthopedic clinic and a primary care clinic. So clearly, I have lots of exposure to lots of different causes of shoulder pain.

Now, if you've been following us, you'll also know you can still access all three free webinars looking at causes of acute shoulder pain at www.clinicaledge.co/shoulder. There are three free videos, they're still available, looking at some more common causes of shoulder pain and how you can differentially diagnose. Don't miss out on those if you've not seen them already.

To continue our series, normally on a Monday night, but Tuesday this week, this is just a quick 10-15 minutes tonight, looking specifically at long head of biceps and anterior shoulder pain. Now, if we look at long head of biceps, if we consider its anatomy, first of all, we get quite a lot of clues as to where things can potentially go wrong.

Now it originates at the supraglenoid tubercle and depending on different individuals from various parts of that superior labrum. About 50 to 60 percent of patients will have an attachment to the posterior labrum. About 30 percent to the supraglenoid tubercle. And then the rest, there's kind of a combination of both.

Now, depending on who you read, there can be huge variation in that superior labrum attachments. And clearly that will dictate if somebody has a particular injury mechanism, whether it actually tears off that long head of biceps attachment or not. But we'll come back to it in just a little bit later.

As the biceps then travels through the joints, it's intra-articular but extrasynovial. And then it kind of is angled down about 30 degrees into that bicipital groove. Now, in the bicipital groove, its stability is very dependent on several different structures.

Basically, there's something that's called the biceps reflection pulley that is formed by four main things. You've got your coracohumeral ligament, your superior glenohumeral ligaments, your supraspinatus and your subscapularis.

Basically, subscapularis has a deep and superficial reinforcement of that biceps in the groove. And as I say, those other things actually give it that stability in the groove itself.

We hear quite a lot in the literature about the transverse ligament, but there's quite a lot of controversy as to whether that actually exists and whether, in fact, it's just an extension of some of those of the ligament structures.

So why does that matter? Well, poor old biceps has a bit of a hard time because obviously it's in a relatively small space. And that means if anything happens to overload it, if we get any sort of tendinopathy or any degenerative changes resulting in increased fluid in that tendon, then potentially it's very vulnerable.

So, where's it going to cause you pain? Well, that's going to be very, very dependent on the mechanism of injury.

One thing I would say to you in our non-traumatic populations, so more of our overload pathologies or perhaps in degenerative pathologies. The bottom line is that actually long head of biceps tendinopathy is only a primary pathology in about 5 to 10 percent of cases.

In the majority of people that present with overload pathology or something secondary to pre-existing rotator cuff pathology. Generally, there is another cause and biceps are really a window into telling you that probably that system isn't doing its job properly.

Certainly, if we look at very specific groups, there's no doubt that young patients with instability quite often develop a long head of biceps tendinopathy, purely because of that loss of control in the joints. And so, the poor old long head of biceps gets battered.

Now, again, I know there's lots of people out there that get terribly excited when we talk about and humeral head moving too much on the glenoid. But in instability, we do have 3D fluoroscopy studies that show us that that humeral head just moves more than perhaps in people who don't have symptoms. And as I say, poor old long had a biceps cops for it. And we have EMG studies telling us that long head of biceps works harder in those situations.

If we look at massive rotator cuff tears, interestingly, if you look at people with massive rotator cuff tears with good symptoms, as in not lots of pain and actually quite good function, they use their biceps at higher levels than patients with massive rotator cuff tears who have lots of symptoms and have issues. So that's, that's quite interesting.

Who else can we think about? Again, if you look at people who've had traumatic cuff tears often, particularly if it compromises that part of supraspinatus that is reinforcing the biceps in its groove and particularly also the effects of subscapularis, again, those two things can potentially destabilise the biceps in the groove. It may not actually produce frank subluxation or any popping or clicking in the groove, but it can be sufficient to increase the load on that tendon and therefore it can become symptomatic.

As I say, the problem is, if it's under undue load and it gets a little bit full of fluid as we see when we look on ultrasound sometimes, it's in a relatively small space so that in itself can actually starts to contribute to symptoms.

So, the other thing that's interesting, there's quite a lot of controversy in terms of biomechanically what long head of biceps actually does? There's quite a lot of experts that think that actually if we continue to follow up the population over many years in terms of evolution, it will disappear as we're not swinging through trees anymore. And I'm not sure I entirely believe that because clearly, we've got climbers and people doing all sorts of wacky things in those positions. But what's very controversial is whether or not it actually has any depressive effect on that humeral head, whether it be passive or active.

Most of the evidence supports its role as a strong supinator, but also perhaps elbow flexion and some control of eccentric elbow extension in terms of our throwing populations. But again, long head of biceps seems to work harder when the rest of the rotator cuff isn't doing its job.

Probably one of the key messages to take away from this evening, is if somebody presents you with long head of biceps symptoms, your target is really to get the rest of the cuff doing its job properly because that's likely to unload the biceps and make its life easier. You may do some local work to settle it down and we can talk about those exercises.

So, what are the pathologies that you're likely to see and then what can we do in terms of assessment? Well, there's no doubt that degenerative pathology is clearly one aspect that you may see.

Certainly, if you're over 50 and you've got pre-existing rotator cuff pathology and you get somebody who comes to you that's may be lifted up something heavy or just had a spontaneous rupture of their long head of biceps, that's telling you that their cuff is probably pretty unhappy as well. Patients who have a spontaneous rupture, what you really hope for them, it will completely rupture. And you haven't got any strands left of attachment because if they have they can actually, that can cause them quite a lot of pain and actual spasm in the muscle itself.

The most common things I see tend to be patients who have a secondary overload or a reactive tendinopathy of the long head of biceps either resulting from instability or because they've done a lot of overhead work and fatigue their cuff and again long held biceps has become symptomatic.

The people that you tend to see with a true local irritable or reactive bicep tendon may be people who've perhaps moved house over the weekend or they decided to go to the gym and just do biceps curls. But as I say, generally, if people are telling you that they've done repeated overhead work or cut the hedge, then it's more the fact that the cuff is fatigued if we look at the EMG evidence that we have. In terms of other pathologies that you need to think of, rotator cuff tear and particular a history of traumatic rotator cuff tear, again, a natural sequelae of that is people develop secondary changes in their long head of biceps.

In terms of trauma, if you think of those pulleys that I talk to you about that actually reinforce that biceps in the groove. You can imagine that any forced extension injuries, any forcing into abduction external rotation. Then again, those again have the potential to actually tear off those pulleys.

Now, it's no great surprise to note you if you think of that kind of mechanism of injury that it's very common to see pulley lesions in conjunction with biceps tendinopathy or tendinosis type changes, but also SLAP lesions and AC joint pathology. So, all things that potentially affect that anterior shoulder.

Certainly, again, if you have people who have fractures, so you can imagine somebody who has a coracoid fracture with any kind of callus formation that can compromise a long head of biceps. But similarly, any humeral fractures that potentially have an influence on the size, the shape or again, any bony callus that actually impacts that groove. So as ever, our history is absolutely paramount.

Now there's two key traumas that you need to watch out for that again can potentially develop long head of bicep symptoms as a natural sequelae. The first is AC joint injuries.

So, if somebody has an injury where they fall onto the points of their shoulder, the typical type 1 or type 2 injury, again, they can get some secondary stiffness in the joints. And again, when we follow people up with those type 1 and 2 AC joint injuries, the evidence would suggest that perhaps they might do well in the short term, but quite a lot of them will have grumbly symptoms or recurrence of pain.

And we look at why that is, often it's just they lose some of that clavicular rotation because they get a little bit stiff in the joints. You can imagine that if I've lost some of that clavicular rotation and I'm doing end range or elevation activities, the consequence of that, is going to be more load in my biceps, because I purely just don't get those normal clavicular mechanics.

So again, the key thing is where they're getting their pain. Biceps is pretty friendly, in that, if it's the source of your symptoms, particularly in that bicipital groove, so that extra articular portion, they will point to it at the front of their shoulder.

Now, in terms of palpation, there's lots of studies showing that our local palpation of biceps isn't particularly good, but actually if you internally rotate the shoulder slightly and come down about 3 inches or six and a half centimetres or whatever metric is from the acromion that actually if you then palpate it, it's sore and you rotate the arm, you will feel that biceps move and your fingers.

So, the AC joint in terms of traumatic injuries and natural sequelae of that is people can then develop bicep symptoms because that loss of rotation, that stiffness in the AC joints, but the other group is SLAP lesions. So again, you might have somebody who had a fall years and years ago, they had some niggly symptoms, managed to get back to function, didn't cause them any issues, but then present with cuff signs, AC joint signs, long head of bicep signs.

And as a say, if you look at the average delay in terms of diagnosis of some of those patients, it can be up to three years before they actually get their diagnosis, by which time if they have what we call a type 2 or type 4 SLAP lesion where the long head of biceps attachment into the labrum is unstable so that every time they put it underload or in overhead positions or even just concentric load, it kind of destabilises that attachment.

Now, over time, you can actually get creep in the tendon. So, they then start to develop really nasty bicipital signs, whereas originally their pain was all originally inside.

Age can be a really useful indicator in those traumatic populations. If you have somebody under the age of 40 that has trauma, usually horizontal extension, big eccentric pull on the biceps, a fall onto an outstretched hand where the humeral head goes up through the top of the glenoid and takes the labrum with it. If you're under 40, you're more likely to take your superior labrum than you are your long head of biceps. The older you get over 40, certainly over 50, the more likely it is that your long head of biceps will rupture rather than tearing off your labrum. So again, the history, the age is ever a really important and that mechanism of injury.

If you look at long head of biceps rupture, often it's carrying something helping you make move the fridge. They let go. You get a sudden eccentric load again. If you're younger, that's more likely to take your superior labrum.

So again, hearing that history is really, really important. And don't forget those fractured populations that can get callus that can actually impact the groove or just literally have an impact on changing the mechanics. So again, because that biceps is at such an angle as it becomes intra-articular, again, it's very vulnerable to any changes in that humeral head morphology.

If we look at diagnosis of biceps pathology, again, like everything else with our special tests, they're very limited. But there are some things that seem to give us best value. But there's also a couple of things to share with you about some specific pathologies that can be quite hard to nail down.

So, local palpation as I say, in a little bit of internal rotation coming straight down from the acromion. If it's sore and when you rotate, you can feel it move under your fingers, then that's the most accurate way according to the evidence to palpate it. Palpation alone is not terribly useful, and particularly if somebody's got pre-existing cervical spine problems or just long-standing shoulder pain. They're likely to be tender because that biceps are just very sensitive.

Interesting for you to know that if you have somebody going for surgery with rotator cuff pathology, always read the op notes because if somebody has evidence of intra-articular synovitis in the long head of biceps, they've got a high risk of developing stiffness and having problems with persistent pain after surgery. So, intra-articular biceps synovitis or inflammation is a really important marker to follow your patients carefully to minimise the risks and getting stiff. So, that's just a little tip.

In terms of diagnosis, interestingly, there's been some studies looking at combinations of test, particularly for pathology in the groove, and the most recent one is the uppercut test. If you get the elbow in 90 degrees in neutral and make a fist and then get the patient to pull up hard as if they're literally doing a boxing uppercut that combined with local palpation, tenderness has been shown to be very sensitive. So basically, in terms of ruling in, it can be very, very useful.

There was another study that basically showed that if the uppercut test was positive and you then did spurt Speed's and Yergason's, then again, you could be fairly confident that your long had a biceps was a generator of pain.

Now, in terms of other tests that are out there, there's O'Brien's, which probably everybody knows is a SLAP test, is also depending on the reproduction of location of pain, and only with the relevant age in history can also be useful in ruling in or ruling out. So, if we do our uppercut and then we do an O'Brien's, which is our adduction of about 10 to 15 degrees and don't-let-me-push-you and they get biceps pain and then that's less in the second position with the hand turned up. That's a positive O'Brien's sign. And again, that seems to have high sensitivity in terms of ruling things in. And again, that's a useful part of your decision making.

But again, let's be sensible. If somebody says it hurts here, if I've got biceps pathology, which movements are likely to hurt? Well, external rotation, because I put the tendon on stretch in that groove, particularly if it's a little bit tendinopathic and it's a little bit full of fluid.

Similarly, I won't like abduction external rotation because I wind up that space, and again, I put more load on that tendon. So as ever, hearing the movements that irritate are very important. End range elevation for exactly the same reason, again, because you're going to get some local irritation of that tendon at end range, purely again because that is not going to slide as well in the groove. So, some very simple things there. There was a recent paper that reported the three-pack examination, which sounds interesting. I've only heard about six packs that I definitely haven't got one at the moment. But they talked about, again, a combination of three things: local palpation, the O'Brien's tests and their third test, was actually the Thrower's test. Now, this combination of tests was specifically for patients that they were trying to pick up again, intra-articular pathology. But these are people that often have had investigations that haven't shown anything. But when they went in to scope them and they did a very specific approach so they could visualise that intra-articular portion. They found these three tests were the most reliable in combination.

So, as I say, they did the O'Brien's that we talked about before, this Thrower's test, which again, makes sense because you're really winding up that long head of biceps attachment and then asking them to pull forward does that reproduce their pain with that local palpation, seemed to be a very nice way of actually ruling in that pathology. They said that in their study, they said you could confidently exclude any intra-articular pathology if you had a negative O'Brien's and no local palpation. So again, that's really, really useful. The thing I would say to you that the patients that I see generally fall into that degenerative group where they've probably got some underlying rotator cuff pathology. And the biggest challenge that we have is actually ruling in or ruling out rotator cuff pathology again, because we know our special tests aren't necessarily very useful.

What I would say to you is the one that seems to cause the most misdiagnosis is an undetected subscapularis tear and subscapularis tear is a probably more prevalent than we think. So, our bear hug test is meant to be one of the most reliable tests. It's described in two positions because you have two parts of subscapularis - upper and lower. But obviously, depending on which part of, that's affected, you can get a lot of pain inhibition when you test in this position. So, the most reliable is actually with this kind of 45-degree position and don't-let-me-pull-you-away.

Now, the issue is that, again, you can get a lot of false negatives with testing subscapularis because of those two parts. And often, it's only when they have a scope that they actually pick that up. So, let's say that you've got somebody that you think they've got local biceps pain, they give you a history the way they may have had a previous cuff tear or maybe they've just got loading. They're not getting back better with your rehab. What can we do, investigation wise to see if there's anything structural there that's causing the problem? Well, this isn't without its challenges. Ultrasound is very useful. It just looking at intrinsic pathology in terms of, "Is it full of fluid?", "Can I see anything obvious in terms of instability when I look at rotation movements?"

And again, if you're looking for instability because of compromise of those pulleys, winding it up and then resisting biceps, you often will feel some subluxation or you'll feel the movement of the groove. Okay, but say you haven't got those signs and you trying to work out why your rehab isn't working well, MRI can be useful, but the evidence would suggest it's not as good as MR Arthrogram, which is much more sensitive in terms of picking up those pulley lesions and those more subtle lesions. Again, not infallible.

Interestingly, even arthroscopy is not the best at visualising pathology unless it's done in a very specific way. So, when you have pathology within the group and sometimes it can get little bits of bone behind that actually irritate the tendon. You have to look at it very specifically during arthroscopy in a very specific position to actually visualise the whole of that tendon. A lot of traditional approaches where they just try to pull that tendon out a bit, doesn't fully visualise it. And actually, some studies show that actually people have been wrongly cleared of having associated biceps pathology purely because they have not adequately visualised that tendon.

So, where does that leave us and what we're going to do to treat it? Well, let's say somebody's got ongoing biceps pathology in that degenerative group. If you're in France, you're going to get it cut out because essentially, they will say that once the biceps is very irritable and you've got associated pathology, the biceps is a real source of symptomology. So, cutting it out is probably one of the most useful things you can do. If you look at patients with SLAP lesions under 40, there is a big kind of trend now to actually do a biceps tenodesis.

Why do a tenodesis rather than the tenotomy? Mainly for cosmesis, but also because your tenodesis potentially will just maintain a little bit more strength than your tenotomy. Both groups can have problems with muscle spasm and pain afterwards, but fundamentally losing that intra-articular portion of biceps doesn't seem to cause huge problems.

What are your thoughts about the role of the rotator cuff interval in allowing the degenerative cuff to maintain its function particularly above 90 degrees?

I think there's a lot of interest at the moment, one in the rotator interval and in fact, there's a study just coming out looking at the effects of selectively dissecting that. But I think what is interesting, there's a couple of key things when we look at patients that compensate well. There is no doubt if you lose the whole of the subscapularis, it doesn't matter what we do, they don't seem to do well with our we rehab. Patients who have one part of their subscap intact, and with their teres minor, are the group that really seems to do well. In terms of the rotator interval itself, there's no doubt if that's intact, patients have a much better chance of compensating, because if you imagine my knuckles like that kind of continuum and then my rotator interval, if that's intact, even if I've got tears elsewhere in the cuff, I can still transfer that load to the rest of the system.

There are also studies looking at how far that cuff retracts around the equator of the humeral head. And again, it would seem that where it stays above it again, patients have more chance of compensating. But what I'll do is I'll post a link to an article that speaks particularly about that rotator interval and also the types of cuff that can compensate well.

I think the big thing for me is if you look at any of these massive rotator cuff tears or any large two massive cuff tears is two or more tendons with or with five centimetres of more of retraction, whereas we just look at some of our big rotator cuff tears long head of biceps, pathology is a real feature.

Let's recap. Basically, long head of biceps is generally secondary rather than a primary pathology. As ever, your history is really important in terms of trauma, generally, if you've got biceps pathology, it's secondary to injuring your cuff, either the anterior leading edge of your supraspinatus or your subscapularis.

But remember in your younger cohort, it could be secondary to a SLAP lesion. So as ever, mechanism really matters. And age really matters too.

So again, remember, somebody with long standing rotator cuff pathology again just can lose that clavicular rotation. So, whether they've had an AC joint injury or they've just had longstanding shoulder pain and develop some AC joint stiffness purely just because of the alteration, because of how they've compensated and moved, biceps usually tells you that actually you could get your cuff going and just make sure your AC joints doing its job. So, it's very, very rare for long head of biceps to be a primary issue.

Remember, unless they give you a history where they've specifically loaded that biceps with some concentric or eccentric load, it's unlikely to be a primary tendinopathy. Your rehab is going to target the rest of the cuff. Of course, you can do isometrics, you can do isometric-eccentric work. If you imagine I'm holding a table and I just take myself away, a nice way, to get fluid out the tendon. But fundamentally the best way to unload is to get the rest of the cuff doing its job.

I'm going to put a summary together for you. And I'm going to put some key articles that just target some of that information. And I'll just put together a little flowchart to kind of talk through it. This has just been about continuing our series of considering the things that can potentially cause problems in the shoulder. Most of the things I see is secondary, either to instability in my younger cohort or to rotator cuff pathology in my older cohort. But again, remember, patients with any sort of trauma around the shoulder, again, it can be a secondary thing compensating for those change in mechanics or change in muscle activation.

The pulley lesions, when I've seen them, they've been in goalkeepers or people who've had a fall onto an outstretched hand. And again, they do all right with rehab but as soon as they start loading in these positions, they have very specific local symptoms. That's where your investigations can be really, really helpful in terms of just answering the question.

But remember, you need to be talking to a shoulder surgeon who really understands his biceps, because not all tests or not all investigations tell us what we need to do.

So, if you're looking for a pulley lesion, you need an MR arthrogram. If you looking for intra-articular pathology, your ultrasounds not showing it, then actually doing an arthroscopy with a surgeon whose got a proper visualisation in that intra-articular portion. Then you can be confident it's not a problem.

So, guys, loads of information as ever. Just continuing our story about the shoulder and understanding causes of shoulder pain. If you haven't seen our three free webinars, please do go and get those at www.clinicaledge.co/shoulder. And I'll be back here again very soon.

I’ll post the time on Facebook to do some more shoulder geeking and share some knowledge with you. Guys, thank you for all the lovely comments. I feel like I've jumped around a bit, but hopefully given you loads of great information as I say, I'll summarise it for you so you've got the key hints and some key articles.

Thanks for joining me on a Tuesday evening and I look forward seeing you again soon.