Is biceps tenotomy indicated for a patient with positive provocative tests for rotator cuff and long head of biceps, but MRI shows an intact biceps tendon with minimal fluid?

Biceps Tenotomy for Positive Provocative Tests with Intact Biceps Tendon on MRI

Biceps tenotomy is not indicated for a patient with positive provocative tests for rotator cuff and long head of biceps tendon (LHBT) when MRI shows an intact biceps tendon with minimal fluid. 1

Diagnostic Considerations

Imaging Reliability

• MRI is the gold standard for definitive diagnosis of biceps pathology when surgical intervention is being considered 1
• However, MRI has limitations in diagnosing LHBT pathology:
  • Moderate accuracy for partial LHBT tears (sensitivity 77-80%, specificity 71-73%) 2
  • High accuracy for complete LHBT tears (sensitivity 80-100%, specificity 100%) 2
  • Poor correlation between imaging and arthroscopic findings for intrinsic tendon abnormalities (45-65% correlation) 3

Clinical Examination vs. Imaging

• Provocative tests for biceps pathology include:
  • Speed's test
  • Yergason's test
  • Hook test
  • Passive forearm pronation test
  • Biceps crease interval test 1
• Despite positive provocative tests, an intact tendon on MRI with only minimal fluid suggests:
  • Tendinopathy rather than a tear requiring surgical intervention
  • Possible referred pain from associated rotator cuff pathology

Management Algorithm

For Intact Biceps Tendon with Minimal Fluid:

1. First-line: Conservative Management

   • Rest, immobilization, elevation
   • Pain management with acetaminophen and NSAIDs (if not contraindicated)
   • Limited opioid use only for severe pain 1

2. Rehabilitation

   • Gradual progressive strengthening exercises
   • Range of motion exercises (starting 1-2 weeks after injury)
   • Supervised physical therapy 1

3. Follow-up Imaging

   • Consider ultrasound for follow-up (sensitivity 95%, specificity 71% for distinguishing complete vs. partial tears) 1
   • Repeat MRI if symptoms persist despite conservative management

When Biceps Tenotomy Would Be Indicated:

• Complete LHBT tears
• Partial tears >50% of tendon thickness
• Failed conservative management with persistent symptoms 1
• Symptomatic full-thickness rotator cuff tears with LHBT involvement where surgical repair is not possible/refused 4

Clinical Pearls and Pitfalls

• Key Pitfall: Relying solely on provocative tests without correlating with imaging findings can lead to unnecessary surgical intervention

• Important Consideration: MRI may not detect all intrinsic biceps tendon abnormalities, but minimal fluid with an intact tendon is insufficient justification for tenotomy

• Caution: Biceps tenotomy can result in complications including:

  • Popeye deformity (cosmetic deformity of the arm)
  • Potential cramping or pain in the biceps
  • Possible weakness in elbow flexion 4

• Follow-up Recommendation: If symptoms persist despite conservative management, consider diagnostic arthroscopy as it remains the gold standard for definitive diagnosis of LHBT pathology 3