Rev. bras. ortop. vol.51 número1

rev bras ortop.2016;51(1):96–99

w w w . r b o . o r g . b r

Case

Report

Tendon

of

the

long

head

of

the

biceps

originating

from

the

rotator

cuff

–

An

uncommon

anatomical

variation:

case

report

夽

Carlos

Vicente

Andreoli

_,

_Leonardo

_Roure

_Esteves,

_Eduardo

_Figueiredo,

Paulo

Santoro

Belangero,

Alberto

de

Castro

Pochini,

Benno

Ejnisman

UniversidadeFederaldeSãoPaulo(Unifesp),SãoPaulo,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received31December2014

Accepted14January2015

Availableonline21December2015

Keywords:

Tendons Shoulder

Rotatorcuff

a

b

s

t

r

a

c

t

Anatomicalvariationsattheoriginofthebicepstendonhavebeendescribedbyseveral

authors,butoccurrencesofanorigininthesupraspinatusarerare.Itisunclearwhether

thisvariationmightcontributetowardpathologicalconditionsoftheshoulder.Ourobjective

herewastodescribeacaseofananatomicalvariationintheoriginofthetendonofthelong

headofthebiceps.

The clinicalinformation, preoperative images and arthroscopicimages relating to a

patientwithanaberrantoriginofthelongheadofthebiceps,whichwasobservedduring

shoulderarthroscopy,werereviewed.

Inthiscasestudy,theoriginofthebicepswasfoundintherotatorcuff,withoutany

originfromthesupraglenoidtubercleorupperlabrum.Thisvariantdidnotseemto

con-tributetowardthepathologicalconditionoftheshoulder,andstandardtreatmentforthe

concomitantconditionwassufficientfortreatingit.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.Allrightsreserved.

Tendão

da

cabec¸a

longa

do

bíceps

originado

do

manguito

rotador

–

Uma

variac¸ão

anatômica

incomum:

relato

de

caso

Palavras-chave:

Tendões Ombro

Bainharotadora

r

e

s

u

m

o

Asvariac¸õesanatômicasnaorigemdotendãodobícepsforamdescritasporváriosautores,

masaocorrênciadesuaorigemnosupraespinhalérara.Nãoestáclaroseessavariac¸ão

podecontribuirparacondic¸õespatológicasdoombro.Nossoobjetivoédescreverumcaso

deumavariac¸ãoanatômicadaorigemdacabec¸alongadotendãodobíceps.

夽

WorkperformedintheDisciplineofSportsMedicine,DepartmentofOrthopedicsandTraumatology,EscolaPaulistadeMedicina

(EPM),UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:andreolicruz@uol.com.br(C.V.Andreoli).

http://dx.doi.org/10.1016/j.rboe.2015.12.004

rev bras ortop.2016;51(1):96–99

97

Informac¸õesclínicas,imagenspré-operatóriaseimagensartroscópicasforamrevisadas

apartirdeumpacientequeteveumaorigemaberrantedacabec¸alongadobícepsobservada

duranteaartroscopiadoombro.

Nesteestudodecaso,aorigemdobícepsfoiencontradanomanguitorotador,semorigem

dotubérculosupraglenoidaloulabrumsuperior.Essavariantenãoparececontribuirparaa

patologiaombroeotratamentopadrãodepatologiaconcomitantefoisuficiente.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier

EditoraLtda.Todososdireitosreservados.

Introduction

Aseriesofdescriptionsoftheoriginofthetendonofthelong

headofthebicepshavebeenmade.Mostofthesestudieshave

describedanorigininthesupraglenoidtubercle.1,2 _Recently,

many reports from anatomical dissections and findings of

arthroscopyhaveshownthatthetendonveryfrequently

ori-ginatesfromthesupraglenoidtubercleandtheupperglenoid

labrum.2

Vangsnesset al.2 _{observed that in around 50% oftheir}

patients,thetendonofthelongheadofthebicepsoriginated

fromtheupperlabrumandinaround50%fromthe

supra-glenoidtubercle.

During normalembryo development, the tendon ofthe

bicepsdevelopsfromtheshouldercapsuleandcanbefoundas

anindependentstructureinfetusesagedaroundnineweeks.

Interruptionstodevelopmentorabnormalitiesoveritscourse

mayresultinvariationsfromthenormalanatomy.3

Therehavebeenseveraldescriptionsofanomalousorigins

ofthe tendon ofthe biceps, but their clinical implications

remainmostlyunknown.Thesereportscomefrom

inciden-talfindingsduringarthroscopicsurgeryandincludeaberrant

intra-articularorigins,extra-articularoriginsandagenesis.3–6

Theaimofthisarticlewastodescribeararevariationinthe

originofthelongheadofthebicepsandtheassociatedclinical

condition.

Case

report

Thepatientwasa43-year-oldmalemanualworkerwhohad

presentedpaininhisrightshoulder(dominantarm)fortwo

years,withprogressiveworseningwhileperforminghiswork.

Atthe timewhenhissymptomsbegan, hesought medical

adviceandwas diagnosedwithshoulderimpactsyndrome

(stage1,accordingtotheNeerclassification),basedon

physi-calexaminationandultrasonographyontheshoulder.Hewas

treatedwithan anti-inflammatorydrug (meloxicam,15mg

orallyfor10days)andwasreferredforphysiotherapeutic

reha-bilitation.Hecompleted50physiotherapysessions,witha50%

improvementofthepain.

One year after the first treatment, magnetic resonance

imagingshowedalesionthataffected40%ofthe

supraspina-tustendon.Theconservativetreatmentwascontinued,using

aninjectablecorticosteroid(threeintramuscularinjectionsof

dexamethasone,every15days)andphysiotherapeutic

reha-bilitation. After two years of treatment, he still presented

Fig.1–Coronalslicefrommagneticresonanceimaging,

highlightingtheanomalousoriginofthelongheadofthe

biceps.

positiveimpactmaneuvers(NeerandHawkins),withoutpain

on palpation of the bicipital groove, and with a negative

O’Brien test. Aradiographic examination showed atype II

acromion(Biglianiclassification).

A second magnetic resonance image revealed a bursal

lesionoccupying80%ofthethicknessofthesupraspinatus

tendon(Fig.1).Becauseofthepersistentpainandthepresence

ofalesionofthesupraspinatustendon,arthroscopicrepairof

therotatorcuffwasindicated.Duringthearthroscopic

proce-dure,avariationintheanatomicaloriginofthetendonofthe

longheadofthebicepswasobserved,suchthattheoriginwas

inthelowersurfaceofthesupraspinatustendon(Figs.2–4).

Thetendonofthebicepswasstableuponpalpationanddid

not present any signs ofinflammationor fibrillation along

itspath.Bursectomyandacromioplastywereperformedand

thelesionofthesupraspinatustendonwasrepairedusingan

absorbableanchor.

Noprocedurewasperformedonthetendonofthebiceps.

Thepatientreturnedtoworkfivemonthsaftertheoperation

andwasseentobeasymptomaticandperforminghisworkin

anormalmannerafter14monthsoffollow-up.

Discussion

Hymanand Warren7 _{describedanextra-articular originfor}

thelongheadofthebicepsinthesupraspinatus.Kimetal.6

98

Fig.2–Arthroscopicimageshowingtheoriginofthelong

headofthebicepsonthelowersurfaceofthe

supraspinatustendon.

thebiceps,intherotatorcuff.InthevariantdescribedbyLang

etal.,8_{thebicepsoriginatedintherotatorheadwithoutan}

annexgoingtotheupperlabrumandthiscasepresenteda

par-tialarticularlesionoftherotatorcuff.Theseauthorsobserved

thatthe biceps wasnotdiseased andthey thereforeleft it

intact.Theyreportedthatcompleteresolutionofthe

symp-tomswasachievedthrougharthroscopicrepairoftherotator

cuff.

Other intra-articular variants that have been described

includeabifurcatedoriginofthebicepsinthesupraglenoid

tubercleandposterosuperiorlabrum,atendonofthebiceps

bifiduswithasingleorigininthesupraglenoidtubercleand

atendonofthebicepsthatwentthroughthesupraspinatus

tendon.9 _{OgawaandNaniwa}10 _{raisedthehypothesisthatif}

thetendonofthebicepspassesthrough thesupraspinatus

tendon,thismaycontributetowardtearingoftherotatorcuff.

Fig.3–Anotherarthroscopicview,withtheprobeatthe

insertionofthebiceps.

Fig.4–Arthroscopicviewsof:(1)humeralhead;(2)upper

labrum;(3)originofthelongheadofthebiceps.

Enad4 _{presented two patients with a Y-shaped}

bifur-catedorigininthesupraglenoidtubercleandposterosuperior

labrum.Therewasnoconnectionwiththerotatorcuff.Both

ofthesepatientsweretreatedforconditionsofsubacromial

impact and acromioclaviculararthrosis,bymeans ofdistal

decompression withdistalexcision ofthe clavicle.The

ori-ginofthebicepswasnotinflamedanddidnotappeartobe

diseased,anditwasleftintactinbothcases.

There is a consistent association between congenital

absence ofthe long head ofthe biceps and glenohumeral

instability,andstudieshaveshownthatthelongheadofthe

bicepshasastabilizingrole.8–10_{Specifically,thelongheadof}

thebicepsactsasadepressoroftheheadofthehumerusand

adynamicstabilizerfortheglenohumeraljoint.

Ourcasereportandmostotherpublishedreportsoncases

ofabnormalintra-articularoriginsforthelong headofthe

bicepssuggest thattheseanatomicalvariationsare benign,

withoutanyevidencethatthesefindingsarepathological.

Inthisreportonararecase,wefoundadifferent

anatomi-caloriginforthelongheadofthebiceps,inwhichitoriginated

from the lower surface ofthe supraspinatus tendon,

with-out originatinginthesupraglenoidtubercleorintheupper

labrum.

Thisvariantdidnotappeartocontributetowardthe

patho-logicalconditionoftheshoulderandconcomitantstandard

treatmentfortheconditionwassufficienttoachieveaclinical

improvement.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2. VangsnessCTJr,JorgensonSS,WatsonT,JohnsonDL.The originofthelongheadofthebicepsfromthescapulaand glenoidlabrum–ananatomicalstudyof100shoulders.J BoneJointSurgBr.1994;76(6):951–4.

3. AudenaertEA,BarbaixEJ,VanHoonackerP,BerghsBM. Extraarticularvariantsofthelongheadofthebicepsbrachii: areminderofembryology.JShoulderElbowSurg.2008;17 Suppl.1:114S–7S.

4. EnadJG.Bifurcateoriginofthelongheadofthebiceps tendon.Arthroscopy.2004;20(10):1081–3.

5. KimKC,RheeKJ,ShinHD.Alongheadofthebicepstendon confluentwiththeintra-articularrotatorcuff:arthroscopic andMRarthrographicfindings.ArchOrthopTraumaSurg. 2009;129(3):311–4.

6.KimKC,RheeKJ,ShinHD,KimYM.Bicepslongheadtendon revisited:acasereportofsplittendonarisingfromsingle origin.ArchOrthopTraumaSurg.2008;128(5):495–8.

7.HymanJL,WarrenRF.Extra-articularoriginofbicepsbrachii. Arthroscopy.2001;17(7):E29.

8.LangJE,VinsonEN,BasamaniaCJ.Anomalousbicepstendon insertionintotherotatorcable:acasereport.JSurgOrthop Adv.2008;17(2):93–5.

9.GhalayiniSR,BoardTN,SrinivasanMS.Anatomicvariations inthelongheadofbiceps:contributiontoshoulder dysfunction.Arthroscopy.2007;23(9):1012–8.