Thank you, I want to thank John Kelly for including me in this program. Is the long head of the biceps an innocent bystander or is it something else? To tenotomize in tinnitus or not? These are my disclosures. The long head of the biceps in most cases is not the problem. In most cases, the soft tissue biceps pulley outlet portion of the anterior rotator interval is the problem and that's the subject of the rest of this talk. Anterior rotator interval lesion, it is a superior glenohumeral ligament lesion that produces a widened bicep soft tissue pulley outlet which destabilizes the biceps at the outlet. The biceps becomes unstable and then becomes the pain generator due to that. This is the mechanism of injury. In a thrower, it's caused by a mechanical flaw of throwing across your body and follow through at a high flexion angle where the SGHL, if I can get my pointer here, impinges on the anterior superior glenoid and then fails producing this which then produces biceps instability. You can see Dennis Eckersley here gets away with it because he's at a low flexion angle but this kid's in trouble which is why he ends up on the end of my arthroscope. If you look at the anatomy, the roof of the soft tissue outlet is the corco-humeral ligament. The anterior buttress is the SGHL and the posterior buttress is the anterior portion of the supraspinous tendon. This is what it looks like with a 70-degree lens and the pulley is just a little bit larger than the cross-sectional diameter of the biceps. This used to be called the hidden lesion. It's no longer hidden if you know what to look for. Reliable diagnostic parameters, they usually have pain in the upper bicipital groove. These patients will come in with one finger and point right there. They have increased glenohumeral external rotation of about 25 degrees. This is because the lower reflection of the injured SGHL becomes the upper MGHL which becomes lax and produces excessive total motion arc and external rotation of about 25 degrees. They have an asymmetric sulcosign due to this. They have a widened bicep soft tissue interval which is quite diagnostic on sagittal cuts on an arthrogram that I'll show you. And they have hyperemia in the area of the upper middle glenohumeral ligament and the SGHL. This is the 25 degrees of excessive external rotation total motion arc that you get in these folks. This is what the MRI looks like. The subscap falls down here and the interval is widened. You can see the biceps drops out. You can actually measure this angle from the center of the humeral head to the front of the supraspinatus and the top of the subscap. You need to do this on a sagittal cut where you see the acromion only. In the interval lesions, throwing acquired, they average 58 degrees with normal being 25 degrees with this tight range. This is what it looks like arthroscopically. You have hyperemia in the SGHL and upper MGHL. You have adhesions here because this biceps has been windshield wipering back due to its instability at the outlet. When you see these parallel adhesions here, it's pathognomonic for the problem. It is recognizable arthroscopically. You can get this lipstick hyperemia due to the instability which is fairly diagnostic. Here you can see the SGHL torn with a hyperemia here, the widened outlet. This is diagrammatically what's going on. This is what it looks like on the MRI. Here's the torn SGHL hanging down here and the widened outset with a biceps dropout sign. If you have a patient that comes in, they got pain right there and a burr. They got an asymmetric sulcus sign. They've got a widened outlet on MRI. They've got 25 degrees of excessive external rotation. They got the problem. This isn't a primary biceps problem. This is an interval lesion. It's easy to fix. You put a simple stitch in the upper MGHL anterior labrum and pick it up by penetrating the SGHL just behind the biceps. One or two stitches usually does it. You don't want to include the C8 corticohumeral ligament which you can see here by looking down the cannula after you've closed the interval. Clinical material, currently I have 478 cases with minimum two-year follow-up. Two percent of them develop symptomatic subacromial adhesions and I had to go back and remove those arthroscopically. There were no other complications. These players are all throwing pain-free at long-term follow-up. Conclusions, the biceps is not the problem. The anterior rotator interval is the problem and it's an SGHL injury. Interval closure is highly successful in solving this problem. I don't do a biceps tenodesis for this problem. I know of five biceps tenodesis that I know of that have come to my office. Three of them are pros. They're all out of baseball and they never rehabbed well because the real problem was never addressed. I also have two high school kids that underwent biceps tenodesis and they still had pain because the interval problem was never addressed. I fixed their interval and they're back throwing at relatively low levels but they're throwing pain-free. Thank you.

long head of the biceps

shoulder pain

soft tissue biceps pulley outlet

anterior rotator interval

interval closure