I want to thank John Kelly for including me in this wonderful program. I'm Craig Morgan from Wilmington, Delaware. My subject deals with, is the long head or the biceps an innocent bystander or is it something else? To tenotomize a tinnitus or not. These are my disclosures. The long head or the biceps is not the problem. In most cases, the soft tissue biceps pulley outlet portion of the anterior rotator interval is the problem. If you do a biceps tinnitus in this setting, to me, it's like looking at a sidewalk after a hard rain and looking at all the worms and concluding that it rained worms. You need to address the interval, not the biceps. The anterior rotator interval lesion, this used to be referred to as the hidden lesion. If you know how to look at it, it's not hidden. And if you pay attention to this lecture, I guarantee you'll see one or two of these on Monday. It's an SGHL failure. It produces a widened biceps soft tissue pulley outlet, which results in biceps instability at the outlet where the biceps becomes the pain generator. An anterior rotator interval closure restores biceps stability and solves the problem. The mechanism of injury, this is a forward flexion adduction internal rotation injury whereby the SGHL becomes impinged on the anterior superior glenoid and fails either in continuity or as a frank tear. In a thrower, this occurs when he has improper biomechanics and is throwing across his body and follow through at a high flexion angle. In the bottom right here, you can see Dennis Eckersley gets away with this because he throws across his body at a low flexion angle, whereas the guy above him's in trouble, which is why he ends up on the other end of my arthroscope. So if we look at the anatomy of this, it's very well documented in the literature, but very few people truly understand it. The roof of the soft tissue outlet is the corco-humeral ligament. The floor is the humerus. The anterior buttress is the SGHL, which becomes injured with this entity. And the posterior buttress is the anterior aspect of the supraspinous tendon. This is what it looks like with a 70-degree scope. And the transsectional area of the biceps outlet is only a little larger than the cross-sectional area of the biceps tendon. Reliable diagnostic parameters to diagnose this. They all have isolated pain over the upper biceps and the bicipital groove. They'll come in, they'll take one finger and point right there. That's where my pain is, doc, when I'm up here in abduction external rotation. They have anterior superior shoulder pain. They have increased glenohumeral external rotation and total motion by about 25 degrees. This is because as the SGHL fails, the lower reflection becomes the upper middle glenohumeral ligament, which becomes lax, causing the excessive external rotation. They have an asymmetric sulcus sign. Arthroscopically, you can see the widened biceps rotator interval, and you can see it on MRI, and I'll go through that. They have hyperemia in the injured areas, the biceps, the SGHL, and the upper MGHL. You can see this with an arthroscope. I teach my fellows, follow the red brick road if you want to know where the pathology is. This is a kid that pitched for Delaware. He's got an interval lesion. You can see his 25 degrees of excessive external rotation compared to his non-throwing left shoulder. On MRI, you want to look at the sagittal oblique views that show the acromion only. You can actually measure a sagittal rotator interval angle from a central dot in the humeral head to the upper aspect of the subscapularis, which falls down, and the anterior aspect of the supraspinatus. This is a classic interval lesion with a 54 degree angle. People that have this problem average that angle at 58 degrees, whereas the normal angle is 25 degrees with a tight range. Wes Nottage looked at 240 normal MRIs and came up with these numbers as a control group. What does it look like arthroscopically? Follow the red brick road. The upper middle glenohumeral ligament and SGHL are hyperemic. The outlet is widened. The biceps is dropped down inferiorly, and then they have these adhesions. If you see these parallel adhesions, like on the lower left, exiting the widened outlet with the biceps, it's pathopneumonic of the problem. They can get this lipstick hyperemia on the dorsal aspect of the biceps due to the biceps outlet instability. Here's the hyperemic road. You can see in the upper left the torn SGHL falling down with the MGHL. So they can have what I call a chandelier sign, which is the torn SGHL stump hanging down, which you can see on the lower left image. So if you have a patient with pain in the upper bicipital groove, an asymmetric sulcus sign, widened biceps, sagittal rotator internal angle, and excessive external rotation, they got the problem and you need to fix it, not do a biceps tenodesis. It's easy to fix. It's a stitch between the upper middle glenohumeral ligament and the SGHL. Usually one or two stitches gets the job done, restores normal tension back into the MGHL, and restores the widened biceps outlet to a normal size, resolving the biceps instability. You don't want to include the coracohumeral ligament, which you can see in the lower right slide, because there's nothing wrong with a coracohumeral ligament. Clinical material. As of today, I've done 478 of these with a minimum two-year follow-up. Two percent of them developed symptomatic subacromial adhesions that require a second surgery for removal, and there were no other complications. Conclusions. The biceps is not the problem. Doing a tenodesis is not the solution. The anterior rotator interval is the problem, if you know how to look for it. Interval closure is highly successful in solving this problem. Don't be a biceps killer. The biceps has a function. It acts like a tension band, as Ben Kibler has shown us. It also acts as a head depressor. I did a study with Ty Lee and Brian Hynipsiak, where we put pressure-sensitive film in the shoulder and looked at the range of motion, and we loaded the cuff. With arm elevation, the contact pressure on the hyaline cartilage in the upper half of the glenoid increases three-fold. If you do a biceps tenodesis in this setting, over time, the patient's going to get superior glenohumeral arthritis, which should be avoided. Thank you for your attention.

shoulder pain

biceps pulley outlet

anterior rotator interval

diagnostic parameters

biceps stability