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\begin{document}

\title{A partial articular-sided supraspinatus tear caused by the biceps
tendon: a novel etiology of internal impingement}



\author[1]{Alexander Rosinski}%
\author[2]{James Chen}%
\author[2]{Patrick McGahan}%
\affil[1]{San Francisco Orthopaedic Residency Program}%
\affil[2]{Advanced Orthopaedics and Sports Medicine}%


\vspace{-1em}



  
  \date{June 16, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Our patient is a 19-year-old female who presented with left shoulder
pain. Diagnostic arthroscopy revealed an articular-sided supraspinatus
tear. When the shoulder was taken out of traction and placed in 90
degrees of abduction and external rotation, we visualized the biceps
tendon directly impinging the undersurface of the supraspinatus tendon.%
\end{abstract}%



\sloppy


\textbf{A partial articular-sided supraspinatus tear caused by the
biceps tendon: a novel etiology of internal impingement}

Running Title: Internal impingement caused by the biceps tendon

Alexander Rosinski, MD, MS

James L. Chen, MD, MPH

Patrick J. McGahan, MD

Investigation performed at Advanced Orthopaedics and Sports Medicine

\textbf{Mailing address for all authors:}

Advanced Orthopaedics and Sports Medicine

450 Sutter St., Suite 400

San Francisco, CA 94108, U.S.A

\textbf{Corresponding author:}

Alexander Rosinski, MD, MS

Advanced Orthopaedics and Sports Medicine

450 Sutter St., Suite 400

San Francisco, CA 94108, U.S.A

Phone: 1.415.900.3000

Fax: 1.415.900.3001

Email: arosinsk@uci.edu

\textbf{Conflict of Interest:}

Dr. Chen is an educator for Arthrex Inc. The authors declare no
conflicts of interest related to the subject of this article. No outside
funding or grants were received for this study.

Alexander Rosinski, MS: This author, their immediate family, and any
research foundation with which they are affiliated did not receive any
financial payments or other benefits from any commercial entity related
to the subject of this article.

James Chen, MD, MPH: This author, their immediate family, and any
research foundation with which they are affiliated did not receive any
financial payments or other benefits from any commercial entity related
to the subject of this article.

Patrick McGahan, MD: This author, their immediate family, and any
research foundation with which they are affiliated did not receive any
financial payments or other benefits from any commercial entity related
to the subject of this article.

\textbf{Word Count:} 2,055

\textbf{A partial articular-sided supraspinatus tear caused by the
biceps tendon: a novel etiology of internal impingement}

\textbf{Abstract}

Our patient is a 19-year-old female who presented with left shoulder
pain. Diagnostic arthroscopy revealed an articular-sided supraspinatus
tear. When the shoulder was taken out of traction and placed in 90
degrees of abduction and external rotation, we visualized the biceps
tendon directly impinging the undersurface of the supraspinatus tendon.

\textbf{Key Clinical Message}

Impingement of the LHB can directly lead to articular-sided
supraspinatus tears. When pain persists despite arthroscopic
debridement, we recommend taking the arm out of traction
intra-operatively and placing it in the 90-90 position.

\textbf{Introduction}

As shoulder arthroscopy progressed, surgeons noticed an association
between partial articular-sided rotator cuff tears and superior labral
lesions {[}1,2{]}. It has been proposed that this pathology is caused by
contact between the posterior-superior margin of the glenoid and the
humeral head when the arm is abducted and externally rotated {[}3,1{]}.
This phenomenon has been labeled ``Internal Impingement'' as it is
believed to result in impingement of the posterior-superior labrum and
the articular side of the supraspinatus tendon {[}1{]}. Internal
impingement is classically associated with throwing and other repetitive
overhead athletic activities, particularly in the late cocking and early
acceleration phases {[}4{]}. Over time, repetitive loading at the limits
of the functional arc of motion leads to predictable osseous and
soft-tissue adaptations which have been associated with internal
impingement. Several pathological conditions may result including
articular-sided rotator cuff tears, labral tears, biceps tendonitis, and
anterior shoulder instability {[}5{]}.

Over time, additional theories have emerged to explain the common
association between articular-sided rotator cuff tears and superior
labral lesions. Burkhart et al proposed that these lesions develop over
time due to the excessive shear and torsional forces placed on the
shoulder by repetitive abduction and external rotation {[}4{]}. Andrews
et al proposed that repetitive eccentric loading leads to similar
pathology {[}6{]}. Although the true etiology of these lesions remains
the subject of debate, the concept of internal impingement remains an
important framework for understanding the painful shoulder in an
overhead athlete.

The prevalence of internal impingement has not been well established due
to the constellation of findings that characterize this condition and
its strong association with other pathological lesions of the shoulder
{[}5{]}. However, several authors have identified internal impingement
as a leading cause of partial articular-sided rotator cuff tears in
throwing athletes {[}5,7{]}. The purpose of this case report is to
describe a novel etiology of internal impingement between the biceps
tendon and the undersurface of the supraspinatus tendon leading to a
symptomatic articular-sided rotator cuff tear. The patient's symptoms
persisted despite initial treatment with arthroscopic debridement and
subacromial decompression. However, subsequent treatment with
arthroscopic debridement and open sub-pectoral biceps tenodesis was
successful and the patient has remained asymptomatic at latest
follow-up. To the authors' knowledge, no previous study has identified
the biceps tendon as a cause of internal impingement.

\textbf{Case History}

A 19-year-old right-handed female presented to our clinic with a chief
complaint of left shoulder activity-related pain of approximately six
months' duration. She subsequently underwent six months of physical
therapy and received two subacromial cortisone injections with minimal
relief. On physical examination, she reported pain over the anterior and
lateral shoulder. She had pain with resisted supraspinatus testing but
full strength. She also had moderate discomfort with abduction and
external rotation (posterior impingement sign). There was mild
tenderness to palpation over the biceps tendon in the groove as well.
She had full range of motion and no anterior or posterior shoulder
instability. Subscapularis and infraspinatus tests were normal and she
had a negative O'Brien's test, negative jerk test, and negative
subacromial impingement test. There was no scapular dyskinesis or
glenohumeral internal rotation deficit (GIRD). The remainder of her exam
was unremarkable.

An MRI showed a partial supraspinatus tendon tear and moderate
tendinosis of the intra-articular portion of the long head of the biceps
(LHB). There was no evidence of anterior or superior labral tear. The
upper border of the subscapularis tendon was intact. She opted for
surgical management after a thorough discussion of operative and
non-operative treatment options.

\textbf{Surgical Treatment}

Left shoulder arthroscopy was performed in the lateral decubitus
position with 10 pounds of longitudinal traction. Diagnostic arthroscopy
revealed a 1 cm (medial-lateral) by 5 mm (anterior-posterior) lesion of
the undersurface of the anterior aspect of the supraspinatus tendon
(Figure 1). There was mild posterior-superior labral fraying, but no
significant labral pathology. Mild biceps tendinitis was observed as the
tendon was pulled into the joint, but its anchor on the superior labrum
was intact. There was mild subacromial bursitis. There was also no
evidence of an anterior labral tear or subscapularis tear. We performed
an arthroscopic debridement of the rotator cuff and a sub-acromial
decompression. Biceps tenodesis was not performed as there was no
evidence of a superior labral tear, significant bicipital tendonitis,
medial subluxation of the tendon, or concurrent subscapularis tear
{[}8,9{]}.

Her postoperative course was uneventful and she quickly regained full
range of motion and strength. However, she continued to have similar
activity-related shoulder pain at six months of follow-up. Physical
examination demonstrated identical findings to her pre-operative exam 6
months earlier. She was unable to return to collegiate swimming and
water polo. After a thorough discussion, she returned to the operating
room for a left shoulder diagnostic arthroscopy with possible rotator
cuff repair, labral repair, and open biceps tenodesis.

Diagnostic arthroscopy once again arthroscopy revealed a 1 cm
(medial-lateral) by 5 mm (anterior-posterior) lesion of the undersurface
of the anterior aspect of the supraspinatus tendon (Figures 2 and 3).
There was mild posterior-superior labral fraying, but no significant
labral pathology. There was mild biceps tendinitis as the tendon was
pulled into the joint, but its anchor on the superior labrum was intact.
There was no evidence of an anterior labral tear or subscapularis tear.
At this point, the shoulder was taken out of traction and dynamic
testing under direct arthroscopic visualization was performed. The arm
was placed in a position of 90 degrees of abduction and 90 degrees of
external rotation. To our surprise, we did not discover impingement
between the supraspinatus tendon and the posterior-superior glenoid. The
articular side of the rotator cuff would not contact the
posterior-superior labrum. Instead, we visualized the biceps tendon
directly impinging and abrading the undersurface of the supraspinatus
tendon (Figure 4B). The biceps tendon fell directly into the
articular-sided tear of the supraspinatus tendon during abduction and
external rotation. As a result, we elected to proceed with sub-pectoral
biceps tenodesis to prevent further impingement.

The patient wore a shoulder sling for four weeks postoperatively and was
instructed to avoid active biceps flexion. She began light resistive
biceps strengthening at 8 weeks postoperatively and progressed to full
activity at 3 months postoperatively. At six months, she had regained
full strength and range of motion and had returned to competitive
swimming and water polo. She has remained asymptomatic at two years of
follow up.

\textbf{Discussion}

Previous biomechanical and clinical studies have demonstrated the
concept of internal impingement {[}1-4{]}. In abduction and external
rotation, the humeral head often contacts the superior glenoid,
resulting in impingement of the articular side of the supraspinatus
tendon and the superior labrum {[}1{]}. This impingement, in turn, can
potentially lead to pathologic lesions of the rotator cuff and labrum
{[}1,2{]}. Although alternative explanations for this pathology exist
{[}4,6{]}, this theory has served as a useful conceptual framework for
understanding pathology commonly found in the overhead athlete. The
purpose of this case report is to describe an alternative etiology of
internal impingement involving impingement of the biceps tendon on the
undersurface of the supraspinatus tendon.

The association between partial articular-sided rotator cuff tears and
superior labral lesions is well documented in the literature
{[}6,2,10,1{]}. It should be noted, however, that not all partial
articular-sided rotator cuff tears are accompanied by superior labral
lesions {[}11{]}. The fact that not all articular sided rotator cuff
tears are accompanied by labral lesions leads us to believe that there
are alternative causes of articular-sided rotator cuff tears other than
internal impingement. Over time, additional theories have emerged to
explain the common association between articular sided rotator cuff
tears and superior labrum lesions. Burkhart et al proposed that these
lesions can develop over time due to the excessive shear and torsional
forces cause by repetitive abduction and external rotation {[}4{]}.
Andrews et al proposed that repetitive eccentric loading can similarly
lead to this pathology {[}6{]}. As demonstrated in this case report, we
believe that direct impingement of the biceps tendon on the undersurface
of the rotator cuff can lead to articular-sided rotator cuff tears.

Posterior biceps instability and friction may represent an
under-diagnosed and under-recognized source of internal impingement.
This may especially be true among patients whose symptoms persist
despite adequate treatment of concomitant pathology. Partial
articular-sided rotator cuff tears and type-1 labral lesions are
typically treated non-operatively with good results {[}12{]}. When
conservative treatment fails, arthroscopic debridement has been the
standard of care {[}13{]}. However, some studies have reported
suboptimal results with this treatment approach {[}14,10{]}. When
partial tears of less than 50\% thickness are treated with arthroscopic
debridement, the incidence of progression to full-thickness tears ranges
from 6.5-34.6\% in the literature {[}13{]}. Our experience reflects
these findings as we have observed high rates of persistent symptoms in
our practice with debridement alone. This observation has led us to
search for other potential pain generators in the shoulder that may be
overlooked. The biceps tendon as a source of pain and pathology in the
shoulder has been well described {[}15{]}. There are three primary
sources of biceps-related shoulder pain: bicipital tendonitis, traction
on a Type-2 SLAP tear, and biceps instability. Each of these conditions
can be treated effectively with biceps tenodesis. In the case presented
in this report, there was no evidence of significant bicipital
tendonitis or labral detachment.

Multiple anatomic changes and pathologic conditions contribute to biceps
instability in throwing athletes. Increased external rotation with
repetitive throwing is achieved by shoulder adaptations including
anterior capsule laxity and posterior capsule tightening {[}16,17{]}.
Laxity of the superior glenohumeral and coracohumeral ligaments, which
form the ``biceps pulley'' along with the supraspinatus and
subscapularis, may contribute to biceps instability. Braun et al
demonstrated that tears of both the anteromedial and posterolateral
pulley are associated with biceps subluxation and dislocation from the
bicipital groove {[}18{]}. Acute trauma can also cause biceps pulley
lesions {[}19{]}. Swimmers such as our patient often have an element of
underlying shoulder laxity {[}20,21{]}. Our patient's history of
competitive swimming and water polo may have contributed to posterior
biceps instability and the resulting internal impingement seen
intraoperatively (Figure 4B).

In addition, abduction and external rotation in the late cocking phase
of throwing is known to shift the biceps tendon posteriorly {[}4{]}. In
this position, the biceps tendon may assume a more vertical and
posterior angle (as was observed in our patient during diagnostic
arthroscopy in the 90-90 position). Burkhart et al attributed the
``peel-back phenomenon'' seen intraoperatively in patients with SLAP
lesions to this posterior shift in biceps vector forces {[}22{]}. Of
note, the patient presented in this case report had some evidence of
labral fraying, but the biceps anchor was intact. Although the
``peel-back phenomenon'' was not observed, tension on the
intra-articular biceps tendon in the late cocking phase may have
resulted in posterior displacement and impingement on the rotator cuff
without fully disrupting its anchor.

Several clinical studies have demonstrated an association between
rotator cuff tears and biceps instability {[}8,23-26{]}. The LHB is
stabilized by a sling formed by the supraspinatus and subscapularis
tendons proximal to the bicipital groove {[}27{]}. Therefore, rotator
cuff tears may increase and alter mechanical loading on the LHB and lead
to progressive deterioration {[}24,23{]}. LHB lesions have been reported
in 29-86\% of patients with rotator cuff tears {[}26,24,23,8,25{]}. In a
prospective study of 200 arthroscopic rotator cuff repairs, LHB
subluxation or dislocation was observed in 45\% of patients {[}23{]}.
Posterior LHB instability was commonly observed with anterior
supraspinatus tendon tears {[}16{]}.

The are several weaknesses of this case report. First, this is an
isolated case and it remains to be seen whether this approach is valid
when applied to a larger patient population. Second, the patient
underwent an additional debridement at the time of her second surgery,
which may have contributed to the positive results. Third, biceps
tenodesis is an effective treatment for biceps pathology. It is possible
that the rotator cuff lesion was incidental and that the true pathology
was intrinsic to the biceps tendon.

In summary, we present an interesting case report of a small, partial
articular-sided supraspinatus tendon tear initially treated with
arthroscopic debridement (Figure 1). Unfortunately, the patient did not
improve with simple debridement. In addition, the tear was relatively
small and was not felt to be large enough to be causing significant pain
on its own. This led us to search for an alternative explanation for the
patient's shoulder pain. During arthroscopy, we observed direct
impingement of the biceps tendon on the undersurface of the rotator cuff
as the arm was abducted and externally rotated (Figure 4B). In addition,
the remaining rotator cuff beyond this site of impingement was intact.
This led us to perform an open biceps tenodesis. The patient recovered
fully from this operation and is pain free at latest follow-up.

\textbf{Conclusion}

In this case report, we propose a novel biomechanical source of internal
impingement: direct impingement of the biceps tendon on the undersurface
of the supraspinatus tendon. We believe that impingement of the LHB can
either directly lead to, or potentially aggravate, articular-sided tears
of the supraspinatus tendon. This proposed mechanism of impingement may
help explain why debridement alone can produce suboptimal results
{[}10,14,13{]}. In cases where pain persists despite arthroscopic
debridement, we recommend performing a biceps tenodesis. In addition, we
recommend taking the arm out of traction during arthroscopy and placing
it in the 90-90 position. If the biceps tendon can be seen directly
abrading the supraspinatus tendon, we recommend primary biceps
tenodesis.

\textbf{Figure Legend}

\textbf{Figure 1.} The patient's first diagnostic arthroscopy of the
left shoulder revealed a 1 cm (medial-lateral) by 5 mm
(anterior-posterior) lesion of the undersurface of the anterior aspect
of the supraspinatus tendon. SS -- supraspinatus tendon. LHB -- long
head of the biceps. HH -- head of the humerus.

\textbf{Figure 2.} The patient's second diagnostic arthroscopy similarly
revealed a 1 cm (medial-lateral) by 5 mm (anterior-posterior) lesion of
the undersurface of the anterior aspect of the supraspinatus tendon. SS
-- supraspinatus tendon. LHB -- long head of the biceps. HH -- head of
the humerus.

\textbf{Figure 3.} Diagnostic arthroscopy demonstrated mild
posterior-superior labral fraying, but no significant labral pathology.
There was evidence of mild biceps tendinitis but its anchor on the
superior labrum was intact. LHB -- long head of the biceps.

\textbf{Figure 4.} (A) Diagnostic arthroscopy of the shoulder in neutral
position. (B) The biceps tendon directly impinges the undersurface of
the supraspinatus tendon when the shoulder is abducted and externally
rotated (ABER). The LHB also assumes a more vertical and posterior angle
in this position. SS -- supraspinatus tendon. LHB -- long head of the
biceps. HH -- head of the humerus.

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\selectlanguage{english}
\FloatBarrier
\end{document}

