Joe A Shaw PA-C - 7/26/2008

Question
Hi Joe - I had e-mailed you twice before about biceps pain returning after surgery (3/25 and then again last week).  I got my rather unfortunate answer from MRI yesterday and have just a few questions regarding that.

The MRI showed a longitudinal tear of the biceps tendon. My ortho has mentioned biceps tenodesis, but seems rather hesitant at this point.  So we are trying Voltaren gel and he's trying to get insurance approval for iontophoresis, or possibly another cortisone injection.  

Here are my questions: 1. If I've not gotten better (and really I've gotten worse) after a year, are we just fighting the inevitable surgery by continuing to throw cortisone at it? I've already had two injections into the biceps - one pre-op and one post-op. 2. What are your feelings on tenodesis vs. tenotomy? I need my arms and my strength for work, and I like to play sports. How much strength would I lose with a tenotomy and how noticeable is the deformity? 3. Because the tear is not intra-articular and is longitudinal, does that make a tenodesis more complicated?  4. The ortho also mentioned in passing that he only does biceps tenodesis about 3x / year. I'm inclined to get another opinion, but how do I say this?

The MRI also showed a partial thickness tear of the supraspinatus and a small posterior labral tear.  Could that have happened during post-op PT? There were a few occasions when the therapist stretched me past the point of pain (once in abduction/external rotation that brought me to tears). Supraspinatus was frayed when I was scoped on March 3.

Sorry for all the questions... thanks for your help!

Answer
Yes I think I remember..the "pristine" bicep tendon??


1)If I've not gotten better (and really I've gotten worse) after a year, are we just fighting the inevitable surgery by continuing to throw cortisone at it?

---Probably, but you want to try everything before surgery so you won't have any doubts that you need surgery.

2) 3). What are your feelings on tenodesis vs. tenotomy? I need my arms and my strength for work, and I like to play sports. How much strength would I lose with a tenotomy and how noticeable is the deformity?

---I don't have any personal exp with doing or assisting on this procedure. The studies are conflicting but seems show you will have less strength with the tenotomy in certain functions of the bicep if you are active and use your arms alot, seems you would notice it more..than say a 55 yr old grandmother..and you will have a lump area just up from your elbow crease..how big?..really depends on how big your muscles are and how much subcutaneous tissue(or fat) you have under the skin.



4. The ortho also mentioned in passing that he only does biceps tenodesis about 3x / year. I'm inclined to get another opinion, but how do I say this?

----Thats not bad about one every 4 mos..it's a fairly uncommon procedure anyway..compared to shoulder and carpal tunnel etc..But most orthos I know would welcome a 2nd opinion on a complicated case like this. On any surgery I would recommend a 2nd opinion.  I would say I appreciate all you have done and your hard work etc..and because it is a complicated case what do you think about a 2nd opinion?


The MRI also showed a partial thickness tear of the supraspinatus and a small posterior labral tear.  Could that have happened during post-op PT? There were a few occasions when the therapist stretched me past the point of pain (once in abduction/external rotation that brought me to tears). Supraspinatus was frayed when I was scoped on March 3.

---That would be impossible for me to say over the net

Best overall explanation I have seen

http://www.orthosupersite.com/view.asp?rID=24606

http://www.ejbjs.org/cgi/content/abstract/89/4/747

http://cat.inist.fr/?aModele=afficheN&cpsidt=13653092

http://www.ortho.ufl.edu/BMAL/papers/Wolf-Zheng-longhead.pdf