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12/17/2018 Anatomy, Shoulder and Upper Limb, Biceps Muscle - StatPearls - NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK519538/?report=printable 1/5
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.
Anatomy,ShoulderandUpperLimb,BicepsMuscle
Authors
ManpreetS.Tiwana ;MatthewVaracallo .
Affilations
UniversityofCaliforniaBerkeley
DepartmentofOrthopaedicSurgery,UniversityofKentuckySchoolofMedicine
LastUpdate:November14,2018.
Introduction
Thebicepsbrachiiisalarge,thickmuscleontheventralportionoftheupperarm.Themuscleiscomposedofashort
head(caputbreve)andalonghead(caputlongum).Theshortheadoriginatesfromthetipofthecoracoidprocess,
andthelongheadoriginatesfromthesupraglenoidtubercle(tuberculumsupraglenoidale)oftheglenoid/scapula.Both
headscoursedistallyandbecomeaconfluentmusclebellybeforetaperingacrosstheanterioraspectoftheelbow,
eventuallyinsertingontheradialtuberosityandthefasciaoftheforearmviathebicipitalaponeurosis.[1][2]The
antagonistofthebicepsmuscleisthetricepsbrachiimuscle.[3][4][5]
StructureandFunction
Thelongheadofthebiceps(LHB)brachiitendonoriginatesatthesupraglenoidtubercleandsuperiorglenoid
labrum.Itslabraloriginismostlyposteriorinoverhalfofcases,andthetendon,onaverage,is9cminlength.Inside
thejoint,thetendonisextrasynovialandpassesobliquelyheadingtowardthebicipitalgroove.Asitexitsthedistal
bicipitalgrooveintheupperarm,theLHBTjoinstheshortheadofthebicepstendon(SHBT)asbothtransitionsinto
theirrespectivemusclebelliesinthecentralthirdoftheupperarm.Aftercrossingthevolaraspectoftheelbow,the
bicepsbrachiiinsertsontheradialtuberosityandmedialforearmfascia.Thelatteroccursviathebicipital
aponeurosis.[6]
Thedistalinsertionpointhasbecomearelevant,yetcontroversialtopicofinterest.Overthelastdecade,therehas
beenarenewedinterestininvestigatingtheinsertionalanatomyofthedistalbicepstendon,specificallywithrespect
toitsrelevanceintheevolutionofdistalbicepsreconstructiontechniques.Historically,theinsertionsitewas
describedasonehomogenoustendoninsertingontheradialtuberosity.Morerecentstudieshavereporteditsdistal
attachmentastwodistincttendons.Morespecifically,recentstudieshavedemonstratedthepresenceofan
entirelybifurcateddistalbicepstendoninsertion.Thestudiesfoundthattheshortheadofthedistalbicepstendon
commonlyinsertsmoredistallythanthelongheadandtypicallyinsertsattheapexofthetuberosity.Thelonghead
passesdeeptothedistaltendonoftheshortheadbeforeinsertingproximaltothetendinousfootprintoftheshort
head.[7]
Biomechanics
Thebicepsbrachiimuscleprimarilyisastrongforearmsupinator,butaweakelbowflexor.[8]Biomechanically,the
LHBThasacontroversialroleinthedynamicstabilityoftheshoulderjoint.Ithasbeendemonstrated,mostlyin
biomechanicalcadavericbasedstudiesandanimalmodels,thatthetendonatleastplaysapassivestabilizingrolein
theshoulder.Neerproposedinthe1970sthattheLHBTsstabilizingrolevarieddependingonthepositionofthe
elbowSeveralsubsequentstudiesrefutedthetheorythattheLHBTplayedanyactiveshoulderstabilizingeffect[9].
JobeandPerryevaluatedtheactivationofthebicepsduringthethrowingmotioninathletes.Theauthorsreportedthe
peakmusclestimulationoccurredinrelationtoelbowflexionandforearmdeceleration,withverylittleproximal
bicepsactivityduringtheearlierphasesofthrowing.[10]
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12/17/2018 Anatomy, Shoulder and Upper Limb, Biceps Muscle - StatPearls - NCBI Bookshelf
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Paingeneration
TheLHBTisawellrecognizedsourceofanteriorshoulderpain.Mechanicalcausesincluderepetitivetraction,
friction,andglenohumeralrotation.Thebicipitalsheathitselfisvulnerabletotenosynovialinflammationby
associationasitiscontiguouswiththesynovialliningoftheglenohumeraljoint.TheupperonethirdoftheLHBT
demonstratesarichsympatheticinnervationnetworkincludingneuropeptidessuchassubstancePandCalcitonin
generelatedpeptide.Thesefactorsarepresentinthesensorynervesinthisregionofthetendon.Thissympathetic
networkisknowntoexhibitvasodilatorychangesaspartoftheneurogenicinflammatoryprocessintheLHBT,which
mayplayacriticalroleinatleastthechronicphaseofpathophysiologyaffectingtheLHBT.[11][12]
BloodSupplyandLymphatics
Theprimaryarterialbloodsupplyforthebicepsbrachiimuscleisviathemuscularbranchesofthebrachialartery.
Nerves
Thenervesupplytothebicepsisprovidedbythemusculocutaneousnerve(rootC5,C6).
PhysiologicVariants
Approximately30%ofadultshavesomevariationintheoriginofthemuscle.Inmanypatients,athirdheadmay
arisefromthehumerus,butinabout2%to5%ofpeople,theremaybesupernumeraryheadsnumberinganywhere
from3to7intotal.
Thedistalbicepstendonmaybebifurcatedinabout20%orbecompletelyseparatedinabout40%ofindividuals.
Thesevariationshavenoadverseeffectonarmfunction.[13]
SurgicalConsiderations
Proximalbiceps(LHBT)surgicalconsiderations:
InthesettingofadvancedtendinopathyaffectingtheLHBT,andinthesettingofpersistent,debilitatingsymptoms
despiteexhaustingallnonoperativetreatmentoptions,twocommonprocedurescanbeperformed.
Bicepstenotomy[14]
ArthroscopicinspectionofthetendonallowsforestimationoftherelativepercentageoftheLHBtendonthatis
compromised.ApopularclassificationsystemutilizedfortheintraoperativegradecorrespondingtodegreeofLHB
tendonmacroscopicpathologyistheLafossegradingscale:[15]
Grade0:Normaltendon
Grade1:Minorlesion(partial,localizedareasoftendonerosion/fraying,focalareasaffect<50%ofthetendon
width)
Grade2:Majorlesion(extensivetendonloss,compromising>50%ofthetendonwidth)
Somesurgeonssolelydebridethetendoninthesettingof<25%50%tendinouscompromise.Arthroscopicbiceps
tenotomyisperformedbyreleasingthetendonascloseaspossibletothesuperiorlabrum.Aslongasthetendonis
freefromintimatesofttissueadhesionstosurroundingstructures,thetendonshouldretractdistallytowardthe
bicipitalgroove.Ifadhesionsarepresent,alleffortsshouldbemadetomobilizethetendoninordertoallowfor
retractionfollowingthetenotomy.IncaseswheretheLHBtendonisparticularlyhypertrophicandscarredtoother
softtissuestructuresinthejoint,thisservesasapotentialsourceofpostoperativepain.
Bicepstenodesis[16]
RecommendedovertenotomyinthesettingofLHBTinstability
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Preferredtechniqueinyoungerpatients,athletes,laborers,andthosepatientsspecificallyconcernedwith
postoperativecosmetic(“popeye”)deformity
Optimizesthelengthtensionrelationshipofthebicepsmuscle;mitigatespostoperativeriskofmuscleatrophy,
fatigue,andcramping
ClinicalSignificance
Theinitialmanagementforpathologicconditionsaffectingthebicepsbrachiitendon(bothproximalanddistal)is
oftennonoperativemanagementmodalities.Conditionsaffectingthedistalbicepsbrachiitendonisbeyondthescope
ofthisreview.Proximally,shoulderrangeofmotion,rotatorcuffsrengtheningandperiscapularstabilization
parametersfocusonrestoringmusclebalanceacrosstheshouldergirdle.
ForconditionsaffectingtheLHBTproximally,thefollowingphysicaltherapyregimenscanbeconsidered:
Proximalbicepsstretching/strengtheningexercises
NSAIDs
Iontophoresis(e.g.dexamethasone)
Focusedstretchingontheanteriorshoulderstructures,includingpectoralisminor,shouldalsobeconsidered.Other
modalitiessuchasdryneedlinghavedemonstratedpromiseinpreliminaryanimalstudies.
Inrefractoryconditions,orconditionsbeyondthescopeofthisreview,surgicalconsiderationiswarranted.
Questions
Toaccessfreemultiplechoicequestionsonthistopic,clickhere.
References
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12/17/2018 Anatomy, Shoulder and Upper Limb, Biceps Muscle - StatPearls - NCBI Bookshelf
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Figures
FrontofrightupperextremityAnatomy,FlexorCarpalRadius,AbductorandExteriorPollicisLongusandBrevis,
PalmarisLongus,MedialgroupofAntebrachialmuscles,Antecubitalfossa,LateralgroupofAntebrachial
muscles,Brachialis,Bicepsbrachii,Tricepsbrachii,Medialepicondyle.ContributedbyGray'sAnatomyPlates
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