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Anatomy, Shoulder and Upper Limb, Biceps Muscle

Authors:
  • Penn Highlands Healthcare System

Abstract

The biceps brachii is a large, thick muscle on the ventral portion of the upper arm. The muscle is composed of a short head (caput breve) and a long head (caput longum). The short head originates from the tip of the coracoid process, and the long head originates from the supraglenoid tubercle (tuberculum supraglenoidale) of the glenoid/scapula. Both heads course distally and become a confluent muscle belly before tapering across the anterior aspect of the elbow, eventually inserting on the radial tuberosity and the fascia of the forearm via the bicipital aponeurosis. [1][2] The antagonist of the biceps muscle is the triceps brachii muscle.[3][4][5]
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,ShoulderandUpperLimb,BicepsMuscle
Authors
ManpreetS.Tiwana ;MatthewVaracallo .
Affilations
UniversityofCaliforniaBerkeley
DepartmentofOrthopaedicSurgery,UniversityofKentuckySchoolofMedicine
LastUpdate:November14,2018.
Introduction
Thebicepsbrachiiisalarge,thickmuscleontheventralportionoftheupperarm.Themuscleiscomposedofashort
head(caputbreve)andalonghead(caputlongum).Theshortheadoriginatesfromthetipofthecoracoidprocess,
andthelongheadoriginatesfromthesupraglenoidtubercle(tuberculumsupraglenoidale)oftheglenoid/scapula.Both
headscoursedistallyandbecomeaconfluentmusclebellybeforetaperingacrosstheanterioraspectoftheelbow,
eventuallyinsertingontheradialtuberosityandthefasciaoftheforearmviathebicipitalaponeurosis.[1][2]The
antagonistofthebicepsmuscleisthetricepsbrachiimuscle.[3][4][5]
StructureandFunction
Thelongheadofthebiceps(LHB)brachiitendonoriginatesatthesupraglenoidtubercleandsuperiorglenoid
labrum.Itslabraloriginismostlyposteriorinoverhalfofcases,andthetendon,onaverage,is9cminlength.Inside
thejoint,thetendonisextrasynovialandpassesobliquelyheadingtowardthebicipitalgroove.Asitexitsthedistal
bicipitalgrooveintheupperarm,theLHBTjoinstheshortheadofthebicepstendon(SHBT)asbothtransitionsinto
theirrespectivemusclebelliesinthecentralthirdoftheupperarm.Aftercrossingthevolaraspectoftheelbow,the
bicepsbrachiiinsertsontheradialtuberosityandmedialforearmfascia.Thelatteroccursviathebicipital
aponeurosis.[6]
Thedistalinsertionpointhasbecomearelevant,yetcontroversialtopicofinterest.Overthelastdecade,therehas
beenarenewedinterestininvestigatingtheinsertionalanatomyofthedistalbicepstendon,specificallywithrespect
toitsrelevanceintheevolutionofdistalbicepsreconstructiontechniques.Historically,theinsertionsitewas
describedasonehomogenoustendoninsertingontheradialtuberosity.Morerecentstudieshavereporteditsdistal
attachmentastwodistincttendons.Morespecifically,recentstudieshavedemonstratedthepresenceofan
entirelybifurcateddistalbicepstendoninsertion.Thestudiesfoundthattheshortheadofthedistalbicepstendon
commonlyinsertsmoredistallythanthelongheadandtypicallyinsertsattheapexofthetuberosity.Thelonghead
passesdeeptothedistaltendonoftheshortheadbeforeinsertingproximaltothetendinousfootprintoftheshort
head.[7]
Biomechanics
Thebicepsbrachiimuscleprimarilyisastrongforearmsupinator,butaweakelbowflexor.[8]Biomechanically,the
LHBThasacontroversialroleinthedynamicstabilityoftheshoulderjoint.Ithasbeendemonstrated,mostlyin
biomechanicalcadavericbasedstudiesandanimalmodels,thatthetendonatleastplaysapassivestabilizingrolein
theshoulder.Neerproposedinthe1970sthattheLHBTsstabilizingrolevarieddependingonthepositionofthe
elbowSeveralsubsequentstudiesrefutedthetheorythattheLHBTplayedanyactiveshoulderstabilizingeffect[9].
JobeandPerryevaluatedtheactivationofthebicepsduringthethrowingmotioninathletes.Theauthorsreportedthe
peakmusclestimulationoccurredinrelationtoelbowflexionandforearmdeceleration,withverylittleproximal
bicepsactivityduringtheearlierphasesofthrowing.[10]
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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 2/5
Paingeneration
TheLHBTisawellrecognizedsourceofanteriorshoulderpain.Mechanicalcausesincluderepetitivetraction,
friction,andglenohumeralrotation.Thebicipitalsheathitselfisvulnerabletotenosynovialinflammationby
associationasitiscontiguouswiththesynovialliningoftheglenohumeraljoint.TheupperonethirdoftheLHBT
demonstratesarichsympatheticinnervationnetworkincludingneuropeptidessuchassubstancePandCalcitonin
generelatedpeptide.Thesefactorsarepresentinthesensorynervesinthisregionofthetendon.Thissympathetic
networkisknowntoexhibitvasodilatorychangesaspartoftheneurogenicinflammatoryprocessintheLHBT,which
mayplayacriticalroleinatleastthechronicphaseofpathophysiologyaffectingtheLHBT.[11][12]
BloodSupplyandLymphatics
Theprimaryarterialbloodsupplyforthebicepsbrachiimuscleisviathemuscularbranchesofthebrachialartery.
Nerves
Thenervesupplytothebicepsisprovidedbythemusculocutaneousnerve(rootC5,C6).
PhysiologicVariants
Approximately30%ofadultshavesomevariationintheoriginofthemuscle.Inmanypatients,athirdheadmay
arisefromthehumerus,butinabout2%to5%ofpeople,theremaybesupernumeraryheadsnumberinganywhere
from3to7intotal.
Thedistalbicepstendonmaybebifurcatedinabout20%orbecompletelyseparatedinabout40%ofindividuals.
Thesevariationshavenoadverseeffectonarmfunction.[13]
SurgicalConsiderations
Proximalbiceps(LHBT)surgicalconsiderations:
InthesettingofadvancedtendinopathyaffectingtheLHBT,andinthesettingofpersistent,debilitatingsymptoms
despiteexhaustingallnonoperativetreatmentoptions,twocommonprocedurescanbeperformed.
Bicepstenotomy[14]
ArthroscopicinspectionofthetendonallowsforestimationoftherelativepercentageoftheLHBtendonthatis
compromised.ApopularclassificationsystemutilizedfortheintraoperativegradecorrespondingtodegreeofLHB
tendonmacroscopicpathologyistheLafossegradingscale:[15]
Grade0:Normaltendon
Grade1:Minorlesion(partial,localizedareasoftendonerosion/fraying,focalareasaffect<50%ofthetendon
width)
Grade2:Majorlesion(extensivetendonloss,compromising>50%ofthetendonwidth)
Somesurgeonssolelydebridethetendoninthesettingof<25%50%tendinouscompromise.Arthroscopicbiceps
tenotomyisperformedbyreleasingthetendonascloseaspossibletothesuperiorlabrum.Aslongasthetendonis
freefromintimatesofttissueadhesionstosurroundingstructures,thetendonshouldretractdistallytowardthe
bicipitalgroove.Ifadhesionsarepresent,alleffortsshouldbemadetomobilizethetendoninordertoallowfor
retractionfollowingthetenotomy.IncaseswheretheLHBtendonisparticularlyhypertrophicandscarredtoother
softtissuestructuresinthejoint,thisservesasapotentialsourceofpostoperativepain.
Bicepstenodesis[16]
RecommendedovertenotomyinthesettingofLHBTinstability
12/17/2018 Anatomy, Shoulder and Upper Limb, Biceps Muscle - StatPearls - NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK519538/?report=printable 3/5
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10.
Preferredtechniqueinyoungerpatients,athletes,laborers,andthosepatientsspecificallyconcernedwith
postoperativecosmetic(“popeye”)deformity
Optimizesthelengthtensionrelationshipofthebicepsmuscle;mitigatespostoperativeriskofmuscleatrophy,
fatigue,andcramping
ClinicalSignificance
Theinitialmanagementforpathologicconditionsaffectingthebicepsbrachiitendon(bothproximalanddistal)is
oftennonoperativemanagementmodalities.Conditionsaffectingthedistalbicepsbrachiitendonisbeyondthescope
ofthisreview.Proximally,shoulderrangeofmotion,rotatorcuffsrengtheningandperiscapularstabilization
parametersfocusonrestoringmusclebalanceacrosstheshouldergirdle.
ForconditionsaffectingtheLHBTproximally,thefollowingphysicaltherapyregimenscanbeconsidered:
Proximalbicepsstretching/strengtheningexercises
NSAIDs
Iontophoresis(e.g.dexamethasone)
Focusedstretchingontheanteriorshoulderstructures,includingpectoralisminor,shouldalsobeconsidered.Other
modalitiessuchasdryneedlinghavedemonstratedpromiseinpreliminaryanimalstudies.
Inrefractoryconditions,orconditionsbeyondthescopeofthisreview,surgicalconsiderationiswarranted.
Questions
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12/17/2018 Anatomy, Shoulder and Upper Limb, Biceps Muscle - StatPearls - NCBI Bookshelf
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Figures
FrontofrightupperextremityAnatomy,FlexorCarpalRadius,AbductorandExteriorPollicisLongusandBrevis,
PalmarisLongus,MedialgroupofAntebrachialmuscles,Antecubitalfossa,LateralgroupofAntebrachial
muscles,Brachialis,Bicepsbrachii,Tricepsbrachii,Medialepicondyle.ContributedbyGray'sAnatomyPlates
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Bookshelf ID: NBK519538 PMID: 30137823
... The biceps brachii is a large muscle located in the ventral section of the upper arm. Biceps brachii acts as a strong forearm supinator and a weak elbow flexor [30]. The primary function of the brachioradialis is located in the lateral forearm. ...
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... The LHBT originates at the supraglenoid tubercle of the scapula and superior glenoid labrum. The tendon contributes to the stability of the shoulder as it courses along the glenohumeral joint, eventually joining with the short head of the biceps tendon [13,14]. LHBT injuries are usually secondary to rotator cuff disease rather than traumatic injury. ...
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Acute shoulder pain is a common ED presentation with a wide range of pathologies that are often initially investigated with radiography. However, diagnosing rotator cuff injuries often requires further imaging for proper diagnosis and management. Bedside shoulder ultrasound is an application that allows for the evaluation of ligaments and tendons in addition to bony structures, all while utilizing direct patient feedback of focally tender areas, expediting diagnosis and therapeutic intervention. In this case series, we discuss our evaluation of patients with suspected rotator cuff pathology and the practice of using the stepwise shoulder ultrasound protocol. Four cases are presented that illustrate the use of shoulder ultrasound in diagnosing biceps tendon injury, supraspinatus tear, chronic supraspinatus tear with hemarthrosis, and subacromial-subdeltoid bursitis. This narrative highlights the valuable role of shoulder ultrasound for the expedited diagnosis and management of patients whose initial shoulder radiographs do not indicate any bony abnormalities.
... Both the long and short head of the biceps brachii muscle develop from the same myotome antecedent to the development of the scapula (Birnbaum et al., 1998). Initially the origins of the biceps brachii muscle are separated, though they are closely united (Tiwana and Varacallo, 2018). Then they become separated again into two apparent origins by the development of the scapula. ...
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Purpose: Our aim was to characterize the morphology of the proximal attachment of the biceps brachii short head. We hypothesize that it has an aponeurotic component that may affect shoulder joint biomechanics. Methods: The coracoacromial region and the biceps brachii muscle were dissected in 30 cadaveric shoulders. The course and dimensions of the tendon and aponeurosis were evaluated. The cross-sectional area of the belly of the short head and the length of the whole muscle were measured. Correlations between the aponeurosis and dimensions of the muscle were tested with the Spearman's rank correlation coefficient. Results: Aponeurosis was present in all specimens, although in 10 cases it was vestigial. The aponeurotic part of the muscle (mean length 90.7 ± 16.3 mm, mean width 12.5 ± 2.9 mm) branched off laterally and traveled to the acromion, blending with the coracoacromial ligament creating the aponeurotic membrane. We named this structure the "superior biceps aponeurosis". The mean length of the biceps brachii was 31.3 ± 2.1 cm and the mean cross-sectional area of the short head was 210.7 ± 54.3 mm2. The dimensions of the "superior biceps aponeurosis" correlated positively with the cross-sectional area of the muscle (R2 from 0.37 to 0.52, p from 0.014 to 0.001). Conclusion: The origin of the short head of the biceps brachii muscle has a varied aponeurotic component combining the aponeurotic part of the muscle and the aponeurotic membrane. Together, they create the "superior biceps aponeurosis". Clinical relevance: The morphology of the origin of the biceps brachii short head is relevant in Bristow/Latarjet procedures. This aponeurotic component may affect the shoulder joint biomechanics after the coracoid process transfer.
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Introduction Biceps tendinosis, a milder form on the spectrum of biceps tendinopathy, is unusual at the distal insertion site. Patients with distal biceps tendinosis may experience pain and dysfunction which could inhibit their activities of daily living. Diagnosis of distal biceps tendinosis may be facilitated with ultrasonography (US), whose accuracy is increasingly recognised, while providing many benefits over other modalities, like magnetic resonance imaging (MRI). Case report We report two cases of distal biceps tendinosis diagnosed by US with clinical details, imaging findings and patient management. Two patients present with elbow pain after nontraumatic activities. US revealed a thickened distal biceps tendon with mild heterogeneous hypoechogenicity without fibre disruption or retraction in both cases and evidence of hyperemia on Doppler with surrounding bursal fluid in case 2. Discussion Tendinosis has variable aetiologies, but US commonly cannot differentiate among these; therefore, patient’s clinical history is the major component in determining the underlying cause. Chronic progression of tendon pathology leads to partial and full thickness tears. Tendinosis has a characteristic US appearance. US has many benefits and clinicians may use this modality to assess possible pathological structures with ease, convenience and efficiency compared with using MRI. Conclusion Distal biceps tendinosis may present with clinical symptoms of pain and decreased activities of daily living, and may progress to more severe forms of tendinopathy. Early diagnosis is beneficial for the treatment outcomes of this condition. US can visualise distal biceps tendinosis with reliability, providing an alternative diagnostic technique with many benefits compared with MRI.
Chapter
Arm shape is determined by the muscle structure and mass of each patient. In terms of underlying structure, three main muscles are responsible for arm shape: the deltoid, triceps, and biceps. More pronounced musculature in men is considered more athletic and healthy, but such a description can be considered a deformity in women. Male patients desire a body structure having wide shoulders and prominent biceps and triceps muscles. High-Definition Liposculpture has given both sexes an athletic appearance by shaping body fat with a multi-layered and 3-dimensional shaping approach. This approach is based on creating concave and convex areas instead of flattening areas with liposuction alone. Fat is removed from some areas but grafted onto others to improve the anatomical architecture. However, the general appearance of the arm is very different in men than in women. In this chapter, we gave information about male upper arm definition with fat transfer together with our own experiences.
Chapter
The biceps brachii muscle consists of a long head and a short head that originate at the supraglenoid tubercle and the coracoid process, respectively. The tendons progress into two attached but distinct muscle bellies that insert at the radial tuberosity. When there is an eccentric force on the muscle, it susceptible to tearing, resulting in a distal biceps tear. Tears can either be partial or complete, with partial tears as the focus of this chapter. Partial tears can be identified by both clinical exam and advanced imaging techniques such as MRI and ultrasound. Partial tears are initially treated with a non-operative approach, which stresses almost immediate return to activities of daily living. If patients remain symptomatic after a period of non-operative treatment, then surgical intervention should be considered. There are two common techniques for surgical repair of the distal biceps, the single-incision and the double-incision technique, which have similar clinical outcomes. Overall patients with a partial tear of the distal biceps tendon have favorable clinical outcomes.
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Tenodesis of the long head of the biceps tendon is a frequently performed procedure during shoulder arthroscopy. Various open and arthroscopic techniques have been described with comparable outcomes and complication rates. We describe a simple, knotless, arthroscopic extra-articular biceps tenodesis technique using a 4.5-mm knotless anchor. This technique avoids the complications associated with open tenodesis surgery while still removing the diseased biceps tendon from the bicipital groove. The benefits from knotless suture anchor include no requirement of arthroscopic knot tying and no risk of the knot irritation under the coracoid and coracoacromial ligament.
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Biceps brachii muscle frequently exhibits variant morphology in terms of origin, insertion, and mode of innervation. Nevertheless, the three-headed biceps brachii is described to be the most common variation. During routine cadaveric dissection, we came across a unique case of tricipital biceps brachii present on both the sides and variant course and branching pattern of musculocutaneous nerve. The third-headed biceps brachii emerged from the deep investing fascia of the brachialis muscle on both the sides. The musculocutaneous nerve (MCN) did not pierce the coracobrachialis muscle on the right side and terminated by supplying the muscles of the anterior compartment of the arm. However, a normal course was pursued by the MCN on the left side. Thus, scrupulous knowledge of the variant morphology of the biceps and associated structures may facilitate preoperative diagnosis and management of the upper limb diseases and circumvent iatrogenic injuries.
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Congenital absence of the long head of the biceps (LHB) tendon is a rare variation in shoulder anatomy. The authors present a case of congenital absence of the long head of the biceps tendon associated with a large insertion of the subscapularis muscle. The patient initially presented with shoulder pain on overhead activity. Shoulder examination was negative for signs of a torn biceps tendon. MRI revealed congenital absence of the LHB tendon, a rim rent tear of the supraspinatus, and a large insertion of the subscapularis muscle. This is the first reported case describing a large insertion of the subscapularis muscle associated with absence of the LHB tendon.5
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Management of proximal and distal biceps tendon pathology is evolving. The long head of the biceps tendon, if inflamed, may be a pain-producing structure. In appropriately indicated patients, a symptomatic long head of the biceps tendon can be surgically managed via tenotomy, tenodesis, and/or superior labrum anterior to posterior repair. In some patients, primary superior labrum anterior to posterior pathology can be managed via biceps tenodesis. Determining which procedure is most appropriate and which technique and implant are preferred for a given patient with biceps tendon pathology is controversial. Less debate exists with regard to the timing of distal biceps tendon repair; however, considerable controversy exists with regard to selection of an appropriate surgical technique and implant. In addition, the treatment of patients with a chronic and/or retracted distal biceps tendon tear and patients in whom distal biceps tendon repair fails is extremely challenging. Orthopaedic surgeons should understand the anatomy of, nonsurgical and surgical treatment options for, and outcomes of patients with proximal or distal biceps tendon pathology.
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Supernumerary or accessory heads of the biceps brachii are persistent muscular structures which can vary in number and location in the arm. Variations in other arm muscles, such as the coracobrachialis, can accompany supernumerary biceps brachii musculature in the upper limb. In this case report, we describe two rare muscular variants in a single adult male: a four-headed biceps brachii and the muscular elevator of the latissimus dorsi tendon. Additionally, accessory muscles of the brachialis and flexor digiti minimi brevis were identified in the upper limb. To our knowledge, the muscular variants identified here are considered rare, and their co-occurrence in a single upper limb has not been described previously. Also, a four-headed biceps brachii consisting of both the infero-medial and infero-lateral humeral heads has not been described previously to our knowledge. We postulate that the simultaneous appearance of several muscular variations may indicate a signaling disruption in embryogenesis during muscle patterning of the ventral limb bud. Knowledge of variant musculature in the arm is important for surgeons and clinicians as these muscles and their aberrant innervation patterns can complicate surgical procedures and may compress arteries and nerves producing upper limb pain and paresthesia. The clinical, functional and embryological implications of the upper limb variants are discussed.
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KEYWORDS Biceps reflection pulley; Pulley lesions; Biceps tendon injuries; Biceps instability KEY POINTS - The biceps reflection pulley (BRP) is a capsuloligamentous complex acting to stabilize the long head of the biceps tendon (LHB) before it enters the bicipital groove. - Injuries to the biceps pulley contribute to instability of the LHB. - The unstable and inflamed LHB may lead to painful impairment of shoulder function. - In most cases, surgical intervention is required to treat biceps pulley lesions and different surgical options exist. - Tenotomy or tenodesis of the LHB seems most reliable.
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The diagnosis and treatment of proximal biceps tendon injuries continue to be a challenge. The difficulty lies on determining if there is isolated biceps pathology versus concomitant rotator cuff tears or instability. Imaging modalities, such as magnetic resonance imaging, continue to provide us with the extra tool to help us confirm our suspicion of additional pathology. Symptomatic biceps tendon tears can undergo debridement, tenotomy, or tenodesis if nonoperative measures fail to provide relief. Reports from performing a biceps tenotomy often give similar functional outcomes compared with tenodesis. Cosmetic deformity on the lateral arm may be noted with tenodesis and initial fatigue. Tenodesis may subject the patient to a longer rehabilitation process and increased pain. The decision of which one should be performed lies between the physician and the patient's expectations.
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This is the second report in a series of projects dealing with electromyographic (EMG) analysis of the upper extremity during throwing. Better understanding of the muscle activation patterns could lead to more effective preseason conditioning regimens and rehabilitation programs. Indwelling wire electrodes recorded the output from the biceps, long and lateral heads of the triceps, pectoralis major, latissimus dorsi, serratus anterior, and brachialis for four professional baseball pitchers. These signals were synchronized electronically with high speed film records of a fast ball. The EMG signals were converted from analog to digital records. Results showed that wind-up and early cocking phases showed minimal activity in all muscles, and such firing which occurred was of low intensity. Late cocking, which occurred after the front foot was firmly planted, showed moderate activity in the biceps. Cocking was terminated by the pectoralis major and latissimus dorsi. At this point, the trunk began to rotate forward, while the arm remained elevated and the elbow flexed. Also, the shoulder was moving to maximum external rotation. During the acceleration phase, the biceps was notably quiescent, while the pectoralis major, latissimus dorsi, triceps, and serratus anterior were all active. Muscle action at this time terminated external rotation and elbow flexion; i.e., the muscles fired as decelerators and also initiated the opposite actions for ball acceleration, internal rotation and elbow extension. Follow-through was not only a time of eccentric contraction with muscle activity decelerating the upper extremity complex, it was also an active event with the shoulder moving across the body and the elbow into extension with forearm pronation.