J Shoulder Elbow Surg (2014) -, e1-e3
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Brachial neuralgia due to stretching of the musculocutaneous nerve after arthroscopic tenotomy of the long head of the biceps: a case report Soufyane Bouacida, MD*, Cyril Lazerges, MD, Bertrand Coulet, MD, Michel Chammas, MD, PhD Department of Upper Limb Surgery, Hand Surgery, Peripheral Nerve Surgery, H^opital Lapeyronie, Montpellier, France The tendon of the long head of the biceps brachii is a frequent cause of shoulder pain. Tenotomy with or without tenodesis provides good pain relief in the elderly or lowdemand patients.9 The most common complications of this procedure are decreased strength, cramping pains, and cosmetic deformities such as the Popeye sign, which corresponds to the distal retraction of the biceps brachii and may be responsible for cramping or painful sensations.2 In this paper, we describe a complication never described in the literature: brachial neuralgia due to stretching of the musculocutaneous nerve after an arthroscopic tenotomy of the long head of the biceps.
Case study A 69-year-old active woman had been suffering from pain in her left (nondominant) shoulder for 3 years. The pain was incapacitating and resisted all well-conducted medical treatment consisting of painkillers, systemic anti-inflammatory drugs, intra-articular corticoid injections, and physiotherapy. The physical examination found a deficit in range of motion of 20 for both external rotation and active anterior elevation,
The authors received consent of the patient to publish this case report. *Reprint requests: Soufyane Bouacida, MD, Department of Upper Limb Surgery, H^ opital Lapeyronie, 371 avenue du Doyen Gaston Giraud, F-34295 Montpellier Cedex 5, France. E-mail address: [email protected] (S. Bouacida).
which can related to the ‘‘hourglass syndrome.’’1 Findings on rotator cuff testing were normal, but the long head of the biceps was painful with a positive palm-up test result and a subacromial syndrome. A partial rupture of the deep layer of the supraspinatus tendon was seen on the computed tomography arthrogram, with grade A intratendinous calcification according to the French Arthroscopic Society classification.4 The age-adjusted Constant score was 29 of 100 (Table I). An arthroscopic tenotomy of the long head of the biceps was performed by the classic procedure.2 The intratendinous calcification was treated, and an acromioplasty was performed at the same time. The arm was immobilized for 6 weeks, and immediate passive rehabilitation was begun by the physiotherapist. A Popeye sign appeared a few days after surgery in association with brachial neuralgia in the musculocutaneous nerve territory. The patient was complaining of burning sensations with electric shocks, tingling, pins and needles, and numbness at each contraction of the biceps. The DN4 score was 5 of 10.3 A dynamic electromyogram did not show any sign of damage to the upper limb nerves. Six months postoperatively, the adjusted Constant score was 20 of 100, and we decided to make a tenodesis of the long head of the biceps because of an increase in symptoms (Fig. 1). The patient was in a beach chair position. A longitudinal incision was made along the coraco-biceps, and its fascia was opened to locate and to release the musculocutaneous nerve up to its branches to the biceps brachii and the brachialis. The stump of the tendon of the long head brachii
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.09.023
e2 Table I
S. Bouacida et al. Adjusted Constant score at each assessment: before and after tenotomy and after tenodesis of the long head of the biceps
Constant score
Before tenotomy
After tenotomy
After tenodesis
Pain (/15) Activity (/20) Mobility (/40) Strength (/25) Adjusted score (/100)
1 8 16 4 29
6 8 6 0 20
14 16 40 10 81
Figure 1 (A) Perioperative view of the long head of the biceps (B) retracted with stretching of the musculocutaneous nerve (N) and bowstring effect. (B) Perioperative view of the long head of the biceps (B); the bowstring effect of the musculocutaneous nerve (N) has disappeared.
was dissected from the fibrosis. The musculocutaneous nerve appeared stretched by the biceps retracted distally at rest with the elbow at 90 . Perioperative electrostimulation of the nerve confirmed its stretching at each contraction of the biceps with a bowstring effect (Fig. 1, A). The long head of the biceps was retensioned and fixed with a 3.5-mm anchor in the proximal humerus and a suture to the pectoralis major tendon. The bowstring effect had disappeared after retensioning with electrostimulation (Fig. 1, B). The arm was immobilized for 6 weeks with immediate passive rehabilitation by a physiotherapist. The patient was assessed at 2 and 6 months postoperatively. The pain previously described had totally disappeared at day 1 after surgery; the DN4 score was 0 of 10. The Popeye sign had decreased with a good cosmetic result. At 6-month follow-up, the adjusted Constant score had improved from 20 of 100 to 81 of 100 (Table I).
Discussion Arthroscopic tenotomy of the long head of the biceps was first proposed by Walch9 to treat massive cuff tears,
providing good pain relief and improvement of the shoulder function. Hsu et al7 recommended tenotomy of the long head of the biceps in elderly and low-demand patients, in cases of obesity, and for those who are not concerned about the cosmetic appearance. Many series in the literature report the results and complications with tenotomy of the long head of the biceps. Gill et al,6 in a series of 30 patients who had undergone a tenotomy of the long head of the biceps for tenosynovitis, luxation, or partial rupture, found a 13% complication rate (4 shoulders). One Popeye sign was not painful, but reoperation by tenodesis was performed because of aesthetic concerns; 2 patients complained of loss of mobility in anterior elevation, and 1 patient had persistent moderate pain. For Kelly et al,8 the incidence of Popeye sign, due to the distal migration of the biceps after tenotomy, was 70%, with 38% of the patients complaining of fatigability and discomfort during flexion of the elbow. In a meta-analysis comparing the results of tenotomy and tenodesis, Hsu et al7 found a 41% rate of Popeye sign in the tenotomy group vs. 25% in the tenodesis group, with pain in the biceps in 17% and 24%, respectively.
Musculocutaneous nerve stretching after biceps tenotomy In a series comparing 45 tenotomies vs. 37 tenodeses in patients with irreparable cuff tears, Boileau and Chuinard2 found cramping sensations in the biceps in 21% and pain in the intertubercular groove of the humerus in 46% of the tenotomy group vs. 9% and 30%, respectively, of the tenodesis group, with no significant difference. The Popeye sign was significantly worse for the tenotomy group (61% vs. 3%), with 40% of these patients complaining about the cosmetic aspect. In a series of 117 tenotomies, Duff and Campbell5 found cramping sensations in 19%, with mild to severe pain in 11%. Failure of tenotomies with revision surgery has not been studied in the literature, and brachial neuralgia after an arthroscopic tenotomy of the long head of the biceps has never been described in the literature. Our clinical and perioperative observations, in addition to the DN4 score, led us to believe that the distal retraction of the biceps is responsible for stretching of the musculocutaneous nerve and causing neurogenic pain. Indeed, a DN4 score of more than 4 of 10 indicates pain of a neurogenic origin. After a tenotomy of the long head of the biceps, the muscle retracts distally, causing the Popeye sign. After crossing the coracobrachial muscle, the musculocutaneous nerve gives branches to the biceps and brachial muscles. When the biceps retracts, the nerve is stretched distally, and this phenomenon increases at each contraction, causing electric shocks in the musculocutaneous territory. The bowstring effect observed on the nerve preoperatively had disappeared after tenodesis of the long head of the biceps. This hypothesis was confirmed by a quick and complete disappearance of the neurogenic pain, postoperatively, during biceps contraction, in association with a decrease of the Popeye sign. A normal electromyography recording eliminates any injury of the nerve caused by the nerve block performed by the anesthetist. In addition, an interscalene nerve block cannot affect the musculocutaneous nerve selectively as it is made on the brachial plexus areas.
Conclusion It is possible that a part of the cramping and painful sensations described after a biceps tenotomy is due to the stretching of the musculocutaneous nerve. This case study needs to be documented by an anatomic study of the
e3 relationship between the biceps and the musculocutaneous nerve after tenotomy of the long head of the biceps.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Boileau P, Ahrens PM, Hatzidakis AM. Entrapment of the long head of the biceps tendon: the hourglass bicepsda cause of pain and locking of the shoulder. J Shoulder Elbow Surg 2004;13:249-57. http://dx.doi.org/ 10.1016/j.jse.2004.01.001 2. Boileau P, Chuinard C. Arthroscopic biceps tenotomy: technique and results. Oper Tech Sports Med 2007;15:35-44. http://dx.doi.org/10. 1053/j.otsm.2006.11.002 3. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005;114:29-36. http://dx.doi.org/10.1016/j.pain.2004.12.010 4. Clavert P, Sirveaux F, Societe franc¸aise d’arthroscopie. [Shoulder calcifying tendinitis]. Rev Chir Orthop Reparatrice Appar Mot 2008; 94(Suppl):336-55. http://dx.doi.org/10.1016/j.rco.2008.09.010 5. Duff SJ, Campbell PT. Patient acceptance of long head of biceps brachii tenotomy. J. Shoulder Elbow Surg 2012;21:61-5. http://dx.doi.org/10. 1016/j.jse.2011.01.014 6. Gill TJ, McIrvin E, Mair SD, Hawkins RJ. Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii. J Shoulder Elbow Surg 2001;10:247-9. 7. Hsu AR, Ghodadra NS, Provencher CMT, Lewis PB, Bach BR. Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results. J Shoulder Elbow Surg 2011;20:326-32. http://dx.doi. org/10.1016/j.jse.2010.08.019 8. Kelly AM, Drakos MC, Fealy S, Taylor SA, O’Brien SJ. Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results. Am J Sports Med 2005;33:208-13. http://dx.doi.org/10. 1177/0363546504269555 9. Walch G, Edwards TB, Boulahia A, Nove-Josserand L, Neyton L, Szabo I. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder Elbow Surg 2005;14:238-46. http://dx.doi.org/10. 1016/j.jse.2004.07.008
www.elsevier.com/locate/ymse
Brachial neuralgia due to stretching of the musculocutaneous nerve after arthroscopic tenotomy of the long head of the biceps: a case report Soufyane Bouacida, MD*, Cyril Lazerges, MD, Bertrand Coulet, MD, Michel Chammas, MD, PhD Department of Upper Limb Surgery, Hand Surgery, Peripheral Nerve Surgery, H^opital Lapeyronie, Montpellier, France The tendon of the long head of the biceps brachii is a frequent cause of shoulder pain. Tenotomy with or without tenodesis provides good pain relief in the elderly or lowdemand patients.9 The most common complications of this procedure are decreased strength, cramping pains, and cosmetic deformities such as the Popeye sign, which corresponds to the distal retraction of the biceps brachii and may be responsible for cramping or painful sensations.2 In this paper, we describe a complication never described in the literature: brachial neuralgia due to stretching of the musculocutaneous nerve after an arthroscopic tenotomy of the long head of the biceps.
Case study A 69-year-old active woman had been suffering from pain in her left (nondominant) shoulder for 3 years. The pain was incapacitating and resisted all well-conducted medical treatment consisting of painkillers, systemic anti-inflammatory drugs, intra-articular corticoid injections, and physiotherapy. The physical examination found a deficit in range of motion of 20 for both external rotation and active anterior elevation,
The authors received consent of the patient to publish this case report. *Reprint requests: Soufyane Bouacida, MD, Department of Upper Limb Surgery, H^ opital Lapeyronie, 371 avenue du Doyen Gaston Giraud, F-34295 Montpellier Cedex 5, France. E-mail address: [email protected] (S. Bouacida).
which can related to the ‘‘hourglass syndrome.’’1 Findings on rotator cuff testing were normal, but the long head of the biceps was painful with a positive palm-up test result and a subacromial syndrome. A partial rupture of the deep layer of the supraspinatus tendon was seen on the computed tomography arthrogram, with grade A intratendinous calcification according to the French Arthroscopic Society classification.4 The age-adjusted Constant score was 29 of 100 (Table I). An arthroscopic tenotomy of the long head of the biceps was performed by the classic procedure.2 The intratendinous calcification was treated, and an acromioplasty was performed at the same time. The arm was immobilized for 6 weeks, and immediate passive rehabilitation was begun by the physiotherapist. A Popeye sign appeared a few days after surgery in association with brachial neuralgia in the musculocutaneous nerve territory. The patient was complaining of burning sensations with electric shocks, tingling, pins and needles, and numbness at each contraction of the biceps. The DN4 score was 5 of 10.3 A dynamic electromyogram did not show any sign of damage to the upper limb nerves. Six months postoperatively, the adjusted Constant score was 20 of 100, and we decided to make a tenodesis of the long head of the biceps because of an increase in symptoms (Fig. 1). The patient was in a beach chair position. A longitudinal incision was made along the coraco-biceps, and its fascia was opened to locate and to release the musculocutaneous nerve up to its branches to the biceps brachii and the brachialis. The stump of the tendon of the long head brachii
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.09.023
e2 Table I
S. Bouacida et al. Adjusted Constant score at each assessment: before and after tenotomy and after tenodesis of the long head of the biceps
Constant score
Before tenotomy
After tenotomy
After tenodesis
Pain (/15) Activity (/20) Mobility (/40) Strength (/25) Adjusted score (/100)
1 8 16 4 29
6 8 6 0 20
14 16 40 10 81
Figure 1 (A) Perioperative view of the long head of the biceps (B) retracted with stretching of the musculocutaneous nerve (N) and bowstring effect. (B) Perioperative view of the long head of the biceps (B); the bowstring effect of the musculocutaneous nerve (N) has disappeared.
was dissected from the fibrosis. The musculocutaneous nerve appeared stretched by the biceps retracted distally at rest with the elbow at 90 . Perioperative electrostimulation of the nerve confirmed its stretching at each contraction of the biceps with a bowstring effect (Fig. 1, A). The long head of the biceps was retensioned and fixed with a 3.5-mm anchor in the proximal humerus and a suture to the pectoralis major tendon. The bowstring effect had disappeared after retensioning with electrostimulation (Fig. 1, B). The arm was immobilized for 6 weeks with immediate passive rehabilitation by a physiotherapist. The patient was assessed at 2 and 6 months postoperatively. The pain previously described had totally disappeared at day 1 after surgery; the DN4 score was 0 of 10. The Popeye sign had decreased with a good cosmetic result. At 6-month follow-up, the adjusted Constant score had improved from 20 of 100 to 81 of 100 (Table I).
Discussion Arthroscopic tenotomy of the long head of the biceps was first proposed by Walch9 to treat massive cuff tears,
providing good pain relief and improvement of the shoulder function. Hsu et al7 recommended tenotomy of the long head of the biceps in elderly and low-demand patients, in cases of obesity, and for those who are not concerned about the cosmetic appearance. Many series in the literature report the results and complications with tenotomy of the long head of the biceps. Gill et al,6 in a series of 30 patients who had undergone a tenotomy of the long head of the biceps for tenosynovitis, luxation, or partial rupture, found a 13% complication rate (4 shoulders). One Popeye sign was not painful, but reoperation by tenodesis was performed because of aesthetic concerns; 2 patients complained of loss of mobility in anterior elevation, and 1 patient had persistent moderate pain. For Kelly et al,8 the incidence of Popeye sign, due to the distal migration of the biceps after tenotomy, was 70%, with 38% of the patients complaining of fatigability and discomfort during flexion of the elbow. In a meta-analysis comparing the results of tenotomy and tenodesis, Hsu et al7 found a 41% rate of Popeye sign in the tenotomy group vs. 25% in the tenodesis group, with pain in the biceps in 17% and 24%, respectively.
Musculocutaneous nerve stretching after biceps tenotomy In a series comparing 45 tenotomies vs. 37 tenodeses in patients with irreparable cuff tears, Boileau and Chuinard2 found cramping sensations in the biceps in 21% and pain in the intertubercular groove of the humerus in 46% of the tenotomy group vs. 9% and 30%, respectively, of the tenodesis group, with no significant difference. The Popeye sign was significantly worse for the tenotomy group (61% vs. 3%), with 40% of these patients complaining about the cosmetic aspect. In a series of 117 tenotomies, Duff and Campbell5 found cramping sensations in 19%, with mild to severe pain in 11%. Failure of tenotomies with revision surgery has not been studied in the literature, and brachial neuralgia after an arthroscopic tenotomy of the long head of the biceps has never been described in the literature. Our clinical and perioperative observations, in addition to the DN4 score, led us to believe that the distal retraction of the biceps is responsible for stretching of the musculocutaneous nerve and causing neurogenic pain. Indeed, a DN4 score of more than 4 of 10 indicates pain of a neurogenic origin. After a tenotomy of the long head of the biceps, the muscle retracts distally, causing the Popeye sign. After crossing the coracobrachial muscle, the musculocutaneous nerve gives branches to the biceps and brachial muscles. When the biceps retracts, the nerve is stretched distally, and this phenomenon increases at each contraction, causing electric shocks in the musculocutaneous territory. The bowstring effect observed on the nerve preoperatively had disappeared after tenodesis of the long head of the biceps. This hypothesis was confirmed by a quick and complete disappearance of the neurogenic pain, postoperatively, during biceps contraction, in association with a decrease of the Popeye sign. A normal electromyography recording eliminates any injury of the nerve caused by the nerve block performed by the anesthetist. In addition, an interscalene nerve block cannot affect the musculocutaneous nerve selectively as it is made on the brachial plexus areas.
Conclusion It is possible that a part of the cramping and painful sensations described after a biceps tenotomy is due to the stretching of the musculocutaneous nerve. This case study needs to be documented by an anatomic study of the
e3 relationship between the biceps and the musculocutaneous nerve after tenotomy of the long head of the biceps.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Boileau P, Ahrens PM, Hatzidakis AM. Entrapment of the long head of the biceps tendon: the hourglass bicepsda cause of pain and locking of the shoulder. J Shoulder Elbow Surg 2004;13:249-57. http://dx.doi.org/ 10.1016/j.jse.2004.01.001 2. Boileau P, Chuinard C. Arthroscopic biceps tenotomy: technique and results. Oper Tech Sports Med 2007;15:35-44. http://dx.doi.org/10. 1053/j.otsm.2006.11.002 3. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005;114:29-36. http://dx.doi.org/10.1016/j.pain.2004.12.010 4. Clavert P, Sirveaux F, Societe franc¸aise d’arthroscopie. [Shoulder calcifying tendinitis]. Rev Chir Orthop Reparatrice Appar Mot 2008; 94(Suppl):336-55. http://dx.doi.org/10.1016/j.rco.2008.09.010 5. Duff SJ, Campbell PT. Patient acceptance of long head of biceps brachii tenotomy. J. Shoulder Elbow Surg 2012;21:61-5. http://dx.doi.org/10. 1016/j.jse.2011.01.014 6. Gill TJ, McIrvin E, Mair SD, Hawkins RJ. Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii. J Shoulder Elbow Surg 2001;10:247-9. 7. Hsu AR, Ghodadra NS, Provencher CMT, Lewis PB, Bach BR. Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results. J Shoulder Elbow Surg 2011;20:326-32. http://dx.doi. org/10.1016/j.jse.2010.08.019 8. Kelly AM, Drakos MC, Fealy S, Taylor SA, O’Brien SJ. Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results. Am J Sports Med 2005;33:208-13. http://dx.doi.org/10. 1177/0363546504269555 9. Walch G, Edwards TB, Boulahia A, Nove-Josserand L, Neyton L, Szabo I. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder Elbow Surg 2005;14:238-46. http://dx.doi.org/10. 1016/j.jse.2004.07.008
