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Ultrasound is more reliable than clinical tests to both confirm and rule out pathologies of the long head of the biceps: a systematic review and meta-analysis

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To synthesize the literature and critically appraise current evidence to determine the most accurate physical examination (clinical test or ultrasound) to detect pathologies of the long head of the biceps tendon (LHBT).

Methods

A search was performed on PubMed, Embase®, and Cochrane. Studies that compared the diagnostic accuracy of clinical tests or ultrasound versus arthroscopy for the assessment of LHBT pathologies were included.

Results

Seven studies were included reporting on a total of 448 patients. One study on instability using ultrasound reported sensitivity and specificity of 1.00 and 0.96, respectively. Two studies on full-thickness tears using ultrasound reported sensitivity and specificity of 0.88–0.95 and 0.71–0.98, respectively. Four studies on partial-thickness LHBT tears reported sensitivity and specificity of 0.17–0.68 and 0.38–0.92, respectively, for clinical tests, versus 0.27–0.71 and 0.71–1.00, respectively, for ultrasound. Three studies on other LHBT pathologies reported sensitivity and specificity of 0.18–0.79 and 0.53–0.85, respectively, for clinical tests, versus 0.50 and 1.00, respectively, for ultrasound.

Conclusion

To detect LHBT pathologies, sensitivity is high-to-excellent using ultrasound, and moderate using Neer’s sign and Speed’s test, while specificity is high-to-excellent also using ultrasound, as well as the belly press, lift-off and Kibler’s tests. The clinical relevance of these findings is that clinical tests are only reliable either to confirm or rule out LHBT pathologies, whereas ultrasound is reliable both to confirm and rule out LHBT pathologies. While diagnostic imaging cannot substitute for patient history and physical examination, the reliability and accessibility of ultrasound render it practical for routine use, particularly if clinical tests render unclear or contradictory findings.

Level of evidence

Level III.

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References

  1. Ahrens PM, Boileau P (2007) The long head of biceps and associated tendinopathy. J Bone Joint Surg Br 89(8):1001–1009

    Article  CAS  Google Scholar 

  2. Alpantaki K, McLaughlin D, Karagogeos D, Hadjipavlou A, Kontakis G (2005) Sympathetic and sensory neural elements in the tendon of the long head of the biceps. J Bone Joint Surg Am 87(7):1580–1583

    Google Scholar 

  3. Ardic F, Kahraman Y, Kacar M, Kahraman MC, Findikoglu G, Yorgancioglu ZR (2006) Shoulder impingement syndrome: relationships between clinical, functional, and radiologic findings. Am J Phys Med Rehabil 85(1):53–60

    Article  Google Scholar 

  4. Armstrong A, Teefey SA, Wu T, Clark AM, Middleton WD, Yamaguchi K, Galatz LM (2006) The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. J Shoulder Elbow Surg 15(1):7–11

    Article  Google Scholar 

  5. Arrigoni P, Ragone V, D’Ambrosi R, Denard P, Randelli F, Banfi G, Cabitza P, Randelli P (2014) Improving the accuracy of the preoperative diagnosis of long head of the biceps pathology: the biceps resisted flexion test. Joints 2(2):54–58

    Article  Google Scholar 

  6. Baptista E, Malavolta EA, Gracitelli MEC, Alvarenga D, Bordalo-Rodrigues M, Ferreira Neto AA, de Barros N (2019) Diagnostic accuracy of MRI for detection of tears and instability of proximal long head of biceps tendon: an evaluation of 100 shoulders compared with arthroscopy. Skeletal Radiol 48(11):1723–1733

    Article  Google Scholar 

  7. Baumann Q, Hue AG, Lutz PM, Hardy A, Mertl P, Courage O (2020) Diagnostic value of the hourglass biceps test for the detection of intra-articular long head of the biceps hypertrophy. JSES Int 4(4):906–912

    Article  Google Scholar 

  8. Boileau P, Ahrens PM, Hatzidakis AM (2004) Entrapment of the long head of the biceps tendon: the hourglass biceps–a cause of pain and locking of the shoulder. J Shoulder Elbow Surg 13(3):249–257

    Article  Google Scholar 

  9. Borrero CG, Costello J, Bertolet M, Vyas D (2018) Effect of patient age on accuracy of primary MRI signs of long head of biceps tearing and instability in the shoulder: an MRI-arthroscopy correlation study. Skeletal Radiol 47(2):203–214

    Article  Google Scholar 

  10. Bruyn GA, Naredo E, Moller I, Moragues C, Garrido J, de Bock GH, d’Agostino MA, Filippucci E, Iagnocco A, Backhaus M, Swen WA, Balint P, Pineda C, Milutinovic S, Kane D, Kaeley G, Narvaez FJ, Wakefield RJ, Narvaez JA, de Augustin J, Schmidt WA (2009) Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis. Ann Rheum Dis 68(3):357–361

    Article  CAS  Google Scholar 

  11. Cardoso A, Amaro P, Barbosa L, Coelho AM, Alonso R, Pires L (2019) Diagnostic accuracy of clinical tests directed to the long head of biceps tendon in a surgical population: a combination of old and new tests. J Shoulder Elbow Surg 28(12):2272–2278

    Article  Google Scholar 

  12. Charousset C, Bellaiche L, Duranthon LD, Grimberg J (2005) Accuracy of CT arthrography in the assessment of tears of the rotator cuff. J Bone Joint Surg Br 87(6):824–828

    Article  CAS  Google Scholar 

  13. Chen HS, Lin SH, Hsu YH, Chen SC, Kang JH (2011) A comparison of physical examinations with musculoskeletal ultrasound in the diagnosis of biceps long head tendinitis. Ultrasound Med Biol 37(9):1392–1398

    Article  Google Scholar 

  14. Creech MJ, Yeung M, Denkers M, Simunovic N, Athwal GS, Ayeni OR (2016) Surgical indications for long head biceps tenodesis: a systematic review. Knee Surg Sports Traumatol Arthrosc 24(7):2156–2166

    Article  Google Scholar 

  15. de la Fuente J, Blasi M, Martinez S, Barcelo P, Cachan C, Miguel M, Pedret C (2018) Ultrasound classification of traumatic distal biceps brachii tendon injuries. Skeletal Radiol 47(4):519–532

    Article  Google Scholar 

  16. Deeks JJ, Macaskill P, Irwig L (2005) The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol 58(9):882–893

    Article  Google Scholar 

  17. Demir Y, Aras B, Aydemir K, Tan AK (2015) Efficacy of ultrasound in the diagnosis of biceps tendon dislocation. Am J Phys Med Rehabil 94(9):e87-88

    Article  Google Scholar 

  18. ElMaraghy A, Devereaux M, Tsoi K (2008) The biceps crease interval for diagnosing complete distal biceps tendon ruptures. Clin Orthop Relat Res 466(9):2255–2262

    Article  Google Scholar 

  19. Fischer CA, Weber MA, Neubecker C, Bruckner T, Tanner M, Zeifang F (2015) Ultrasound vs. MRI in the assessment of rotator cuff structure prior to shoulder arthroplasty. J Orthop 12(1):23–30

    Article  Google Scholar 

  20. Gill HS, El Rassi G, Bahk MS, Castillo RC, McFarland EG (2007) Physical examination for partial tears of the biceps tendon. Am J Sports Med 35(8):1334–1340

    Article  Google Scholar 

  21. Godeneche A, Kempf JF, Nove-Josserand L, Michelet A, Saffarini M, Hannink G, Collin P (2018) Tenodesis renders better results than tenotomy in repairs of isolated supraspinatus tears with pathologic biceps. J Shoulder Elbow Surg 27(11):1939–1945

    Article  Google Scholar 

  22. Habersack A, Zussner T, Thaller S, Tilp M, Svehlik M, Kruse A (2022) Validity and reliability of a novel 3D ultrasound approach to assess static lengths and the lengthening behavior of the gastrocnemius medialis muscle and the Achilles tendon in vivo. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-07076-2

    Article  Google Scholar 

  23. Hagemeijer NC, Lubberts B, Saengsin J, Bhimani R, Sato G, Waryasz GR, Kerkhoffs G, DiGiovanni CW, Guss D (2022) Portable dynamic ultrasonography is a useful tool for the evaluation of suspected syndesmotic instability: a cadaveric study. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-07058-4

    Article  Google Scholar 

  24. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, Cochrane Bias Methods G, Cochrane Statistical Methods G (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928

    Article  Google Scholar 

  25. Holtby R, Razmjou H (2004) Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy 20(3):231–236

    Article  Google Scholar 

  26. Iagnocco A, Coari G, Leone A, Valesini G (2003) Sonographic study of painful shoulder. Clin Exp Rheumatol 21(3):355–358

    CAS  Google Scholar 

  27. Kibler WB, Sciascia AD, Hester P, Dome D, Jacobs C (2009) Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med 37(9):1840–1847

    Article  Google Scholar 

  28. Lalevee M, van Rooij F, Nover L, Kumble A, Saffarini M, Courage O (2022) 3D imaging has good specificity but poor sensitivity for the diagnosis of pathologies of the long head of the biceps: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 30(7):2510–2520

    Article  Google Scholar 

  29. Li D, Wang W, Liu Y, Ma X, Huang S, Qu Z (2020) The backward traction test: a new and effective test for diagnosis of biceps and pulley lesions. J Shoulder Elbow Surg 29(2):e37–e44

    Article  Google Scholar 

  30. Lobo Lda G, Fessell DP, Miller BS, Kelly A, Lee JY, Brandon C, Jacobson JA (2013) The role of sonography in differentiating full versus partial distal biceps tendon tears: correlation with surgical findings. AJR Am J Roentgenol 200(1):158–162

    Article  Google Scholar 

  31. Loock E, Michelet A, D’Utruy A, Molinazzi P, Hannink G, Bertiaux S, Courage O (2019) Magnetic resonance arthrography is insufficiently accurate to diagnose biceps lesions prior to rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 27(12):3970–3978

    Article  Google Scholar 

  32. Mazaleyrat M, Barthelemy R, Bouilleau L, Charousset C, Berhouet J (2020) Inter- and intra-observer reproducibility of ultrasound analysis of the long head of the biceps. Orthop Traumatol Surg Res 106(2):235–239

    Article  Google Scholar 

  33. McInnes MDF, Moher D, Thombs BD, McGrath TA, Bossuyt PM, and the P-DTAG, Clifford T, Cohen JF, Deeks JJ, Gatsonis C, Hooft L, Hunt HA, Hyde CJ, Korevaar DA, Leeflang MMG, Macaskill P, Reitsma JB, Rodin R, Rutjes AWS, Salameh JP, Stevens A, Takwoingi Y, Tonelli M, Weeks L, Whiting P, Willis BH (2018) Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies: The PRISMA-DTA Statement. JAMA 319(4):388–396

    Article  Google Scholar 

  34. Mehta SK, Teefey SA, Middleton W, Steger-May K, Sefko JA, Keener JD (2020) Prevalence and risk factors for development of subscapularis and biceps pathology in shoulders with degenerative rotator cuff disease: a prospective cohort evaluation. J Shoulder Elbow Surg 29(3):451–458

    Article  Google Scholar 

  35. Micheroli R, Kyburz D, Ciurea A, Dubs B, Toniolo M, Bisig SP, Tamborrini G (2015) Correlation of findings in clinical and high resolution ultrasonography examinations of the painful shoulder. J Ultrason 15(60):29–44

    Article  Google Scholar 

  36. Momenzadeh OR, Gerami MH, Sefidbakht S, Dehghani S (2015) Assessment of correlation between MRI and arthroscopic pathologic findings in the shoulder joint. Arch Bone Joint Surg 3(4):286–290

    Google Scholar 

  37. Qiu RY, Fitzpatrick DWD, Cohen D, Kay J, Almasri M, de Sa DL (2022) MRI as the optimal imaging modality for assessment and management of osteochondral fractures and loose bodies following traumatic patellar dislocation: a systematic review. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-07043-x

    Article  Google Scholar 

  38. Schaeffeler C, Waldt S, Holzapfel K, Kirchhoff C, Jungmann PM, Wolf P, Stat D, Schroder M, Rummeny EJ, Imhoff AB, Woertler K (2012) Lesions of the biceps pulley: diagnostic accuracy of MR arthrography of the shoulder and evaluation of previously described and new diagnostic signs. Radiology 264(2):504–513

    Article  Google Scholar 

  39. Sethi N, Wright R, Yamaguchi K (1999) Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 8(6):644–654

    Article  CAS  Google Scholar 

  40. Simmonds M (2015) Quantifying the risk of error when interpreting funnel plots. Syst Rev 4:24

    Article  Google Scholar 

  41. Skendzel JG, Jacobson JA, Carpenter JE, Miller BS (2011) Long head of biceps brachii tendon evaluation: accuracy of preoperative ultrasound. AJR Am J Roentgenol 197(4):942–948

    Article  Google Scholar 

  42. Sokal PA, Norris R, Maddox TW, Oldershaw RA (2022) The diagnostic accuracy of clinical tests for anterior cruciate ligament tears are comparable but the Lachman test has been previously overestimated: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-06898-4

    Article  Google Scholar 

  43. Tadros AS, Huang BK, Wymore L, Hoenecke H, Fronek J, Chang EY (2015) Long head of the biceps brachii tendon: unenhanced MRI versus direct MR arthrography. Skeletal Radiol 44(9):1263–1272

    Article  Google Scholar 

  44. Urita A, Funakoshi T, Amano T, Matsui Y, Kawamura D, Kameda Y, Iwasaki N (2016) Predictive factors of long head of the biceps tendon disorders-the bicipital groove morphology and subscapularis tendon tear. J Shoulder Elbow Surg 25(3):384–389

    Article  Google Scholar 

  45. Wengert GJ, Schmutzer M, Bickel H, Sora MC, Polanec SH, Weber M, Schueller-Weidekamm C (2019) Reliability of high-resolution ultrasound and magnetic resonance arthrography of the shoulder in patients with sports-related shoulder injuries. PLoS ONE 14(9):e0222783. https://doi.org/10.1371/journal.pone.0222783

    Article  CAS  Google Scholar 

  46. Zabrzynski J, Paczesny L, Zabrzynska A, Grzanka D, Lapaj L (2018) Sonography in the instability of the long head of the biceps tendon confronted with histopathologic and arthroscopic findings. Folia Morphol (Warsz) 77(3):583–590

    Article  CAS  Google Scholar 

  47. Zappia M, Chianca V, Di Pietto F, Reginelli A, Natella R, Maggialetti N, Albano D, Russo R, Sconfienza LM, Brunese L, Faletti C (2019) Imaging of long head biceps tendon. A multimodality pictorial essay. Acta Biomed 90(5S):84–94

    Google Scholar 

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Acknowledgments

The authors are grateful to GCS Ramsay Santé pour l'Enseignement et la Recherche for funding data extraction and statistical analysis, and would like to thank Luca Nover and Ankitha Kumble for their assistance with article screening and data extraction.

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  1. Ramsay Santé, Hopital Prive del’Estuaire, LeHavre, France

    Olivier Courage

  2. ReSurg SA, Rue Saint Jean 22, 1260, Nyon, Switzerland

    Floris van Rooij & Mo Saffarini

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Courage, O., van Rooij, F. & Saffarini, M. Ultrasound is more reliable than clinical tests to both confirm and rule out pathologies of the long head of the biceps: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 31, 662–671 (2023). https://doi.org/10.1007/s00167-022-07154-5

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