Surgical Treatment
Left shoulder arthroscopy was performed in the lateral decubitus position with 10 pounds of longitudinal traction. Diagnostic arthroscopy revealed a 1 cm (medial-lateral) by 5 mm (anterior-posterior) lesion of the undersurface of the anterior aspect of the supraspinatus tendon (Figure 1). There was mild posterior-superior labral fraying, but no significant labral pathology. Mild biceps tendinitis was observed as the tendon was pulled into the joint, but its anchor on the superior labrum was intact. There was mild subacromial bursitis. There was also no evidence of an anterior labral tear or subscapularis tear. We performed an arthroscopic debridement of the rotator cuff and a sub-acromial decompression. Biceps tenodesis was not performed as there was no evidence of a superior labral tear, significant bicipital tendonitis, medial subluxation of the tendon, or concurrent subscapularis tear [8,9].
Her postoperative course was uneventful and she quickly regained full range of motion and strength. However, she continued to have similar activity-related shoulder pain at six months of follow-up. Physical examination demonstrated identical findings to her pre-operative exam 6 months earlier. She was unable to return to collegiate swimming and water polo. After a thorough discussion, she returned to the operating room for a left shoulder diagnostic arthroscopy with possible rotator cuff repair, labral repair, and open biceps tenodesis.
Diagnostic arthroscopy once again arthroscopy revealed a 1 cm (medial-lateral) by 5 mm (anterior-posterior) lesion of the undersurface of the anterior aspect of the supraspinatus tendon (Figures 2 and 3). There was mild posterior-superior labral fraying, but no significant labral pathology. There was mild biceps tendinitis as the tendon was pulled into the joint, but its anchor on the superior labrum was intact. There was no evidence of an anterior labral tear or subscapularis tear. At this point, the shoulder was taken out of traction and dynamic testing under direct arthroscopic visualization was performed. The arm was placed in a position of 90 degrees of abduction and 90 degrees of external rotation. To our surprise, we did not discover impingement between the supraspinatus tendon and the posterior-superior glenoid. The articular side of the rotator cuff would not contact the posterior-superior labrum. Instead, we visualized the biceps tendon directly impinging and abrading the undersurface of the supraspinatus tendon (Figure 4B). The biceps tendon fell directly into the articular-sided tear of the supraspinatus tendon during abduction and external rotation. As a result, we elected to proceed with sub-pectoral biceps tenodesis to prevent further impingement.
The patient wore a shoulder sling for four weeks postoperatively and was instructed to avoid active biceps flexion. She began light resistive biceps strengthening at 8 weeks postoperatively and progressed to full activity at 3 months postoperatively. At six months, she had regained full strength and range of motion and had returned to competitive swimming and water polo. She has remained asymptomatic at two years of follow up.