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.