Boileau P, Ahrens P-M, Trojani C, Coste J-S, Cordéro B, Rousseau P
Service de Chirurgie Orthopédique et Traumatologie du Sport, Hôpital de L'Archet, CHU de Nice, 151, route de Saint-Antoine de Ginestière, 06202 Nice.
Rev Chir Orthop Reparatrice Appar Mot. 2003 Dec;89(8):672-82.
We describe a mechanical condition affecting the long head of the biceps tendon (LHBT) causing potentially unrecognized entrapment within the joint and subsequent pain and locking. This is caused by a hypertrophic intra-articular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm.
Twenty one patients were identified, during open (14 cases) or arthroscopic (7 cases) surgery, with a so called "hourglass biceps" i.e., hypertrophic intraarticular portion of the LHBT and incarceration of the tendon during elevation. All cases occurred in conjunction with a rotator cuff rupture except one who had a partial deep tear. All patients were treated by excision of the biceps, after tenodesis or bipolar tenotomy, and appropriate treatment of the concomitant lesions.
All patients presented with anterior shoulder pain and loss of passive elevation averaging 10-20 degrees. A dynamic intraoperative test involving forward elevation with the elbow extended demonstrated entrapment of the tendon within the joint in each case. This test creates a characteristic "buckling" of the tendon and "squeezing" of the tendon between the humeral head and the glenoid ("hourglass test"). Excision of the tendon allowed immediate restoration of complete elevation. Mean Constant score increased from 38 points to 76 points postoperatively.
The "hourglass biceps" is caused by a hypertrophic intraarticular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm. Loss of 10-20 degrees of passive elevation, bicipital groove tenderness, and radiographic findings of a hypertrophied tendon can aid in diagnosis. The "hourglass biceps" should not be misdiagnosed for a frozen shoulder. Definitive diagnosis is made at surgery with the "hourglass test": incarceration and squeezing of the tendon within the joint during forward elevation of the arm with the elbow extended. Simple tenotomy cannot resolve this mechanical block. Either tenotomy with excision of the intraarticular portion of the LHBT or tenodesis must be performed. The "Hourglass" biceps is an addition to the familiar pathologies of the long head of the biceps tendon (tenosynovitis, prerupture, rupture, instability), and should be considered in any case of chronic anterior shoulder pain associated with a loss of shoulder elevation.
我们描述了一种影响肱二头肌长头肌腱（LHBT）的机械状况，该状况会导致肌腱在关节内潜在地未被识别的卡压，进而引发疼痛和绞锁。这是由肌腱关节内部分肥厚所致，在手臂抬高时，肥厚的肌腱无法滑入肱二头肌沟。
在开放手术（14例）或关节镜手术（7例）中，共识别出21例患者存在所谓的“沙漏状肱二头肌”，即LHBT关节内部分肥厚且在手臂抬高时肌腱嵌顿。除1例为部分深层撕裂外，所有病例均合并肩袖撕裂。所有患者在进行肌腱固定术或双极腱切断术后，均接受了肱二头肌切除术，并对伴随病变进行了适当治疗。
所有患者均表现为肩部前方疼痛，被动抬高平均丧失10 - 20度。一项动态术中测试，即伸直肘部进行前屈抬高，结果显示每例患者的肌腱在关节内均有卡压。该测试会使肌腱产生特征性的“屈曲”以及在肱骨头和关节盂之间对肌腱的“挤压”（“沙漏测试”）。切除肌腱后可立即恢复完全抬高。Constant评分术后平均从38分提高到76分。
“沙漏状肱二头肌”是由肌腱关节内部分肥厚引起的，在手臂抬高时无法滑入肱二头肌沟。被动抬高丧失10 - 20度、肱二头肌沟压痛以及肌腱肥厚的影像学表现有助于诊断。“沙漏状肱二头肌”不应被误诊为肩周炎。通过“沙漏测试”在手术中可做出明确诊断：伸直肘部手臂前屈抬高时肌腱在关节内的嵌顿和挤压。单纯腱切断术无法解决这种机械性阻碍。必须进行LHBT关节内部分切除的腱切断术或肌腱固定术。“沙漏状”肱二头肌是肱二头肌长头肌腱常见病变（腱鞘炎、破裂前、破裂、不稳定）之外的一种情况，在任何伴有肩部抬高丧失的慢性肩部前方疼痛病例中均应予以考虑。
