Accessory Long Head of the Biceps Tendon (LHBT)! The LHBT originates from the supraglenoid tubercle and to some extent from the superior labrum. It courses within the glenohumeral articulation (intra articular but extra synovial) and is stabilized within the rotator cuff interval before exiting into the inter tubercular groove. Within the RC interval, the superior glenohumeral ligament and coracohumeral ligament form a “biceps pulley” that keeps it from subluxation. Symptomatic pathology related to the LHBT is common and can be due to degeneration, tear, subluxation or dislocation. There are several anatomical variants including diverse origins, bifid configuration and congenital absence. These variants are asymptomatic except for congenital absence which may be associated to shoulder instability. Accessory LHBT can occur in up to 25% of patients and is more common in Asians. These accessory tendons usually originate from the anterior capsule, humeral tuberosities or coracoid process. In this case, three different tendons are seen within the inter tubercular groove; originating from 1. The expected supraglenoid tubercle, 2. The lesser tuberosity and 3. The anterior capsule. Multiple accessory tendons within the intertubercular groove can be mistaken for a longitudinal tear in MR imaging. When two or more well defined circular LHB tendons are seen, it’s important to track the tendons to their origin. This way we can differentiate between a longitudinal tear versus an asymptomatic variant. This patient also has a supraspinatus tendon tear, advanced glenohumeral osteoarthritis and synovitis.
