Biceps Management: Tenodesis or Tenotomy?

    Should anterior shoulder pain caused by the long head of the biceps be treated with tenodesis or tenotomy?

    At ICJR’s Shoulder Course in Las Vegas, Brian J. Cole, MD, MBA, from the Rush University Medical Center in Chicago, Illinois, reviewed current research and standard of care for this complex problem.


    Biceps pathology can be divided into three categories:

    • Inflammatory, which includes primary (rare), rotator cuff (most common), and
      after superior labrum anterior and posterior (SLAP) repair
    • Instability, which includes subluxation and dislocation with subscapularis problems
    • Attachment issue related to SLAP lesions


    Patients with biceps pathology generally present with a chief complaint of anterior shoulder pain. These patients may have co-existing pathology, such as rotator cuff tears, degenerative joint disease, or SLAP lesions.

    It is important for the surgeon to take a detailed surgical history, asking for any previous operative reports and images, and to find out the patient’s response to previous treatment.

    Magnetic resonance imaging can help in the diagnosis, although it is less helpful if the patient does not have subscapularis problems.

    Certain tests can be done during the physical exam, including Yergason’s test, Speed’s Test, and the uppercut maneuver. However, Dr. Cole noted that these tests lack high levels of sensitivity and specificity and that good clinical judgment is needed.

    Indications for Surgical Treatment

    Biceps tendonopathy can be very responsive to non-surgical treatment consisting of injections and rehabilitation. In Dr. Cole’s practice, for example, selective biciptal injection under ultrasound guidance has become a mainstay of treatment, as injection into the biceps tendon sheath can provide complete pain relief.

    But not all patients will respond well. Those that do typically have a primary pathology. They have pectoralis minor tightness and poor posture, and they carry themselves very far forward, with the scapula sitting forward. Dr. Cole has been successful in keeping these patients out of the operating room by prescribing an anterior shoulder stretching program with eccentric strengthening plus selective injections.

    Dr. Cole noted that another group of patients – those who have had prior shoulder surgery – are less likely to improve with non-surgical treatment. Those who benefit from surgery include:

    • Patients with an intact biceps and discrete symptoms anteriorly
    • Patients who have failed non-operative treatment
    • Patients with concomitant pathology (rotator cuff tears, degenerative joint disease, SLAP lesions)

    Tenotomy vs. Tenodesis

    So how does Dr. Cole decide between a tenotomy and a tenodesis for these patients? Studies have shown that both procedures provide excellent pain relief. Historically the decision came down to cosmesis: Was the patient willing to accept a “Popeye deformity” following a tenotomy? If not, a tenodesis was done.

    However, research shows that a Popeye deformity isn’t the only problem with tenotomy. Several studies have found poor functional results, cramping, and fatigue following tenotomy.

    Dr. Cole said there are a few patient-specific indications for tenotomy:

    • Patients with an increased risk for infection
    • Patients unwilling to comply with postoperative rehabilitation
    • Older sedentary patients with no cosmetic concern

    This is a very small group of patients, Dr. Cole said. Most of his patients are good candidates for a tenodesis procedure.

    Tenodesis Surgical Technique

    Dr. Cole gave an overview of the many techniques available for tenodesis, and pointed out in particular the advantage of pain relief with distal tenodesis over proximal tenodesis. He also emphasized how the load-to-failure of the tenodesis repair depends on the integrity of the proximal tendon.

    Dr. Cole’s preferred technique is an open subpectoral biceps tenodesis using interference screw fixation. This technique does carry a risk of damage to nearby neurovascular structures. Dr. Cole said he minimizes those risks by using blunt medial retractor, and by externally rotate the arm, to move these structures away medially.

    A 2% complication rate associated has been reported with this technique. The main complications are:

    • Loss of fixation
    • Popeye deformity
    • Pain
    • Infection
    • Damage to the musculocutaneous nerve
    • Brachial plexus injury
    • Humerus fracture


    The long head of the biceps is a common pain generator, either isolated or in combination with other shoulder pathologies, Dr. Cole said. In his practice, most patients are candidates for a subpectoral tenodesis, and the outcomes of this procedure are good with only a 2% complication rate reported.

    No matter which surgical technique is used, Dr. Cole said, the load-to-failure of the tenodesis repair depends on the integrity of the proximal tendon.

    Dr. Cole’s presentation can be found here.