What is a biceps tenodesis?
The biceps tendon is one of two tendons (“bi”) that originate in the shoulder and form the muscle in the front of the arm that bends and rotates the elbow. The tendon in the shoulder specifically that is susceptible to injury and pain development is called the long head, which is a thin noodle-like tendon that is located in the shoulder joint. This location makes it susceptible to irritation and tearing, much like the process that affects the adjacent rotator cuff tendon.
When the long head biceps (herein “biceps”) is a cause of pain, the observation is that by surgically cutting (tenotomy) or cutting and reattaching it to the humerus (tenodesis), the pain can resolve without any impairment in the function of the arm. In fact, some patients that develop a rupture of the long head biceps will actually feel much better after the tendon “pops”. This was the case with the famed NFL quarterback John Elway who spontaneously ruptured his biceps tendon in his throwing arm in 1997 and went on to consecutive Super Bowl victories without having surgery(1). Elway frequently commented that “…as soon as I popped it, it was great”(1). While not all patients have this experience with rupturing their biceps, the lesson is that alleviating the pull and tension on a torn and inflamed biceps can alleviate symptoms in the shoulder without adversely affecting the function in the arm.
Further evidence of the role of the biceps tendon in pain generation was observed by the French surgeon Gilles Walch, who noted that simply only cutting the biceps tendon in older patients with irreparable rotator cuff tears resulted in significant pain and outcome improvements(2). In these patients, simply cutting the pain-generating biceps helped them where the rotator cuff was effectively untreatable because of the extent of the tearing. This data is evidence that the biceps itself contributes to pain, in addition to the torn and damaged rotator cuff.
While there is substantial evidence that simply cutting (tenotomy) or repairing to the humerus (tenodesis) lead to equivalent outcomes(3), more patients undergoing tenotomy will have a “lumpy” and deformed biceps muscle, called the “popeye” sign, after the fictional cartoon character’s arms. The popeye sign is present in a minority of patients undergoing biceps tenotomy, and when present is uncommonly bothersome(4). However, in modern shoulder surgery practice, due to the advent of arthroscopic and minimally invasive techniques, most patients are treated with tenodesis to avoid the potential problem after surgery of deformity and cramping in the biceps muscle.
If I am having a rotator cuff repair, do I also need a biceps tenodesis?
Due the anatomic proximity there is a very high coexistence of biceps pathology in the setting of MRI-confirmed rotator cuff tears. The rotator cuff and biceps live in the relatively same position in the front of the shoulder and both tissues are susceptible to degeneration and impingement from the overlying acromion bone. MRI is better at picking up rotator cuff tears than irritation/inflammation or partial tearing of the biceps and for this reason biceps injury is often only diagnosed on direct visualization at the time of arthroscopy. Oftentimes, the biceps portion of a rotator cuff-based surgery is noted as “possible”, pending the findings at the time of surgery. If the biceps is normal, it is left alone, otherwise when torn or inflamed, it is treated (usually with tenodesis), to alleviate a potential pain generator in the shoulder. Whether the biceps is treated at surgery typically does not appreciably affect the rehabilitation after surgery, which is based on the status of other tissues such as the rotator cuff.
When is a biceps tenodesis used in a younger active patients?
Biceps tenodesis is not just reserved for patients with rotator cuff tears. Some patients, especially young throwing athletes, can develop pain in the labrum, called SLAP tears, and releasing the pull of the biceps from the torn and injured labrum can alleviate the pain from the damaged labrum tissue. Treating this population with a biceps tenodesis, with or without labrum repair, can result in high rates of return to sport and high satisfaction rates(5).
How is a biceps tenodesis performed?
There are different techniques for performing a biceps tenodesis, depending on how the tendon is repaired and at which location the tendon is repaired to the humerus. Studies have suggested that an arthroscopic approach, low enough on the humerus to not cause residual pain, may be the most ideal position for biceps tenodesis(6). In this method, the more proximal diseased tendon in the bicipital groove is removed so that there is a lower incidence of postoperative pain. Another option is making an open incision called subpectoral, which generally is acceptable but requires a bigger incision and is more invasive. The technical challenge of performing biceps tenodesis is to ensure the tendon is repaired under the appropriate tension, so that the popeye deformity does not occur despite the tenodesis.
Dr. Obermeyer’s preferred technique of biceps tenodesis involves the minimally invasive arthroscopic approach of inserting a suture anchor through a tiny incision (portal) above the pectoralis where the tendon is repaired onto the humerus under anatomic tension (called onlay). This provides the benefit from removing the painful and damaged tendon higher in the bicipital groove while repairing the tendon securely under appropriate tension. Dr. Obermeyer can discuss the technique in your particular case that will result in the best outcome with the least invasive approach.
Schedule a shoulder exam
If you considering a Biceps Tenodesis, call our office or book an appointment with shoulder surgeon Dr. Thomas Obermeyer. Dr. Obermeyer specializes in diagnosing and treating rotator cuff injuries. Dr. Obermeyer has orthopedic offices in Schaumburg, Bartlett, and Elk Grove Village, Illinois. Dr. Obermeyer regularly sees patients from throughout Illinois including Hoffman Estates, Palatine, Elgin, Streamwood, Arlington Heights, and Roselle communities.
- Millstein ES. Editorial Commentary: “Popeye” Deformity After Spontaneous Proximal Biceps Tendon Rupture: Image, Treat, or Ignore? Arthroscopy. 2018 Apr;34(4):1171-1172. doi: 10.1016/j.arthro.2018.01.044. PMID: 29622253.
- Walch G, Edwards TB, Boulahia A, Nové-Josserand L, Neyton L, Szabo I. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder Elbow Surg. 2005 May-Jun;14(3):238-46. doi: 10.1016/j.jse.2004.07.008. PMID: 15889020.
- MacDonald P, Verhulst F, McRae S, Old J, Stranges G, Dubberley J, Mascarenhas R, Koenig J, Leiter J, Nassar M, Lapner P. Biceps Tenodesis Versus Tenotomy in the Treatment of Lesions of the Long Head of the Biceps Tendon in Patients Undergoing Arthroscopic Shoulder Surgery: A Prospective Double-Blinded Randomized Controlled Trial. Am J Sports Med. 2020 May;48(6):1439-1449. doi: 10.1177/0363546520912212. Epub 2020 Mar 30. PMID: 32223645.
- van Deurzen DFP, Garssen FL, Wessel RN, Kerkhoffs GMMJ, van den Bekerom MPJ, van Wier MF. The Popeye sign: a doctor’s and not a patient’s problem. J Shoulder Elbow Surg. 2021 May;30(5):969-976. doi: 10.1016/j.jse.2020.10.040. Epub 2020 Dec 5. PMID: 33290851.
- Waterman, Brian R. MD; Dean, Robert S. BS; Gregory, Bonnie MD; Romeo, Anthony A. MD. Surgical Treatment of Superior Labral/Biceps Pathology in the Overhead Thrower. Journal of the American Academy of Orthopaedic Surgeons 31(8):p e424-e434, April 15, 2023. | DOI: 10.5435/JAAOS-D-21-01199
- Lutton DM, Gruson KI, Harrison AK, Gladstone JN, Flatow EL. Where to tenodese the biceps: proximal or distal? Clin Orthop Relat Res. 2011 Apr;469(4):1050-5. doi: 10.1007/s11999-010-1691-z. PMID: 21107924; PMCID: PMC3048262.
At a Glance
Dr. Thomas Obermeyer
- 15+ years of training and experience treating complex shoulder and sports medicine conditions
- Expert subspecialized and board-certified orthopedic care
- Award-winning outstanding patient satisfaction scores
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