Biceps Tenodesis / Tenotomy (LHB)

Pathology Requiring Tenodesis or Tenotomy

LHB Pathology Spectrum

Bicipital tenosynovitis: Inflammation within the synovial sheath in the bicipital groove. Presents with anterior shoulder pain, positive Speed test (resisted forward flexion in supination with elbow extended), positive Yergason test (resisted supination against examiner with elbow flexed 90 degrees), groove tenderness on palpation.

LHB partial tear: Fraying or partial-thickness tearing in the groove or at the intertubercular entrance. MRI shows focal signal change, irregular contour, or partial defect. Often associated with subscapularis superior fibre tear (upper subscapularis tendon border attaches partly to bicipital groove sheath).

LHB instability (medial subluxation): Subscapularis tear or rotator interval disruption allows the LHB to sublux or dislocate medially over the lesser tuberosity. Presents with clicking on rotation. Associated with subscapularis tear in virtually all cases — treat the subscapularis AND the biceps.

SLAP lesions (Superior Labrum Anterior to Posterior): Snyder classification Types I-IV. Type II (most common operative type): detachment of the superior labrum and LHB anchor from the supraglenoid tubercle. Critical decision: repair vs tenodesis.

Tenotomy vs Tenodesis — Decision Framework

Tenotomy — appropriate for:

• Older, low-demand, non-manual patient
• Patient accepting of a possible Popeye deformity (explicitly counselled and accepts)
• Frail patient where the shorter operative time is advantageous
• Bilateral shoulder surgery in elderly patient (minimise additional surgical time)
• Associated massive irreparable rotator cuff tear (concomitant tenotomy during cuff debridement)

Tenodesis — appropriate for:

• Younger, active lifestyle, manual worker
• Patient concerned about cosmesis (Popeye deformity unacceptable)
• Patient who specifically prioritises arm symmetry and contour
• SLAP II in patient over 35-40 (tenodesis preferred to SLAP repair)
• Young patient with isolated LHB pathology and intact cuff

Key Evidence

Koh et al. 2010 (PMID 20551285): Prospective cohort of 90 patients over 55 years with a rotator cuff tear plus LHB lesion (tear over 30%, subluxation/dislocation, or degenerative Type II SLAP); 45 tenodesis versus 45 tenotomy. Popeye deformity occurred in 9% of the tenodesis group versus 27% of the tenotomy group (P = 0.04). There was NO significant difference in cramping pain or in elbow flexor power ratio (0.92 tenodesis vs 0.94 tenotomy). ASES and Constant scores improved similarly in both groups. Conclusion: suture-anchor tenodesis produces less Popeye deformity, but no other clinical variable differs.

Boileau et al. 2009 (PMID 19229046): Cohort of 25 patients with an isolated Type II SLAP lesion — 10 SLAP repairs (mean age 37) versus 15 arthroscopic biceps tenodeses (mean age 52). 87% (13/15) returned to their previous level of sport after tenodesis versus only 20% (2/10) after SLAP repair (P = 0.01); the Constant score improved more after tenodesis. Four failed SLAP repairs were successfully salvaged by subsequent tenodesis. Supports tenodesis as an effective alternative to repair for Type II SLAP (groups differed in age, so findings should be confirmed).

Mazzocca et al. 2005 (PMID 16325079): Cadaveric biomechanical comparison of four tenodesis fixation methods (subpectoral bone tunnel, arthroscopic suture anchor, subpectoral interference screw, arthroscopic interference screw). The subpectoral interference screw showed the LEAST cyclic displacement (1.5mm), but there was NO statistically significant difference in ultimate failure load between methods (all roughly 165-252 N). All specimens failed at the tenodesis site.

Mazzocca et al. 2008 (PMID 18697951): Prospective clinical case series of subpectoral biceps tenodesis with an interference screw — 41 of 50 patients followed (mean age 50, mean 29 months). Significant improvement in ASES, Constant, Rowe and SANE scores, with only one fixation failure (tendon pull-out producing a Popeye deformity). Patients with a coexistent rotator cuff lesion had significantly lower ASES scores, reinforcing the need to treat concomitant pathology.

Provencher et al. 2013 (PMID 23460326): Prospective analysis of 179 Type II SLAP repairs in a young active cohort. 37% met failure criteria with a 28% revision rate; age over 36 years was the only independent predictor of failure (relative risk 3.45). Establishes the high failure rate of SLAP repair and the age effect that underpins the tenodesis decision.

Pooled randomised-trial evidence (Hartland 2022, PMID 36220319; Zhou 2021, PMID 33545991): Meta-analyses of randomised trials (860 patients across 11 RCTs, and 9 RCTs respectively) confirm that tenotomy and tenodesis give equivalent patient-reported function, pain and elbow flexion/supination strength. Tenodesis reliably reduces Popeye deformity (OR about 0.29); tenotomy has a shorter operative time.

Long Head of Biceps — Course and Anatomy

Intra-articular Portion

Origin: Supraglenoid tubercle and posterosuperior glenoid labrum (superior labrum). The LHB anchor accounts for approximately 40-50% of the posterosuperior labral attachment, with the remaining attachment from the anterior and posterior superior labrum.

Intra-articular course: Passes over the humeral head from posterosuperior to anteroinferior, entering the rotator interval between the supraspinatus (superior) and subscapularis (inferior). The rotator interval contains the SGHL (superior glenohumeral ligament) and CHL (coracohumeral ligament) which form a pulley mechanism stabilising the LHB at the groove entrance.

Groove entrance (intertubercular groove entrance): The LHB passes through the bicipital groove between the greater tuberosity laterally and lesser tuberosity medially. The transverse humeral ligament crosses superficially, holding the tendon in the groove.

Bicipital Groove

Location: Between the greater and lesser tuberosities. Groove width 5-12mm, depth 4-6mm, length 7-8cm. The groove is oriented anteriorly at approximately 15-25 degrees medial to the bicipital axis.

Groove contents: LHB tendon surrounded by a synovial sheath continuous with the glenohumeral joint. Anterior humeral circumflex vessels run along the inferior groove margin.

Pectoralis major relationship: The inferior border of the pectoralis major tendon inserts on the crest of the greater tuberosity, lateral lip of the groove, at approximately 6-7cm distal to the top of the lesser tuberosity. The subpectoral tenodesis site is 1-2cm below this insertion.

Musculocutaneous Nerve

Origin: Lateral cord of the brachial plexus (C5-C7). Exits posterior and lateral to pectoralis minor.

Course: Passes obliquely to enter the deep (posteromedial) surface of the coracobrachialis muscle a variable distance distal to the coracoid tip (classically a few centimetres, but with wide individual variation). After traversing coracobrachialis and the biceps-brachialis interval it continues distally and becomes the lateral cutaneous nerve of the forearm.

Danger zone: In a cadaveric model of subpectoral tenodesis the musculocutaneous nerve lay a mean 37mm from the tenodesis site and the radial nerve about 48mm (Sethi 2014, PMID 25193486) — so direct hardware injury is unusual, and the main subpectoral risk is stretch or retraction injury from aggressive MEDIAL retraction with deep Langenbeck or Hohmann retractors. The more clinically important pitfall is bicortical posterior-cortex drilling at the SUPRApectoral level, where the axillary nerve lies only about 10mm away.

Pectoralis Major Tendon

Insertion anatomy: The pectoralis major inserts on the crest of the greater tuberosity in a bilaminar fashion — anterior lamina (clavicular fibres) and posterior lamina (sternocostal fibres). The posterior lamina insertion extends more proximally. The anterior lamina inferiorly is the landmark for the subpectoral incision placement.

Subpectoral working window: 3-4cm incision in the axillary crease just below the pectoralis major inferior border. Provides direct access to the LHB at the proximal bicipital groove without entering the shoulder joint.

LHB Function — Why it Matters for Tenodesis Tensioning

The LHB acts as:

1. Elbow flexor: Contributes to elbow flexion, most efficiently with the forearm supinated; the long head provides only part of total biceps flexion force (short head, brachialis and brachioradialis contribute the rest)
2. Forearm supinator: The biceps is a powerful supinator (especially with the elbow flexed), working synergistically with the supinator muscle; the long head is only one contributor, which is why isolated LHB release causes little measurable net supination deficit in clinical studies
3. Shoulder stabiliser: The intra-articular LHB exerts a depressing and compressive force on the humeral head during deltoid activation, acting as a humeral head depressor (its role is debated, but it may contribute to head depression in massive rotator cuff tears)
4. Superior labral anchor: The LHB-superior labrum complex acts as a secondary superior shoulder restraint; its disruption is the pathology in Type II SLAP

Tensioning implications during tenodesis: If the tenodesis is too loose (tendon fixed with slack), the LHB muscle belly retracts distally producing cosmetic Popeye deformity and loss of supination force. If too tight (tendon fixed under excessive tension), elbow flexion contracture develops (the biceps is artificially shortened). Correct tension: elbow at 90 degrees, forearm neutral rotation, no active pulling during fixation — allow the tendon to sit at physiological resting length.

SLAP Classification — Complete Reference

Snyder Classification (1990):

• Type I: Fraying and degeneration of the superior labrum, LHB anchor intact — degenerative, treat with debridement
• Type II: Detachment of the superior labrum and LHB anchor from the supraglenoid tubercle — most common operative type (50-60% of SLAP lesions); operative decision as above
• Type III: Bucket-handle tear of the superior labrum, LHB anchor intact — resect the unstable bucket-handle fragment if displacing; LHB anchor preserved
• Type IV: Bucket-handle tear extending into the LHB tendon itself — if LHB extension significant (greater than 50% tendon width), consider tenodesis; if less than 50%, repair bucket-handle and tubularise LHB

Exam tip: Know which types require LHB tenodesis (Type II over 35-40, Type IV with significant LHB extension) vs debridement (Type I, III) vs repair (Type II under 35 in throwing athlete).

Tenotomy — Technique

Arthroscopic Tenotomy

Position: Beach chair or lateral decubitus.

Step 1 — Identify LHB: Standard posterior viewing portal. Anterior rotator interval portal for instrumentation. Identify LHB origin at the supraglenoid tubercle and superior labrum. Assess tendon quality, degree of fraying, and intra-articular length.

Step 2 — Release: Using arthroscopic scissors or radiofrequency device, transect the LHB as close to its origin at the supraglenoid tubercle as possible. This minimises the intra-articular stump that may impinge in the joint if left long.

Step 3 — Allow retraction: After tenotomy, the LHB retracts distally into the groove. In most patients it comes to rest below the bicipital groove. The stump may migrate to the subpectoral region.

Post-tenotomy assessment: Inspect the superior labrum — if associated Type II SLAP has been converted to tenotomy rather than repaired, confirm no labral flap remains that could cause mechanical symptoms.

Tenodesis — Subpectoral Technique (Mazzocca)

Position and Setup

Beach chair 45 degrees. Standard shoulder arthroscopy setup. Two stages: arthroscopic first (treat concomitant pathology), then subpectoral incision for tenodesis.

Stage 1 — Arthroscopic Assessment and Preparation

Identify LHB: Posterior portal viewing, anterior portal working. Assess LHB origin and intra-articular portion. Confirm tenosynovitis, partial tear, or SLAP pathology.

Release LHB intracapsular: Transect the LHB at or just proximal to the groove entrance with arthroscopic scissors. Do NOT cut too proximally (supraglenoid) — leave a 1-2cm intra-articular stump only briefly. The tendon will retract into the groove.

Treat concomitant pathology: Subacromial decompression if impingement, rotator cuff repair if tear, rotator interval closure if instability pattern.

Stage 2 — Subpectoral Tenodesis

Patient setup for subpectoral incision: With the arm still draped free and the shoulder arthroscopy completed, place the arm in slight abduction and external rotation to expose the axillary fold. This brings the pectoralis major inferior border into a more accessible position for a 3-4cm incision.

Incision: 3-4cm longitudinal incision in the axillary fold at the inferior border of the pectoralis major. Incise skin and subcutaneous fat. Identify the inferior border of the pectoralis major tendon.

Expose bicipital groove: Develop the interval between the medial aspect of the pectoralis major tendon insertion and the proximal humerus. Use blunt dissection with finger or small Cobb elevator. Identify the bicipital groove 1-2cm below the pectoralis major tendon inferior border. Palpate the groove anteriorly on the humeral shaft.

Retrieve LHB: Using a small curved haemostat or tendon-grasping forceps, retrieve the LHB tendon from within the groove. The tendon will be in the groove, having retracted from the arthroscopic cut. Gently pull it distally into the wound.

Tendon preparation: Whipstitch the distal 2cm of the LHB tendon with No. 2 FiberWire or equivalent non-absorbable suture (Krachow stitch). Do not trim the tendon excessively — maintain appropriate length to prevent shortening the biceps.

Prepare bone socket: Identify the anterior surface of the proximal humerus 1-2cm below the inferior pectoralis major border. Use a cannulated drill over a guide wire to prepare an intramedullary socket of appropriate diameter (typically 7-8mm diameter, 2.5cm depth). Confirm socket in appropriate position with fluoroscopy if available.

Interference screw fixation: Pass the tendon-loaded suture into the socket. Insert a bioabsorbable or metal interference screw of matching diameter (7-8mm, 2.5cm length) while maintaining tension on the whipstitch sutures. Tie the sutures over the screw for added security. Alternatively, a cortical button (Endobutton technique) may be used — tendon passed through a bone tunnel and button flipped on the far cortex.

Tensioning: The biceps should be tensioned in a comfortable resting position — elbow at 90 degrees, forearm neutral rotation, no excessive distal traction on the tendon. Overtensioning causes elbow flexion contracture.

Closure: Close subcutaneous fat with absorbable suture, skin with subcuticular absorbable suture.

Suprapectoral Tenodesis — Alternative Approach

Through the arthroscopic portals alone, the LHB tendon is fixed in the bicipital groove at or just below the groove entrance using a knotted or knotless suture anchor or an interference screw. Simpler and does not require a second incision. The tendon remains nearer the pathological groove and is not secured as distally, which may leave a higher residual Popeye risk than the subpectoral site. Critically, bicortical posterior-cortex drilling at this proximal level brings the axillary nerve very close (about 10mm; Sethi 2014) — keep fixation unicortical or use a low-profile socket.

Fixation Methods — Direct Comparison

Interference screw (most common — Mazzocca subpectoral):

• Biomechanics: snug fit between screw, tendon, and socket walls; in cadaveric testing the subpectoral interference screw showed the least cyclic displacement, with ultimate failure load similar to other methods (roughly 165-252 N across constructs; Mazzocca 2005, PMID 16325079)
• Screw material: bioabsorbable (PLLA) or metal (titanium); both have comparable fixation strength
• Risk: screw too small = inadequate compression; screw too large = socket splitting; avoid mismatched sizing
• Advantage: no hardware prominent subcutaneously, reliable fixation, well-studied technique

Cortical button (Endobutton technique):

• Tendon passed through a bone tunnel (diameter matching tendon) and a button flipped on the far (lateral) cortex
• Advantage: no interference screw needed, can be used if socket preparation difficult
• Disadvantage: button proud on lateral cortex may be palpable; requires accurate tunnel direction

Suture anchor (suprapectoral / all-arthroscopic):

• Anchor drilled into the bicipital groove, suture passed through tendon and tied
• Simple, single incision, avoids subpectoral dissection
• Disadvantage: higher Popeye deformity, fixation strength lower than interference screw, tendon remains in pathological groove

Postoperative Management

Immobilisation

Tenotomy: Arm sling for comfort only, 2-4 weeks. No formal restriction required as there is no repair to protect.

Tenodesis: Arm sling 4-6 weeks. Elbow restricted to gravity-assisted flexion only (no active resisted elbow flexion for 6 weeks). Shoulder ROM as dictated by concomitant pathology treated (e.g. rotator cuff repair protocol may take priority).

Critical point: Do not allow early resisted elbow flexion or forceful supination against resistance — this loads the tenodesis site and risks fixation failure in the first 6 weeks.

Rehabilitation Phases — Tenodesis

Phase 1 (weeks 0-6): Sling wear, passive and active-assisted shoulder ROM within pain tolerance, no resisted elbow flexion, no supination against resistance. Gentle pendulums, wrist and hand exercises from day 1.

Phase 2 (weeks 6-12): Wean sling, introduce active elbow flexion against gravity, gentle isometric biceps exercises, progressive ROM. Light activities of daily living.

Phase 3 (weeks 12-16): Progressive resistive biceps strengthening, supination strengthening, sport-specific upper limb loading. Target full elbow flexion and supination strength by 16 weeks.

Phase 4 (weeks 16-24): Return to manual work and sport. Heavy manual work or contact sport: 4-6 months. Overhead throwing sport: typically 6 months minimum.

Rehabilitation Phases — Tenotomy

Simpler protocol. No elbow restriction — early active ROM. Physiotherapy directed at treating the underlying shoulder pathology (subacromial, cuff, AC joint) that was addressed simultaneously. Full activities at 6-12 weeks unless restricted by concomitant procedure.

Driving

Tenotomy: return to automatic driving when comfortable, typically 2-4 weeks. Tenodesis: 4-6 weeks (sling removal), manual vehicle 8-10 weeks.

Physiotherapy Programme — Tenodesis Specific Points

Elbow flexion and supination strengthening (key for tenodesis patients): Begin submaximal isometric elbow flexion at 6 weeks, progressive resistance through weeks 8-12, eccentric loading programme at weeks 12-16. Target full return of elbow flexion and supination strength by 16-20 weeks. Biceps curl against resistance: begin at 50% effort at 8 weeks, 75% at 12 weeks, full at 16 weeks.

Periscapular and rotator cuff strengthening: Critical — LHB pathology commonly occurs in the context of rotator cuff disease and scapular dyskinesia. Address these with formal physiotherapy for optimum shoulder function. Scapular setting exercises from week 1, progression through kinetic chain loading as ROM and strength allow.

Pain during rehabilitation: Some discomfort during early ROM is expected and acceptable. Persistent sharp pain with elbow loading in the first 6 weeks may indicate tenodesis site stress — reduce load and reassess. Significant crepitus with elbow flexion in subpectoral tenodesis (uncommon) may indicate interference screw irritation of surrounding soft tissue — typically resolves with continued activity.

Assessment of Concomitant Pathology Treated

If tenodesis/tenotomy was combined with subacromial decompression: subacromial phase 2 strengthening protocol runs in parallel. If combined with rotator cuff repair: the cuff repair protocol takes priority and is the rate-limiting step for progression. If combined with subscapularis repair (for medial LHB instability): protect subscapularis repair (no active external rotation against resistance for 6 weeks), as per standard subscapularis post-op protocol.

Outcome Expectations — Patient Counselling Points

Pain relief: Anterior shoulder pain from LHB pathology is expected to resolve progressively over 3-6 months. Some residual achiness around the tenodesis site is common for 6-12 months and is not a sign of failure.

Strength: Elbow flexion and forearm supination strength are expected to return to near-symmetric with either procedure — pooled RCT data show no significant difference between tenotomy and tenodesis (Zhou 2021). Reassure patients that measurable strength loss is small and usually adapts.

Cosmesis: Tenodesis patients should be reassured that Popeye deformity (visible asymmetry) is much less likely than after tenotomy, with the subpectoral technique giving the most reliable contour, but that some asymmetry remains possible and patients should be counselled at each clinic visit, not just at initial consent.