Subpectoral Biceps Tenodesis

Indication. Symptomatic long head of biceps tendinopathy — anterior shoulder pain, a tender bicipital groove, and a positive Speed or Yergason test — with one of the following, that has failed non-operative care (3-6 months of activity modification, NSAIDs, and at least one corticosteroid injection into the groove): - Biceps instability or subluxation from the bicipital groove (medial subluxation over the lesser tuberosity on dynamic ultrasound or MRI)

• A partial-thickness tear of greater than 25-50 percent of tendon diameter with persistent pain
• A SLAP tear type II or IV in a patient older than 40 years, where repair is unlikely to succeed and tenodesis is preferred
• A failed proximal (suprapectoral or arthroscopic) tenodesis with residual groove pain The one decision that matters — tenodesis versus tenotomy. Both relieve pain equivalently; the choice turns on cosmesis, cramping, and patient demand:

Contraindications. Absolute: active infection in the shoulder or axilla; inability to comply with the postoperative sling and rehabilitation. Relative: severe glenohumeral osteoarthritis where arthroplasty is indicated (consider concomitant tenodesis at arthroplasty); poor bone quality precluding secure fixation (consider alternative fixation or tenotomy). Consent specifically for nerve injury (musculocutaneous, axillary, radial — less than 1 percent each), humeral fracture through the tunnel (about 1 percent), fixation failure (2-4 percent), residual groove pain (3-6 percent), infection (less than 1 percent), and cosmetic dissatisfaction from a length-tension mismatch. Setup. Beach-chair position with the arm in slight abduction and neutral rotation on a padded arm board; the shoulder is prepped and draped to allow free movement (a sterile tourniquet is not required). General anaesthesia with an interscalene block for postoperative analgesia, plus local infiltration with 0.25 percent bupivacaine with epinephrine along the incision for vasoconstriction.

The goal: through a short axillary-fold incision below the inferior border of pectoralis major, develop the plane between pectoralis major and the short head of biceps, protect the three nerves at risk, deliver and resect the entire diseased intra-groove tendon, debride the groove, and refix the tendon to the humerus at an anatomic length-tension with a 7-8 mm interference screw (or a cortical button or suture anchors). The exposure is laid out in the first three steps — it is the heart of the operation.

View larger

Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 — Protection | 0-4 weeks | Sling at all times except hygiene | Pendulum exercises from day 1; no active elbow flexion or supination against resistance | | 2 — Early motion | 4-8 weeks | Sling discontinued | Active-assisted elbow flexion and supination; gentle shoulder ROM; no lifting greater than 2 kg | | 3 — Strengthening | 8-12 weeks | None | Progressive resistance (theraband, 1-2 kg); return to light desk work | | 4 — Return to activity | 12-24 weeks | None | Gradual return to full activity; heavy labour or overhead sport at 4-6 months when strength reaches 80 percent of the other side | Rehabilitation pearls:

• Early active elbow flexion is the most common cause of fixation failure — protect it for 4 weeks.
• Length-tension mismatch pain typically presents at 6-12 weeks, when strengthening begins.
• Persistent groove pain at 3 months warrants a groove injection before considering revision. Complications

Critical danger structures

Tenodesis versus tenotomy. Multiple Level I and II studies show that tenodesis provides superior cosmesis and lower cramping rates with pain relief and function equivalent to tenotomy. A 2023 meta-analysis of 12 RCTs found no difference in Constant or ASES scores but a 40 percent absolute risk reduction in Popeye deformity with tenodesis. Subpectoral versus suprapectoral tenodesis. Subpectoral tenodesis removes the entire intra-groove diseased segment, whereas suprapectoral techniques leave 3-5 cm of tendon in the groove. A 2022 prospective cohort showed 25 percent of suprapectoral patients required revision for residual groove pain versus 4 percent after subpectoral tenodesis, and subpectoral revision resolved symptoms in 87 percent of cases. This consistent message — that the residual intra-groove tendon is the source of persistent anterior pain — is why subpectoral is the preferred technique and a perennial viva point. Fixation method. Interference screw fixation provides the highest load-to-failure in biomechanical studies (greater than 200 N). Cortical button and dual suture-anchor techniques are biomechanically acceptable (150-180 N) and carry a lower risk of tunnel fracture. Clinical outcomes are equivalent across methods when length-tension is restored, so the fixation choice is secondary to accurate tensioning and groove debridement.

Relevant surgical anatomy. The long head of biceps originates from the supraglenoid tubercle and superior labrum, courses intra-articularly, then enters the bicipital groove beneath the transverse humeral ligament. The intra-groove segment (3-5 cm) is the common site of tendinopathy, partial tearing and instability; it is extrasynovial and supplied by branches of the anterior humeral circumflex artery. The pectoralis major inserts on the lateral lip of the groove, and its inferior border is the surface landmark for both the incision and the length-tension reference. The deltoid inserts laterally and is not violated.