Biceps Tenodesis for Biceps Tendonitis and Rotator Cuff Tear
A 55-year-old male patient presents with increasing right shoulder pain and mild weakness when performing overhead activities and lifting heavy objects. When pathology of the long head of the biceps is diagnosed, the authors propose subpectoral biceps tenodesis, the surgical technique for which is outlined in this article.
Patrick Kane, MD, and Kevin B. Freedman, MD
The authors have no disclosures relevant to this article.
Although the function of the long head of the biceps (LHB) tendon has been debated, it is known to be a potential pain generator in the shoulder. Patients with LHB tendon disorders frequently report anterior shoulder pain in the area of the bicipital groove. Biceps tendon disorders are often found in conjunction with other shoulder pathology such as glenohumeral arthritis and rotator cuff tears. [1,2]
Several physical examination maneuvers, including Speed’s, Yergason’s, and Obrien’s tests, have been developed to isolate LHB tendon pathology; however, Level I and Level II studies have questioned their accuracy. [3,4] The diagnosis of LHB disorders is usually made with advanced imaging or visualization during shoulder arthroscopy. Failure to address biceps pathology during treatment of other shoulder pathology can be a source of persistent pain following surgery.
LHB pathology is typically treated with 2 surgical options:
- Tenotomy (release)
- Tenodesis (reattachment)
Some systematic reviews have shown no difference between the techniques. However, other studies have shown increased biceps cramping, pain, cosmetic deformity, and patient dissatisfaction with tenotomy. [5-7]
Tenodesis of the biceps tendon can be accomplished at several sites, including: [8-11]
- Lesser tuberosity
- Bicipital groove
- Pectoralis major tendon
- Short head of the biceps
- Subpectoral bone tunnels
The optimal tenodesis location is still debated, with no current Level I or Level II studies comparing tenodesis above, within, or below the bicipital groove. However, tenodesis of the biceps tendon in a subpectoral location does offer several advantages:
- By placing the musculotendinous junction of the biceps at the inferior border of the pectoralis major tendon, the anatomic length tension relationship of the biceps muscle can be adequately restored.
- The subpectoral tenodesis location completely removes the biceps tendon from the bicipital groove, eliminating potential pain from inflammation of residual tendon in this area.
A variety of fixation methods for biceps tenodesis have been developed including:
- Interference screw
- Suture fixation
- Bone tunnels
- Soft tissue tenodesis
Multiple biomechanical studies have shown most techniques provide adequate and comparable fixation. [12-15]
The indications for biceps tenodesis are also expanding, with many Type II superior labral anterior posterior (SLAP) tears now being treated with this method primarily. [16-18]
The following case example illustrates a typical presentation of a patient with biceps tendonitis and concomitant rotator cuff tear. The surgical technique of subpectoral biceps tenodesis for the treatment of this disorder will be outlined.
Patient Presentation and History
A 55-year-old, right hand-dominant male who works as a laborer presents with a history of pain in his right shoulder that has been increasing over the past 6 months. He denies any trauma, injury, or fall onto the right shoulder. He has had episodes of night pain, which have interrupted his sleep.
The patient’s pain is primarily located in the anterior and lateral aspect of the right shoulder. It does not radiate down the arm, and he denies any numbness or tingling. He reports mild weakness with overhead activities and lifting heavy objects.
He has tried anti-inflammatory medications, physical therapy, and corticosteroid injections into the right shoulder, which have provided minimal, temporary relief.
- Inspection of both shoulders reveals no atrophy or asymmetry.
- Range of motion both supine and upright is symmetric and full.
- Palpation of the right shoulder reveals mild pain in the anterior shoulder and the bicipital groove and over the greater tuberosity by the supraspinatus insertion.
- Strength testing of the rotator cuff musculature is 4/5 with abduction of the arm in the plane of the scapula and 5/5 in both internal and external rotation.
- Provocative testing demonstrates:
- Positive Neer impingement
- Positive Jobe’s/drop arm test
- Positive Speed’s test
- Positive Yergason’s test
- Negative lift off and belly press test
- Plain radiographs including AP, axillary, and scapular Y views were reviewed and found to be normal.
- MRI demonstrated a medium-size, full-thickness, 2-cm supraspinatus tear with mild retraction without muscular atrophy.
- Inflammation of the long head of the biceps tendon with mild fluid surrounding the tendon within the bicipital groove was also seen on MRI.
- Rotator cuff tear
- Biceps tendonitis
- SLAP tear
- 55-year-old male with full-thickness supraspinatus tear and biceps tendonitis
The patient underwent right shoulder arthroscopy with rotator cuff repair followed by open subpectoral biceps tenodesis.
- Diagnostic shoulder arthroscopy revealed significant biceps tendon disease with tearing of the tendon and an intact labrum attachment (Figure 1).
- The LHB tendon was released from the superior labrum with the use of arthroscopic instruments and a shaver.
- Arthroscopic rotator cuff repair was performed in a standard fashion.
- Following rotator cuff repair, the arthroscope was removed and a 2- to 3-cm skin incision was made within the axillary fold, centered over the pectoralis major tendon (Figure 2).
- The border of the pectoralis major was found superiorly and the short head of the biceps was seen inferomedially (Figure 3).
- The fascia overlying these muscles was divided and blunt dissection was used to aid in retracting these tendons.
- Once these tendons were retracted, the LHB tendon could be clearly seen within the bicipital groove below. This tendon was then delivered from the bicipital groove and a locking Krakow stitch was placed at the musculotendinous junction with a #2 Orthocord suture (Mitek; Ryman, Massachusetts) (Figure 4).
- After this stitch was completed, excess biceps tendon was excised approximately 1 to 2 cm from the musculotendinous junction.
- The bicipital groove was then exposed with electrocautery and a 2.4-mm guide pin was placed just superior to the inferior margin of the pectoralis tendon.
- A 7.5-mm acorn reamer was placed over top of the guide pin and was used to make a unicortical central drill hole.
- The 2.4-mm drill pin was again used to make 2 accessory holes distal to the previously placed central hole.
- When completed, an equilateral triangle was made among the 3 drill holes with approximately 1 cm separating each hole.
- A short, straight blade from the Spectrum suture passer (CONMED/Linvatec; Largo, Florida) was then used to place a passing O-PDS suture from the accessory drill holes to the central hole. A crochet hook from the rotator cuff repair tray was used to retrieve the PDS sutures from the central drill hole.
- A simple loop was then made in each PDS suture to shuttle the #2 Orthocord through the central hole and out the accessory holes on each side of the bicipital groove (Figure 5).
- The sutures were tensioned and the biceps tendon was pulled into the central hole within the bicipital groove. The 2 suture limbs were tied on the lateral side of the tendon to prevent tendon strangulation.
- The musculotendinous junction of the LHB could be seen directly beneath the inferior border of the pectoralis tendon, providing anatomic fixation (Figure 6).
- The fascia was left open, the wound was irrigated, the subcutaneous tissue was closed with a 2-0 vicryl, and the skin was closed with a running monocryl suture.
Figure 1. Arthroscopic image of the right shoulder in beach chair position showing significant tearing of the long head of the biceps tendon.
Figure 2. Skin incision in the axillary fold centered over the pectoralis major tendon.
Figure 3. After superficial, blunt dissection, the pectoralis major tendon can be seen superiorly and the short head of the biceps tendon can be seen inferomedially.
Figure 4. Long head of the biceps tendon brought out of bicipital groove with a Krakow stitch placed at the musculotendinous junction. Excess tendon is excised approximately 1-2 cm from the musculotendinous junction.
Figure 5. Central hole and accessory holes with shuttling PDS suture.
Figure 6. Final tenodesis of biceps tendon with musculotendinous junction at inferior margin of pectoralis major tendon, restoring anatomic length-tension relationship.
- Postoperatively, the patient was placed into a standard sling.
- Patients have no restriction in elbow motion following surgery. Elbow flexion was limited to 5 pounds for the first 6 weeks, and then advanced as tolerated.
- For concomitant rotator cuff repair, immediate passive range of motion of the shoulder was allowed, with active shoulder strengthening beginning at 6 weeks postoperatively.
- The patient presented for 1-year follow-up with no residual shoulder pain, full range of motion, and no evidence of “popeye deformity.”
- Examination revealed full symmetry of the biceps contour and equal strength.
Open subpectoral biceps tenodesis represents a valuable surgical treatment option for managing all biceps tendon pathology. Subpectoral tenodesis completely removes the biceps tendon from the bicipital groove, eliminating pain from residual stenosis or tenosynovitis from remaining, diseased synovium. 
Multiple studies report a low incidence of failure, reliable symptom relief, and maintenance of anatomic length-tension relationship with subpectoral tenodesis. [20,21]
One study showed higher revision rates for tenodesis within the bicipital groove compared with a subpectoral location (12% vs. 2.7%). 
Additionally, success rates following arthroscopic repair of Type II SLAP lesions vary greatly (22% to 75%). [16-18] One study showed higher satisfaction rates and return to play for tenodesis compared with repair of Type II SLAP lesions. 
Finally, when compared to other tenodesis methods, suture tenodesis using the technique described utilizes readily available instrumentation and is associated with minimal additional implant costs.
In conclusion, open subpectoral biceps tenodesis provides a reliable, reproducible, and cost-effective treatment option for all LHB tendon disorders.
Patrick Kane, MD, is a PGY-3 orthopaedic surgery resident with an interest in sports medicine at Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania. Kevin B. Freedman, MD, is a sports medicine surgeon with The Rothman Institute, Philadelphia, Pennsylvania. He is Director of the Bryn Mawr Hospital Cartilage Restoration Program, Bryn Mawr, Pennsylvania.
- Beall DP, Williamson EE, Ly JQ, et al. Association of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior portions of the rotator cuff. AJR Am J Roentgenol. Mar 2003; 180(3):633-639.
- Murthi AM, Vosburgh CL, Neviaser TJ. The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg. Sep-Oct 2000; 9(5):382-385.
- Holtby R, Razmjou H. Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. Mar 2004; 20(3):231-236.
- Kibler BW, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. Sep 2009; 37(9):1840-1847.
- Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Bach BR. Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results. J Shoulder Elbow Surg. Mar 2011; 20(2):326-332.
- Frost A, Zafar MS, Maffulli N. Tenotomy versus tenodesis in the management of pathologic lesions of the tendon of the long head of the biceps brachii. Am J Sports Med. Apr 2009; 37(4):828-833.
- Koh KH, Ahn JH, Kim SM, Yoo JC. Treatment of biceps tendon lesions in the setting of rotator cuff tears: prospective cohort study of tenotomy versus tenodesis. Am J Sports Med. Aug 2010;38(8):1584-1590.
- Gumina S, Carbone S, Perugia D, Perugia L, Postacchini F. Rupture of the long head biceps tendon treated with tenodesis to the coracoid process. Results at more than 30 years. Int Orthop. May 2011; 35(5):713-716.
- Hitchcock HH, Bechtol CO. Painful shoulder; observations on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg Am. Apr 1948; 30A(2):263-273.
- Becker DA, Cofield RH. Tenodesis of the long head of the biceps brachii for chronic bicipital tendinitis. Long-term results. J Bone Joint Surg Am. Mar 1989; 71(3):376-381.
- Mariani EM, Cofield RH, Askew LJ, Li GP, Chao EY. Rupture of the tendon of the long head of the biceps brachii. Surgical versus nonsurgical treatment. Clin Orthop Relat Res. Mar 1988; 228:233-239.
- Klepps S, Hazrati Y, Flatow E. Arthroscopic biceps tenodesis. Arthroscopy. 2002; 18:1040-1045.
- Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy. Nov 2005; 21(11):1296-1306.
- Kilicoglu O, Koyuncu O, Demirhan M, et al. Time-dependent changes in failure loads of 3 biceps tenodesis techniques: in vivo study in a sheep model. Am J Sports Med. Oct 2005; 33(10):1536-1544.
- Ozalay M, Akpinar S, Karaeminogullari O, et al. Mechanical strength of four different biceps tenodesis techniques. Arthroscopy. Aug 2005; 21(8):992-998.
- Ide J, Maeda S, Takagi K. Sports activity after arthroscopic superior labral repair using suture anchors in overhead-throwing athletes. Am J Sports Med. Apr 2005; 33(4):507-514.
- Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. J Bone Joint Surg Am. Jan 2003; 85-A(1):66-71.
- Nam EK, Snyder SJ. The diagnosis and treatment of superior labrum, anterior and posterior (SLAP) lesions. Am J Sports Med. Sep-Oct 2003; 31(5):798-810.
- Lutton DM, Gruson KI, Harrison AK, Gladstone JN, Flatow EL. Where to tenodese the biceps: proximal or distal? Clin Orthop Relat Res. Apr 2011; 469(4):1050-1055.
- Mazzocca AD, Cote MP, Arciero CL, Romeo AA, Arciero RA. Clinical outcomes after subpectoral biceps tenodesis with an interference screw. Am J Sports Med. Oct 2008; 36(10):1922-1929.
- Millett PJ, Sanders B, Gobezie R, Braun S, Warner JJ. Interference screw vs. suture anchor fixation for open subpectoral biceps tenodesis: does it matter? BMC Musculoskelet Disord. 2008; 9:121.
- Sanders BS, Warner JJP, Pennington S, et al. Biceps tendon tenodesis: success with proximal versus distal fixation. AAOS Annu Meeting. 2007.
- Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R. Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med. May 2009; 37(5):929-936.