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Long head of biceps tendon – Tenotomy, tenodesis, or leave it alone?

Results of a well performed RCT published in 2016.

Surgical treatment of lesions of the long head of the biceps brachii tendon with rotator cuff tear: a prospective randomized clinical trial comparing the clinical results of tenotomy and tenodesis.

Lee HJ et al, J Shoulder Elbow Surg. 2016 Jul;25(7):1107-14


The long head of biceps tendon has long been a subject of controversy. Its function in the shoulder and its contribution to pain and disability, especially in association with chronic rotator cuff tears has long been debated.

Studies based on arthroscopic findings have shown that partial tears, fraying, an hourglass swelling of the LHB or a subluxating LHB tendon often cause significant pain in the shoulder. But studies focussing on histologic examination of the tendon have shown chronic degenerative process or tendinopathy even in tendons that are macroscopically normal-looking. Hence there is increasing recognition of the need to manage the LHB tendon concomitant with most arthroscopic procedures for rotator cuff pathology.

Again, there are two ways the LHB can be managed – tenotomy (just release the tendon at its insertion on the glenoid or tenodesis (reattach it to the proximal part of humerus/arm bone). The former is a less technically demanding procedure than the latter, but a high incidence of “popeye deformity” in the arm. Tenodesis maintains tendon function theoretically, but is a more extensive procedure and takes longer to rehab.

What does the study by Drs Lee Hj et al show?

At one year followup, both tenotomy and tenodesis gave very similar clinical and functional outcomes. Tenotomy patients did have a higher incidence of popeye deformity compared to tenodesis group.

(19.6% vs 5.6 %). It was also found that supination strength (which is a function of the biceps muscle and is important in certain trades and occupations) was significantly greater in the tenodesis group.

Have we reached a verdict yet?

Not really. The authors suggest more studies with a large number of patients and specifically study patient satisfaction in the short and long term to arrive at a definitive answer.

But it can be reasonably concluded that tenodesis is the way to go in patients whose occupations involve repetitive lifting of weights, supination movements and those who are not willing to accept a popeye deformity. Tenotomy may be a good procedure with equal clinical results as a tenodesis in many patients in whom the above criteria do not apply.