Clinical Faceoff: Tenotomy Versus Tenodesis for the Treatment of Proximal Biceps Pathology

The long head of the biceps tendon is commonly viewed as a potential pain generator in the shoulder. Although originally considered a vestigial structure in humans, research has shown that it may have an important role as a dynamic stabilizer of the glenohumeral joint [¹⁰]. The long head of the biceps tendon is readily visible when we begin a shoulder arthroscopy; for this reason, it is perhaps frustrating that we do not have a clear idea of what to do with it when patients seem to have symptoms there or when we see any signs of inflammation. Treatment approaches for proximal biceps tendon pathology are controversial, both in isolation and in the setting of rotator cuff tears. Although biceps tenotomy is a simple, inexpensive procedure with a faster recovery than biceps tenodesis, it may be associated with increased risk of visible deformity, cramping, and weakness.

To gain better insight into this treatment dilemma, I am joined by two international shoulder experts on proximal biceps pathology: Dr. Philippe Collin completed his shoulder fellowships in the United States and France, and he is currently the President of the European Shoulder and Elbow Society and is the Past President of the French Shoulder and Elbow Society. Dr. Patrick J. Denard is a shoulder specialist at Oregon Shoulder Institute in Medford, OR, USA. He completed his shoulder fellowships in the United States and France, and he is also the Director of the Oregon Shoulder Fellowship.

Mariano E. Menendez MD:Shoulder surgeons are often referred to as “biceps killers.” How do you diagnose proximal biceps pathology, and how often are you “killing” the biceps—that is, performing either a tenotomy or a tenodesis—in the setting of rotator cuff tears?

Patrick J. Denard MD: For isolated biceps tendonitis, I try to determine this preoperatively, and I rely on three factors: (1) pain to palpation at the bicipital groove, (2) pain on provocative maneuvers (the uppercut test, in which the patient performs an “uppercut” punch while the examiner resists the upward movement [¹]), and (3) good response to an ultrasound-guided injection of the bicipital groove.

In the setting of an associated rotator cuff tear, physical exam tests are less useful in my view, and so I rely upon arthroscopic appearance (like tearing and disruption of the medial or lateral slings). I also perform a tenodesis on the biceps in all patients with an associated subscapularis tear. As a result, I perform a tenodesis on the biceps in approximately 80% of patients in which I perform an arthroscopic rotator cuff repair. That said, if we critically look at the research, there is no robust evidence for the philosophy of being a “biceps killer.” Rather, I think most of this is based on weighing the potential surgical morbidity of tenodesis (low) versus the risk of revision for persistent biceps pain when the biceps is left untreated (undesirable).

Philippe Collin MD: I agree that preoperatively, in patients with an associated rotator cuff tear, it is impossible for me to clinically diagnose proximal biceps pathology. The bicipital groove is almost always painful, and all the physical exam tests are nonspecific. Similarly, MRI has limited sensitivity for detection of biceps pathology [⁹]. As such, my decision-making takes place intraoperatively. During surgery, I add an associated biceps procedure (tenotomy or tenodesis) in three situations: (1) in instances with macroscopic signs of degeneration (severe inflammation or delamination), (2) in instances with an associated lesion on the subscapularis (even small superior lesions that do not benefit from arthroscopic repair), and (3) in instances with supraspinatus tear extension to the biceps tendon, when viewed from a lateral portal.

Overall, I would say that I surgically address the biceps in 60% of patients with an associated rotator cuff tear.

Dr. Menendez:Biceps tenotomy is a simple, inexpensive procedure with a fast recovery, but it may be associated with visible deformity, cramping, and weakness. How should surgeons consider this tradeoff?

Dr. Collin: As you mentioned, biceps tenotomy is quicker and less expensive (by means of reduced surgical time and eliminating implant costs). But in theory, it’s associated with more complications like deformity, cramping, and weakness. We should start by comparing the potential complications associated with biceps tenodesis to determine whether it is more frequent compared with biceps tenotomy. Unfortunately, despite the fact that biceps tenotomy and tenodesis are frequently performed, there are no randomized trials comparing them. Personally, I usually perform biceps tenotomy. In my experience, in the setting of an associated arthroscopic rotator cuff repair, I observe a patient-rated Popeye deformity in about 1 in 10 patients, though it’s about twice that high when rated by clinicians. Likewise, by 1 year after surgery, about 10% of patients report cramping, and about that many also report discomfort in the bicipital groove or muscle belly.

Dr. Denard: As shown by Galdi et al. [³], patients in the United States have strong preferences for tenodesis over tenotomy. Of the 100 patients surveyed in their study, 64 chose to have biceps tenodesis [³]. In a Taiwanese population, Hong et al. [⁷] documented that even patients older than 55 years of age prefer a tenodesis. Like it or not, people across all age groups seem to care about their postoperative arm appearance a good deal. Therefore, I prefer to avoid the Popeye deformity conversation and just perform the tenodesis.

The additional cost and time are overestimated in my view. Most of the time, I perform an onlay biceps tenodesis high in the groove with a knotless anchor. I use this same anchor in many patients for simultaneous subscapularis repair or as the anteromedial anchor for supraspinatus repair. Regarding surgical time, with a high-in-the-groove intraarticular technique, it takes me no more than 5 additional minutes.

The low risk of Popeye deformity that Dr. Collin cites is not consistent with published research. Based on a systematic review by Slenker et al. [¹¹], a Popeye deformity occurred in 43% of patients after a tenotomy compared with only 8% after a tenodesis. Put another way, the proportion of patients experiencing a Popeye deformity was about fivefold higher after tenotomy.

I would caution surgeons to not focus on patient-reported outcomes alone as most of these systems do not have a method for accounting for biceps symptoms (cramping, fatigue, and strength). Several studies have reported that arm flexion strength and endurance decreases after biceps tenotomy [^{4, 8}].

I believe that the downsides of a tenodesis (a few minutes) are far outweighed by the potential gains (patient preferences, cosmetic appearance, and function).

Dr. Menendez:How has your treatment of proximal biceps pathology changed in the last decade?

Dr. Denard: Although I have always performed my tenodesis at the top of the bicipital groove, my fixation has changed from an inlay technique to an onlay technique. Initially, I was taught an interference screw technique. But I was dissatisfied by the large amount of bone violation with a 7- to 8-mm screw, and more importantly, by the frequency of postoperative Popeye deformity. It became apparent that the failure of tendon healing was occurring at the anchor-tendon interface with the screw tearing into the tendon. I saw this despite taking appropriate measures (whipstitching past the screw length and beveling the bone tunnel). I then converted to an onlay technique and observed a much lower frequency of postoperative Popeye deformity (9% versus 27%) [⁶]. Additional benefits of this technique include decreased surgical time and the ability to use a smaller anchor.

Dr. Collin: I was taught to perform a procedure on the biceps in every single rotator cuff tendon repair, regardless of whether the biceps was normal or pathologic. You could say that I was a true “biceps killer.” However, a research team of which I was a part of was surprised to find out that adjuvant biceps procedures in patients with supraspinatus tears and normal-appearing biceps do not seem to add any long-term clinical benefit (as measured, for example, by Constant scores at 10 years) [⁵].

From a technical point of view, I now almost always perform a biceps tenotomy. The risk of Popeye deformity is very low in my patient population. I only perform biceps tenodesis for manual heavy workers.

Dr. Menendez:What are some of the gaps in knowledge in the treatment of proximal biceps pathology, and how do you counsel your patients considering these gaps?

Dr. Collin: The treatment of proximal biceps pathology has followed an approach of “we learn by doing.” Tenotomy of the long head of the biceps was first described by Dr. Gilles Walch for an older patient with a painful massive rotator cuff tear, and his clinical data further showed that isolated arthroscopic biceps tenotomy in the setting of rotator cuff tears can yield improved Constant scores and a high degree of patient satisfaction [¹²]. As a result, biceps tenotomy became more widely used in France, and French surgeons became known as “biceps killers.” In 2017, my team and I published a multicenter study of rotator cuff repairs with a 10-year follow-up; we found that the biceps tendon could be conserved in some circumstances, which was a big surprise in the French orthopaedic community [²]. That being said, I think that today we know the involvement of the biceps as a source of pain in the setting of rotator cuff tears relatively well. However, for the other kinds of pathology of the biceps tendon, it is totally different. The kinds of pathology we observe in this anatomic location span a wide spectrum. Speaking broadly, I think we can differentiate them into three categories: inflammatory pathologies, dynamic pathologies (with or without subscapularis involvement), and rotator cuff tear–associated pathologies. I think that unfortunately for treatment guidance about many of these conditions, all we have is expert opinion.

Dr. Denard: I would agree that much of treatment is based on opinion, especially when associated with the rotator cuff. When there is a clear rotator cuff tear, I base my treatment primarily on intraoperative appearance and tear pattern. In these patients, rehabilitation is guided by the rotator cuff tear, so I don’t find it worthwhile in most instances to have an additional discussion about the biceps. The most common time the discussion comes up in the setting of a rotator cuff tear is when the patient presents with a Popeye deformity as well. If it is chronic (> 6 months), I advise the patient to leave it. If the tear is acute, I will offer them a subpectoral tenodesis if the patient is bothered by the appearance or by symptoms (such as cramping), because this will not change the rehabilitation process.