Onlay Versus Inlay Biceps Tenodesis for Long Head of Biceps Tendinopathy: A Systematic Review and Meta-analysis : JAAOS Global Research & Reviews

Journal Logo

Research Article

Onlay Versus Inlay Biceps Tenodesis for Long Head of Biceps Tendinopathy: A Systematic Review and Meta-analysis

Jackson, Garrett R. MD; Meade, Joshua BS; Coombes, Kyle BS; Young, Bradley L. MD; Hamid, Nady MD; Piasecki, Dana P. MD; Fleischli, James E. MD; Trofa, David P. MD; Saltzman, Bryan M. MD

Author Information
JAAOS: Global Research and Reviews 6(12):e22.00255, December 2022. | DOI: 10.5435/JAAOSGlobal-D-22-00255
  • Open


Tendinosis of the long head of the biceps tendon (LHBT) arises from various causes related to instability or trauma and is a common cause of anterior shoulder pain.1 Biceps tenodesis and tenotomy have been widely accepted as the treatments of biceps tendinopathy that is recalcitrant to nonsurgical management.15 When compared with biceps tenotomy, tenodesis of the LHB has gained popularity because of its ability to preserve function of the LHBT; maintain its length-tension relationship; and reduce cramping, pain, loss of strength, and cosmetic defects.1,4,612

Several tenodesis techniques have been developed to treat patients with LHBT pathologies. These techniques can be divided into onlay, inlay, and soft-tissue fixation.2,1316 Soft-tissue fixation has markedly decreased clinical and structural outcomes compared with the onlay and inlay bony fixation techniques.15 The inlay technique is an intraosseous tenodesis that secures the LHBT within a subcortical bone socket by using interference screws or bicortical suspensory devices while the onlay technique secures the tendon to the cortical surface by suture anchors or unicortical suspensory devices. Many studies have reported the inlay technique to have increased biomechanical strength when compared with the onlay technique; however, it is associated with increased risk of torsional fracture of the proximal humerus secondary to the stress created from the drill hole used to create the bone socket.2,1722 The onlay technique results in decreased revision rates compared with the inlay technique.23 Current literature does not offer consensus regarding whether onlay or inlay tenodesis is the preferred surgical technique for a proximal biceps tenodesis.

The purpose of this meta-analysis was to compare the clinical outcomes between onlay versus inlay humeral fixation for biceps tenodesis for LHBT pathology. The authors hypothesized that both onlay and inlay biceps tenodeses for long head of biceps tendinopathy demonstrate no notable difference in clinical outcomes and “Popeye” deformities.


Search Strategy and Data Extraction

The literature search and data extraction were conducted using the guidelines of the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis. In January 2021, a comprehensive database search was conducted using PubMed, EMBASE, and Cochrane Library. The reference lists of the original studies were searched for additional studies. The search criteria included the keywords “biceps” and “tenodesis.”

The initial search yielded 2470 articles. Articles in languages other than English, biomechanical studies, letters to editors, non–full-text articles, case reports, meta-analyses, and review articles were excluded. Of the 2470 articles, 808 were duplicates. The title and abstract screening included 1662 articles, of which 1513 were excluded. Only 149 full-text articles were evaluated for eligibility (Figure 1). After the full-text screening, six studies met our criteria comparing inlay with onlay biceps tenodesis. The data were extracted from the results of the included studies and was entered into a Microsoft Excel version 16.63 (Redmond) spreadsheet for additional analysis. The selected articles were not blinded for the author, affiliation, or source.

Figure 1:
Chart showing Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram.

Two independent authors (G.R.J. and J.M.) reviewed the abstracts, followed by a full-text review for the identified articles. To avoid duplicate patient cohorts, multiple studies that included the same authorship were flagged and only the most recent article was included for our data extraction.

Outcomes Measures

The following outcomes measures were analyzed: American Shoulder and Elbow Surgeons shoulder score (ASES), visual analog pain scale (VAS), Constant score (CS), the presence of a Popeye deformity, and postoperative cramping. Only five of the included studies reported on the presence of a Popeye deformity while only two studies reported on postoperative cramping.

Methodological Quality Assessment

Methodological quality assessment of the selected articles was conducted using the Coleman score, which evaluates the quality of randomized and nonrandomized orthopaedic studies. This score includes a list of 10 criteria, with a final score ranging from 0 to 100. Higher scores indicate the absence of biases, whereas lower scores equate to increased biases. The scores are categorized into excellent (85 to 100), good (70 to 84), fair (50 to 69), and poor (<50). Each selected study was given a calculated score by reviewers.

Data Analysis

The meta-analysis software Review Manager 5.4.1 (Cochrane Collaboration) was used for the data analysis. Each outcome measure was depicted in a forest plot. The forest plots indicated the standardized mean differences, individual study weights, and 95% confidence intervals for each article. The event outcomes for postoperative Popeye deformities and failure rates were individually depicted in forest plots indicating the odds ratios (ORs), individual study weights, and 95% confidence intervals. Failure was defined by visualizing the failure of the tendon fibers to trace longitudinally within the intertubercular groove at the insertion site as seen on MRI or ultrasonography. To measure the heterogeneity of the included studies, a chi square index was used. Owing to the presence of a high level of heterogeneity, a random-effects meta-analysis was used because of its ability to weigh studies more equally. To analyze publication bias of the included studies, a funnel plot was used. A P value of < 0.05 indicated statistical significance.


Six studies with a total of 418 patients met our search criteria. Of the 418 patients, 252 received an onlay biceps tenodesis using suture anchors and 166 received an inlay biceps tenodesis using an interference screw, with a mean patient age of 56.84 years (219 males, 187 females). Eighty-nine patients received an open tenodesis (89 inlay, zero onlay); 329 patients received an arthroscopic tenodesis (77 inlay, 252 onlay). A suprapectoral technique was used in 180 patients (70 inlay, 143 onlay) while a subpectoral technique was used in 143 patients (89 inlay, 54 onlay). Patients included in this analysis were treated with concomitant procedures such as rotator cuff repairs and débridement, labral repairs and débridement, subacromial decompressions, and distal clavicle excisions. The minimum length of follow-up was 6 months for one study, 12 months for five studies, and 24 months for the study by Park et al.14Table 1 summarizes the characteristics of each study. Of the six included articles, three are of Level II evidence (one prospective, two randomized control trials) and three are of Level III evidence and retrospective.2,13,14,16,24,25 The Coleman score ranged between 53 and 74, indicating a fair quality of evidence.

Table 1 - Study Characteristics
Author LoE, Study CS No. of Patients Mean age (range), yr Sex(M/F), (n) Mean Follow-up (range), mo Tenodesis Fixation Open/Arthroscopic (n) Suprapectoral/Subpectoral, n Outcomes Complications (n)
Haidamous et al. 2 III, retrospective cohort 55 Onlay: 53
Inlay: 37
Total: 90
Onlay: 63.1 (44-85)
Inlay: 60.2 (43-76)
Onlay: 34/19 Inlay: 21/16 Onlay: 14.1 (12-25)
Inlay: 18.2 (12-27)
Onlay: Suture anchor
Inlay: Interference screw
Onlay: 0/53
Inlay: 0/37
Onlay: 53/0
Inlay: 37/0
Forward flexion, external rotation, internal rotation, VAS, ASES, SSV, return to activity, and satisfaction Onlay: Popeye deformity (5), cramping (2), and revision surgery (0)
Inlay: Popeye deformity (10), cramping (4), and revision surgery (4)
Millet et al. 25 III, retrospective cohort 53 Onlay: 54
Inlay: 34
Total: 88
Onlay: 51 (22-77)
Inlay: 51 (22-77)
Onlay: N/A
Inlay: N/A
Total: 57/31
Onlay: 13
Inlay: 13
Onlay: Suture anchor
Inlay: Interference screw
Onlay: 0/54
Inlay: 34/0
Onlay: 0/54
Inlay: 0/34
VAS, ASES, and CS Onlay: Postoperative groove
Inlay: Postoperative groove tenderness (1)
Yi et al. 16 III, retrospective cohort 59 Onlay: 36
Inlay: 35
Total: 71
Onlay: 54.32±1–0.73
Inlay: 53.46 ± 8.45
Onlay: 16/20
Inlay: 17/18
Onlay: 21.45 ± 1.24
Inlay: 21.03 ± 2.42
Onlay: Suture anchor
Inlay: Interference screw
Onlay: 0/36
Inlay: 35/0
Onlay: 36/0
Inlay: 0/35
UCLA, CS, ASES, VAS, forward flexion, external rotation, abduction, and internal rotation Onlay: Synovitis (3)
Inlay: None reported
Franceschetti et al. 13 II, randomized control trial 67 Onlay: 20
Inlay: 20
Total: 40
Onlay: 57.9 ± 3.2 (56-63)
Inlay: 58.5 ± 3.5 (55-64)
Onlay: 13/7
Inlay: 12/8
Onlay: 12
Inlay: 12
Onlay: Suture anchor
Inlay: Interference screw
Onlay: 0/20
Inlay: 20/0
Onlay: 20/0
Inlay: 0/20
VAS, CS, SST, and LHB score Onlay: Popeye deformity (1)
Inlay: None reported
Samargandi et al. 24 II, prospective comparative 70 Onlay: 55
Inlay: 7
Total: 62
Onlay: 55.6
Inlay: 52.2
Onlay: 26/29
Inlay: 7/0
Onlay: 7.3 (median)
Inlay: 7.3 (median)
Onlay: Suture anchor
Inlay: Interference screw
Onlay: 0/55
Inlay: 0/7
Onlay: Not given
Inlay: Not given
VAS, SSV, and CS Onlay: Popeye deformity (11) and cramping (2)
Inlay: Popeye deformity (5)
Park et al. 14 II, randomized control trial 74 Onlay: 34
Inlay: 33
Total: 67
Onlay: 62.4 ± 8.2
Inlay: 61.2 ± 7.2
Onlay: 15/19
Inlay: 13/20
Onlay: 26.6 ± 5.3
Inlay: 28.8 ± 7.3
Onlay: Suture anchor
Inlay: Interference screw
Onlay: 0/34
Inlay: 0/33
Onlay: 34/0
Inlay: 33/0
VAS, ASES, SST, CS, KSS, LHB score, and forward flexion. External rotation and internal rotation Onlay: Failure (2)
Inlay: Failure (7)
ASES = American Shoulder and Elbow Surgeons shoulder score, CS = Constant score, SSV = Subjective Shoulder Score, SST = Simple Shoulder Test, KSS = Knee Society Score, LHB = Long Head of the Biceps, UCLA = University of California at Los Angeles, VAS = visual analog pain scale

American Shoulder and Elbow Surgeons Shoulder Score

The American Shoulder and Elbow Surgeons shoulder score was reported in three studies (Figure 2).1,2,16,25 Onlay biceps tenodesis (143 patients) showed improved discrete postoperative results (84.31 ± 7.65) versus inlay biceps tenodesis (106 patients; 82.77 ± 7.65), which was not statistically significant (mean difference, 1.53; P = 0.21).

Figure 2:
Illustration depicting the forest plot for American Shoulder and Elbow Surgeons shoulder score (ASES).

Visual Analog Pain Scale

In five studies that reported VAS (Figure 3), onlay biceps tenodesis (218 patients) showed increased discrete postoperative results (2.33 ± 1.14) versus inlay biceps tenodesis (133 patients; 2.29 ± 0.56), which was not statistically significant (mean difference, 0.04; P = 0.83).2,13,16,24,25

Figure 3:
Illustration depicting the forest plot for visual analog pain scale (VAS).

Constant Score

CS was reported in four studies (Figure 4).13,14,16,25 Inlay biceps tenodesis (122 patients) showed increased postoperative results (79.74 ± 6.39) versus onlay biceps tenodesis (144 patients; 78.95 ± 6.38), which was not statistically significant (mean difference, −0.78; P = 0.64).

Figure 4:
Illustration depicting the forest plot for Constant score (CS).

Popeye Deformity

In the five studies that reported Popeye deformity (Figure 5), inlay biceps tenodesis showed increased postoperative Popeye deformities (15 of 133 patients; 11.28%) versus onlay biceps tenodesis (17 of 218 patients; 7.80%), which was found not to be statistically significant (OR, 0.28; P = 0.07).2,13,16,24,25

Figure 5:
Illustration depicting the forest plot for Popeye deformity.

Postoperative Cramping

In the two studies that reported postoperative cramping (Figure 6), inlay biceps tenodesis showed an increased incidence of cramping (4 of 44 patients; 9.1%) versus onlay biceps tenodesis (4 of 108 patients; 3.7%), which was not statistically significant (OR, 0.39; P = 0.23).2,24

Figure 6:
Illustration depicting the forest plot for postoperative cramping.

Failed Repairs

Three studies reported failure of fixation (Figure 7).14,16,25 The inlay tenodesis reported an increased failure of fixation at 6.86% (7 of 102 patients) versus the 1.61% (2 of 124 patients) seen with the onlay tenodesis, which was not statistically significant (OR, 0.23; P = 0.08). Failure of fixation was determined by MRI or ultrasonography visualizing failure of the tendon fibers to trace longitudinally within the intertubercular groove at the insertion site.14

Figure 7:
Illustration depicting the forest plot for failure of fixation.


This meta-analysis aimed to compare outcomes and complications between onlay and inlay biceps tenodeses, but found no statistically significant difference in ASES, VAS, CS, Popeye deformities, or failure rates between the two techniques. These findings were consistent with the initial hypothesis proposed by the authors.

Regardless of whether the biceps tenodesis was done using an onlay or inlay technique, both methods report improved outcomes, with few complications.2,13,14,25,26 Although this analysis showed no statistical difference in Popeye deformities between the two techniques, a recent study of 37 patients reported an increased number of deformities with the inlay technique (27%) when compared with the onlay technique (9.4%).2 These findings were greater than the findings within this analysis in which 11.28% of inlay patients and 7.80% of onlay patients reported Popeye deformities, which were not statistically significant. The increased incidence of Popeye deformities seen in the inlay group is thought to be secondary to interference screws cutting into the tendon during insertion into the bone socket.2,14,27

An additional reported disadvantage of using the inlay technique is the need to create the bone socket. The increased size of the socket has been associated with a greater risk of torsional fracture of the proximal humerus.9,22,27 Creating this socket has also been found to increase the risk of causing musculocutaneous neuropathy and increased risk of infections with subpectoral fixation; 2830 however, these complications were not reported in the included studies of this meta-analysis.

Historically, biomechanical studies have shown an increase in load to failure with inlay biceps tenodesis when compared with onlay tenodesis.21,25,31,32 One such study conducted by Richards et al.,21 using cadaver models, found a stronger load to failure using the biotenodesis screw (233N) when compared with suture anchors (135N). Despite this increased load to failure, a study of 65 patients conducted by Park et al.14 found that the inlay tenodesis was associated with decreased healing when compared with the onlay tenodesis. However, the authors reported that healing had no effect on the outcomes scores but did increase the rate of Popeye deformities. Conversely, Mazzocca et al.31 found no difference in cyclic displacement and load to failure in 20 cadaveric shoulders when comparing onlay (suture anchor) and inlay (biotenodesis screw) techniques using a suprapectoral approach.

Studies have reported a higher incidence of anterior shoulder pain associated with the suprapectoral tenodesis approach.31 This increased shoulder pain has been described to be a result of the biceps tendon placement within the intertubercular groove, which is lined with synovium, and a cause of tenosynovitis. The subpectoral tenodesis approach anchors avoid the intertubercular groove and its associated synovitis. Despite these findings, a recent systematic review of 409 patients comparing suprapectoral versus subpectoral biceps tenodesis showed no notable difference in VAS for anterior shoulder pain, CS, or Popeye deformities.33 Thus, it remains unclear whether the results of this analysis were solely because of onlay versus inlay tenodesis or the location of fixation influenced these findings.

Several limitations have been identified in this analysis. Patients included in this analysis were treated with additional procedures such as rotator cuff repairs and débridement, labral repairs and débridement, subacromial decompressions, and distal clavicle excisions, which are known to influence postoperative outcomes. Multiple studies have shown worsened proximal biceps tendon pathology with larger rotator cuff tears.2,33,34 In addition, multiple factors have been established to further influence the outcomes and complications that were not well-controlled in these articles. Such factors include postoperative rehabilitation, length of follow-up, prior interventions, and the anatomic location of fixation—suprapectoral versus subpectoral fixation.


This meta-analysis provides evidence that both onlay and inlay biceps tenodeses for long head of biceps tendinopathy result in improved clinical outcomes and are at low risk of Popeye deformities, with no statistically significant differences between either method. Additional studies are required to assess the clinical significance of these differences.


1. Ahmad CS, ElAttrache NS: Arthroscopic biceps tenodesis. Orthop Clin North Am 2003;34:499-506.
2. Haidamous G, Noyes MP, Denard PJ: Arthroscopic biceps tenodesis outcomes: A comparison of inlay and onlay techniques. Am J Sports Med 2020;48:3051-3056.
3. Lacheta L, Imhoff AB, Siebenlist S, Scheiderer B: Subpectoral biceps tenodesis: All-suture anchor onlay technique. Arthrosc Tech 2020;9:e651-e655.
4. Patel KV, Bravman J, Vidal A, Chrisman A, McCarty E: Biceps tenotomy versus tenodesis. Clin Sports Med 2016;35:93-111.
5. Saltzman BM, Leroux TS, Cotter EJ, et al.: Trends in open and arthroscopic long head of biceps tenodesis. HSS J 2020;16:2-8.
6. Friedman JL, FitzPatrick JL, Rylander LS, Bennett C, Vidal AF, McCarty EC: Biceps tenotomy versus tenodesis in active patients younger than 55 years: Is there a difference in strength and outcomes? Orthop J Sports Med 2015;3:2325967115570848.
7. 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 2009;37:828-833.
8. Kelly AM, Drakos MC, Fealy S, Taylor SA, O'Brien SJ: Arthroscopic release of the long head of the biceps tendon: Functional outcome and clinical results. Am J Sports Med 2005;33:208-213.
9. Khalid MA, Morris RP, Black N, Maassen NH: Biomechanical evaluation of humerus fracture after subpectoral biceps tenodesis with interference screw versus unicortical button. Arthroscopy 2020;36:1253-1260.
10. 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 2010;38:1584-1590.
11. 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 1988;228:233-239.
12. Shang X, Chen J, Chen S: A meta-analysis comparing tenotomy and tenodesis for treating rotator cuff tears combined with long head of the biceps tendon lesions. PLoS One 2017;12:e0185788.
13. Franceschetti E, Giovannetti de Sanctis E, Palumbo A, et al.: The management of the long head of the biceps in rotator cuff repair: A comparative study of high vs. subpectoral tenodesis. J Sport Health Sci 2020.
14. Park JS, Kim SH, Jung HJ, Lee YH, Oh JH: A prospective randomized study comparing the interference screw and suture anchor techniques for biceps tenodesis. Am J Sports Med 2017;45:440-448.
15. Scheibel M, Schröder RJ, Chen J, Bartsch M: Arthroscopic soft tissue tenodesis versus bony fixation anchor tenodesis of the long head of the biceps tendon. Am J Sports Med 2011;39:1046-1052.
16. Yi G, Yang J, Zhang L, Liu Y, Guo X, Fu S: Small-incision open distal subpectoral vs. arthroscopic proximal biceps tenodesis for biceps long head tendon lesions with repair of rotator cuff tears. Exp Ther Med 2020;19:861-870.
17. Beason DP, Shah JP, Duckett JW, Jost PW, Fleisig G, Cain EL: Torsional fracture of the humerus after subpectoral biceps tenodesis with an interference screw: A biomechanical cadaveric study. Clin Biomech (Bristol, Avon) 2015;30:915-920.
18. Patzer T, Rundic JM, Bobrowitsch E, Olender GD, Hurschler C, Schofer MD: Biomechanical comparison of arthroscopically performable techniques for suprapectoral biceps tenodesis. Arthroscopy 2011;27:1036-1047.
19. Patzer T, Santo G, Olender GD, Wellmann M, Hurschler C, Schofer MD: Suprapectoral or subpectoral position for biceps tenodesis: Biomechanical comparison of four different techniques in both positions. J Shoulder Elbow Surg 2012;21:116-125.
20. Poberaj B, Marjanovič B, Zupančič M, et al.: Biomechanical comparison of the three techniques for arthroscopic suprapectoral biceps tenodesis: Implant-free intraosseous tendon fixation with cobra guide, interference screw and suture anchor. Musculoskelet Surg 2020;104:49-57.
21. Richards DP, Burkhart SS: A biomechanical analysis of two biceps tenodesis fixation techniques. Arthroscopy 2005;21:861-866.
22. Sears BW, Spencer EE, Getz CL: Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients. J Shoulder Elbow Surg 2011;20:e7-e11.
23. Cook JB, Sedory DM, Freidl MC, Adams DR: Low incidence of failure after proximal biceps tenodesis with unicortical suture button. J Orthop 2017;14:384-389.
24. Samargandi R, Abduh W, Favard L, Du CL, Collin P, Berhouet J: “Tomydesis” might be a reliable technique for lesions of the long head of the biceps tendon associated with rotator cuff tears: A minimum 6-month prospective clinical follow-up study. Eur J Orthop Surg Traumatol 2020;30:83-87.
25. Millett PJ, Sanders B, Gobezie R, Braun S, Warner JP: Interference screw vs. suture anchor fixation for open subpectoral biceps tenodesis: Does it matter?. BMC Musculoskelet Disord 2008;9:121.
26. Green JM, Getelman MH, Snyder SJ, Burns JP: All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii without the use of interference screws. Arthroscopy 2017;33:19-25.
27. Slabaugh MA, Frank RM, Van Thiel GS, et al.: Biceps tenodesis with interference screw fixation: A biomechanical comparison of screw length and diameter. Arthroscopy 2011;27:161-166.
28. Ma H, Van Heest A, Glisson C, Patel S: Musculocutaneous nerve entrapment: An unusual complication after biceps tenodesis. Am J Sports Med 2009;37:2467-2469.
29. Rhee PC, Spinner RJ, Bishop AT, Shin AY: Iatrogenic brachial plexus injuries associated with open subpectoral biceps tenodesis: A report of 4 cases. Am J Sports Med 2013;41:2048-2053.
30. Takahashi N, Sugaya H, Matsuki K, et al.: Hypertrophy of the extra-articular tendon of the long head of biceps correlates with the location and size of a rotator cuff tear. Bone Joint J 2017;99-B:806-811.
31. Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA: The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy 2005;21:1296-1306.
32. Ozalay M, Akpinar S, Karaeminogullari O, et al.: Mechanical strength of four different biceps tenodesis techniques. Arthroscopy 2005;21:992-998.
33. van Deurzen DFP, Gurnani N, Alta TDW, Willems JH, Onstenk R, van den Bekerom MPJ: Suprapectoral versus subpectoral tenodesis for long head biceps brachii tendinopathy: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2020;106:693-700.
34. Chen CH, Hsu KY, Chen WJ, Shih CH: Incidence and severity of biceps long head tendon lesion in patients with complete rotator cuff tears. J Trauma 2005;58:1189-1193.
Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.