biceps tendon as a pain mediator-tenotomy versus tenodesis

When the biceps tendon is torn, degenerative, thickened, frayed, unstable  or merely inflammed, pain can occur in the front of the shoulder. This finding--Biceps Tendonopathy--for lack of a better term, is the single easiest cause of shoulder pain to cure.

There are 2 schools of thought regarding treatment--but when the biceps is more than just "synovitic"-- both agree that the biceps tendon needs to be removed from the inside of the joint. Not to worry though, the biceps muscle has 2 proximal tendons, and so, release will not affect function, diminish the ability to flex the elbow, or weaken strength of flexion.

Biceps tenotomy simply lets the tendon slip out of joint--although it usually gets stuck and scars to the intertubercular groove, and there will be no visible evidence that it has been tenotomized. However, there is a 30% chance that it will slip further, resulting in a "popeye-like" deformity. Ofcourse, for those of us without sculpted biceps muscles, this will not be visible. The literature suggests that tenotomy may result in long-tern fatiguability in the muscle---but i have not observed this in my patients--and I routinely ask.
For those of us that do care about this potential cosmetic consequence--a biceps tenodesis can be performed. Biceps tenodesis can be performed through a small incision just below the arm pit (a so-called subpectoral tenodesis), which is very effective and removes the tendon completely from the groove or arthroscopically, in a "suprapectoral approach which still removes the tendon from the groove. Ihave attached video clips below of an arthroscopic technique that I occasionally use. In patients in whom successful tenodesis is felt to be important---I will usually use a small incision and perform the procedure in a subpectoral location. with the use of an Intererence screw. This technique is increasingly in popularity among shoulder surgeons because of it reliability.

If you are undecided on what to do if you hve a biceps tendon that is causing pain-------It has been my experiene  that recovery following Acromioplasty for Impingement is slightly longer when a tenodesis is performed, as compared to when tenotomy alone is performed. I think this is related to the inflammatory process in the front of the shoulder--related to the tendon healing to the bone--even though it is occurring outside of the joint.

Based on personal scrutiny of the literature which compares tenodesis and tenotomy, I have the following opinion/recommendation:
1.If the biceps is a potential cause of pain, tenotomy should be performed.
2.Unless you really will be disturbed by a slight deformity in the muscle, which occurs about 30% of the time, there is no Evidence-based advantage associated with tenodesis.
3.If you absolutely want a normal looking biceps, tenodesis should be performed--but there is still a 10-15% chance that the muscle will not look entirely normal.
4.Some cramping may accompany tenotomy without tenodesis, but this usually resolves by around 3 months.

The biceps will only be addressed with either of these 2 options if it is degenerative, thickened or torn----all in the interest of pain relief.


knaussal    4/11/11 at 4:18 pm

Dr Tomaino, I am having severe pain in my right bicep, ;probably from the fall in january. When you operate on my right shoulder on 4/26/11, will you also be able to look at the bicep and perfrom a tenotomy? What is the probability of deformity? I'd like the pain to stop, but I don't want to look like popeye.

Thanks, Anne Knauss

mtomaino    5/9/11 at 12:58 pm

During arthroscopy I will be able to evaluate the long head of your biceps as well as its labral attachment. The tenotomy, if necessary, will likely allevate the pain that is radiating down your biceps, and in my experience, unlikely to result in any significant deformity.

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