When it comes to addressing long head biceps tendon (LHBT) pathology—such as tears, inflammation, or instability—there are two primary surgical approaches: biceps tenotomy and biceps tenodesis. Both procedures aim to relieve pain and restore function, but they differ significantly in technique, recovery time, and potential outcomes. This article will help you understand the differences between these procedures, their advantages and disadvantages, and factors that might influence which option is best for you.

A biceps tenotomy is a surgical procedure that involves simply cutting the long head of the biceps tendon where it attaches to the superior labrum in the shoulder joint. Once released, the tendon retracts down the arm, and the body forms scar tissue around the end. This effectively eliminates the source of pain by removing the damaged tendon's attachment point within the shoulder joint.

• Typically performed arthroscopically (minimally invasive)

• The surgeon cuts the long head biceps tendon at its attachment to the labrum

• The tendon then retracts into the arm

• Generally takes 10-20 minutes to complete

• Often performed in conjunction with other shoulder procedures

A biceps tenodesis is a more complex procedure that involves detaching the long head biceps tendon from its original attachment point (similar to tenotomy), but then reattaching the tendon to a new location typically to the humerus (upper arm bone). This reattachment preserves the length-tension relationship of the biceps muscle.

• Can be performed arthroscopically or through a small open incisionLonger rehabilitation (typically 3-6 months)

• More restrictive postoperative protocol to protect the fixation

• Gradual return to activities under physical therapy guidance

• May have more initial postoperative pain

• The damaged portion of the tendon is removed

• The remaining healthy portion is reattached to the humerus using screws, anchors, or other fixation devices

• Generally takes 30-45 minutes to complete

• Can be performed along with other shoulder procedures

• Shorter rehabilitation period

• Minimal postoperative restrictions

• Return to normal activities typically within 2-4 weeks

• Less postoperative pain

• Longer rehabilitation (typically 3-6 months)

• More restrictive postoperative protocol to protect the fixation

• Gradual return to activities under physical therapy guidance

• May have more initial postoperative pain

• Simpler, faster procedure

• Shorter recovery time

• Less postoperative pain

• Fewer activity restrictions

• Lower risk of complications

• Suitable for older, less active patients

• Potential for cosmetic deformity ("Popeye" deformity) with reported rates varying widely from 10-47% (Slenker et al. found 43% in their systematic review of 699 patients)

• Possible cramping or fatigue with repetitive activities (research shows approximately 20% of patients report cramping, with half of those experiencing it about 5 times per week)

• Potential for slight decrease in supination strength (turning palm upward)

• May not be ideal for younger, athletic patients

• Preserves biceps length and function

• Lower risk of "Popeye" deformity compared to tenotomy (33% vs. 47% in van Deurzen's Level 1 study)

• Better preservation of strength

• Lower risk of cramping or fatigue (8% vs. 20% in Aflatooni's 2020 study)

• Better option for younger, active patients

• Slightly higher patient satisfaction rates (96% vs. 91% in Aflatooni's study)

• More complex procedure

• Longer recovery time

• More postoperative restrictions

• Potential for failure of fixation, varying by surgical technique (21% with interference screw vs. 6% with onlay technique in Park's study)

• "Popeye" deformity can still occur (27% with interference screw vs. 9.4% with onlay technique in Haidamous's study)

• Potential for pain at fixation site

• Location-specific concerns (suprapectoral location may increase stiffness; subpectoral approach carries rare risk of serious complications)

• Older patients (typically >65 years)

• Less active individuals

• Patients seeking faster recovery

• Patients with significant medical comorbidities

• Those who don't mind potential cosmetic changes

• Younger patients (typically <60 years)

• Highly active individuals or athletes

• Manual laborers

• Patients concerned about cosmetic appearance

• Those willing to undergo longer rehabilitation

The choice between tenotomy and tenodesis should be made in consultation with your orthopedic surgeon, taking into account:

1. Your age and activity level

2. Occupation and functional demands

3. Cosmetic concerns

4. Willingness to undergo longer rehabilitation

5. Overall health status and surgical risk factors

Remember that both procedures have high success rates for pain relief, which is the primary goal of treatment. Your surgeon will help you weigh the pros and cons based on your specific situation and goals.

Multiple studies have provided valuable insights into patient outcomes after biceps procedures:

• A 2017 case series by Brett D. Meeks, MD et al. in The Orthopedic Journal of Sports Medicine examined 104 patients with an average age of 64 who underwent biceps tenotomy. Key findings included:

  • 91% of patients reported being satisfied or very satisfied with their procedure

  • Men reported lower satisfaction rates than women

  • Age had no significant effect on patient satisfaction

  • 20% of patients reported experiencing cramping, with half of those patients experiencing cramping approximately 5 times per week

• A 2012 study by Duff et al. in the Journal of Elbow Surgery found that 95% of tenotomy patients were satisfied or very satisfied with their results.

• Walch et al. in the Journal of Shoulder and Elbow Surgery (2005) reported 86% good/excellent results following tenotomy.

• A systematic review by Slenker et al. in the Arthroscopy Journal (2012) analyzed 699 patients and found 77% good/excellent results following tenotomy, although 43% of patients had a "Popeye" deformity.

• A prospective randomized study by Ji Soon Park, MD et al. in the American Journal of Sports Medicine found significant differences in failure rates based on surgical technique:

  • 21% failure rate in the interference screw group

  • Only 6% failure rate in the onlay group

• Similarly, Haidamous et al. in the American Journal of Sports Medicine (2020) found "Popeye" deformity following tenodesis in:

  • 27% of cases in the interference screw inlay group

  • 9.4% of cases in the onlay group (approximately 1 in 10 failures)

• A Level 1 study by Derek F.P. van Deurzen, MD et al. found:

  • A non-statistically significant 7-point higher Constant shoulder score improvement following tenodesis versus tenotomy

  • "Popeye" deformity in 33% of patients treated with tenodesis versus 47% treated with tenotomy

• Justin O. Aflatooni, MD in the Journal of Orthopedic Surgery and Research (2020) reported:

  • 96% satisfied/very satisfied with tenodesis versus 91% with tenotomy

  • 20% of tenotomy patients reported spasms/cramping versus 8% of tenodesis patients

• Multiple comparison studies of arthroscopic versus open approaches have failed to show superiority of one technique over the other.

• Location of tenodesis may affect outcomes:

  • A suprapectoral location of tenodesis may lead to increased early stiffness

  • A subpectoral tenodesis carries a rare risk of potentially serious complications

These studies demonstrate that both procedures can provide excellent pain relief and high patient satisfaction rates when appropriately matched to patient characteristics, though each carries specific risks that should be considered during surgical planning.

Understanding the differences between biceps tenotomy and tenodesis can help you have a more informed discussion with your surgeon about which procedure might be right for you. Both approaches effectively address biceps tendon pathology but come with different trade-offs regarding recovery time, functional outcomes, and cosmetic appearance.

The research evidence suggests:

• Both procedures achieve high patient satisfaction (91-96%)

• The "Popeye" deformity is more common with tenotomy (43-47%) than with tenodesis (9.4-33%, depending on technique)

• Cramping is more common with tenotomy (20%) than with tenodesis (8%)

• Surgical technique matters for tenodesis outcomes (onlay technique appears superior to interference screw)

• Neither arthroscopic nor open approach has proven superior for tenodesis

Ultimately, the choice between procedures should be individualized based on your age, activity level, concerns about cosmesis, and willingness to undergo longer rehabilitation. A thorough discussion with your orthopedic surgeon, informed by this research evidence, will help you make the best decision for your shoulder health.

Disclaimer: This article is for informational purposes only and does not constitute personalized medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment options.