I read a lot of stuff on the internet. I like to keep up with a ton of blogs, websites, and journals to make sure I am on top of recent trends, but also to share with my readers. I recently came across an article at Science Direct entitled Getting Athletes Back in the Game Sooner Following Shoulder Injuries. Nice headline, right? It made me want to click.
Interestingly, they were talking about how a biceps tenodesis can cut down the rehabilitation time from SLAP tears in comparison to a SLAP repair. That wasn’t what I was expecting!
OK, would a tenodesis cut down (no pun intended…) the rehab time in comparison to a SLAP repair? No doubt, I agree with that. But I am not sure if this is what we want to do, especially in athletes, as the title of the article suggested. Let’s dig into this deeper, but first, let’s discuss SLAP tears and what the biceps tenodesis surgery actually does.
What is a SLAP Tear and Biceps Tenodesis?
I’ve covered superior labral tears, or SLAP tears extensively in the past. If you don’t know much about SLAP tears, start there, but essentially a SLAP tear is a superior labral tear at the junction of where the long head of the biceps comes in and attaches to the superior labrum. SLAP tears are common, and can be especially troublesome for overhead athletes. (Photo from Wikipedia)
A biceps tenodesis is a surgical procedure that detaches the biceps attachment from the superior labrum and reattaches it to the humerus. Here is a surgical demonstration from Smith and Nephew:
By removing the biceps, this essentially eliminates the patient’s pain from the SLAP lesion or biceps tendonitis, however at what consequence? By performing a tenodesis, you are changing the anatomy of the shoulder and the function of the biceps. This procedure has become more popular in older individuals, essentially those that chose a decrease in function for a decrease in pain. But what about athletes, as the paper I mentioned above proposed was happening, can they return to sports faster by simply cutting the biceps off instead of trying to repair it?
One of the most popular studies on this subject was in AJSM in 2009. The authors reported that the results of biceps tenodesis were superior to SLAP repairs in athletes with superior labral tears. The authors mention both “overhead athletes” and “return to sport” in the paper, though they report the age range of subjects was 24-69 years old. Furthermore, significant differences in age existed between the two groups, with the mean age of 37 years old in the SLAP repair group and mean age of 52 years old in the biceps tenodesis group. One could certainly argue that the level of “sport” participation was different between the groups and could certainly influence their subjective satisfaction.
What is the Function of the Biceps?
Biomechanical studies have shown that the biceps labrum complex has a role in providing both translational and rotational stability, and that repair of a SLAP lesion restores this ability to provide static stability. This is especially true in overhead athletes who need to use their arm in the abducted and externally rotated position. Contraction of the long head of the biceps in this position has been shown to reduce anterior humeral head displacement, a functional that is critical in preventing throwing injuries. In fact, peak biceps EMG activity has been shown to occur during this cocking phase of throwing, and has been shown to be higher in pitchers that have anterior instability.
Also, don’t forget that release of the long head of the biceps has been shown to increase superior humeral head migration by over 15%.
As all my readers know, superior humeral head migration is disadvantageous and causes many of the dysfunctions we see with the shoulder. Our whole goal of most shoulder rehabilitation programs is to train the rotator cuff to dynamically stabilize to resist superior humeral head migration. I’ve written about the role of rotator cuff fatigue in shoulder mechanics and how rotator cuff fatigue increases superior humeral head migration.
So if the biceps is involved with translational and rotational glenohumeral stability and helps prevent superior humeral head migration, is this something you want to sacrifice just to reduce pain? How will this impact function, and more importantly, future injuries?
Is a Biceps Tenodesis the Answer?
Is there a role for biceps tenodesis? I am sure there is. I like the recommendations my friend Brian Busconi reports in this paper, stating that he likes to perform SLAP repairs, but will consider biceps tenodesis in patients over the age of 45. This serves a different purpose and return to high level athletics is probably not as important to the patient than reducing their pain. I have heard Dr. Altchek from New York report in meetings that he thinks biceps tenodesis may be an option, but one he reserves for those who fail a SLAP repair. Still, I have to wonder what the long term effects of the biceps tenodesis will do on this patient population as well. Will the increased superior humeral head cause rotator cuff pathology or degenerative changes? Only time will tell.
There is also recent chatter about the use of the biceps tenodesis procedure in overhead athletes and the risk of humeral head fracture. This is a consequence that must be considered.
Noted orthopedist, Dr. James Andrews was recently asked about the biceps and the potential for biceps tenodesis, to which he replied “The biceps is there for a purpose — it’s too intrinsically associated with the shoulder joint. Until we know what the real function of it is, we’re stabbing in the dark.” When asked if a biceps tenodesis is the answer to athletes returning to sport, similar to a Tommy John procedure, he replied “With Tommy John surgery, we’re actually restoring anatomy. In the case of biceps tenodesis, you’re deleting anatomy.”
SEE ALSO: Dr. Lyle Cain from Dr. Andrews’ American Sports Medicine Institute discusses some of the facts and fiction related to the biceps tenodesis surgery.
So, sadly, I don’t think we all learned a great new way “get athletes back in the game sooner following shoulder injuries” like the Science Direct title would suggest. Perhaps I’m wrong, but I would have to agree with Dr. Andrews, I always prefer procedures that restore anatomy when possible. Don’t get me wrong, a biceps tenodesis has it’s place. But I’m not sure if it is the magical secret to getting athletes back faster, there just has to be some consequences.
What has your experience been? Have you seen many athletes opt for a biceps tenodesis rather than a SLAP repair?