Is a Biceps Tenodesis the Answer?
October 22, 2012 
33 Comments
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.
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.”
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?
I agree 100% Mike! Our sports doc always repairs first. He reserves biceps tenodesis for the older “athletes” who want to return to recreational activity. All high school and college athletes get repaired. With proper rehab, they do well without compromising the anatomy of the joint. We are in the preserve anatomy rather than delete it camp!
Good article, wish I had read this a couple years ago. I was diagnosed and treated for biceps tendonitis as a freshman in high school. While recovering, I was out for the entire spring and summer baseball season and it took me much longer than that to fully recover. After my recovery I continued pitching, but never experienced a real increase in velocity. I wonder if restoring the problem would have provided better future results.
Mr. Reinold,
It’s great to read the articles you post. Was at the 1st Annual Cressey Performance Clinic in Hudson this past Sunday. It was nice to pick up the Optimal Shoulder Performance and Functional Stability Training of the Core DVD’s from Eric Cressey. You guys combined and individually are a great resource and asset to your respective industries. I thank you on behalf of others who value your expertise….
Respectfully,
Nicholas
Thanks!
I found that the biceps tenodesis I had done neither relieved my shoulder pain nor helped me get back faster. I had mine done almost 2 years ago now, before some of the “anti-BT” info came out. Now, I’m a bit stuck with the new anatomy and trying to figure out how to move around it. The largest problem has been getting IR back. Everything that purports to help with IR just causes more inflammation. Anyhow, another great post Mike. I hope more folks considering BT surgery read this first.
I respect both sides of the fence on this issue. Personally, I am a 38-year-old athlete who chose the biceps tenodesis route, but I also had biceps tendonosis in addition to the labral tear. I am 58 days out so far and am back to work full-time and generally feel good. Shoulder is still sore, but I understand the pain could hang around for 3-6 months, no matter which shoulder surgery was performed. I feel I made the right decision… I am not going back to any “throwing sports”, and am doing everything I can do keep my RTC muscles and tendons strong to stabilize the shoulder as best as possible.
This has been a very interesting article to read. I am a 29 y/o, healthy male who, while playing college baseball, had a SLAP tear repair. The original surgery date was done in March of 2003. I was rather agressive in my rehab, returning to pitching within 6 months following the surgery. Needless to say, I didn’t play at that competitive level much longer and throughout the nearly 10 years since the surgery, I have dealt with considerable pain while playing recreational hardball.
My personal goal to suffice my competitive nature is to switch to endurance sports such as running races, triathlons, and surfing since I am in a coastal town.
I met with an ortho surgeon last week and am undergoing bicep tenodesis on February 11. While I want to remove the pain, I do still want to be a competitive athlete.
Any thoughts or opinions is greatly appreciated as what I am hearing here is with the biceps tenodesis- I am at risk of having an improperly functioning shoulder.
Wow I wish I had read what you had to say about biceps tenodesis three days sooner. I had arthroscopic surgery on my right shoulder yesterday. The pre-op diagnosis was a SLAP tear but MRI did not clearly reveal the extent of the tear. This injury occurred at work (I am a paramedic for a very busy emergency service and spend at least 48 hours per week on the ambulance). It was a lifting/jerking/pulling motion that caused the injury. I have done the same movement sequence literally thousands of times over my 16 year career without any shoulder discomfort. But, for reasons I cannot figure out, this time was different. I felt an awful tearing sensation, popping, and very intense pain. To make a long comment shorter…the ortho surgeon to whom I was referred recommended arthroscopy to determine the extent of injury and to do a SLAP repair if indicated. Well, when I woke up from anesthesia, I discovered he had performed a biceps tenodesis, removed bone spurs, and decompression of subacromioclavicular space. Not until reading this post after surgery is done, did I understand that tenodesis was done instead of SLAP repair. Okay, so I just turned 40 about a month ago, which, it seems is pretty old in reference to shoulder repair work. But I have two sons, the older is 4 years old and the baby is 16 months. I have a career that I absolutely love but it is very physically demanding. I am not a competitive athlete but the factors listed above are just as important. So I’m wondering why I was not offered a choice of whether to have the tenodesis or the SLAP repair. It seems the surgeon decided for me while I was under anesthesia. Feeling a little cheated now. Also wondering about potential future shoulder injury because of the anatomical modification of the tenodesis. Does it make me more prone to rotator cuff tears or a Bankart lesion or some other pathology? And does tenodesis limit what types of treatment can be done for future injuries? It really seems like I should have been given a choice between the two options in this case. Thank you, sir, for any insight you can provide on this matter.
If you are not an athlete, than a biceps tenodesis may be a great option for you.
I am 52 and looking at having the tenodesis done as part of a repair to a fully ruptured supraspinatus tendon, partially torn infraspinatus, and a LHBT that appears to be split axially. I swim for recreation/fitness and do many manual things around home, garden and garage. Will the tenodesis increase shoulder instability or reduce my shoulder function?
Hi
I am a 26 year old from South Africa. I used to play rugby competitively at a high level. When I was 21 I injured my left shoulder during a game and was told there was not much that could be done then to fix the issue. So I had to retire from the sport I loved. In 2011 I was really struggling with pain in both my left and right shoulders and after an MRI scan, it was confirmed both had severe SLAP lesion tears which were repaired due to new surgical procedures.
In total I had 3 operations, one left and 2 on the right side as one of the anchors fitted pulled out and broke 6 months after the first operation. Now 2 years later I was still having severe pain in the left shoulder and was unable to do much weight training. So I returned to the doc and another MRI scan to discover one of the anchors had pulled out from the previous op.
Anyway, 3 weeks ago I underwent my 4th op to have the SLAP repaired, only to wake up and find that the doc had removed the anchor and done a bicep tenodesis – naturally without asking me.
What I want to know is was this the right move with me being so young still? All I want to do is get back into the gym to lift some weights, heavy weights. What is your opinion on this?
Thanks and sorry for the long winded message.
Regards from South Africa
Greg, it sure could have been the right procedure for you. Difficult to say over the internet but if the surgeon thought that I bet it was. Sometimes a tenodesis is the best option, different for everyone.
Thanks Mike. It will be interesting to see once I get back into the gym how the training and rehab goes.
Thanks Mike for this Forum.
Greg – I am 27 and play tons of basketball. I was advised a BT was the answer just this morning – have had 10 months of pain in my right arm. Anyway, I’m really hoping you post your status here going forward. If you recover fine I’ll likely go your route. All this stuff about changing my anatomy is scary, advil seems to work after a game. But like all here, I want my arm back as I remember it. I don’t want something bad to get worse..
But haha, I want to lift heavy weights too. Bench press has been off my workout list for a year now – and pullups for a few months.
Thanks for the tips and stories all!
Sean
Thanks Sean, I will keep you all updated with my progress. I’m into week 4 after the surgery and my shoulder feels pretty good. A lo more mobile and pain free than my other 3 operations. The bicep does feel weak but I haven’t loaded it at all as the doc warned me not to until at least 6 weeks after the op.
To give you an idea, I used to single arm bicep curl 45kg (+- 100 pounds) that was before my ops with SLAP lesion tears. So if after these ops I cannot get to that weight then I would definitely consider it all a failure.
I do believe that surgery should be the last option though, I lived with my problem for 4 years and I used to do some very heavy weights, bench included. With correct rotator cuff strengthening and training you can get away with it to a degree.
Dr. Mike, 2 years ago I had a biceps tenodesis, which was unexpected as it was 80% torn, and this was unknown prior to surgery. Prior to my injury I was an avid weight lifter. I have never recovered from having this surgery. I was an athlete growing up and weight lifting was the last activity I had left. 2 years later after 3 surgeries I have not been able to return to the gym, because of the pain and instability. I cannot throw a baseball to my young son because of the pain. My shoulder continues to dislocate Anterosuperiorly, exactly where the biceps tendon crosses the shoulder. My question is, is there no procedure yet conceived that can replaced this structure. Can a cadaver tendon not be joined to the distal portion of the biceps tendon and placed in the supraglenoid tubercle or can the coracobrachialis origin be translocated to this area, or even the short head of the biceps. I feel as though my surgeon may as well have just amputated my right arm.
I should add that like you, I am a physical therapist, and after my experience I would never recommend a tenodesis to anyone, regardless of age.
No there isnt a way to replace, however I am not sure you are experiencing these issues because the biceps. Sounds like you have some capsular issues you should get checked out.
My last surgery was to reattach my superior labrum which was completely detached and scarred down to the cuff. Superior instability is my biggest issue, and since the rotator cuff and the superior joint capsule are contiguous there is really no way to tight the capsule in this area. Not that I know of anyway. Just yesterday a simple shoulder abduction exercise caused me a dislocate anterosuperiorly.
You need to get checked out, you should not be dislocating.
Already made my appointment request with Dr. Andrews.
Mike,
I am a 47 year old male. I saw the surgeon today; he recommended the tenodesis on my left shoulder. He mentioned that, upon completion of the surgery, there will be between 1-2 centimeter redaction of the bicep (making it more defined than the right bicep) I havent read any posts mentioning a noticeable difference. My goal is to be able to swim and participate in all the cross fit workouts I am accustomed to. My “End Goal” (if I have the tenodesis) is to be able to function normally well into my golden years 70′s through 90′s. My surgery is on the 20th of June, so I have a couple of weeks to decide. Do you have knowledge of anyone in their 60′s or 70′s that had this procedure previously?
Mark, it’s all an equation of how much your symptoms limit you and what you want your activity level to be. If you explained all this to your doc, they should have considered all this when they came to the conclusion.
Hello Mike,
Great article, this really helped me understand these procedures and my predicament. When I was 31, 4 1/2 years ago, I had surgery for a SLAP tear and Arthroscopic Subacromial Decompression. After 2 years of PT my shoulder did not get any better. I still have pain on the front side of my shoulder, loss of range of motion, cannot do pull ups or hang from a bar, and have occasional pain or numbness in my biceps tendon. An odd vibration shoots down that tendon. It was suggested by a ortho that I have this procedure done – Biceps Tenodesis. He thinks my shoulders have also moved forward. So when I throw, the humeral head pushes against that area causing pain. I play a little softball (can’t throw with any velocity without significant pain on front side of shoulder). I am past my prime but would like to be able to throw with my 2 boys. Any suggestions?
Thanks
Rob
Rob, if you havent yet, I would get a full evaluation and give rehab a try, perhaps with a different PT?
Thanks Mike. I have tried 2 different physical therapists and worked my butt off doing the exercises with no significant improvement. Leads me to believe there is something else going on in my shoulder.
Rob
I’m currently 40 years old. I originally started feeling pain in my shoulder when I was twenty. I ended up quitting playing sports due to the pain. About 5 years ago I finally went and had surgery on it. After the surgery (slap) my surgeon at the Hospital for Special Surgery told me that many doctors perform tenodesis on every shoulder they repair but that he didn’t agree with it. He then told me that he felt that I was likely to have problems in the future with what he saw in my shoulder and said that I was the first patient that he had seen that he felt actually needed the tenodesis due to the anatomy of my shoulder. He didn’t perform the tenodesis because he had never discussed it as a possibility with me before the surgery. Post surgery my shoulder eventually was better on a day to day basis but once I started playing racquetball and going to the gym I ended up having to get cortisone shots once a year to help with the pain. I finally decided to go back and I just had the tenodesis performed last Wednesday. I was told that my shoulder looked really good but that my tendon was “shredded”. I am very hopeful that this is going to finally fix my shoulder issues. I’m hoping that it won’t eventually cause other problems in the future but hopefully it ended up being the right option for me.
Greg, great example of how sometimes this is a great option for some people. Thanks for sharing.