Biceps Tenodesis
What Is Biceps Tenodesis?
Biceps tenodesis is a shoulder operation in which the long head of the biceps tendon is released from its origin inside the shoulder joint and fixed to the upper arm bone (humerus) at a new point. The aim is to take the intra-articular part of the tendon — a common source of pain — out of the loaded system while preserving the length-tension relationship of the muscle and the arm's ability to bend the elbow and turn the forearm. In this respect the procedure differs from tenotomy, in which the tendon is simply released and not reattached.
Tenodesis is usually planned as part of a whole-shoulder assessment rather than in isolation. Because long head biceps problems often occur alongside other shoulder pathology, the decision weighs tendinitis, partial tearing, tendon instability and SLAP lesions together. For a broader picture of shoulder anatomy and related conditions, the shoulder overview is a useful starting point.
When and Why Is It Performed?
Tenodesis is considered in selected situations where non-operative treatment has not been enough. The typical reasons are:
- Biceps-related front-of-shoulder pain that limits function and persists despite an adequate course of non-surgical treatment.
- A significant partial tear of the tendon, or a tendon that subluxes or dislocates out of its groove (instability).
- A long head tendon judged to be a source of pain during a rotator cuff or labral repair.
The diagnosis, differential diagnosis and non-surgical steps for biceps pain are covered in detail on the biceps tendinitis page, and surgery is considered only once those steps have been exhausted. A complete rupture caused by sudden trauma is a different problem — a biceps tendon injury — and is assessed separately.
Who Is a Candidate, and Who Is Not?
Tenodesis is often preferred for more active patients who want to preserve the contour and strength of the arm and to avoid the "Popeye" appearance and cramping with load that can follow a simple release. By contrast, a simpler tenotomy may be a reasonable option in older, lower-demand patients with limited concern about appearance. Active joint infection, uncontrolled systemic conditions that impair healing and situations where rehabilitation cannot be followed are factors that delay surgery or change the plan. Suitability is judged for each patient individually; one rule does not fit everyone.
Preparation Before Surgery
Before surgery the history, examination and imaging are reviewed together; X-rays show the bony anatomy while MRI shows the state of the tendon and any associated cuff or labral problem. Current medication, blood thinners, smoking and coexisting illnesses are reviewed. The expected benefit, the alternatives, the risks and the length of rehabilitation are explained to the patient. Because associated shoulder problems are frequently addressed in the same session, the scope of the operation is clarified in advance.
How the Operation Is Done: Techniques
Tenodesis can be carried out through two main approaches. In the arthroscopic (suprapectoral) technique, a camera and fine instruments work through small incisions; the tendon is fixed to the humerus in the upper part of the groove and other intra-articular problems can be seen and repaired in the same session. In the open subpectoral technique, the tendon is fixed lower down, near the lower border of the pectoralis major close to the armpit; this approach has the advantage of taking the diseased groove segment of the tendon completely out of the system, and it may be preferred when a previous tenodesis has failed or the tendon is severely damaged.
Fixation options include an interference screw, a suture anchor, a cortical button or a soft-tissue technique. The method and the site of fixation are chosen according to the condition of the tendon, the associated pathology and the surgeon's experience. General information about how other intra-articular steps are carried out can be found on the shoulder arthroscopy page.
Anaesthesia and Duration
The procedure is usually performed under general anaesthesia, often with a regional nerve block that numbs the shoulder and arm and helps control pain in the first hours afterwards. An isolated tenodesis is generally short and is completed as a day case or with a single overnight stay in most patients. When additional work such as a cuff or labral repair is carried out, the operating time and the recovery lengthen accordingly.
The First Period After Surgery
For the first weeks the arm is supported in a sling to protect the fixation. Pain and swelling are managed with ice and appropriate medication, and the wound is kept dry. To let the fixation consolidate, bending the elbow against resistance and forcefully turning the palm upward are avoided for a set period. Gentle supported movements of the hand, wrist and elbow may be allowed early, while loading is gradual and controlled.
Rehabilitation Timeline
Rehabilitation progresses in stages and is guided by goals reached rather than by a fixed calendar. Protected range of motion and shoulder-blade control are restored first, followed by gradual strengthening of the biceps and shoulder girdle. Loading is increased while pain, movement and the security of the fixation are monitored. A personalised programme is planned for each patient, and the pace of progress varies from person to person. Prolonged complete immobilisation is avoided, because stiffness can delay recovery.
Return to Work and Sport
Return to desk work is usually possible within a few weeks, while jobs that demand arm strength and repetitive loading wait longer. Return to sport is planned gradually as strength, endurance and pain-free function reach set criteria, most often over a period of a few months. The timescale depends on the person's work, sport, any associated repairs and the pace of healing; no fixed date is promised.
Risks and Complications
As with any surgery, tenodesis carries some risks: persistent pain or cramping, shoulder stiffness, a change in the shape of the arm (expected less often than after tenotomy), loosening or failure of the fixation, infection, irritation of nerves near the fixation site and, rarely, a bone-related problem in the subpectoral region. The risks vary with the technique, the site of fixation, the quality of the tissue and patient-related factors. For this reason expectations are discussed clearly before surgery.
Factors Affecting the Outcome and Alternatives
The outcome is shaped by the presence and treatment of associated rotator cuff or labral problems, the quality of the tissue, the fixation technique and the patient's adherence to rehabilitation. Where pain is prominent with overhead use and overlaps with impingement, the assessment should also consider shoulder impingement syndrome. The alternatives to surgery are continued non-operative treatment and the simpler tenotomy; the choice is personalised to the patient's expectations and demands.
When Should You See a Doctor?
After surgery, increasing redness, drainage, fever, steadily worsening pain, numbness or weakness in the hand, or a change in colour and temperature should be assessed without delay. Before surgery, front-of-shoulder pain that persists despite non-operative treatment and limits function warrants a proper assessment. To have a shoulder problem evaluated, you can contact Assoc. Prof. Serkan Sürücü.