CORR Insights®: Does Biceps Tenotomy or Tenodesis Have Better Results After Surgery? A Systematic Review and Meta-analysis

Where Are We Now?

On the first day of my sports medicine and shoulder fellowship, I was assigned to cover the Denver Broncos training camp in Fort Collins, CO, USA. It was an exciting assignment for a new sports medicine fellow who had grown up in Pittsburgh, PA, USA, where football is a way of life. When I arrived, I did not have much time to get acclimated to my new surroundings. There were preseason physicals to be done, off-season injuries to be assessed, and a host of new injuries that needed attention, which had occurred on the first day.

When practice ended, I followed the head athletic trainer into the training room to examine the players who needed attention. Many of the younger players were laughing, listening to their earphones, and debating whose college team was better. It was about this time that the athletic trainer came up to me and asked me to take a look at a player who was sitting off in the corner on a training table, separated from the relative chaos around him, reading the Wall Street Journal. The player was legendary quarterback John Elway. He had a bag of ice on his shoulder, and it sounded like he was talking to his stockbroker on his cell phone.

Determined not to look intimidated, I walked up to him, introduced myself, and asked him what was wrong. He said that at the end of the last season, he had developed a fair amount of anterior shoulder pain. It had gotten a bit better during the off season, but it got acutely worse during practice. He said that during a throw, he felt a pop in his arm. The sensation was disturbing, but strangely, he stated that the pain that had been present in the front of his shoulder for so long was gone. Upon examining his shoulder, it became evident that he had ruptured the long head of his biceps.

I felt an unexpected relief that I was able to make the diagnosis for this player, on the first day of my fellowship no less. My inner sense of accomplishment was immediately lost, however, when the player asked what we were going to do to treat it, and when he could throw again. I realized quickly that I had no idea. Surgery would mean the end of his season, and a quick literature search could not find anything published for the treatment of long head biceps rupture in elite throwing athletes. So, I did what any smart fellow would do in that situation; I stalled until I could call my fellowship director to ask what I should do. Surprisingly, although a renowned shoulder surgeon, he did not have any experience with an elite throwing athlete with this injury either. Since surgery would mean an end to his season, we decided to treat him nonoperatively and see how he progressed.

The rest of the story, as they say, is history. John Elway and the Broncos went on to win their first Super Bowl that year. I had never been so happy for doing so little. But the question remained: How should we treat athletes with long head biceps ruptures? Why did Elway feel better after rupturing his biceps? Should we perform biceps tenodesis, or leave them alone and treat them with rehab? Similarly, what should we do for patients with pathologic biceps tendons discovered at surgery? Should we perform a simple biceps tenotomy or a biceps tenodesis?

Pathology of the biceps tendon is one of the most common causes of shoulder pain, especially among patients with rotator cuff pathology. Many studies have described different types of biceps tenodesis techniques, arthroscopic versus open approaches, and kinds of fixation. I don’t find any of them, taken alone, to be particularly convincing or definitive due to their heterogenous associated pathologies, patient populations, surgical techniques, rehabilitation protocols, and outcome measures. There are many advocates for simple biceps tenotomy as well, but there are no studies that actually differentiate the outcomes of this technique in young active patients versus older more sedentary patients and stratify the results accordingly.

In this month’s Clinical Orthopaedics and Related Research®, Pozzetti Daou and colleagues [5] perform a systematic review comparing biceps tenotomy to tenodesis; they found no difference between the groups regarding pain or Constant scores in the long term, and no differences when evaluating for major complications. They do, however, indicate that the review did not have enough patients to evaluate for postoperative adhesive capsulitis, biceps cramping, or the risk of revision surgery, and they found that the Popeye sign was more common in the tenotomy group than in the tenodesis group.

Based on these discoveries, surgeons should feel more confident that their patient’s clinical outcome can be excellent regardless of whether a tenodesis or tenotomy was performed. That said, the issue of biceps cramping and cosmetic deformity can likely be minimized by performing a tenodesis in more active patients under 45 or 50 years of age and employing a tenotomy more commonly in older, less active patients with less cosmetic muscle definition.

Where Do We Need To Go?

Even after performing a systematic review, it is evident that important gaps remain in our knowledge about biceps tendon injuries. It is clear that addressing biceps pathology at the time of rotator cuff repair is important in the interest of minimizing the risk for persistent postoperative pain and the need for additional or revision surgery [4, 8], but it is still not clear which patients treated with biceps tenotomy are likely to be troubled by cramping or weakness. Similarly, we do not know which patients will develop problems after biceps tenodesis, such as pain at the point of tenodesis, recurrent tearing, symptoms from overtensioning or undertensioning at the tenodesis site, or adhesive capsulitis. And if a tenodesis is to be used, how should we best balance the many tradeoffs that go along with the different approaches to this operation? Advocates of arthroscopic tenodesis point to potential benefits like a potentially faster recovery and avoiding making a separate incision and surgical approach to the biceps groove [3]. However, some reports describe an arthroscopic technique proximal in the biceps groove, which other authors have indicated can lead to persistent biceps groove pain and failure to remove the pathologic tendon from the groove itself [6, 7]. If an open tenodesis is chosen, there is still debate as to whether a subpectoral or deltopectoral approach eliminates pain, restores strength, and minimizes postoperative complications such as proximal humerus fracture, cosmetic deformity, and recurrent biceps tendon tearing [9].

It is important for further study to be performed in this regard, as converting a biceps tenotomy to a biceps tenodesis can be difficult because of retraction of the tendon distally, and it can be difficult if not impossible to fully mobilize the tendon proximally without undue risk to the musculocutaneous nerve and other neurovascular structures like the brachial artery. Furthermore, it is not uncommon for patients to have pain at the biceps tenodesis site, or to complain of its relative tension and appearance [1]. Further studies are needed to describe how best to set an anatomic tensioning of the biceps tendon itself, and where that tenodesis should be performed within the groove.

How Do We Get There?

It is hard to design a clinical study to answer the question of whether biceps tenotomy versus tenodesis is better in terms of eliminating biceps-related pain, restoring strength, and preventing postoperative complications such as biceps cramping and cosmetic deformity, since isolated biceps pathology severe enough to treat surgically is uncommon, and when biceps tendon surgery is performed with other interventions around the shoulder (such as rotator cuff repair or distal clavicle excision), it is hard to account for the many obvious confounding variables. Specifically, it can be difficult to ascertain whether improvements are the result of the concomitant rotator cuff repair or distal clavicle excision, or whether the treatment of the biceps tendon made the difference [4, 8].

That said, a randomized prospective trial comparing biceps tenotomy versus tenodesis is possible. Given the inherent difficulty in identifying patients who only have isolated biceps pathology, the study should be performed with study cohorts who have only an associated rotator cuff tear that are matched in size and chronicity and no other associated procedures such as a distal clavicle excision or labral repair. This can be performed at a single institution with matched rehabilitation protocols and rotator cuff repair techniques, with data collected on biceps groove–related pain, tenderness, cosmetic deformity, or cramping

In addition, a prospective study that compares patients who have an arthroscopic biceps tenodesis performed proximally in the biceps groove to a tenodesis performed more distally, with only a concomitant rotator cuff repair and no other associated procedures such as a distal clavicle excision or labral repair, would also fill an important gap in our knowledge.

All too often, it seems that the decision to perform a biceps tenodesis versus tenotomy is simply made on level 5 evidence: the expert opinion of the surgeon. this exact sentiment is often made in the concluding sentence of multiple articles on the subject. We need well-designed multicenter studies to investigate the many important variables involved in order to develop a better evidence base to guide our decisions here.

Having this would also help the next generation of sports medicine fellows to be ready to look an all-star professional athlete in the eye and say with confidence what to do when the baseball pitcher, football quarterback, or tennis player tears his or her biceps tendon and asks what the best treatment for it should be.