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Biceps tenotomy or tenodesis

Upper Biceps Surgery

Your biceps muscle has two heads and two tendons at the top end attach it to bone.  The larger (short-head) tendon inserts onto the coracoid process of your shoulder blade outside your shoulder joint.  This tendon very rarely causes any problems.  The smaller long head takes a path right through the front of your shoulder and inserts at the top of your socket.  This tendon commonly becomes degenerate, frayed and painful. 

Your long head of biceps tendon can be cut if it is causing you pain. The tendon is divided by keyhole surgery (often as part of another procedure e.g. subacromial decompression or rotator cuff repair).  If your tendon is to be re-fixed, this normally involves a 3cm scar near the armpit crease.  It is performed under General anaesthetic +/- regional nerve block


If you are having a tenotomy, your biceps tendon is cut at its base by the top of your shoulder socket and the tendon is allowed to retract out of the joint.  In about half of patients they will notice the contour of their biceps muscle changes (this is called a Popeye sign).  Performing a tenotomy is safe and effective.  In young men who do a lot of heavy lifting or gym work, sometimes the altered tension in the biceps muscle causes cramping, but this is rare.  They may however not like the idea of an altered muscle contour and request a tenodesis. 


If you are having your biceps tendon re-fixed, the best way to do this is below your Pectoralis major muscle: this is called a sub-pectoral tenodesis and it involves a small cut just at the front outside edge of your armpit fold. The tendon is fixed to bone using sutures that are secured to bone by a small titanium button or an anchor.


What is my recovery after tenodesis surgery?

You will go home a few hours after your operation. Please take your prescribed painkillers regularly for the first few days. Take down any bulky padded dressings on day 2 after surgery. Keep your wound dry and covered with a dressing for 12 days. You can shower after 4 days if your waterproof dressings are on.

You will need to wear a sling for the first four weeks to protect the fixation of the tendon.  You will come out of your sling after four weeks and increase your range of movement.  Strengthening will begin at ten weeks. All restrictions will be removed by six months.

Patients vary in their symptoms after surgery, but in general you can expect to return to:

Office work after two weeks (in a sling)

Light physical work after eight to twelve weeks

Heavier labour may take 16-24 weeks

Contact sport usually takes six months

Driving is allowed once you are competent and confident to control a car both for routine and emergency manoeuvres.  It will probably take six to eight weeks for you to be ready. 

Which should I have - tenotomy or tenodesis?

Both options are effective at removing the pain caused by a degenerate or damaged long head of biceps tendon.  Objective strength outcomes are not significantly different between patients who've had a tenotomy or tenodesis. The complication rate of tenodesis is slightly higher than for tenotomy.  However the tenodesis minimises the chance of a Popeye sign (altered muscle contour) and also the chance of cramping with heavy biceps loading. 

For most patients with biceps pain a tenotomy is a good option.  If however you are a very high-demand athletic person, especially a younger man, then you may choose to have a tenodesis over a tenotomy.   

When will I be followed up?

You will be seen at two weeks after your operation.  Depending on your progress, your on-going follow up will vary, but many patients can be discharged between three months and nine months after surgery

What can go wrong?

Keyhole Shoulder surgery is generally very safe, but specific risks of upper biceps surgery include:

Stiffness (5%), rarely needs surgery

Humeral fracture is a very rare risk following tenodesis, where the fixation slightly weakens the bone.  If the humerus does break, it may require surgery to fix it

Nerve injury is very rare

Popeye sign (discussed above) - this is expected in tenotomy in 50% of cases, but uncommon after tenodesis

Cramping is occasionally reported in high-demand patients after a tenotomy, and rarely after a tenodesis procedure.  This is an ache felt in the upper arm on endurance loading of the biceps muscle.

Scarring - a sub pectoral tenodesis has to be done through a small (3cm) incision at the front of your armpit crease.  This usually heals well, but may occsionally create an unsightly or widened scar.