1 Introduction

The long head of the biceps tendon (LHBT) lesions, including dislocation, subluxation, partial tears and tendinitis, are frequently associated with partial or complete rotator cuff tears (RCTs), particularly in elderly patients.^1–8 In 1972, Neer⁹ reported that 95% of cases of biceps tendinitis are a result of impingement syndrome, and in 1982 Neviaser et al.¹⁰ called attention to the strong association between rotator cuff tears and abnormalities of the biceps tendon. In a study by Walch et al.¹¹ in 1998, of the 445 patients with rotator cuff tears who were studied, 16% presented with associated biceps tendon dislocation or subluxation.

In 1990, Patte et al.¹² also observed the analgesic effect of spontaneous rupture of the LHBT and proposed simple arthroscopic tenotomy as a palliative treatment in patients with irreparable rotator cuff tears. Full-thickness rotator cuff tears are commonly associated with lesions of the long head of biceps, contributing to anterior shoulder pain and forward flexion dysfunction.^8,13 Additionally, Ahmad et al.¹⁴ observed that diseased LHBT, in cadavers, have an increased cross-sectional area and a higher average load to failure compared with the healthy tendons. The authors also reported a relative stenosis of the bicipital groove in these shoulders, enhancing the hypothesis of the parallel degeneration model of the LHBT with the rotator cuff tendons.

According to the literature, no classification system has yet been established that describes LHBT lesions as a type of biceps pathology associated with RCTs. Chen et al.¹⁵ proposed a simplified classification system of LHBT lesions combined with RCTs. The study included five types of lesions: tendinitis, subluxation, dislocation, partial tear, and complete ruptures. More recently the same main author¹⁶ after reviewing 176 shoulders with complete, full-thickness RCTs defined six types of LHBT pathology: tendinitis (Type I), subluxation (Type II), dislocations (Type III), partial tears (Type IV), complete tears (Type V), and SLAP lesions (Type VI). Nevertheless, these retrospective publications need longer follow-up and further studies to confirm previous observations and to enhance surgical management.

The most frequently used surgical modalities for these lesions are tenotomy, tenodesis or debridement¹⁷ and all these surgical techniques have been demonstrated to be effective in alleviating pain and improving activities of daily life in patients with massive cuff tears,^1,2,4,7,8 but controversy revolves around optimal treatment for these lesions.

Partial tears involving less than 25% of the LHBT can be treated conservatively with partial debridement or observation. However, when the biceps tendon shows subluxation or a tear greater than 30%, surgical treatment such as tenotomy^8,11,18 or tenodesis^19,20 is considered necessary. Even so, debate continues regarding the use of simple tenotomy instead of tenodesis for the treatment of LHBT lesions. Different studies have reported widely variable differences in the clinical outcomes of these two surgical methods of treatment, and no clear-cut advantage of any one of those two treatment modalities has been proven to date.^21–24

Additionally, there is no standard management algorithm of LHBT lesions due to lack of studies with high levels of evidence. Unofficially, a general approach suggests biceps tenotomy in patients over 55–60 years old, while heavy laborers and younger active patients may benefit from tenodesis.¹⁹ Some others advocate routine biceps tenodesis with rotator-cuff repair²⁵ or tenotomy if a massive tear proves irrepairable.⁸ Hence this article aims to review the current literature available on the role of biceps surgery in rotator cuff surgery, whether it should be routinely performed, and whether tenotomy or tenodesis is the preferred surgical option.

2 Role of biceps surgery in rotator cuff repair

Pathology of the LHBT is frequently observed in the setting of rotator cuff tears and when a significant tear or instability of the LHBT is identified during a planned rotator cuff repair, a biceps tenotomy or tenodesis is typically performed.^13,15 Despite the exact pathology, the LHBT is known to be a persistent pain generator in most cases of rotator cuff disease or impingement processes, and surgical intervention is often indicated.^26,27

RCTs may produce more pressure and friction on the LHBT, resulting in the high risk for lesions of LHBT.²⁸ Accordingly, RCTs are often involved with LHBT lesions, causing significant shoulder pain and dysfunction. These lesions may vary in degree, ranging from minor tendinitis to a complete rupture.²⁹ The diagnosis for these lesions is often difficult, and it is a tough decision for surgeons to choose an optimal treatment.

In subscapularis tears, the biceps pulley is nearly always disrupted or damaged and dynamic arthroscopic exploration of the shoulder has shown that instability and entrapment of the LHBT is frequent.²⁵ Surgical repair of the anterior portion of the supraspinatus or subscapularis is unlikely to allow normal movement of the biceps in the groove or at the entry to the joint, and clinical studies have shown that associated biceps tenodesis improves the results of repair of the cuff in the long term.³⁰ As such, to many, the biceps tendon is an important consideration and some even advocate routine biceps tenodesis in patients with rotator cuff tears²⁵ or tenotomy if a massive lesion proves irrepairable.⁸

In loss of active elevation associated with a large rotator cuff tear, tenotomy or tenodesis of the LHB can be effective in restoring active elevation when surgical repair of the rotator cuff is not indicated or is not feasible. However, patients with true ‘pseudoparalytic shoulder’ (and thus insufficient strength to maintain the extended arm above the horizontal) will not benefit from tenotomy and is considered a contraindication to biceps tenotomy or tenodesis.²⁵

Watson et al.³¹ compared the outcomes of patients who underwent an LHBT procedure (tenotomy or tenodesis) concomitant and Rotator Cuff Repair (RCR) with those of patients who undergo isolated RCR at 1-year follow-up. The study found that the LHBT procedure group had significantly worse baseline ASES scores (mean, 48.9 vs 58.7; P = .032), supporting the theory of LHBT pathology being a significant pain generator and limiter of shoulder function in patients with RCTs. Patients who had either LHBT tenotomy or tenodesis (n = 45) demonstrated significantly greater mean improvement in American Shoulder and Elbow Surgeons score (ASES) (mean, 42.7 vs 23.8; P = .002), VAS (mean, 49.2 vs 35.7; P = .020), and Western Ontario Rotator Cuff score (WORC) scores (mean, 928 vs 743; P = .029) at 1-year follow-up as compared to patients who had isolated RCR. Linear regression also found biceps procedure to be predictive of a significantly greater improvement in ASES score (P = .01). Analysis of variance revealed that both the LHBT tenotomy (P = .04) and tenodesis (P = .01) groups demonstrated more favorable improvement in ASES when compared with RCR alone.

Similarly, Gill et al.²⁸ demonstrated a significant reduction in pain and improvement in function in a study of 30 patients who underwent isolated biceps tenotomy, 12 of whom had a pre-operative diagnosis of rotator cuff tear.

Baumgarten et al.³² compared pre-operative, patient-determined outcomes scores of patients undergoing primary arthroscopic RCR with and without biceps tenodesis with post-operative scores at a minimum of 2 years follow-up. Both groups had improvements in WORC, ASES, Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) (P < .0001) scores. However, there was no difference in the change in outcome scores between the groups for WORC (46 vs. 47; P = .85), ASES (46 vs. 47; P = .82), SANE (53 vs. 51; P = .35) and SST (5.8 vs. 5.8; P = .93). There was also no difference between the groups in complications that required revision surgery (1.5% vs. 1.3%; P = .91). As such, the authors concluded that arthroscopic biceps tenodesis with RCR is safe and effective with equivalent patient-determined outcomes compared with patients undergoing RCR without biceps tenodesis.

In another study, Ji et al.³³ studied the use of a new arthroscopic trans-tendon repair technique with tenotomized LHBT augmentation for high grade partial articular RCT with the goal of providing increased tendon healing, as well as to minimize the probability of failure of the construct and to improve the clinical outcomes. The clinical results of the first 39 consecutive patients were reported showing significant decrease in pain and improved shoulder scores, as well as the post-operative range of motion and with no cases of re-tear of the rotator cuff tendon. This is despite the fact that in high grade partial articular-sided degenerative rotator cuff tears (involving >50% of the tendon) in older patients, there is a possibility of poor healing or re-tear of the rotator cuff repair, which may be associated with poor tendon quality and substantial thinning of the rotator cuff.

Overall, although results are varied, the current available literature still generally supports the view that biceps surgery does lead to improved clinical and patient-reported outcomes after RCR. However, whether such biceps surgery should be performed routinely and if so, whether tenotomy or tenodesis should be performed remains to be discussed.

3 Should biceps surgery be routinely done in rotator cuff repair

Some authors recommend routine tenotomy or tenodesis with rotator cuff repair,²⁵ while some only in association with tears of subscapularis, and others only in the presence of significant pathology of the biceps.

Anatomical and clinical studies have shown that there is a tendency towards degeneration of the tendon in the distal, extra-articular portion of the biceps.³⁴ In a series of 80 patients undergoing biceps tenodesis, only 49% of grossly inflamed, fibrotic and degenerated tendons were seen intra-articularly with the arthroscope.¹³ This study also found that the incidence of biceps pathology was directly proportional to the extent of disease of the rotator cuff and to the age of the patient. In subscapularis tears, the biceps pulley is nearly always disrupted or damaged and dynamic arthroscopic exploration of the shoulder has shown that instability and entrapment of the LHBT is frequent.²⁵ Surgical repair of the anterior portion of the supraspinatus or subscapularis is unlikely to allow normal movement of the biceps in the groove or at the entry to the joint, and clinical studies have shown that associated biceps tenodesis improves the results of repair of the cuff in the long term.³⁰ The functional role of the LHBT in glenohumeral stability and depression of the head is limited. Hence, retaining an abnormal tendon has more negative functional consequences than the loss of the tendon itself.

Furthermore, a number of failed rotator cuff repairs may be attributed to persistent problems with the LHBT. In a recent review on failed rotator cuff repairs, Desmoineaux³⁵ explained that the need for treatments to correct concomitant abnormalities during the cuff repair procedure should always be discussed – and of note, in thin but muscular patients, biceps tenodesis should be performed routinely to prevent downwards displacement of the biceps brachii muscle. Furthermore, rupture of the LHBT with retraction of the muscle belly produces an unsightly lump on the arm (Popeye sign), a complication which can be prevented by routine tenodesis or self-locking tenotomy removing the superior labrum.³⁶

Gialanella et al.³⁷ studied the role of biceps surgery on functional recovery after RCR. Ninety-three consecutive patients who had undergone surgery for full-thickness symptomatic rotator cuff tear and were undergoing rehabilitation were prospectively recruited, comparing the functional recovery of patients who underwent RCR and tendon biceps surgery (n = 25), with those who underwent RCR only (n = 68). In their study, patients with RCR and tendon biceps surgery were found to have lower final scores (36.5 ± 12.0 vs 49.3 ± 13.0, P < .001), effectiveness (40.6 ± 18.0 vs 60.3 ± 20.0, P < .001), and efficiency (0.80 ± 0.5 vs 1.19 ± 0.6, P = .010) in Constant score than those with RCR only at the end of rehabilitation. Moreover, they had a lower final score (53.3 ± 14.0 vs 64.5 ± 10.0, P < .001) and effectiveness (66.9 ± 21.0 vs 84.0 ± 16, P < .001) in Constant score 6months postoperatively. Gender was a determinant of final score, efficiency, and effectiveness in Constant score at the end of the rehabilitation period, while tendon biceps surgery was a determinant of final score and effectiveness in Constant score at the end of the rehabilitation period and at 6months postoperatively. Such findings support the case against routine biceps surgery with RCR due to possible poorer functional recovery at the end of rehabilitation and 6 months post-surgery. However, this study is limited by a small sample size and the lack of other commonly validated scoring systems such as ASES and WORC which are commonly used in other similar studies. Further studies are needed to determine the role of routine biceps surgery on functional recovery after RCR more conclusively.

4 Biceps tenodesis vs tenotomy

Although tenotomy and tenodesis have both been reported to produce good clinical results, there is a constant dilemma over the preferred treatment of RCTs combined with LHBT lesions. Biceps tenotomy is generally a more popular operative strategy in treating tendon lesions, especially when these lesions are accompanied by RCTs.²¹

There have been numerous research studies comparing the clinical outcomes of biceps tenotomy and tenodesis in treating LHBT lesions in recent years.^1,19,38–40 For example, in comparing tenotomy and tenodesis in treating LHBT degeneration with concomitant repairable rotator cuff tears, De Carli et al.³⁸ found that tenodesis did not provide more significant clinical or functional improvement than isolated tenotomy except for fewer incidences of the Popeye sign.³⁸ Koh et al.¹⁹ also found that suture anchor tenodesis of the LHBT could lead to less Popeye deformity than tenotomy, while surgical times and clinical results between tenotomy and tenodesis showed no statistical difference.

Single studies, systematic reviews^41,42 and meta-analyses have also been carried out, comparing these two techniques.^43,44 However, some of these studies included low-quality studies and different patient populations which might affect the results. For example, in the systematic review and meta-analysis by Leroux et al.,⁴³ there were 12 studies included, of which 6 were treated with tenodesis (levels 4), 3 were treated with tenotomy (levels 1 and 2) and only 3 directly compared the tenotomy and tenodesis (levels 1 and 2).⁴³ Furthermore, although pathology of the LHBT is most commonly encountered in the setting of RCTs, there are only a few reports on the treatment of biceps lesions combined with RCTs and currently no meta-analysis comparing the functional results of tenotomy or tenodesis of the LHBT associated with arthroscopic rotator cuff repair.

Arthroscopic tenotomy of the biceps was described in the French literature in 1990 and the clinical observation that spontaneous rupture of the LHBT could alleviate pain in rotator cuff disease led Walch et al.⁸ to develop arthroscopic tenotomy as a simple and reproducible technique in patients with massive, irreparable tears of the rotator cuff.

Although there is no consensus regarding choosing tenodesis or tenotomy, proponents of tenodesis describe several theoretic advantages, such as maintained cosmetic appearance, closer reproduction of normal anatomy, avoidance of atrophy, cramping, and fatigue, and an improved ability for return to physical activity.^30,41,45

Supporters of biceps tenotomy advocate that it is simple and short procedure, requires only simple post-operative rehabilitation, avoids implant complications, has very low surgical morbidity, and produces satisfactory pain relief with minimal function impairment.^39,46 In contrast, tenodesis takes longer surgical time than tenotomy.⁴⁷ Besides, it might be complicated to perform the tenodesis by identifying the biceps tendon in the subacromial space when impingement syndrome or partial-thickness RCT is present or the cuff tear size is small.

In a randomized and blinded study by Belay et al.,⁴⁸ the mean VAS pain score at 3 months was found to be lower with tenotomy, as compared to tenodesis, but Popeye deformity was found in 5/20 (25%) of tenotomy subjects versus 1/14 (7%) in tenodesis subjects. Hence, the authors concluded that the tenotomy group demonstrated greater incidence of cosmetic deformity but an earlier improvement in post-operative pain as compared to the tenodesis group.

Arthroscopic biceps tenotomy is an easy and fast procedure with less overall operating time and simpler post-operative rehabilitation compared with tenodesis.^3,14,49 However, it has drawbacks including possible “Popeye” sign causing poor cosmesis and deformed appearance of the profile of the arm,^1,4,8,50 loss of the LHBT capability of stabilizing the head of the humerus,² and possible onset of cramping pain or fatigue.^8,41 On the other hand, the tenodesis could theoretically avoid all these possible complications, even though a longer operating time and a longer rehabilitative procedure would be required.^2,4,6,29,51

Advocates of biceps tenodesis believe that tenodesis can better maintain the relationship between length and tension of tendon, avoid muscle atrophy, maintain elbow flexion and supination power, avoid cramping pain, and minimize cosmetic deformities.⁴⁷ Arthroscopic tenodesis of the biceps is becoming more popular with increasing operative experience and many studies have been published describing their variations and biomechanics.^{22,45,52–54}

There are a variety of described methods for performing biceps tenodesis using open and arthroscopic techniques. The LHB tendon is typically released from the origin and secured anywhere along the biceps groove from the glenohumeral joint to the pectoralis major tendon. Methods for securing the tendon have included keyhole and bone tunnel techniques, use of suture anchors, and use of interference screws.^22,52,53,55 Tenodesis associated with arthroplasty, fracture fixation, or repair of the rotator cuff, may more easily be performed with a suture or suture anchor technique, as a result of variations in access and the limited bone stock or space available for an interference screw. The site of tenodesis should be the intertubercular groove of the humerus to avoid potential dysfunction of the shoulder and pain.⁵⁶

Acromioplasty has also been carried out in association with a biceps tenotomy or tenodesis. Many years ago, Becker and Cofield⁵⁷ and Dines, Warren and Inglis⁵⁸ advised against bicipital tenodesis without decompression, but recent studies have found that associated acromioplasty has little or no additional value. Maynou et al.⁵⁹ found that in patients with massive, irreparable cuff tears, a complementary acromioplasty (n = 8) did not confer additional benefit in comparison to those operated on for tenotomy alone (n = 32). In their series of 307 patients followed between 2 and 14 years, Walch et al.⁸ found that concomitant acromioplasty was beneficial only in patients who had a normal acromiohumeral interval (>7 mm) and an isolated supraspinatus tear. Other patients did not benefit from acromioplasty, and indeed it may be detrimental in patients with pre-operative proximal migration of the head of the humerus. Thus, the role of acromioplasty in the surgical management of RCTs undergoing biceps tenodesis is limited and should only be considered in the relevant subgroup of patients instead of being routinely performed.

5 Ideal treatment of LHB disease

In a meta-analysis by Shang et al.,⁶⁰ it was found that when comparing biceps tenotomy and tenodesis groups, there was no significant differences in terms of ASES scores (p = .104), elbow flexion strength index (p = .910), forearm supination strength index (p = .391) and range of motion (p > .05), suggesting that there is minimal differences in terms of functional outcomes between tenotomy versus tenodesis in managing LHBT lesions. Instead, the pros and cons of each surgery should be taken into account in the context of the patient, to influence the decision of whether a tenotomy or tenodesis should be performed. Table 1 summarizes and compares the advantages and disadvantages associated with each procedure.

However, in considering such meta-analyses, it is important to note that the included studies in such studies are varied in methodological quality, and only few are randomized controlled trials. As such, strong evidence in favor of either tenotomy or tenodesis is still largely lacking, emphasising the need for more randomized controlled trials in this area. Of note is the BITE study protocol⁶¹: In this study, patients older than 50 years with a supraspinatus and/or infraspinatus tendon rupture sized smaller than 3 cm, who are encountered with LHBT pathology, will be randomized to either LHBT tenotomy or LHBT tenodesis and clinical and patient-reported data will be collected pre-operatively, 6 weeks, 3 months and 1 year after surgery. Treatment of LHBT lesions is performed differently around the world and meta analyses do not provide conclusive evidence in favor of one of these treatments. Hence, such randomized controlled trials will strengthen evidence on the risks and benefits of LHB tenotomy and tenodesis in adjunct to a rotator cuff repair, which is important for managing patient expectations.

In general, tenodesis results in a good or excellent result in 74% of the cases, cosmetic deformity (Popeye sign) in 8%, and persistent pain in 24% of cases.⁴² Tenotomy procedures result in good or excellent results in 77% of cases with 19% postoperative bicipital pain and 43% occurrence of Popeye sign.⁴²

However, the post-operative position and condition of the LHBT following simple tenotomy have not been adequately studied to date, nor have specific factors affecting the achievement or not of “natural tenodesis” been detected.

According to the “Italian Society for Muscles, Ligaments and Tendons – Rotator Cuff Tear Guidelines” (2015)⁶², when LHBT tears are associated with rotator cuff tears, surgical exploration and possible treatment is recommended if symptoms persist for more than 3 months after conservative treatment. However, according to the results reported in the currently available literature, it is not possible to give an absolute recommendation on which is the best type of treatment for the pathology of the LHBT. Tenotomy of the biceps is generally indicated in older patients with a sedentary lifestyle and low functional demand, and in obese patients who can accept cosmetic problems. Tenodesis of the LHBT is instead recommended in young patients under the age of 40 years who practice physical activity.

Moreover, of note, several new techniques to integrate biceps surgery into rotator cuff repairs have also been described recently. For instance, Checchia et al.²⁹ proposed a new arthroscopic technique that allows an exclusive arthroscopic tenodesis by including the biceps tendon in the rotator cuff suture, a surgical technique with a single suture of the rotator cuff that includes the biceps tendon.

When a tenodesis of the biceps is used, additional anchors and surgical dissection are typically required. This adds additional surgical time, morbidity of additional surgical dissection, and additional anchor load and cost. As such, Levy (2012)⁶³, has recently described a novel technique for arthroscopic biceps tenodesis that uses the anterior lateral row anchor of a double-row rotator cuff repair to simultaneously secure the biceps tenodesis and rotator cuff tear. This technique provides a simple, reproducible, cost-effective means of performing a simultaneous biceps tenodesis and double-row rotator cuff repair.

While further studies comparing the outcomes of these novel techniques with those of traditional techniques are still required, these new techniques of incorporating biceps surgery into rotator cuff repairs are still worth considering and could even be performed routinely with RCRs.

In conclusion, it must be our daily practice to inform all the patients about the two surgical options and the possible prevalence of cosmetic deformities, muscle cramps, or fatigue after tenotomy or pain at the groove after tenodesis. While there is clearly a role for biceps surgery in RCR, further studies are still required to determine if such surgery should be performed routinely instead of selectively in RCRs. Meanwhile, the decision for biceps surgery with RCR should be an individualised one based on assessment of each individual patient's biceps lesion, functional demands and expectations. Finally, when considering tenotomy versus tenodesis for the treatment of biceps lesions, literature guidelines^3,8 should be followed but higher-level studies are still needed in order to adopt a worldwide-accepted treatment algorithm.

Funding acknowledgements

None to declare.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.