Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-013-2587-8

SHOULDER

Tenotomy or tenodesis for long head biceps lesions in shoulders

with reparable rotator cuff tears: a prospective randomised trial
Qiang Zhang Jiaojiao Zhou Hengan Ge
Biao Cheng

Received: 12 January 2013 / Accepted: 24 June 2013

Springer-Verlag Berlin Heidelberg 2013

Abstract
Purpose Tenotomy and tenodesis are both effective for
the treatment of long head biceps lesions. The aim of this
study was to compare the clinical outcomes of the two
procedures in patients older than 55 years of age affected
by reparable rotator cuff tears with concomitant long head
biceps pathologies.
Methods Patients older than 55 years of age with long
head biceps lesions and reparable rotator cuff tears were
selected for this study. A total of 151 patients were randomly assigned to the tenotomy group (77 patients) or the
tenodesis group (74 patients). Arthroscopic rotator cuff
repair was performed in all the patients. Before surgery,
physical and radiological examinations were performed;
the constant score was measured as well. After the operation, the surgical time, cost, pain (VAS scores), Popeye
sign, cramping pain, constant scores, satisfaction level and
the elbow flexion and forearm supination strength indices
were recorded.
Results Patients were followed for an average of
24 months. No significant differences in the clinical results
for the constant scores, the forearm supination and elbow
flexion strength indices, Popeye sign, cramping pain and
satisfaction level were found between the groups. However, tenotomy required a shorter surgical time (40.4 4.0

Q. Zhang
J. Zhou
H. Ge
B. Cheng (&)

Department of Orthopaedics, Shanghai Tenth Peoples Hospital,
School of Medicine, Tongji University, 301 Yanchang Middle
Road, Shanghai 200072, China
e-mail: cbiaob@163.com
Q. Zhang
J. Zhou
H. Ge
First Clinical Medical College, Nanjing Medical University,
Nanjing, China

vs. 50.4 5.9 min, P \ 0.001) and resulted in faster pain

relief (3.1 1.8 vs. 4.8 1.9, P \ 0.001).
Conclusion Both tenotomy and tenodesis are effective
and equal for the treatment of long head biceps lesions.
However, because tenotomy requires a shorter surgical
time and results in faster pain relief, tenotomy may be more
suitable for the treatment of long head biceps lesions in
patients older than 55 years of age with reparable rotator
cuff tears.
Level of evidence Therapeutic studies, Level I.
Keywords Long head of the biceps tendon
Tenotomy

Tenodesis
Rotator cuff
Abbreviations
LHBT Long head of the biceps tendon
SLAP Superior labrum anteriorposterior
SI
Strength index

Introduction
The lesion of the long head of the biceps tendon (LHBT) is
a common cause of anterior shoulder pain, which results in
marked functional impairment. LHBT pathologies can be
divided into inflammation, instability and traumatic lesions
[4]. Although isolated biceps tendinitis has been described,
LHBT pathologies more commonly present (in almost
95 % of the patients) in combination with other shoulder
pathologies, mostly combined with rotator cuff tears in
elderly patients [13, 23, 24, 27].
To date, no clearly defined treatment protocol for LHBT
injuries has been established. However, there is a consensus that severe lesions should be treated with either

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tenotomy or tenodesis, with both favourable results [22].

Only a small number of studies have directly compared the
two procedures, and the results were controversial [6, 8, 9,
19, 25, 31]. Nevertheless, the following consensus appears
to have been reached: patients over 5560 years old should
undergo a biceps tenotomy, whereas patients younger than
50 years or patients of any age involved in heavy labour
should undergo a biceps tenodesis [2, 3, 16]. However, no
study with a high level of evidence directly supports this
consensus.
This study aimed to compare the clinical and functional
outcomes between tenotomy and tenodesis in the treatment
of patients older than 55 years of age with reparable rotator
cuff tears.

is reversible, partial debridement may be selected as the

treatment [30]. After the arthroscopic examination, 160
patients were selected and enrolled in the study. However,
eight patients (three tenotomy and five tenodesis) were lost
to follow-up due to the failed repair of the rotator cuff (five
patients), loss of contact (two patients) and death (one
patient). One patient was excluded additionally for the
fracture of the head of the humerus during follow-up. Thus,
80 female (53 %) and 71 male (47 %) patients with a
median of 61 (range of 5571) years of age were included
in this study. There were 77 patients in the tenotomy group
and 74 patients in the tenodesis group. The flow chart of
the process of patient enrolment is shown in Fig. 1.
Surgical technique

Materials and methods

Tenotomy

All of the arthroscopic LHBT tenotomy and tenodesis

procedures were performed by the same surgeon from 2008
to 2010. Preoperative physical and radiological examinations (magnetic resonance image (MRI), ultrasound,
radiographic and 3D CT reconstruction), which were confirmed by experienced doctors, were used for the clinical
diagnosis of the rotator cuff tears, LHBT lesions and other
pathologies. All the patients had not improved after nonoperative treatments, such as physical therapy and medication with or without corticosteroid injections. Patients
affected by both rotator cuff tears and LHBT pathologies
were eligible for this study. The exclusion criteria included
age younger than 55 with previous surgical treatment on
the affected shoulder, radiological signs of glenohumeral
arthritic and disability at the contralateral arm. Thus, a total
of 204 patients were enrolled in this study. The advantages
and disadvantages of tenotomy and tenodesis, including
Popeye deformity, cramping pain, cost, strength impairment and the rehabilitation procedure, were explained to
these 204 patients. The patients were then randomly
assigned to either the tenotomy or the tenodesis group
through a randomisation process using numbers in a sealed
envelope, which was provided by an independent
researcher. All the patients then underwent an arthroscopic
examination for further diagnosis of rotator cuff and LHBT
pathologies. During the arthroscopic exploration, the surgical decision was made in terms of the intra-operative
findings of reparable rotator cuff tears (small to large fullthickness rotator cuff tears; massive irreparable tears were
excluded) and associated LHBT lesions: severe inflammation or hypertrophy [5, 21], instability with or without a
subscapularis or biceps sling tear [20], partial thickness
tears of 2550 % or greater [20, 30], type IV SLAP tear
and symptomatic type II SLAP tear [3, 12, 30]. If the
partial tear is considered less than 25 % or the biceps lesion

Standard posterior and anterior portals were used for the

glenohumeral joint exploration, and the LHBT was evaluated for any pathological change (Fig. 2). The tendon was
debrided and cut as close as possible to the labrum (Fig. 3).

123

Tenodesis
A suture anchor was inserted into the intertubercular
groove. Using a penetrator or a suture hook, the biceps
tendon was penetrated and grasped with monofilament. The
two Fiberwire sutures were then passed through the biceps
tendon (Fig. 4). Then, the LHBT was cut and the stump
was removed.
Arthroscopic rotator cuff repair and extensive bursectomy were performed in all the patients. In addition,
acromioplasty or distal clavicle resection was also performed if needed.
Post-operative rehabilitation
All the patients (tenotomy or tenodesis) followed the routine rehabilitation procedures after rotator cuff repair.
There was no additional procedure for tenotomy, except
immobilisation of their elbow motion for 1 week. However, the patients treated with tenodesis progressed to
passive range of motion of the elbow 1 week post operation and active range of motion and gentle strength training
6 weeks post operation. Unrestricted use of the biceps
muscle was not allowed until 1620 weeks post operation.
Follow-up evaluation
The patients were followed up conventionally until
24 months after surgery. Constant score was evaluated
before the operation and at the final follow-up. The time of

Knee Surg Sports Traumatol Arthrosc

Fig. 1 Flow diagram of the trial

Enrollment

Clinical diagnosis of rotator cuff tears and LHBT

lesions; failed after at least 3 months nonoperative treatment (n=301)

Excluded (n=97)

Randomized (n=204)

younger than 55 (n=42)

rejected to participate (n=27)
reported previous surgical treatment on the affected
shoulder (n=12)
combined radiological signs of glenohumeral arthritic
(n=16)

Allocation
Allocated to tenotomy (n=103)
Finally enrolled (n=80)

Allocated to tenodesis (n=101)

Finally enrolled (n=80)

Excluded (irreparable rotator cuff tears, LHBT

pathologies just need partial debridement) (n=23)

Excluded (irreparable rotator cuff tears, LHBT

pathologies just need partial debridement)
(n=21)

Follow-Up
Lost to follow-up (failure of the repair of rotator cuff,
n=2; loss of contact, n=1; death, n=1)

Lost to follow-up (fracture of the head of humerus,

n=1; failure of the repair of rotator cuff, n=3; loss of
contact, n=1)

Analysis
Analysed (n=77)

Analysed (n=74)

Fig. 2 Arthroscopic view of a severely inflamed LHBT (a) with

partial thickness tears

Fig. 3 Tenotomy of the LHBT (a) close to the labrum (b)

both procedures (just for the arthroscopic procedure) was

recorded. The pain was monitored using the visual analogue scale (VAS, range of 010) at weeks 2 and 4 after
surgery. At the final follow-up, the patients completed a
questionnaire focused on three questions: (1) Do you notice
any difference in the appearance of the biceps muscle? If
so, do you mind it? (2) Do you have any muscle spasms in
the biceps muscles? If so, define it as mild or severe. (3)
Are you satisfied with the surgery? Judge it as excellent,

good, fair or poor. Additionally, a Chatillon digital dynamometer was used to measure the peak strength of the
elbow flexion and the forearm supination. As the strength
differs significantly based on sex and dominant arm, the
strength index (SI) was selected, which was defined as the
strength of the surgical arm divided by the strength of
the contralateral arm [26]. All of the above-mentioned
evaluations were blinded and performed by an independent
experienced observer.

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(dichotomous variables). Differences between the groups

that exhibited satisfactory significance were compared with
the Wilcoxon test. A difference with a P value of less than
0.05 (5 %) was interpreted as significant. Because previous
studied found that almost 26.8 and 9.3 % of the patients
exhibited Popeye signs after tenotomy and tenodesis,
respectively [19], the sample size was calculated to be at
least 72 each group with a power of 80 % and a P value of
0.05 using a statistical programme (PASS 11).

Fig. 4 Arthroscopic suture anchor tenodesis of the LHBT (a)

Results

Ethics statement

The patients in the two groups were comparable because

there were no significant differences in their ages, genders,
biceps tendon pathologies and preoperatively constant
scores. All the patients were followed up for a median time
of 25 months (range of 2029 months). The characteristics
of the two groups are shown in Table 1.
The surgical time was about 10 min (P \ 0.001) higher
in the tenodesis group compared with the tenotomy group.
For the first 2 weeks, the pain scores on the VAS were
lower in the tenotomy group (P \ 0.001). However, the
pain scores became similar at week four.
The constant scores improved significantly and equally
in both groups. There was also no significant difference
between the two groups in terms of the elbow flexion and
the forearm supination SI.
Additionally, although Popeye deformation and cramping pain appeared more frequently in the tenotomy group,

Ethical approval for this prospective random control trial

was granted by the Ethics Committee of Shanghai Tenth
Peoples Hospital. The registration number was ChiCTRTRC-12002649. The subjects all confirmed that they
understood the study procedures, and written informed
consents were obtained.
Statistical analysis
The statistical analysis was performed using the SPSS
software (version 13.0). The pre- and post-operative constant scores were compared with paired sample t-tests. The
data between the two groups were compared with independent sample t-tests (continuous variables) and either
the Pearson v2 test or the continuity correction v2 test

Table 1 Comparison of the demographic data of the patients in the tenotomy and the tenodesis groups
Tenotomy

Tenodesis

Total

Number of patients

77

74

151

Age (years)

61 (5567)

61 (5571)

61 (5571)

Sex

36 males

35 males

71 males

41 females

39 females

80 females

Follow-up (months)

25 (2029)

25 (2029)

25 (2029)

Biceps tendon pathologies

(some cases overlapped)

Severe inflammation (18)

Severe inflammation (22)

Severe inflammation (40)

Tears more than 25 % (53)

Tears more than 25 % (50)

Tears more than 25 % (103)

subluxations or dislocations (17)

subluxations or dislocations (14)

subluxations or dislocations (31)

Type II or Type IV SLAP

lesions (19)

Type II or Type IV SLAP

lesions (17)

Type II or Type IV SLAP

lesions (36)

Rotator cuff tears

Rotator cuff repair technique

Small size (35)

Small size (36)

Small size (71)

Medial size (27)

Medial size (24)

Medial size (51)

Large size (15)

Large size (14)

Large size (29)

Single row (50)

Single row (49)

Single row (99)

Double row (27)

Double row (25)

Double row (52)

Acromioplasty

17

14

31

Distal clavicle resection

11

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Table 2 Comparison of the clinical results observed in the patients of
the tenotomy and the tenodesis groups

Post-constant

Tenotomy

Tenodesis

P Value

95.6 3.0

96.5 2.6

n.s.

d-constant

52.3 8.1

52.7 8.6

n.s.

Popeye sign

n.s.

Cramps pain

n.s.

VAS (2 weeks postoperatively)

3.1 1.8

4.8 1.9

P \ 0.001

VAS (4 weeks postoperatively)

2.0 1.1

2.1 1.6

n.s.
\0.001

Time (min)

40.4 4.0

50.4 5.9

Flexion strength index

0.9 0.2

0.9 0.2

n.s.

Supination strength index

0.9 0.2

0.9 0.1

n.s.

Excellent or good

65

60

n.s.

Fair

12

13

Poor

Degree of satisfaction

there was no statistically significant difference. Moreover,

of the nine patients who exhibited Popeye sign, only three
noticed the deformation (two in the tenotomy group and
one in the tenodesis group), and none of the patients were
bothered by it. And all of the cramps were mild and disappeared within 2 months post operation.
Most patients were satisfied with the surgery (excellent
or good). Of the 26 patients who judged the surgery as fair
or poor, four patients exhibited Popeye sign and three
patients experienced cramps; however, none of these
patients complained about these symptoms. Most of these
26 patients were disappointed with the surgery as a result
of the long and boring rehabilitation procedure. All of the
post-surgery evaluations are listed in Table 2.

Discussion
The most important finding of the study was that there
was no difference between the clinical outcomes of
tenotomy and tenodesis. However, because tenodesis
involves a longer surgical time and slower pain relief,
tenotomy might be more suitable for the patients older
than 55 years of age with LHBT pathologies and reparable rotator cuff tears.
According to a web-based survey of 1,084 orthopaedic
surgeons, most surgeons chose tenotomy in the setting of
large rotator cuff tears and combined LHBT instability in a
65-year-old male [29]. However, there is no high level of
evidence for this choice right now. Tenotomy is technically
simple, rapid and well tolerated, but there is a risk of
Popeye deformity (1770 %), cramping pain (924 %),

strength impairment and unknown long-term functional

deficits of the humeral head [1, 7, 1118, 32, 33, 34].
Tenodesis is able to avoid or reduce these above-mentioned
disadvantages [2]. Nevertheless, it exhibits a number of
potential problems: recurrent shoulder pain, biomechanical
changes in the humeral head, symptomatic fixation or
hardware and a failure of fixation. As both tenotomy and
tenodesis show favourable results and various limitations,
it is hard to choose the optimal treatment.
This study showed the existence of LHBT had no benefits for strength, consistent with the hypothesis that the
LHBT is a vestigial structure with no function [28]. Or as
the patients included were mostly retired and will not
participate in heavy labour, there was no need for the
additional function of biceps caused by LHBT. Additionally, the strength impairment of the biceps might not result
from the surgical procedures but was due to the myatrophy
of disuse before and after surgery.
Popeye deformity and cramping pain were two important reasons for not choosing tenotomy. However, this
study showed that the deformity is minimally noticeable
and the cramping pain was mild and gradually disappeared
after two months. On the other hand, the incidence of
Popeye sign after tenotomy in this study (9.1 %) was lower
than that reported in most previous studies (1770 %) [6,
10, 12, 16, 19]. The T-shaped structure at the end of the
LBHT might help to form autotenodesis and avoid distal
migration of the LHBT. In addition, the long and strict
immobilisation process in this study compared with those
processes used for the treatment of isolated LHBT
pathologies made it more likely to form autotenodesis.
Most of the patients were satisfied with both procedures.
Patient satisfaction was affected mostly by the rehabilitation procedures which were long, boring and unbearable.
However, as rotator cuff repair was performed in all
patients, the rehabilitation procedure was similar between
the groups. Thus, it slightly offset the fact that the rehabilitation procedure was longer and more complex after
tenodesis for isolated LHBT pathologies.
This study was the first research of high level of evidence to support the consensus that patients over 55 years
old should undergo a biceps tenotomy. However, there are
several limitations to this study. First, patients were not
divided into subgroups based on the size of the rotator cuff
tears, which might affect the treatment results. Second,
there are several other tenodesis techniques, such as subpectoral tenodesis and soft tissue tenodesis. These other
techniques may have different effects compared with those
obtained from suture anchor tenodesis in the biceps groove.
Third, the long-term effects of tenotomy and tenodesis,
such as biomechanical changes over the glenohumeral
joint, should not be ignored. Thus, a follow-up period of
2 years is not sufficiently long.

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Conclusion
Tenotomy may be more suitable for the treatment of long
head biceps lesions in patients older than 55 of age with
reparable rotator cuff tears for the shorter surgical time,
faster pain relief and similar clinical outcomes compared
with tenodesis.
Acknowledgments The authors thank Dr. Sun Yeqing and Yang
Chunxi for the follow-up assessment.

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