Overview
The long head of the biceps runs from the top of the shoulder socket, through the joint, and down a groove on the front of the humerus. That path through the joint is where it becomes inflamed, frays, or is pulled on by a torn labrum. Biceps tenodesis cuts the tendon at its origin inside the joint and re-anchors it to the humerus just below the groove. The pain generator is removed, the muscle keeps its length and contour, and elbow flexion and forearm rotation strength are preserved.
For most patients the result is relief of anterior shoulder pain and the ache down the front of the arm, without the Popeye bulge or cramping that can follow simply cutting the tendon. The procedure is arthroscopic and outpatient at Bayside Surgery Center.
Who It's For
Tenodesis is recommended for biceps tendinitis or a partial tear that has not settled after three months of therapy and an ultrasound-guided injection into the biceps sheath, for a tendon that has slipped out of its groove (subluxation) and snaps, and for a proximal biceps rupture in a patient who wants the arm's contour and supination strength restored. It is also the preferred treatment for a SLAP tear in patients over about 35, and in any patient whose SLAP repair has failed, because reattaching a degenerate labrum in that group leads to stiffness and continued pain more often than tenodesis does. It is often done alongside a rotator cuff repair, since a frayed biceps is a common reason for residual pain after a successful cuff repair.
A young overhead athlete with an unstable SLAP tear and a healthy tendon is usually better served by a labral repair (see shoulder stabilization). Older patients with a painful degenerate tendon who do not need supination strength, and who do not mind a change in the arm's shape, can have a simple tenotomy with almost no restrictions afterward; Dr. O'Donnell discusses that trade-off before surgery.
Biceps fraying or a labral signal change on MRI is not by itself an indication for tenodesis; both are common on scans of shoulders that do not hurt. Dr. O'Donnell recommends the operation only when the tenderness in the groove, the Speed and O'Brien tests and the imaging point to the same tendon, and a course of therapy and an injection have not settled it. See biceps tendinitis and SLAP tears.
What the Procedure Involves
Surgery is performed under an interscalene block and general anesthesia. The joint is inspected through a posterior portal to confirm the diagnosis and check the labrum, cuff and cartilage. The biceps is examined by pulling it into the joint, which shows fraying that MRI often misses, and is then released from the top of the labrum.
The free tendon is retrieved outside the joint and fixed to the humerus at the bottom of the bicipital groove, so the inflamed portion of the tendon and its sheath are removed rather than left behind. Fixation uses either an interference screw in a small bone tunnel or a suture anchor; both hold the tendon at its correct resting length, set by tensioning the muscle before fixation. The arthroscopic suprapectoral position is used for most patients; a mini-open subpectoral tenodesis through a 2 cm incision in the armpit crease is chosen when the groove itself is inflamed or the tendon is badly degenerate. Any cuff, labral or subacromial problem found at the same time is treated in the same sitting.
The operation takes about 45 to 60 minutes alone. The arm is placed in a sling and patients go home the same day.
Risks & How They Are Minimized
The specific risk of tenodesis is that the fixation fails before the tendon heals to bone, producing the Popeye deformity the operation is meant to avoid. This happens when resisted elbow flexion or forearm supination is loaded too early, so the protocol prohibits resisted biceps activity for six to eight weeks and lifting until cleared. Persistent groove pain is avoided by placing the fixation below the groove. Stiffness is uncommon because shoulder motion begins immediately.
Infection is rare and is guarded against with preoperative antibiotics and small incisions. The musculocutaneous nerve lies near a subpectoral tenodesis site and is protected by careful retractor placement; block-related numbness clears within a day. A humeral fracture through the tunnel is a rare risk of screw fixation, minimized by keeping the tunnel small relative to the bone. Blood clots are unusual after shoulder arthroscopy; patients walk the same day and those with risk factors take aspirin for two weeks.
Recovery & Rehabilitation
Dr. O'Donnell's tenodesis protocol restores shoulder motion while the biceps fixation is protected. When a rotator cuff repair is done at the same time, the slower cuff protocol takes precedence.
| Phase | Timing | What happens |
|---|---|---|
| Protection | Weeks 0–4 | Sling except for exercise. Pendulums, passive and active-assisted shoulder flexion and external rotation within comfort, gentle passive elbow motion, scapular setting, ice. No active or resisted elbow flexion or supination; no shoulder extension stretch. |
| Active motion | Weeks 4–8 | Sling weaned. Active shoulder motion in all planes, full unresisted elbow flexion, extension and forearm rotation, scapular and rotator cuff isometrics, posture work. No resisted biceps activity until 6–8 weeks. |
| Strengthening | Weeks 8–12 | Progressive rotator cuff and scapular strengthening; progressive biceps flexion and supination strengthening begins; endurance work. Advance at 80% of the strength of the other side. |
| Return to activity | Months 3–4 | Advanced strengthening and sport- or job-specific progression. Full activity once strength is symmetric and function painless. |
Desk work is possible within a few days, driving at two to four weeks once the sling is off, and gym work, swimming, golf and tennis by three to four months.
Protocol summary
The sling is worn for two to four weeks. The fixation is protected by avoiding resisted elbow flexion and forearm supination for six to eight weeks, by avoiding forceful shoulder extension and passive biceps stretching early, and by not lifting with the operative arm until cleared. Passive and active-assisted shoulder motion begins in the first week.
Progression requires controlled pain and improving passive motion to leave Phase I, full active shoulder and elbow motion to begin strengthening at eight weeks, and 80% of the opposite side's strength with full painless motion to enter the return-to-activity phase at about three months.
Physical Therapy Protocol
Arthroscopic Biceps Tenodesis PDF ↗Frequently Asked Questions
What is the difference between biceps tenodesis and tenotomy?
Both release the long head of the biceps from inside the joint. Tenotomy stops there and lets the tendon retract, which relieves pain but can leave a Popeye bulge and some cramping or loss of supination strength. Tenodesis re-anchors the tendon to the humerus, preserving the muscle's shape and strength at the cost of six to eight weeks of protecting the fixation.
Will I lose strength in my arm after biceps tenodesis?
No lasting loss is expected. The long head is one of two heads of the biceps, and after tenodesis it works at its normal length from a new attachment. Elbow flexion and supination strength return through the strengthening phase from week eight and are usually symmetric by three to four months.
How long am I in a sling after biceps tenodesis?
Two to four weeks. Shoulder motion starts in the first week, so the sling is mostly for comfort and as a reminder not to lift. The more important restriction is no resisted elbow bending or forearm twisting, such as carrying a bag or turning a stiff door handle, for six to eight weeks.
When can I drive after biceps tenodesis?
Usually at two to four weeks, once the sling is off, you are not taking prescription pain medication and you can turn the wheel comfortably. Driving is not permitted in a sling, and gripping and twisting the wheel hard is a form of resisted supination, so keep early drives short and local.
When can I lift weights or play sport after biceps tenodesis?
Rotator cuff and scapular strengthening begins at eight weeks and biceps curls and supination work at eight to twelve weeks. Swimming, golf, tennis and unrestricted gym training return at three to four months once strength is symmetric. The criteria for each phase are in the biceps tenodesis protocol.
This page is for general education and is not a substitute for a medical evaluation. The right procedure depends on your individual diagnosis, anatomy, and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.