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Biceps Tendinopathy and Long-Head Rupture

Long head of biceps tendinopathy and rupture: tenotomy vs tenodesis (corpus-synthesised).

106 citationsUpdated Oct 2026

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Overview

Pathology of the long head of the biceps tendon encompasses inflammation, instability, and rupture, each requiring specific diagnostic and nonoperative protocols [3]. High-resolution ultrasound is a reliable modality for confirming suspected tendon pathologies [1]. While treatment decisions are largely driven by expert opinion and patient preferences rather than robust randomized evidence [66], surgical management is indicated based on clinical presentation, physical examination findings, associated pathologies, and the failure of nonsurgical treatment [2]. Although comparative studies are lacking, tenotomy or tenodesis appears more reliable than pulley repair [161], and biceps tenodesis remains a reliable treatment for pathologic abnormalities [5].

Surgical options include arthroscopic tenotomy, which yields good objective improvement and high patient satisfaction in selected patients [36], and arthroscopic release, which is appropriate for chronic, refractory biceps tendinitis [37]. Tenodesis techniques, including all-arthroscopic approaches and soft tissue methods, provide suitable options for improved functional outcomes in labral and biceps pathology [18, 31]. At short-term follow-up of 1 year, no reoperations or revisions occurred for failed tenodesis using the arthroscopic-assisted locked loop suprapectoral technique [20], and tenodesis provided significant clinical improvement with high survivorship rates at 2 years postoperatively [22]. The 2-incision technique for late advancement and repair of chronic rupture is straightforward, requires minimal special equipment, and can be performed on an outpatient basis [6].

The role of biceps intervention in concurrent shoulder repairs remains nuanced. In isolated subscapularis tears, favorable outcomes are achieved by performing both tear repair and biceps tenodesis with a double-loaded single anchor [15], though functional outcomes of biceps stabilization during early subscapularis repair are comparable to tenodesis or tenotomy [16]. Routine tenodesis associated with arthroscopic subscapularis repair may not be necessary to ensure satisfactory short-term outcomes [69], and biceps pathology or treatment did not influence postoperative outcomes in arthroscopic subscapularis repairs regardless of tear size [26]. Conversely, untreated biceps pathology during rotator cuff repair resulted in decreased improvements in patient-reported outcomes and external rotation compared to patients without biceps pathology [25]. The long head of the biceps tendon promotes healing of the rotator cuff repair construct and remains worth considering as an augmentation when no intraoperative signs of tendon degeneration are present [28]. Current literature lacks consensus regarding the use of tenotomy versus tenodesis [38], and ongoing studies aim to establish clinical practice guidelines by identifying indications, optimal techniques, and advantages of each method [9, 58].

Anatomy & Pathophysiology

Bony Anatomy and Tendon Origin

The long head of the biceps originates from the bicipital tubercle at the superior rim of the glenoid and along the posterior superior rim of the glenoid and labrum [43]. Approximately 40% to 60% of the tendon attaches to the supraglenoid tubercle, located 5 mm medial to the superior glenoid rim, while the remaining fibers attach directly to the superior glenoid labrum [41]. Attachment patterns vary: type I involves entirely labral attachment, type II is predominantly posterior, type III has equal anterior and posterior contributions, and type IV is predominantly anterior [41]. The glenoid labrum consists of parallel collagen fibers coursing around the glenoid circumference, inserting on the superior rim medial to the articular cartilage margin through a fibrocartilage transitional zone [41]. A normal synovial recess exists between the meniscoid superior labrum and the articular cartilage extension over the superior glenoid rim [41]. The tendon is an intra-articular but extrasynovial structure that exits the shoulder through a capsular defect between the greater and lesser tuberosities, passing distally in the bicipital groove [43]. This groove is bounded by the greater and lesser tuberosities [21]. A shallow bicipital groove and supratubercular ridge above the lesser tubercle were thought to predispose to pathology [43]. The medial wall of the groove was higher, with an opening angle of 30 to 40 degrees in the largest fraction of patients [43].

Vascularity and Innervation

Vascularity to the glenoid labrum originates from the scapular, circumflex scapular, and posterior circumflex humeral arteries via capsular or periosteal vessels [41]. The inner portion of the labrum is avascular, and the superior labrum is less vascular compared with the inferior and posterior labrum [44]. Biceps tendon vascularity is provided primarily by the ascending branch of the anterior humeral circumflex artery within the bicipital groove [41]. An avascular zone exists at the proximal portion of the tendon, close to the superior glenoid [41]. Blood is also supplied from the thoracoacromial and brachial arteries via the osteotendinous and musculotendinous junctions, respectively [44]. A hypovascular zone near the tendon origin at the superior glenoid attachment corresponds to where it commonly tears at the long head of the biceps pulley near the proximal groove [44]. The tendon is innervated by thinly myelinated sensory neurons [44]. Most innervation occurs at the tendon origin, meaning pathology in this region can generate pain [44]. Innervation is supplied by branches of the musculocutaneous nerve (C5 and C6) [43].

Stabilizing Structures and Kinematics

Stability of the biceps within the bicipital groove is afforded by the biceps sling, or pulley, consisting of fibers from the subscapularis tendon, supraspinatus tendon, coracohumeral ligament, and superior glenohumeral ligament [41]. The long head of the biceps pulley is a capsuloligamentous complex comprising the superior glenohumeral ligament, the coracohumeral ligament, and fibers from the subscapularis and supraspinatus tendons [44]. The bicipital tendon does not move up and down in the groove; rather, the humerus moves down and up with adduction and abduction relative to the tendon [43]. From full adduction to full elevation of the arm, the groove moves a distance of up to 2 to 5 cm along the tendon [100]. Maximal excursion of the humeral head along the tendon results when the shoulder is in a position of maximal external rotation [100]. Minimal excursion is seen when the shoulder is in a position of maximal internal rotation [100]. The synovial pouch extends from the shoulder joint, lining the greater part of the intertubercular groove to facilitate excursion along the tendon [100].

Kinematic and Biomechanical Role

The long head of the biceps tendon has a minimal effect on in vivo glenohumeral kinematics [94]. However, loading the long head of the biceps significantly affects glenohumeral rotational range of motion, translations, and kinematics [107]. Biomechanical studies indicate that the long head contributes to stability of the glenohumeral joint in all directions, though in vivo studies have yet to establish this stabilizing effect [97]. The tendon has a stabilizing effect on the glenohumeral joint and counteracts humeral translation when the subscapularis or infraspinatus is affected by a simulated tear [117]. It has a pertinent biomechanical role in glenohumeral stability regardless of the condition of the superior labrum [127]. Loss of the long head attachment is manifested mainly as a 20% loss of supination strength and a smaller 8% loss of elbow flexion strength [43]. Lucas reported a 20% loss of elevation strength in external rotation with rupture of the long head of the biceps [43].

Pathophysiology and Disease Associations

Long head of the biceps tendinopathy is associated with age, with a 100% prevalence by age 85 on MRIs obtained for shoulder pain [12]. Long head of the biceps tendinopathy and rotator cuff tendinopathy are related and both are conditions of senescence [12]. Signal changes, thinning, and rupture of the tendon can be considered an expected aspect of aging [12]. Biceps tendinitis is rarely the primary cause of shoulder pain and is usually secondarily involved as part of an impingement syndrome or degenerative lesions of the rotator cuff [50]. In bicipital tendonitis, pain is almost always accompanied by rotator cuff symptoms [21]. Because of the relatively anterior position of the bicipital groove along the humeral head combined with humeral retroversion, the tendon is exposed to medial instability, which can increase the risk of tendon degeneration [49]. Variations of bicipital groove morphology can increase the risk of long head of the biceps tendon pathology [49]. Isolated long head of the biceps tendon pathology can occur but frequently is associated with other shoulder pathologies, especially rotator cuff pathology [49]. Primary long head of the biceps tendinitis usually occurs in younger patients who participate in overhead activities such as volleyball and baseball [49]. A subscapularis tear is associated with long head of the biceps medial instability [49]. A supraspinatus tear is associated with posterolateral instability of the long head of the biceps [49]. Bicipital instability is usually associated with rotator interval injury or subscapularis tendon injury, or both [50]. Intra-articular changes precede extra-articular changes in the biceps tendon after rotator cuff tears in a rat model [162]. Increased loading resulted in decreased mechanical properties along the entire length of the biceps tendon at both 4 and 8 weeks following rotator cuff detachments in a rat model [92]. The long head of the biceps is hypertrophied when paralysis or rupture of the supraspinatus has occurred, probably because the patient uses the muscle as a depressor of the humeral head [43].

Mechanisms of Injury

SLAP tears can be caused by forceful traction to the arm, direct compression loads, and repetitive overhead throwing [49]. Increased external rotation of the shoulder in the late cocking phase increases torsional force at the long head of the biceps root, resulting in a peel-back injury to the posterosuperior labrum [49]. Throwing athletes demonstrate increased shoulder external rotation and decreased internal rotation in abduction, which causes posterosuperior migration of the humeral head in the late cocking phase [49]. Increased external rotation results in greater torsional loads across the superior labrum from the more posteriorly oriented long head of the biceps tendon, causing the labrum and tendon to displace medially over the glenoid rim [49]. The proximal long head of the biceps tendon is a source of substantial anterior shoulder pain [49]. Long head of the biceps pathology includes tendinitis, tendinopathy, tears, subluxation, entrapment, delamination, and dislocation out of the bicipital groove [49]. The long head of the biceps tendon is a pain generator [106]. The long head of the biceps tendon is an important part of the functional anatomy of the normal shoulder [106].

Classification of Instability and Dislocation

Long head of the biceps tendon disorders are classified into inflammatory, unstable, or traumatic based on the original initiating event [35]. Subluxation types are defined by the location of the lesion relative to the bony groove: * Type I subluxation: Involves a partial or complete tear of the superior glenohumeral and coracohumeral ligaments, resulting in loss of restraint above the entrance to the groove [105]. * Type II subluxation: Involves a lesion below the entrance to the bony groove where the tendon slips over the medial rim and rides on the border of the lesser tuberosity [105]. The principal criterion is a partial rupture of the outer, superficial tendinous portions of the subscapularis muscle [105]. * Type III subluxation: Is caused by malunion or nonunion of the lesser tuberosity, which compromises medial bony restraint [105].

Dislocation types are defined by the integrity of the subscapularis tendon and the location of the displaced tendon: * Type I dislocation: Is extraarticular and combined with a partial tear of the subscapularis tendon [35]. The long head of the biceps tendon is completely dislocated to a point over the lesser tuberosity [90]. There is invariably a rupture of the common attachment of the superior glenohumeral ligament and coracohumeral ligament [90]. * Type II dislocation: Is intraarticular and combined with a full-thickness tear of the subscapularis tendon [35]. The long head of the biceps tendon is widened and flattened as a result of its contact with the lesser tuberosity [90]. The subscapularis tendon is torn from its attachment on the lesser tuberosity, and the long head of the biceps tendon is interposed into the joint space and displaced inferomedially [90].

Dislocation of the long head of the biceps tendon over a completely intact subscapularis tendon is very rare, occurring in only 3% of a series of 70 patients with subluxation and dislocations [90]. Approximately half of type II intraarticular dislocations of the long head of the biceps have a traumatic etiology [90]. Frank dislocations of the long head of the biceps are usually traumatic in origin and associated with complete tears of the subscapularis [21].

Anatomic Variants

Anatomic variants in the superior labrum include a sublabral foramen or absence of the superior labrum, often seen together with a cordlike middle glenohumeral ligament [44]. 3.3% of shoulders had a sublabral foramen [44]. 8.6% of shoulders had a sublabral foramen with a cordlike middle glenohumeral ligament, also called a Buford complex [44]. 1.5% of shoulders had an absent anterosuperior labrum [44]. Recognizing these anatomical variants intraoperatively is of critical importance because surgical repair can result in loss of external shoulder rotation [44].

Classification

Primary Etiologic Classification: Disorders of the long head of the biceps tendon are classified into inflammatory, unstable, or traumatic categories based on the original initiating event [35]. This framework organizes pathogenesis and facilitates the formulation of management protocols [35]. The distinction between these categories is not always clear, as degenerated and inflamed tendons are more prone to trauma, and repeated trauma may result in changes indistinguishable from inflammation [35].

Inflammatory Disorders: Inflammatory biceps tendon disorders include biceps tendinitis concurrent with rotator cuff disease and primary bicipital tendinitis [35].

Instability Disorders: Instability biceps tendon disorders include subluxation and dislocation [35]. Subluxation is classified into Type I (superior subluxation), Type II (unstable at proximal portion of groove), and Type III (subluxation following melanin or nonunion of lesser tuberosity) [35]. Dislocation is classified into Type I (extraarticular, combined with partial tear of subscapularis) and Type II (intraarticular, combined with full-thickness tear of subscapularis) [35].

Traumatic Disorders: Traumatic biceps tendon disorders include traumatic rupture and superior labral tears (SLAP lesion) [35]. Traumatic rupture is classified into Type I (partial) and Type II (complete) [35]. Superior labral tears associated with the long head of the biceps tendon are classified into Type I (significant fraying), Type II (complete detachment of biceps tendon and superior labrum from glenoid), Type III (“bucket-handle” tear of superior labrum), and Type IV (central superior labrum tear with extension into the biceps) [35].

Other Considerations: Diagnosis and nonoperative management of long head of biceps tendon disorders are categorized as inflammation, instability, and rupture [3]. A classification system for long head of the biceps pain exists that emphasizes the need for comprehensive evaluation to determine causative factors in developing a treatment program [53]. The Biceps Inflammation Section Integrity classification is used to evaluate the long head of the biceps tendon in the context of rotator cuff repair [51]. A classification of 12 variations of the intra-articular portion of the long head of the biceps tendon has been proposed, suggesting these congenital conditions may acquire pathologic significance due to partial detachment from mesothelial or synovial fusion with the inferior surface of the capsule [148].

Clinical Presentation

Pain Characteristics and Location

Patients with biceps tendonitis or subluxation consistently report pain localized to the bicipital groove [21]. This pain typically migrates laterally with external rotation of the arm [21]. In contrast, pain originating from rotator cuff tendonitis generally radiates to the deltoid insertion and remains stationary during arm rotation, a key distinction from biceps-related symptoms [21]. Patients with bicipital tendonitis often describe anterior arm pain, particularly exacerbated by extension and internal rotation [21]. As the disease progresses, rest pain and significant night pain may develop [21]. In longstanding cases, pain from the long head of the biceps tendon can spontaneously resolve following a full-thickness tendon rupture [21].

Instability and Mechanical Symptoms

Clinical assessment of biceps tendon instability, specifically subluxation, is extremely difficult [21]. Patients with biceps subluxation frequently report a painful snapping or clicking sensation in the shoulder, particularly during overhead movements transitioning from internal to external rotation [21]. The mechanism behind these snapping or clicking symptoms is unclear, given that the tendon is generally fixed in a luxated position [21]. Because subluxation typically occurs in the presence of partial or full-thickness rotator cuff defects, symptoms are usually concurrent with those associated with rotator cuff disease [21].

Diagnostic Challenges and Demographics

Diagnosing long head biceps tendon pathology remains challenging due to vague patient complaints and unreliable physical examination maneuvers [10]. The diagnosis of long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology is further complicated by limitations in MRI and arthroscopic visualization [57]. Surgeons must maintain a high level of suspicion and utilize specific techniques to prevent missing long head biceps tendon and subscapularis pathology [57]. The literature reveals a lack of consensus regarding which diagnostic elements are integral to establishing biceps involvement in injured throwing shoulders [39]. A high incidence of chronic inflammation of the long head of the biceps is observed in shoulders with benign-appearing intraarticular portions [59]. Consequently, long head of the biceps disease should be considered in patients with painful rotator cuff disease and arthritic shoulder conditions [59]. In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes [8]. Anterior shoulder pain attributed to the biceps tendon does not appear to be due to an inflammatory process in most cases [62]. The diagnosis of biceps tendinitis or long head of the biceps tearing at or before the time of surgery was an especially significant risk factor for revision surgery [14]. All three case reports of biceps rupture at the tendon-labrum junction involved patients aged around 40 years, considerably younger than the usual presentation for ruptures of the long head of the biceps [4].

Associated Pathology

Disorders of the long head of the biceps often occur in conjunction with other shoulder pathology [32]. The association of biceps tendon lesions requiring surgical repair and rotator cuff tears is not uncommon [27]. Subscapularis tears were associated with progressive thickening and degeneration of the long head of the biceps tendon at 4 and 12 weeks postoperatively [30]. Aberrant origins of the long head of the biceps can be seen with concomitant cuff tear pathology [24]. Nonsynovitic and nondegenerative aberrant biceps origins have not clearly contributed to other shoulder pathology [24].

Investigations

Clinical Examination

No single physical examination finding is completely accurate for the diagnosis of a SLAP tear [52]. A combined physical examination approach aids in the diagnosis of SLAP or long head of the biceps (LHB) pathology [52]. The "3-pack" examination consists of the active compression test, throwing test, and bicipital tunnel palpation [42]. These "3-pack" tests were highly sensitive (73% to 98%) for biceps-labrum complex disease [42].

Imaging

Plain radiography: Plain radiographs (scapular Y, AP, and axillary lateral views) should be obtained to assess the glenohumeral joint for abnormalities [109]. Radiography cannot be used to help discriminate between traumatic and nontraumatic rotator cuff lesions, a distinction for which MRI is required [176].

MRI: MRI may be used to assess the LHB tendon, associated fluid and possible synovitis, the morphology of the bicipital groove, and the presence of bony osteophytes [109]. It can also help identify concomitant shoulder and AC joint pathologies [109]. However, studies have demonstrated poor correlation between MRI and arthroscopic findings regarding LHB pathology [109]. MRI has poor to moderate sensitivity for inflammation, partial-thickness tendon tears, and tendon ruptures of the LHB [109]. The usefulness of MRI for the diagnosis of partial tears of the biceps tendon remains limited [63]. Biceps tendon pain in the absence of tears is associated with microscopic changes consistent with tendinopathy, which are often missed by MRI [149]. Focal partial tears of the biceps tendon at the entrance to the bicipital groove can be difficult to detect on MRI because of their anatomical location [166]. Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders [174].

Magnetic Resonance Arthrography (MRA): MRA is more specific and sensitive for LHB pathology and SLAP tears than MRI [109]. MRA helps diagnose LHB pathology and SLAP tears because it is more specific and more sensitive than MRI alone [52]. Both MRI and MRA should be performed in the sagittal oblique and axial planes because LHB subluxation and dislocation are often associated with partial-thickness and full-thickness subscapularis tendon tears [109]. Proton density–weighted sequences with fat suppression have the greatest sensitivity for detecting tendon degeneration [48]. Tendon caliber change is more specific for detecting tendon degeneration than signal intensity [48]. Diagnosing partial tears of the biceps tendon at the entrance to the bicipital groove can be challenging on MRI or MRA without directed effort [48]. Biceps tendon partial tears at the groove entrance show abnormal signal intensity, but half have an associated caliber change [48]. Evaluation in all imaging planes aids in the identification of a biceps groove entrance lesion [48]. MRA was found to have a sensitivity of 82% to 89% and a specificity of 87% to 98% in the evaluation of the biceps pulley [48]. Diagnostic criteria for biceps pulley evaluation on MRA included nonvisualization or discontinuity of the superior glenohumeral ligament, medial subluxation of the biceps tendon on axial images, biceps tendinopathy, and inferior displacement on oblique sagittal images [48].

CT Arthrography: CT arthrography is more sensitive and specific than MRI for identifying tendinopathy of the intra-articular portion of the long head of the biceps [19]. However, both CT arthrography and MR arthrography perform poorly in the detection of biceps tendon pathology of the shoulder [145].

Ultrasonography: Ultrasonography is accurate and cost-effective in the diagnosis of LHB dislocation, subluxation, and rupture [109]. It is not as accurate in diagnosing partial-thickness tendon tears [109]. The exact role of ultrasonography for the diagnosis of tendon inflammation has not been fully defined [109]. When measuring the long head of the biceps tendon, a mean of 2 measurements is recommended [67].

Associated Pathology and Diagnostic Pitfalls

The diagnosis of biceps tendinitis (OR, 3.5) or long head of the biceps tearing (OR, 5.1) at or before the time of surgery was an especially significant risk factor for revision surgery [14]. Surgeons should maintain a high level of suspicion and utilize specific techniques to prevent missing pathology when evaluating long head biceps tendon and subscapularis pathology in association with rotator cuff pathology [57]. In approximately 80% of the intra-articular biceps tears evaluated in a study of patients undergoing subpectoral tenodesis, a 'hidden lesion' was observed going beyond the bicipital groove and extending to the distal extra-articular portion [65]. Clinicians have been missing a significant number of rotator cuff tears by not routinely ordering MRI on patients with spontaneous proximal biceps tendon ruptures [72].

Treatment

Non-Operative

Nonsurgical management is the first-line treatment for mild long head of the biceps tendon disease and remains the mainstay for calcification at the long head [32, 167]. Conservative protocols include rest, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and corticosteroid injections [32, 89]. A comprehensive evaluation to determine causative factors is critical in developing an appropriate treatment program for the painful long head of the biceps [53]. Nonsurgical treatment can effectively resolve pain and restore function in patients with superior labrum anterior-posterior (SLAP) tears or biceps lesions [170]. Appropriate treatment, whether conservative or surgical, should be based on established pathology [45]. When measuring the long head of the biceps tendon with ultrasound, a mean of 2 measurements is recommended [67]. Recent commentary argues for reframing long head of biceps tendinopathy as a normal aspect of aging rather than a standalone problem, advocating for nonsurgical management strategies to reduce unhelpful interventions [175].

Operative

Indications: Surgical management is indicated for refractory or severe long head of the biceps tendon disease [32]. Surgical intervention is appropriate for symptomatic partial tears, subluxation, biceps pulley lesions, and some SLAP lesions [78]. The indication for arthroscopic biceps tenodesis is usually failure of conservative management of the associated shoulder disorder [82]. Common indications for arthroscopic biceps tenodesis include biceps tears involving >50% of the tendon, medial subluxation of the biceps tendon, and combined subscapularis tears and biceps subluxation [82]. Complete tears are rarely an indication for tenodesis unless there is chronic cramping in the biceps muscle belly with activity [82]. Arthroscopic tenotomy is indicated for severe biceps tendinopathy, partial or full-thickness biceps tendon tears, or biceps instability typically associated with rotator cuff tear [122]. In patients with tendinitis of the biceps long head tendon, an arthroscopic tenotomy can be performed [85]. The management of isolated long head of the biceps tendon pathology is usually non-operative, with surgical treatment reserved for recalcitrant cases after non-operative treatment [87].

Surgical Approach / Technique: Both tenotomy and tenodesis are effective and equal for the treatment of long head biceps lesions in shoulders with reparable rotator cuff tears [120]. Tenotomy is a relatively safe, simple, and quick procedure with shorter rehabilitation demands [87, 89]. Although biceps tenotomy is a much simpler procedure and requires less rehabilitation, it may result in a cosmetic deformity, possible cramping and fatigue pain of the biceps, and a decrease in elbow flexion and supination power [78]. Tenotomy is generally reserved for the elderly population or a patient population who may not frequently engage in strenuous physical activities involving the biceps and shoulder [89]. For younger patients or those who are more active, tenodesis has emerged as the recommended surgical procedure for addressing long head of the biceps pathology [89]. Proponents of tenodesis tout several advantages, including prevention of the Popeye deformity, maintenance of the length-tension relationship of the long head of the biceps tendon, and the subsequent preservation of strength in normal range [89]. Tenodesis is less associated with cramping and cosmetic deformity despite being a more demanding procedure, higher rate of surgical complications and more rigorous postoperative rehabilitation protocols [87]. Post-procedure outcomes for tenotomy have been documented to be comparable to those post-tenodesis [89]. Tenotomy has been found to be associated with a greater risk of a cosmetic “Popeye” deformity, along with symptoms of cramping, spasms, and quicker time to fatigue [89]. Intraoperative estimation of a possible postoperative Popeye deformity via stimulation of the musculocutaneous nerve may present a useful opportunity to decide whether biceps tenodesis is necessary after tenotomy [85].

Implant Selection: Open subpectoral tenodesis and arthroscopic biceps tenodesis both provide favorable outcomes, and neither technique has been shown to be superior to the other [78]. Arthroscopic suprapectoral and open subpectoral biceps tenodesis both yield excellent clinical and functional results for the management of isolated superior labrum or long head biceps pathology [60]. Biceps tenodesis can be performed with use of open or arthroscopic methods and has emerged as a preferred technique for the treatment of abnormalities of the long head of the biceps in younger persons, athletes, laborers, and those wishing to avoid likely cosmetic deformity [78]. Arthroscopic biceps tenodesis is a safe and reliable treatment for managing intra-articular biceps tendon pathology [151]. Tenotomy and open tenodesis are both safe options for treatment of biceps pathology with low 30-day postoperative complication rates [152]. Biceps tenodesis is a reliable surgical option for the treatment of symptomatic long head of the biceps tendon pathology, particularly in patients who have failed non-operative treatment and those undergoing concomitant shoulder procedures [171]. The biceps sling may be a reasonable alternative for treating symptomatic pathologic conditions of the long head biceps tendon [173]. This novel technique provides a safe, minimally invasive fixation of the long head of the biceps and may help to accelerate return to demanding professional and athletic activities [68]. These considerations underscore the need for further biomechanical and clinical evaluation regarding arthroscopic bicortical biceps anchorage [47].

Revision: Although revision to subpectoral biceps tenodesis may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized [71]. Patients who underwent long head of the biceps tenodesis for chronic or revision long head of the biceps rupture with concomitant rotator cuff repair were included in a study comparing primary versus revision open subpectoral biceps tenodesis [86]. In those patients, tenodesis of the long head of the biceps was indicated due to either the desire for a removal of deformity, the specific weakness or the localized pain in the biceps area, based on the SPBS [86].

Other Considerations: Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up [126, 132]. When indicated, biceps tenodesis offers an alternative to SLAP repair in young patients [146]. Biceps tenodesis is a viable option for management of proximal biceps injuries in patients less than 25 years of age [146]. High-quality randomized controlled trials are necessary to understand how different biceps management techniques truly perform [172]. Outcomes of shoulder biceps tenotomy versus tenodesis are difficult to determine from nonrandomized studies due to selection bias, with tenodesis more commonly performed on younger males [172]. The results of a study comparing tenotomy and tenodesis will help to establish clinical practice guidelines for patients suffering from lesions of the long head of the biceps brachii tendon [9]. The objective of a study was to identify the indications for surgical treatment, the best surgical technique, and the advantages and disadvantages of each technique described in the orthopedic literature for the treatment of long head of biceps tendon injuries [58].

Biceps tendon pathology is commonly associated with a torn subscapularis tendon [82]. In combined subscapularis tears and biceps subluxation, biceps tenodesis is done to protect the arthroscopic subscapularis repair [82]. Outcomes were similar regardless of tear size or concurrent repairs, and biceps pathology or treatment did not influence postoperative outcomes in patients undergoing arthroscopic subscapularis tendon repairs [26]. The long head of the biceps tendon promotes the healing of the rotator cuff repair construct and remains worth considering as an augmentation in cases with no intraoperative signs of tendon degeneration for massive and irreparable rotator cuff tears [28]. Concomitant biceps tenodesis appears to have a favorable effect on 1-year treatment success after total shoulder arthroplasty [144]. Both arthroscopic debridement and debridement combined with a biceps tenotomy yields high satisfactory shoulder function in elderly patients at long term for irreparable rotator cuff tears [156]. The surgical treatment for long head of the biceps tendon lesions is often carried out in the same setting of rotator cuff repairs, as 48–52% of cases with rotator cuff tears are associated with long head of the biceps tendinitis and subluxation/dislocation, respectively [87]. In patients undergoing biceps tenodesis or tenotomy with rotator cuff tears, all patients underwent the same postoperative protocol and were placed in a sling for 6 weeks with no weight bearing [88]. After immobilization, patients started active-assisted range of motion with physical therapy [88]. If tenodesis was performed, light resistive biceps strengthening was started at 8 weeks [88]. Strengthening of the rotator cuff was initiated at 12 weeks postoperatively with the goal of no physical therapy or restrictions required by 24 weeks postoperatively [88]. Rehabilitation did not vary based on the degree of rotator cuff tear [88].

Complications

Enthesophyte Formation: Biceps enthesophyte is a rare complication following biceps tenodesis [33].

Persistent Pain: Persistent pain is a potential complication of revision surgery for failed proximal biceps surgery [71].

Other Considerations: The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term [61]. In a study of 54 shoulders followed for an average of 13 years after tenodesis for chronic tendinitis, a satisfactory result was achieved in only 28 shoulders (approximately 50%) [164]. In the same cohort, an additional operation was performed in 8 shoulders (15%) [164]. Tenodesis of the long head of the biceps tendon was not an effective treatment for tendinitis over the long term in a study with an average follow-up of 13 years [164]. At a short-term follow-up of 1 year, no patients had reoperations or revisions for failed biceps tenodesis in a study of arthroscopic-assisted locked loop suprapectoral biceps tenodesis [20]. Biceps tenodesis provided high rates of survivorship 2 years postoperatively [22]. Arthroscopic biceps tenodesis has no long-term difference in clinical outcomes or complications compared with open subpectoral tenodesis [165].

Recovery

Diagnostic and Pathologic Context: The degeneration process and the presence of marginal inflammation are characteristic features of tendinopathy of the long head of the biceps tendon [75].

Operative Outcomes and Survivorship: In the context of arthroscopic-assisted locked loop suprapectoral biceps tenodesis, no patients required reoperations or revisions for failed tenodesis at a short-term follow-up of 1 year [20]. Following arthroscopic transfer of the long head of the biceps tendon, 97% of patients achieved resolution of their preoperative biceps symptoms [74]. In the setting of arthroscopic subscapularis tendon repairs, outcomes were similar regardless of tear size or concurrent repairs, and biceps pathology or treatment did not influence postoperative outcomes [26].

Risk Factors and Complications: The diagnosis of biceps tendinitis (OR, 3.5) or long head of the biceps tearing (OR, 5.1) at or before the time of surgery was an especially significant risk factor for revision surgery after superior labral anterior-posterior repair [14]. Subscapularis tears were associated with progressive thickening and degeneration of the long head of the biceps tendon at 4 and 12 weeks postoperatively, which was more significant in the intra- than in the extra-articular portion [30].

Key Evidence

• [L4] High-resolution ultrasound is reliable to confirm suspected long head of the biceps tendon pathologies. [1] (10.2340/16501977-2563)
• [L4] The decision to perform surgical management of long head of the biceps pathology depends on clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment. [2] (10.1177/2325967114s00246)
• [L5] Diagnosis and nonoperative management of long head of biceps tendon disorders are categorized as inflammation, instability, and rupture, requiring specific protocols. [3] (10.1016/j.csm.2015.08.006)
• [L4] All were aged around 40 years, considerably younger than the usual presentation for ruptures of the long head of the biceps. [4] (10.1016/j.jse.2004.03.003)
• [L3] Biceps tenodesis remains a reliable treatment for pathologic abnormality of the long head of the biceps. [5] (10.1177/0363546515570024)
• [L4] The 2-incision technique for late advancement and repair of chronic long head of biceps rupture is straightforward, requires a minimal amount of special equipment, and can be routinely performed on an outpatient basis. [6] (10.1097/bte.0b013e3181a4474c)
• [L4] In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes. [8] (10.1016/j.arthro.2018.01.021)
• [L1] The results of this study will help to establish clinical practice guidelines for patients suffering from lesions of the long head of the biceps brachii tendon. [9] (10.1186/1471-2474-13-205)
• [L5] Diagnosis of long head biceps tendon pathology remains challenging due to vague complaints and unreliable physical examination maneuvers. [10] (10.1136/jisakos-2017-000128)
• [L3] [12] (10.1097/corr.0000000000003342)
• [L3] The diagnosis of biceps tendinitis (OR, 3.5) or long head of the biceps tearing (OR, 5.1) at or before the time of surgery was an especially significant risk factor for revision surgery. [14] (10.1177/0363546517691950)
• [L4] In the presence of an isolated subscapularis tear associated with long head of the biceps tendon pathologies, favorable clinical outcomes could be achieved by performing both tear repair and biceps tenodesis with a double-loaded single anchor. [15] (10.1016/j.arthro.2024.07.026)
• [L4] The functional outcomes of stabilization of the long head of the biceps tendon in the context of early repair of a traumatic tear of the subscapularis tendon were comparable with the results of tenodesis or tenotomy reported in previous studies. [16] (10.2106/jbjs.f.01012)
• [Paper] All-arthroscopic tenodesis of the long head of the biceps provides a suitable option for improved functional outcomes in the treatment of labral and biceps pathology. [18] (10.1016/j.eats.2019.01.023)
• [L3] Imaging of the intra-articular portion of the long head of biceps remains challenging, with CT arthrography being more sensitive and specific than MRI for identifying tendinopathy. [19] (10.1016/j.otsr.2014.09.005)
• [L4] At a short-term follow-up of 1 year, no patients had reoperations or revisions for failed biceps tenodesis. [20] (10.1016/j.xrrt.2021.02.003)
• [L5] [21] (10.1097/00132589-200109000-00002)
• [L4] Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively. [22] (10.1016/j.arthro.2021.12.014)
• [L4] The authors suggest that aberrant origins of the long head of the biceps can be seen with concomitant cuff tear pathology, but nonsynovitic and nondegenerative biceps origins of this nature have not clearly contributed to other shoulder pathology. [24] (10.1016/j.jse.2012.08.007)
• [L3] Patients with untreated long head of the biceps tendon pathology during rotator cuff repair showed comparable failure rates and pain relief but had decreased improvements in patient-reported outcomes and external rotation compared to those without biceps pathology. [25] (10.1177/2325967125s00081)
• [L4] Outcomes were similar regardless of tear size or concurrent repairs, and biceps pathology or treatment did not influence postoperative outcomes. [26] (10.1016/j.arthro.2019.01.034)
• [L4] The association of biceps tendon lesions requiring surgical repair and rotator cuff tears is not uncommon. [27] (10.1016/j.jse.2004.07.013)
• [L2] The long of the biceps tendon promotes the healing of the rotator cuff repair construct and remains worth considering as an augmentation in cases with no intraoperative signs of tendon degeneration. [28] (10.1016/j.jisako.2025.100816)
• [L5] Subscapularis tears were associated with progressive thickening and degeneration of the long head of the biceps tendon at 4 and 12 weeks postoperatively, which was more significant in the intra- than in the extra-articular portion. [30] (10.1186/s12891-023-06338-5)
• [Paper] Good clinical results have been shown with the use of several soft tissue tenodesis techniques for tenodesis of the long head of the biceps. [31] (10.1097/bte.0b013e31816408ee)
• [L5] [32] (10.5435/00124635-201011000-00002)
• [L4] [33] (10.1016/j.jses.2019.07.007)
• [L4] Arthroscopic tenotomy of the long head of the biceps in selected patients yields good objective improvement and a high degree of patient satisfaction. [36] (10.1016/j.jse.2004.07.008)
• [L4] Arthroscopic release of the long head of the biceps tendon is an appropriate and reliable intervention for patients with chronic, refractory biceps tendinitis. [37] (10.1177/0363546504269555)
• [L1] There is currently no consensus regarding the use of tenotomy versus tenodesis for the treatment of lesions of the long head of the biceps brachii. [38] (10.1016/j.arthro.2011.10.017)
• [L4] The literature review revealed a lack of consensus regarding which elements of the diagnostic process are integral in establishing biceps involvement in injured throwing shoulders. [39] (10.1016/j.asmr.2025.101113)
• [Paper] The article outlines that appropriate treatment for biceps pathology, whether conservative or surgical, should be based on established pathology. [45] (10.1016/j.csm.2009.12.003)
• [L5] These considerations underscore the need for further biomechanical and clinical evaluation. [47] (10.1002/atn2.70089)
• [L3] LHBT preservation may help maintain shoulder biomechanics and offer advantages for future revision surgeries. [51] (10.5397/cise.2025.01319)
• [Paper] The article describes a classification system of long head of the biceps pain and discusses nonoperative treatment concepts and techniques for the painful LHB, emphasizing that a comprehensive evaluation to determine causative factors is critical in developing an appropriate treatment program. [53] (10.1016/j.csm.2015.08.012)
• [L5] Diagnosis of long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology can be challenging due to limitations in MRI and arthroscopic visualization; surgeons should maintain a high level of suspicion and utilize specific techniques to prevent missing pathology. [57] (10.1016/j.arthro.2017.09.005)
• [L4] The objective of this study was to identify the indications for surgical treatment, the best surgical technique, and the advantages and disadvantages of each technique described in the orthopedic literature for the treatment of long head of biceps tendon injuries. [58] (10.1016/j.rboe.2017.04.001)
• [L3] The high incidence of chronic inflammation of the long head of the biceps in shoulders with benign-appearing intraarticular portions is significant, and long head of the biceps disease should also be considered in patients with painful rotator cuff disease and arthritic shoulder conditions. [59] (10.1067/mse.2000.108386)
• [L3] Arthroscopic suprapectoral and open subpectoral biceps tenodesis both yield excellent clinical and functional results for the management of isolated superior labrum or long head biceps pathology. [60] (10.1177/2325967114s00061)
• [L1] The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. [61] (10.1302/0301-620x.99b6.bjj-2016-0569.r1)
• [L4] Anterior shoulder pain attributed to the biceps tendon does not appear to be due to an inflammatory process in most cases. [62] (10.2147/oajsm.s76325)
• [L3] However, its usefulness for diagnosis of partial tears of the biceps tendon remains limited. [63] (10.1016/j.jse.2015.06.020)
• [L4] In approximately 80% of the intra-articular biceps tears evaluated in this study, a 'hidden lesion' was observed going beyond the bicipital groove and extending to the distal extra-articular portion. [65] (10.1177/0363546514554193)
• [L5] Treatment of proximal biceps pathology is largely based on expert opinion and patient preferences rather than robust randomized evidence. [66] (10.1097/corr.0000000000002448)
• [L4] When measuring the long head of the biceps tendon, a mean of 2 measurements is recommended. [67] (10.2340/16501977-2095)
• [L5] This novel technique provides a safe, minimally invasive fixation of the long head of the biceps and may help to accelerate return to demanding professional and athletic activities. [68] (10.1097/bte.0b013e3182270fab)
• [L4] Routine tenodesis of the biceps tendon, in association with arthroscopic subscapularis repair, may not be necessary to ensure at least satisfactory short term outcomes in subscapularis function. [69] (10.1016/j.arthro.2008.04.045)
• [L4] Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. [71] (10.1177/0363546519892922)
• [L5] The commentary concludes that a recent case series makes the case that clinicians have been missing a significant number of rotator cuff tears by not routinely ordering MRI on patients with spontaneous proximal biceps tendon ruptures, while noting the need for further data on whether these findings change treatment. [72] (10.1016/j.arthro.2018.01.044)
• [L3] Ninety-seven percent of patients had resolution of their preoperative biceps symptoms. [74] (10.1177/2325967113s00090)
• [L4] The study demonstrates the prevalence of the degeneration process and the presence of marginal inflammation process in tendinopathy of the long head of biceps tendon. [75] (10.5114/pjp.2017.73928)
• [L4] [78] (10.2106/jbjs.rvw.n.00020)
• [L5] [82] (10.1053/otsm.2002.30651)
• [Paper] [85] (10.1016/j.eats.2020.01.014)
• [L3] [86] (10.1007/s00402-015-2393-5)
• [L1] [87] (10.1177/1758573220942923)
• [L3] [88] (10.1016/j.arthro.2019.02.017)
• [L5] [89] (10.1016/j.eats.2023.04.002)
• [L5] [92] (10.1016/j.jbiomech.2010.07.035)
• [L4] LHB tenodesis does not dramatically alter glenohumeral position during dynamic motions, suggesting the risk for clinically significant alterations in glenohumeral kinematics after tenodesis is low in otherwise intact shoulders. [94] (10.1177/0363546511423629)
• [L5] Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions, though in vivo studies have yet to establish this stabilizing effect and the physiologic load required remains unknown. [97] (10.1016/j.arthro.2010.10.014)
• [L5] Loading the long head of the biceps significantly affects glenohumeral rotational range of motion, translations, and kinematics. [107] (10.1016/j.jse.2008.06.003)
• [Paper] [110] (10.1016/j.eats.2017.05.028)
• [L5] Once the subscapularis or infraspinatus is affected by a simulated tear, the long head of the biceps has a stabilizing effect for the glenohumeral joint and counteracts humeral translation. [117] (10.1016/j.arthro.2023.08.018)
• [L1] Both tenotomy and tenodesis are effective and equal for the treatment of long head biceps lesions. [120] (10.1007/s00167-013-2587-8)
• [L5] It is indicated for severe biceps tendinopathy, partial or full thickness biceps tendon tears, or biceps instability typically associated with rotator cuff tear. [122] (10.1053/otsm.2003.35895)
• [L4] Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up. [126] (10.1177/0363546513520122)
• [L5] The long head of the biceps has a pertinent biomechanical role in glenohumeral stability regardless of the condition of the superior labrum. [127] (10.1016/j.arthro.2025.05.022)
• [L2] Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum two-year follow-up. [132] (10.1016/j.arthro.2014.04.027)
• [L1] Tenotomy and tenodesis offer satisfactory treatment for long head of the biceps tendon lesions with no difference in pain improvement or Constant scores, but patients undergoing tenotomy have worse cosmetic results. [143] (10.1097/corr.0000000000001672)
• [L2] Concomitant biceps tenodesis appears to have a favorable effect on 1-year treatment success after total shoulder arthroplasty. [144] (10.1016/j.jse.2008.06.006)
• [L2] Both CT arthrography and MR arthrography perform poorly in the detection of biceps tendon pathology of the shoulder. [145] (10.1016/j.ejrad.2011.01.121)
• [L4] When indicated, biceps tenodesis offers an alternative to SLAP repair in young patients. [146] (10.1016/j.arthro.2018.10.151)
• [L4] The authors propose a classification of 12 variations of the intra-articular portion of the long head of the biceps tendon and suggest that these congenital conditions may acquire pathologic significance due to partial detachment from the mesothelial or synovial fusion with the inferior surface of the capsule. [148] (10.1016/j.jse.2009.03.006)
• [L5] Biceps tendon pain in the absence of tears is associated with microscopic changes consistent with tendinopathy, which are often missed by MRI. [149] (10.1016/j.csm.2015.08.002)
• [L5] Arthroscopic biceps tenodesis is a safe and reliable treatment for managing intra-articular biceps tendon pathology. [151] (10.1016/j.eats.2024.103207)
• [L3] Tenotomy and open tenodesis are both safe options for treatment of biceps pathology. [152] (10.1016/j.asmr.2024.100928)
• [L4] Both arthroscopic debridement and debridement combined with a biceps tenotomy yields high satisfactory shoulder function in elderly patients at long term. [156] (10.1007/s00264-018-3991-y)
• [L5] The authors present their preferred surgical technique for superior capsular repair with the long head of the biceps tendon. [157] (10.1016/j.eats.2025.103861)
• [L5] Although comparative studies are lacking, tenotomy or tenodesis of the long head of the biceps seems a more reliable procedure than pulley repair. [161] (10.1016/j.csm.2015.08.003)
• [L5] [162] (10.1016/j.jse.2011.04.036)
• [L4] [164] (10.2106/00004623-199072050-00026)
• [Paper] Arthroscopic biceps tenodesis provides consistently favorable outcomes in terms of function and pain relief, with no long-term difference in clinical outcomes or complications compared with open subpectoral tenodesis. [165] (10.1016/j.csm.2015.08.001)
• [L4] We depict a subset of focal partial tears of the biceps tendon, which can be difficult to detect on MRI because of their anatomical location at the entrance to the bicipital groove. [166] (10.1007/s00256-009-0720-z)
• [L4] Conservative treatment remains the mainstay, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy. [167] (10.1177/1758573214567559)
• [L4] Biceps tenodesis is a reliable surgical option for the treatment of symptomatic LHBT pathology, particularly in patients who have failed non-operative treatment and those undergoing concomitant shoulder procedures. [171] (10.1016/j.jisako.2026.101168)
• [L5] High-quality randomized controlled trials are necessary to understand how different biceps management techniques truly perform. [172] (10.1016/j.arthro.2025.01.001)
• [L5] The biceps sling may be a reasonable alternative for treating symptomatic pathologic conditions of the long head biceps tendon. [173] (10.1016/j.arthro.2013.04.001)
• [L3] Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. [174] (10.1016/j.jse.2019.04.001)
• [Paper] This CORR Insights commentary argues for reframing long head of biceps (LHB) tendinopathy as a normal aspect of aging rather than a standalone problem, advocating for nonsurgical management strategies to reduce unhelpful interventions. [175] (10.1097/corr.0000000000003411)
• [L2] MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic rotator cuff lesions. [176] (10.1016/j.jse.2015.06.005)

See Also

• Biceps Tenodesis
• Rotator Cuff Repair
• Rotator Cuff
• Total shoulder arthroplasty

References

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