Lesions of the long biceps tendon: Tenotomy or tenodesis of the LBS?

The long biceps tendon (LBS) is a central component of shoulder function. It runs from the shoulder joint through the bicipital groove to the belly of the biceps muscle.

Due to its location in the shoulder joint, it is susceptible to wear , instability , inflammation and injury – especially during overhead movements and rotational loads.

In this article you will learn:

• What causes lesions of the LBS

• How the diagnosis works

• What treatment options are available

• When a tenotomy or tenodesis is useful

• How the procedure is carried out and what aftercare is necessary

Causes of damage to the long biceps tendon

Lesions of the LBS can have a variety of causes. The most common are:

• Degenerative changes due to age and wear

• Chronic overload , e.g. due to repeated overhead work or sports (e.g. tennis, swimming, climbing)

• Traumatic injuries , e.g. due to dislocations or falls

• Instability of the biceps tendon due to damage to the so-called pulley system

• Concomitant injuries such as SLAP lesions (Superior Labrum Anterior to Posterior)

In older patients, degenerative and arthritic changes are often predominant, whereas in young and athletically active people, traumatic or stress-related lesions predominate.

Symptoms of a biceps tendon lesion

Typical symptoms of LBS lesions include:

• Pain in the front shoulder area

• Increased pain during supination (rotating the forearm outwards)

• Loss of strength when lifting or turning

• Friction noises (crepitations)

• Feeling of instability or “jumping” of the tendon

• In case of rupture: visible muscle deformation (“Popeye sign”)

The symptoms are partly similar to other shoulder diseases, which is why a precise differentiation is necessary.

Diagnosis of LBS lesions

Diagnosis is carried out by:

1. Thorough medical history (pain history, stress behavior)

   
   

2. Clinical examination :

   • Speed test

   • Yergason test

   • Palpation of the biceps tendon groove

     
     

3. Imaging :

   • Ultrasound : well suited for dynamic assessment and tendon progression

   • MRI : Gold standard for visualizing partial tears, inflammation, and associated injuries (e.g., SLAP lesions)

   • Diagnostic arthroscopy: Direct keyhole examination with direct repair. Disadvantages: Anesthesia required, surgical risks.

     
     

Conservative treatment options

Not every LBS lesion requires surgical treatment. In mild cases, conservative treatment may be beneficial:

• Physiotherapy to stabilize the shoulder and arm muscles

• Anti-inflammatory drugs (NSAIDs)

• Cold applications or electrotherapy

• Infiltrations with corticosteroids in acute tendinitis

The aim is to reduce pain , restore function and prevent progression of the lesion.

Surgical procedures: Tenotomy vs. Tenodesis

If conservative measures fail or there is a structural lesion (e.g. partial or complete tear), two surgical options are available:

Tenotomy of the long biceps tendon

During tenotomy, the long biceps tendon is severed in the area of the upper joint section and is not reattached.

Advantages:

• Simple procedure with short operating time

• Less postoperative stress

• Often sufficient for older, less active patients

Disadvantages:

• Risk of cosmetic change (“Popeye sign”)

• Possible strength deficit in flexion and supination

• In rare cases, muscle cramps or pain

Tenodesis of the long biceps tendon

During tenodesis , the tendon is transected and fixed in the biceps groove or on the humerus – usually with a suture anchor or screw implant.

Advantages:

• Anatomical fixation of the tendon

• Maintaining strength and muscle tone

• No cosmetic deformity

• Suitable for active and sporty patients

Disadvantages:

• More complex intervention

• Longer rehabilitation period

• Possible implant complications (rare)

Comparison: When tenotomy, when tenodesis?

The decision depends on:

criterion	Tenotomy	Tenodesis
Old	rather older	rather younger
Sports activity	small amount	high
Cosmetic expectations	small amount	high
Duration of operation	shorter	longer
Functional preservation (strength)	reduced possible	mostly preserved

Conclusion: For older, less active individuals, tenotomy is often sufficient. For younger, athletically active patients, or for those with cosmetic concerns, tenodesis offers better functional and aesthetic results.

Subpectoral vs. intra-articular tenodesis – which technique is better?

There are various fixation sites for tenodesis. The two most common options are:

Intraarticular or suprapectoral tenodesis

Fixation takes place within the shoulder joint or in the biceps tendon groove (sulcus intertubercularis), usually arthroscopically .

Advantages:

• Minimally invasive through shoulder arthroscopy

• Shorter surgical duration

• No additional skin incision outside the joint necessary

Disadvantages:

• Risk of persistent irritation in the biceps groove (residual pain)

• Difficult access with scarred or unstable tendons

• Higher risk of recurrence in pulley lesions

  
  

Subpectoral tenodesis

Here, the tendon is fixed outside the joint , beneath the pectoralis major muscle . The procedure is usually performed openly (mini-open) through a small skin incision.

Advantages:

• Fixation in a less sensitive area – reduces the risk of residual discomfort

• Removal of all inflamed tendon parts

• Less load on the pulley system

• Particularly effective in cases of chronic irritation or incomplete cracks

• Lower recurrence rate in cases of tendon instability

Disadvantages:

• Somewhat more complex technology

• Small additional skin incision below the armpit

Which tenodesis technique is appropriate when?

criterion	Intraarticular/suprapectoral tenodesis	Subpectoral tenodesis
Access type	Arthroscopic	Mini-open
Residual complaints in the biceps groove	Possible	Rarely
Pulley lesions / tendon instability	Less effective	Very effective
Irritation / chronic tendon changes	Possibly incompletely removed	Completely removed
Surgery duration / complexity	Shorter, technically simpler	Somewhat more complex, but more precise

👉 Conclusion: Subpectoral tenodesis is considered a more permanent and safer solution in many cases , especially in patients with irritation, pulley damage, or chronic tendon instability. The intra-articular variant, on the other hand, is faster and well-suited for uncomplicated lesions without associated instability.

The choice of technique should be individually tailored to the patient's findings, symptoms, and life situation – ideally in consultation with an experienced shoulder specialist.

Follow-up treatment and rehabilitation

The aftercare depends on the procedure chosen:

• After tenotomy: short immobilization, rapid increase in load

• After tenodesis: 3 weeks of immobilization, then gradual mobilization, later strengthening of the biceps and shoulder muscles

The rehabilitation period is usually 8–12 weeks.

Conclusion:

• Lesions of the long biceps tendon are common causes of anterior shoulder pain. The decision between tenotomy and tenodesis should be made individually based on age, activity level, and cosmetic expectations.

  
  

• Early diagnosis and targeted therapy usually lead to complete restoration of shoulder function.

  
  

• Both tenotomy and tenodesis offer very good results when correctly indicated.

  
  

• Subpectoral tenodesis is considered a more permanent and safer solution in many cases , especially in patients with irritation, pulley damage or chronic tendon instability.

  
  

• The choice of technique should be individually tailored to the patient's findings, symptoms, and life situation – ideally in consultation with an experienced shoulder specialist.

  
  

Frequently Asked Questions (FAQ)

What is the difference between tenotomy and tenodesis ?

In a tenotomy, the tendon is severed and not reattached. In a tenodesis, it is reattached to the bone at a different location. The latter usually preserves strength and avoids cosmetic changes.

When is surgery on the long biceps tendon necessary?

Surgery is necessary when conservative measures fail or there is structural damage such as a tear or instability of the tendon.

How long does healing take after tenodesis?

Rehabilitation after a tenodesis typically lasts 8–12 weeks. The shoulder is initially immobilized before physiotherapy begins to mobilize and strengthen.

What happens when the long biceps tendon ruptures?

A complete tear can lead to a "Popeye sign"—a visible bulge in the biceps muscle. Pain and loss of strength during twisting movements often occur, but these usually resolve over time. Function can be restored surgically if the injury occurred relatively recently.

Which treatment is better: tenotomy or tenodesis?

It depends on the patient: For older, less active individuals, tenotomy is usually sufficient. For physically active individuals, tenodesis generally offers better functional and cosmetic results.

Do you have a problem with your long biceps tendon and are unsure what the best treatment is for you?

Then make an appointment with our specialist :

Prof. Dr. med. Ben Ockert

Specialist in orthopedics

and trauma surgery,

Sports medicine

MAKE AN APPOINTMENT NOW!