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After conservative treatment measures have failed, if the patient continues to have biceps associated symptoms, surgical management should be considered. The imaging studies previously discussed should be utilized prior to considering surgical treatment because of the significant overlap of biceps disorders and other shoulder conditions.

Biceps tendinitis is commonly associated with impingement syndrome and rotator cuff tendinitis or tears. Ruptures of the biceps tendon can result from trauma often with associated rotator cuff tears or SLAP lesion. Overload flexion force or flexion with forced extension may cause rupture of the biceps tendon .

Other maladies associated with the biceps tendon involve medial dislocation , spontaneous dislocation , and pathologic lesions.

Basically there are only three treatments for biceps tendon disorders. They are debridement of the LHB, biceps tenotomy, or biceps tenodesis. The decision regarding tenotomy vs. tenodesis is a controversial subject. A tenotomy of the proximal biceps has been reported to carry a 21% incidence of a Popeye deformity with distal retraction of the biceps resulting in a larger muscle mass contracted distally and loss of the proximal muscle bulk.

Simple debridement of the biceps tendon is of questionable value. If fraying or partial tearing of the biceps tendon is encountered during arthroscopy its cause should be thoroughly explored. Even a small amount of fraying is suggestive of a mechanical abnormality within the shoulder joint and likely needs further arthroscopic evaluation and treatment.

Although some have advocated biceps tendon debridement for tears of less than 50% , we feel tendon debridement is in essence treating the end result of the mechanical problem and not addressing the source of the problem.

The debate over biceps tenotomy vs. tenodesis will not be fully explored in this chapter, as the subject is quite controversial. We weigh many factors when making the decision to perform tenotomy or tenodesis. These factors include the patient’s age, body habitus, activity level, and extent of biceps tendon degeneration.

Typically tenotomy is reserved for elderly patients, sedentary patients with a larger body habitus, or patients with significant tendon degeneration which extends into the bicipital groove. Tenodesis in the latter situation may result in persistent pain due to pathology extending distal to the tenodesis site.

In general the authors opt for arthroscopic biceps tenodesis in almost every situation other than those mentioned earlier in this chapter. Many open techniques have been implemented in the tenodesis of the LHB. One commonly used open procedure is the keyhole technique. Alternative methods of open tenodesis involve soft tissue/periosteal tenodesis within the bicipital groove.

For chronic retracted ruptures of the LHB, open techniques are usually required although Richards and Burkhart reported an arthroscopic assisted tenodesis technique (the Cobra procedure) for dealing with selected retracted tears of the biceps tendon. The remainder of this article will describe several arthroscopic biceps tenodesis techniques.

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