The long head of the biceps tendon runs from the muscle at the front of the upper arm, up through the shoulder joint, and attaches to the labrum at the rim of the socket. It can tear or become damaged, usually after an injury or a strain, and a damaged biceps tendon inside the joint is a common source of shoulder pain.
A biceps tenodesis detaches the tendon from the labrum and reattaches it lower down, to the humerus, the upper arm bone. This takes the damaged portion of the tendon out of the joint while keeping the biceps muscle working. The operation is usually performed arthroscopically, through keyhole incisions.
The procedure
The shoulder joint is inspected arthroscopically and the damaged part of the biceps tendon is identified. The tendon is released from its attachment to the labrum, and the healthy portion is then fixed to the upper arm bone, below the joint.
A biceps tenodesis can be performed on its own, but it is frequently performed at the same time as another procedure, most often a rotator cuff repair or a shoulder joint replacement. Where it is combined with another procedure, the sling and rehabilitation requirements are set by whichever repair needs the most protection.
Risks and complications
All surgery carries risk. The risks below are the ones that matter most for this operation, and the ones that apply to you are discussed with you in consultation before any decision is made.
General surgical risks
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Bruising and haematoma. The amount of bruising varies from patient to patient. Bruising is a normal side effect of surgery and usually resolves in a short time. A haematoma is a collection of blood that occasionally needs to be drained.
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Infection. Infection is rare but possible, and is usually treated with antibiotics.
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Deep vein thrombosis and pulmonary embolism. Blood clots can form in the veins of the leg and can travel to the lung. The risk of serious harm is significantly reduced when a clot is recognised and treated promptly.
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Anaesthetic risks. These are discussed with your anaesthetist before surgery. The risk of death from a general anaesthetic in Australia is approximately 1 in 100,000.
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Wound problems. Superficial wound problems can occur. Most need only a small intervention.
Risks specific to this procedure
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Nerve injury. Nerves run close to the area where the tendon is reattached and can be injured.
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Pain and stiffness. Ongoing pain at the front of the shoulder or upper arm, and stiffness of the shoulder, can occur.
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Deformity. If the tendon loses its fixation it can bunch up in the upper arm, producing a visible bulge in the muscle. This is often called a “Popeye deformity”.
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Problems at the attachment. The point where the tendon is fixed to the bone can fail to heal, or the fixation can pull out.
Complications after a biceps tenodesis are uncommon, and the specific risks are those listed above.
Before surgery
You will be given detailed written instructions before your operation. The checklist below covers the main points.
- Confirm with your health fund that the hospital fee is covered.
- Confirm the anaesthetist’s fees.
- Register your details with the hospital.
- Read, complete and return the paperwork to the office.
- Plan your transport to and from hospital. You cannot drive yourself home.
- Arrange any recommended pre-operative physiotherapy.
- Complete any requested pre-operative pathology, such as blood tests.
- Confirm your admission details with the office one to two business days before surgery.
Skin preparation
Use a benzoyl peroxide 5% wash on the operative shoulder, five applications in total: twice daily for two days, then once more on the morning of surgery. This reduces the risk of infection from Cutibacterium acnes, a bacterium that lives in the skin around the shoulder.
Packing and medications
- Pack your regular medications in their original packaging, a loose button-up shirt, nightwear and toiletries. Bring your CPAP machine if you have sleep apnoea.
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Blood thinners. Call the office to confirm when to stop these before surgery.
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Diabetes tablets. Call your anaesthetist to confirm whether to stop these.
The day of surgery
Your admission details are confirmed with the office one to two business days beforehand. Note both your admission time and your fasting time. Admission can be as early as 6am, so patients who live outside Brisbane are usually advised to stay in Brisbane the night before. See accommodation for options near the hospital.
After the admissions process you wait in the surgical waiting area. You have a short consultation with your anaesthetist before your general anaesthetic, and Dr Cutbush greets you in the anaesthetic bay and marks the operation site.
The hospital stay is usually one night, with discharge around 10am. You are reviewed before discharge and given a folder containing a letter describing the findings and the operation performed, together with your rehabilitation and post-operative care information. You will need to arrange a driver to take you home.
Recovery and healing
The reattached tendon needs time and protection to heal to the bone, so a good deal of rest is required in the early weeks.
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Sling. Worn full time for the first six weeks.
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First six weeks. No driving, no work and no physical activity.
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Up to 12 weeks. Arm movements remain limited. Driving is generally not permitted until you are out of the sling and can safely control a vehicle, and your surgeon will advise when this applies to you.
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Full recovery. Approximately six months, with a gradual return to normal physical activity.
Rehabilitation
Rehabilitation after a biceps tenodesis is focused on protecting the new attachment first, and then regaining strength and shoulder function.
Day one
The hospital physiotherapist shows you how to fit the sling and how to eat, shower and dress while wearing it. You should be confident with all of these before you leave hospital.
The sling must fit correctly. If the size is wrong, a replacement is arranged for you before discharge.
Phase one: early healing and protection
This first phase protects the biceps while the tendon heals to the bone. The precautions are:
- No active biceps contraction and no loading of the tendon.
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No active elbow flexion. That is, do not bend the elbow using your own muscle power.
- Sling worn for six weeks.
- No forceful gripping.
Exercises permitted in this phase:
- Shoulder pendulum, including small circular movements, which is also permitted for washing under the arm.
- Active-assisted shoulder movements to reduce stiffness at the shoulder joint: pendulum, forward lean and external rotation.
- Wrist and hand range of motion, without forceful gripping.
- Neck range of motion.
- Gentle shoulder blade exercises in neutral, together with general posture work.
- Ice for pain management.
Follow-up
- See your local physiotherapist in weeks one to two. They should be given your post-operative rehabilitation guidelines and precautions so that the protective phase is followed correctly.
- Later stages of rehabilitation, including the return to active biceps use and strengthening, are introduced once the protective phase is complete.
Results after surgery
Most people experience reduced pain and improved shoulder function following a biceps tenodesis. Individual results vary.
How well the shoulder does depends substantially on rehabilitation and on how closely the physiotherapy guidelines are followed during the protective phase, as well as on individual factors such as the extent of the original tendon damage and whether other procedures were performed at the same time.
Next steps
This page is general information about a surgical procedure and is not a recommendation that you have it. Whether surgery is appropriate for you can only be determined after assessment. All surgery carries risk; the risks relevant to you are discussed in consultation before any decision is made.
