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Biceps Tendinopathy and Long-Head Rupture

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

101 citationsUpdated Sep 2026

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Overview

Long head of the biceps tendon disorders are classified into inflammation, instability, and rupture, each requiring specific diagnostic and management protocols [4]. High-resolution ultrasound is a reliable modality for confirming suspected pathologies [2]. Arthroscopic biceps tenodesis is indicated for severe biceps tendinopathy, partial or full thickness biceps tendon tears, or biceps instability typically associated with rotator cuff tear [57]. The decision to proceed with surgical management depends on clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment [3]. Treatment of proximal biceps pathology is largely based on expert opinion and patient preferences rather than robust randomized evidence [65].

Operative options include tenodesis and tenotomy. Biceps tenodesis remains a reliable treatment for pathologic abnormality of the long head of the biceps [5], providing significant clinical improvement and high rates of survivorship two years postoperatively [18]. All-arthroscopic tenodesis provides a suitable option for improved functional outcomes in the treatment of labral and biceps pathology [11], while both arthroscopic suprapectoral and open subpectoral techniques yield excellent clinical and functional results for isolated superior labrum or long head biceps pathology [35]. In a study of arthroscopic-assisted locked loop suprapectoral biceps tenodesis, no patients had reoperations or revisions for failed tenodesis at one-year follow-up [14]. Arthroscopic tenotomy yields good objective improvement and high patient satisfaction in selected patients [22] and is an appropriate intervention for chronic, refractory biceps tendinitis [25]. Tenotomy or tenodesis seems a more reliable procedure than pulley repair, although comparative studies are lacking [158].

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 [36]. However, biceps tenodesis has proven more successful than tenotomy in non-isolated cuff tears [160]. In the presence of an isolated subscapularis tear associated with long head pathologies, favorable clinical outcomes could be achieved by performing both tear repair and biceps tenodesis with a double-loaded single anchor [8]. Functional outcomes of stabilization in the context of early repair of a traumatic subscapularis tear were comparable with results of tenodesis or tenotomy reported in previous studies [9]. Patients with untreated long head 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 [20]. Conversely, outcomes were similar regardless of tear size or concurrent repairs, and biceps pathology or treatment did not influence postoperative outcomes in arthroscopic subscapularis tendon repairs [21]. Routine tenodesis in association with arthroscopic subscapularis repair may not be necessary to ensure at least satisfactory short term outcomes in subscapularis function [70]. 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 [24].

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, with the tendon attaching entirely (type I) or predominantly posterior (type II) on the superior labrum [41]. Less common variants include equal anterior and posterior contributions (type III) or predominantly anterior attachment (type IV) [41]. In a study of 100 fresh-frozen shoulders, four specific types were identified: Type I (entirely posterior), Type II (mostly posterior with small anterior contribution), Type III (equal anterior and posterior contributions), and Type IV (mostly anterior with small posterior contribution) [82].

The glenoid labrum consists of parallel collagen fibers coursing around the glenoid circumference [41]. The superior labrum inserts on the superior glenoid rim, medial to the articular cartilage margin, through a transitional zone of fibrocartilage [41]. A normal synovial recess exists between the meniscoid or triangular superior labrum and the articular cartilage extension over the superior glenoid rim [41]. While usually triangular, the superior labrum can have a meniscoid shape [44]. Anatomic variants include a sublabral foramen, absence of the superior labrum, and a cordlike middle glenohumeral ligament (Buford complex) [44]. In a cohort of 73 shoulders, 3.3% had a sublabral foramen, 8.6% had a sublabral foramen with a cordlike middle glenohumeral ligament, and 1.5% had an absent anterosuperior labrum [44].

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 glenoid labrum is avascular, and the superior labrum is less vascular compared with the inferior and posterior labrum [44]. Vascularity of the biceps tendon is provided primarily by the ascending branch of the anterior humeral circumflex artery, which travels within the bicipital groove [41]. An avascular zone exists at the proximal portion of the biceps tendon, close to the superior glenoid [41]. Blood is also supplied to the long head of the biceps tendon 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 long head of the biceps tendon is innervated by thinly myelinated sensory neurons [44]. Most innervation occurs at its origin, meaning pathology in this region can generate pain [44]. Innervation of the biceps muscle is supplied by branches of the musculocutaneous nerve (C5 and C6) [43]. The blood supply to the biceps muscle is derived from a single large bicipital artery from the brachial artery (35%), multiple very small arteries (40%), or a combination of the two types [43].

Bicipital Groove and Stabilizing Structures

The long head of the biceps tendon passes through the bicipital groove, or intertubercular groove, between the greater and lesser tuberosities [41]. Stability within the 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]. This 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]. The tendon is retained within the groove by a pulley made up of fibers from the coracohumeral and superior glenohumeral ligaments, with some reinforcement from adjacent tendons [43].

The long head of the biceps is an intra-articular but extrasynovial structure within the glenohumeral joint [41]. It courses intra-articularly over the humeral head before exiting the glenohumeral joint through the bicipital groove [44]. The bicipital tunnel is divided into three zones: zone 1 (bony groove), zone 2 (“No Man’s Land”), and zone 3 (subpectoralis) [44]. Zone 1 and zone 2 contain synovial tissue, which may generate pain [44]. Zone 2 cannot be visualized by arthroscopy from above or with an open approach from below the zone [44]. A shallow bicipital groove and supratubercular ridge above the lesser tubercle were thought to predispose to biceps tendon pathology [43]. Variations of bicipital groove morphology can increase the risk of long head of the biceps tendon pathology [49]. 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].

Pathophysiology and Degeneration

Long head of the biceps tendinopathy is associated with age, with a 100% prevalence by age 85 on MRIs obtained for shoulder pain [6]. Biceps tendinopathy and rotator cuff tendinopathy are related conditions of senescence, representing expected changes of tissues with age [6]. Signal changes, thinning, and rupture of the long head of the biceps tendon can be considered an expected aspect of aging [6]. 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]. Isolated long head of the biceps tendon pathology can occur but frequently is associated with other shoulder pathologies, especially rotator cuff pathology [49]. When seen in isolation, primary long head of the biceps tendinitis usually occurs in younger patients who participate in overhead activities such as volleyball and baseball [49].

The distinction between inflammatory, unstable, and traumatic biceps tendon disorders is not always clear, as the degenerated and inflamed tendon is more prone to trauma and repeated trauma may result in changes indistinguishable from inflammation [33]. In a rat model, intra-articular changes precede extra-articular changes in the biceps tendon after rotator cuff tears [159]. Increased loading following rotator cuff tears resulted in decreased mechanical properties along the entire length of the biceps tendon at both 4 and 8 weeks [91]. Decreased loading following rotator cuff tears resulted in variable changes at 4 weeks that were no different from detachment alone by 8 weeks [91]. The supraspinatus tendon thickens in the presence of repetitive tasks, and it thickens the most in those who develop shoulder pain [121].

Instability and Dislocation Mechanisms

Subluxation of the long head of the biceps tendon is defined as a partial and/or transient incomplete loss of contact between the tendon and its bony groove [103]. Subluxation types include: Type I (superior subluxation): Results from a partial or complete tear of the circular sling of the superior glenohumeral and coracohumeral ligaments, resulting in loss of restraint above the entrance to the groove [103]. Type II (subluxation at the groove): Caused by a detachment of the outermost fibers of the subscapularis tendon, allowing the tendon to slip over the medial rim of the bony groove and ride on the border of the lesser tuberosity [103]. Type III: Occurs following malunion or nonunion of the lesser tuberosity, which compromises the medial bony restraint of the long head of the biceps tendon [103].

Dislocation types include: Type I (extraarticular): Combined with a partial tear of the subscapularis tendon [33]. The long biceps tendon is completely dislocated to a point over the lesser tuberosity, and there is invariably a rupture of the common attachment of the superior glenohumeral ligament and coracohumeral ligament [89]. Type II (intraarticular): Combined with a full-thickness tear of the subscapularis tendon [33]. The biceps tendon is widened and flattened as a result of its contact with the lesser tuberosity, and the subscapularis tendon is torn from its attachment on the lesser tuberosity [89].

A subscapularis tear is associated with long head of the biceps medial instability, and a supraspinatus tear is associated with posterolateral instability [49]. Bicipital instability is usually associated with rotator interval injury or subscapularis tendon injury, or both [50]. Dislocation of the long biceps tendon over a completely intact subscapularis tendon is very rare, occurring in only 2 of 70 patients (3%) in one series [89].

Biomechanical Function

The biceps has its main action at the elbow rather than the shoulder and is considered primarily an elbow muscle [43]. Loss of the long head attachment is manifested mainly as a 20% loss of supination strength with a smaller 8% loss of elbow flexion strength [43]. 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 [95]. The long head of the biceps has a stabilizing effect on the glenohumeral joint and counteracts humeral translation when the subscapularis or infraspinatus is affected by a simulated tear [116]. Loading the long head of the biceps significantly affects glenohumeral rotational range of motion, translations, and kinematics [105]. Long head of the biceps 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 [93].

The long head of the biceps has a pertinent biomechanical role in glenohumeral stability regardless of the condition of the superior labrum [124]. In a study by Itoi and colleagues, both the long and short heads of the biceps function as anterior stabilizers of the glenohumeral joint with the arm in abduction and external rotation [98]. Severing the long head of the biceps tendon while both heads were tensed caused significant upward migration of the humeral head in a study by Kumar and colleagues [98]. The role of the biceps tendon on the static and dynamic stability of the shoulder is controversial [98]. Andrews noted a dynamic tensioning of the biceps-labral complex with electric stimulation of the biceps tendon, concluding it helps to stabilize the glenohumeral joint during throwing [98]. The long head of the biceps can act as a static humeral head depressor, preventing migration of the humeral head into the acromion with contraction of the deltoid [98]. In certain conditions, particularly when paralysis or rupture of the supraspinatus has occurred, the long head of the biceps is hypertrophied, probably because the patient is using the muscle as a depressor of the humeral head [43]. The long head of the biceps contributes to joint stability, which is increased in external rotation and decreased in internal rotation [43].

SLAP Lesions and Overhead Mechanics

Superior labrum anterior to posterior (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]. Injuries can result from repetitive contact of the posterosuperior labrum with the undersurface of the rotator cuff in the late cocking phase, known as internal impingement [49]. SLAP tears are seen more frequently in the late cocking position, occurring because of an adaptive posterior capsular contracture [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 long head of the biceps tendon to displace medially over the glenoid rim [49]. SLAP tears may represent an adaptive process, because the peel-back of the superior glenoid labrum permits increased humeral external rotation needed to participate in overhead sporting activity [100]. The proximal long head of the biceps tendon has been recognized as a source of substantial anterior shoulder pain [49].

Classification

Etiologic Classification

Long head of biceps tendon disorders are classified into inflammatory, unstable, or traumatic categories based on the original initiating event [33]. This classification organizes pathogenesis and formulates protocols for appropriate management [33]. The distinction between these categories is not always clear, as degenerated and inflamed tendons are more prone to trauma, and repeated trauma can result in changes indistinguishable from inflammation [33]. Diagnosis and nonoperative management of long head of biceps tendon disorders are categorized as inflammation, instability, and rupture [4].

Inflammatory: Includes biceps tendinitis concurrent with rotator cuff disease and primary bicipital tendinitis [33].

Unstable: Includes subluxation and dislocation [33]. * Subluxation: 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) [33]. * Dislocation: Classified into Type I (extraarticular, combined with partial tear of subscapularis) and Type II (intraarticular, combined with full-thickness tear of subscapularis) [33].

Traumatic: Includes traumatic rupture and superior labral tears (SLAP lesions) [33]. * Traumatic Rupture: Classified into Type I (partial) and Type II (complete) [33]. * Superior Labral Tears: 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) [33].

Arthroscopic Grading

Arthroscopic grading of long head of biceps lesions classifies findings into 4 grades (6 subgrades) based on the extent of partial tendon tear [157]. Longitudinal tears are excluded from the classification of partial tears in this system [157].

Grade 0: Normal [157]. Grade Ia: Redness, flattening, fraying, or longitudinal split [157]. Grade Ib: Partial tear involving less than 25% of the tendon [157]. Grade Ic: Partial tear involving 25% to 50% of the tendon [157]. Grade II: Partial tear involving more than 50% of the tendon [157]. Grade III: Complete tear [157].

Anatomical Variations

A classification of 12 variations of the intra-articular portion of the long head of the biceps tendon has been proposed [146]. Congenital variations of the intra-articular portion may acquire pathologic significance due to partial detachment from the mesothelial or synovial fusion with the inferior surface of the capsule [146]. In rare cases, the long head of the biceps takes origin from the rotator cable and has a second origin medial to the supraglenoid tubercle [40]. Aberrant origins of the long head of the biceps can be seen with concomitant cuff tear pathology [19]. Nonsynovitic and nondegenerative aberrant origins of the long head of the biceps have not clearly contributed to other shoulder pathology [19]. Literature reviews have been unable to link uncommon congenital lesions of the long head of the biceps tendon to a common pathoanatomic presentation or suggest a universally accepted treatment algorithm [26].

Diagnostic Challenges

Diagnosis of long head biceps tendon pathology remains challenging due to vague complaints and unreliable physical examination maneuvers [12]. 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 [17]. 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 [37].

Clinical Presentation

Diagnostic Challenges and Physical Examination

Physical examination for biceps pathology most commonly reveals tenderness over the bicipital groove of the humerus, identified by palpating the anterior aspect of the shoulder with the arm internally rotated [108]. In patients with biceps tenodesis, tenderness to palpation shifts laterally with external rotation of the arm, a finding that helps distinguish this condition from other causes of anterior shoulder pain [108]. Provocative tests used to evaluate biceps pathology include an active compression test of the biceps tendon in the bicipital groove, Speed's test, Yergason's test, and O'Brien's test [108]. Diagnosing 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 [55].

Imaging and Histopathology

The utility of MRI for diagnosing partial tears of the biceps tendon remains limited [61]. Biceps tendon pain in the absence of tears is associated with microscopic changes consistent with tendinopathy, which are often missed by MRI [66]. 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 [7]. Anterior shoulder pain attributed to the biceps tendon does not appear to be due to an inflammatory process in most cases [59]. In approximately 80% of the intra-articular biceps tears evaluated, a 'hidden lesion' was observed going beyond the bicipital groove and extending to the distal extra-articular portion [64].

Associations and Prevalence

Long head of the biceps tendinopathy and rotator cuff tendinopathy are related conditions of senescence [6]. The association of biceps tendon lesions requiring surgical repair and rotator cuff tears is not uncommon [23]. 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 [34]. 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 [27]. 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 [19]. The tendon of the long head of the biceps functions as a dynamic stabilizer of the anterior aspect of the shoulder [16]. While LHBT pathology is a significant cause of anterior shoulder pain, its exact role in shoulder stability remains controversial [144].

Clinical Spectrum and Management Context

Tendinopathy of the long head of the biceps brachii encompasses a spectrum of pathology ranging from inflammatory tendinitis to degenerative tendinosis [29]. Disorders of the long head of the biceps often occur in conjunction with other shoulder pathology [29]. 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 [3]. 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 [15].

Investigations

Clinical Examination

The "3-pack" examination for biceps-labrum complex disease consists of the active compression test, throwing test, and bicipital tunnel palpation [42]. These tests demonstrate high sensitivity, ranging from 73% to 98%, for biceps-labrum complex disease [42]. No single physical examination finding is completely accurate for the diagnosis of a SLAP tear [51]. A combined physical examination approach aids in the diagnosis of SLAP or LHB pathology [51].

Imaging: MRI and MRA

MRI may be used to assess the LHB tendon, associated fluid and possible synovitis, and the morphology of the bicipital groove, as well as to determine the presence of bony osteophytes [107]. However, studies have demonstrated poor correlation between MRI and arthroscopic findings regarding LHB pathology [107]. MRI exhibits poor to moderate sensitivity for inflammation, partial-thickness tendon tears, and tendon ruptures of the LHB [107]. Magnetic resonance arthrography (MRA) is more specific and sensitive for LHB pathology and SLAP tears than MRI [107]. MRA has a sensitivity of 82% to 89% and a specificity of 87% to 98% in the evaluation of the biceps pulley [48]. Proton density–weighted sequences with fat suppression provide the greatest sensitivity for detecting tendon degeneration, although tendon caliber change is more specific [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]. Focal partial tears at this location are difficult to detect on MRI due to their anatomical location [163]. 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]. 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 [107]. Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders [172].

Imaging: Ultrasound

Ultrasonography is accurate and cost-effective in the diagnosis of LHB dislocation, subluxation, and rupture [107]. It is not as accurate in diagnosing partial-thickness tendon tears [107]. The exact role of ultrasonography for the diagnosis of tendon inflammation has not been fully defined [107]. When measuring the long head of the biceps tendon, a mean of 2 measurements is recommended [67].

Radiography

Plain radiographs (scapular Y, AP, and axillary lateral views) should be obtained to assess the glenohumeral joint for abnormalities [107]. The anatomy of the bicipital groove can be evaluated by the Fisk view [50].

Other Considerations

CT arthrography is more sensitive and specific than MRI for identifying tendinopathy of the intra-articular portion of the long head of biceps [17]. Conversely, both CT arthrography and MR arthrography perform poorly in the detection of biceps tendon pathology of the shoulder [142]. In approximately 80% of the intra-articular biceps tears evaluated in a study, a 'hidden lesion' was observed going beyond the bicipital groove and extending to the distal extra-articular portion [64]. 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]. The observation of a notable association of long head of the biceps tendinopathy with age, with a 100% prevalence by age 85 on MRIs obtained for shoulder pain, suggests that long head of the biceps tendinopathy and rotator cuff tendinopathy are related [6]. Long head of the biceps tendinopathy can be regarded as an expected aspect of aging [6].

Treatment

Non-Operative

Nonsurgical management is the initial approach for patients with mild disease and remains the mainstay for calcification at the long head of the biceps tendon [29, 73]. The standard conservative regimen includes rest, nonsteroidal anti-inflammatory drugs, physical therapy, and injections [29]. A comprehensive evaluation to determine causative factors is critical in developing an appropriate treatment program for painful long head of the biceps [52]. Nonsurgical treatment can resolve pain effectively and restore function in patients with SLAP tears or biceps lesions [168]. Appropriate treatment for biceps pathology, 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].

Operative

Indications: Surgical management is indicated for refractory or severe disease [29]. Surgical intervention is appropriate therapy for symptomatic partial tears of the long head of the biceps, subluxation of the long head of the biceps, biceps pulley lesions, and some superior labrum anterior-posterior (SLAP) lesions [77]. 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 [169]. In cases of biceps peritendinitis where patients do not recover promptly after conservative treatment, fastening the tendon into the groove offers a much more rapid recovery with less economic loss [39]. Arthroscopic debridement is reserved for cases where symptoms are not controlled by non-operative therapy for calcification at the long head of the biceps tendon [73].

Surgical Approach / Technique: Tenotomy is a relatively safe, simple and quick procedure with shorter rehabilitation demands [86]. It is generally reserved for the elderly population or a patient population who may not frequently engage in strenuous physical activities [88]. Tenotomy may result in a cosmetic deformity, possible cramping and fatigue pain of the biceps, and a decrease in elbow flexion and supination power [77]. Both arthroscopic debridement and debridement combined with a biceps tenotomy yields high satisfactory shoulder function in elderly patients at long term [152]. Tenotomy and open tenodesis are both safe options for treatment of biceps pathology [149].

Biceps tenodesis 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 [77]. Open subpectoral tenodesis and arthroscopic biceps tenodesis both provide favorable outcomes, and neither technique has been shown to be superior to the other [77]. 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 [69]. At a short-term follow-up of 1 year, no patients had reoperations or revisions for failed arthroscopic-assisted locked loop suprapectoral biceps tenodesis [14]. Arthroscopic biceps tenodesis is a safe and reliable treatment for managing intra-articular biceps tendon pathology [148]. The biceps sling may be a reasonable alternative for treating symptomatic pathologic conditions of the long head biceps tendon [171].

Comparison of Tenotomy and Tenodesis: 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 [38]. Both tenotomy and tenodesis are effective and equal for the treatment of long head biceps lesions in shoulders with reparable rotator cuff tears [118]. High-quality randomized controlled trials are necessary to understand how different biceps management techniques truly perform [170].

Concomitant Pathology Management: Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up [123, 127]. When indicated, biceps tenodesis offers an alternative to SLAP repair in young patients [143]. SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years [153]. Concomitant biceps tenodesis appears to have a favorable effect on 1-year treatment success after total shoulder arthroplasty [141]. 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 [24].

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].

Complications

Enthesophyte Formation: Biceps enthesophyte is a rare complication following subpectoral biceps tenodesis [30].

Cosmetic Outcomes: Patients undergoing biceps tenotomy have worse cosmetic results compared to those undergoing tenodesis [38].

Reoperation: In a long-term follow-up study of 54 shoulders, an additional operation was performed in 8 shoulders (15%) following tenodesis for chronic tendinitis [162].

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

Recovery

Non-Operative Management: Conservative treatment remains the mainstay for long head of the biceps tendon pathology, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy [73]. The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term [58].

Operative Outcomes: At a short-term follow-up of 1 year, no patients had reoperations or revisions for failed biceps tenodesis following arthroscopic-assisted locked loop suprapectoral biceps tenodesis [14]. Ninety-seven percent of patients had resolution of their preoperative biceps symptoms following arthroscopic transfer of the long head of the biceps tendon [28]. Both high arthroscopic and mini-open subpectoral tenodesis of the long head of the biceps tendon produced reliably good functional results [165]. The subpectoral tenodesis group was associated with higher postoperative clinical outcomes compared to the high arthroscopic group [165]. Tenotomy and tenodesis offer satisfactory treatment for long head of the biceps tendon lesions with no difference in pain improvement or Constant scores [38]. Patients undergoing tenotomy have worse cosmetic results compared to those undergoing tenodesis [38].

Complications and Risk Factors: 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 [15]. The preoperative presence of an eccentrically positioned long head of the biceps tendon was associated with further changes of the tendon itself after rotator cuff repair [181].

Key Evidence

• [L4] High-resolution ultrasound is reliable to confirm suspected long head of the biceps tendon pathologies. [2] (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. [3] (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. [4] (10.1016/j.csm.2015.08.006)
• [L3] Biceps tenodesis remains a reliable treatment for pathologic abnormality of the long head of the biceps. [5] (10.1177/0363546515570024)
• [L3] [6] (10.1097/corr.0000000000003342)
• [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. [7] (10.1016/j.arthro.2018.01.021)
• [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. [8] (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. [9] (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. [11] (10.1016/j.eats.2019.01.023)
• [L5] Diagnosis of long head biceps tendon pathology remains challenging due to vague complaints and unreliable physical examination maneuvers. [12] (10.1136/jisakos-2017-000128)
• [L4] At a short-term follow-up of 1 year, no patients had reoperations or revisions for failed biceps tenodesis. [14] (10.1016/j.xrrt.2021.02.003)
• [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. [15] (10.1177/0363546517691950)
• [L5] These cases strengthen the hypothesis that the tendon of the long head of the biceps functions as a dynamic stabilizer of the anterior aspect of the shoulder. [16] (10.2106/jbjs.d.02459)
• [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. [17] (10.1016/j.otsr.2014.09.005)
• [L4] Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively. [18] (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. [19] (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. [20] (10.1177/2325967125s00081)
• [L4] Outcomes were similar regardless of tear size or concurrent repairs, and biceps pathology or treatment did not influence postoperative outcomes. [21] (10.1016/j.arthro.2019.01.034)
• [L4] Arthroscopic tenotomy of the long head of the biceps in selected patients yields good objective improvement and a high degree of patient satisfaction. [22] (10.1016/j.jse.2004.07.008)
• [L4] The association of biceps tendon lesions requiring surgical repair and rotator cuff tears is not uncommon. [23] (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. [24] (10.1016/j.jisako.2025.100816)
• [L4] Arthroscopic release of the long head of the biceps tendon is an appropriate and reliable intervention for patients with chronic, refractory biceps tendinitis. [25] (10.1177/0363546504269555)
• [L4] The authors present three patients with congenital variations of the long head of the biceps tendon, noting that literature reviews have been unable to link these uncommon lesions to a common pathoanatomic presentation or suggest a universally accepted treatment algorithm. [26] (10.1016/j.jse.2006.10.020)
• [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. [27] (10.1186/s12891-023-06338-5)
• [L3] Ninety-seven percent of patients had resolution of their preoperative biceps symptoms. [28] (10.1177/2325967113s00090)
• [L5] [29] (10.5435/00124635-201011000-00002)
• [L4] [30] (10.1016/j.jses.2019.07.007)
• [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. [34] (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. [35] (10.1177/2325967114s00061)
• [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. [36] (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. [37] (10.1016/j.asmr.2025.101113)
• [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. [38] (10.1097/corr.0000000000001672)
• [L4] In rare cases, the long head of the biceps takes origin from the rotator cable and has a second origin medial to the supraglenoid tubercle. [40] (10.1016/j.jse.2011.05.006)
• [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)
• [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. [52] (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. [55] (10.1016/j.arthro.2017.09.005)
• [L5] It is indicated for severe biceps tendinopathy, partial or full thickness biceps tendon tears, or biceps instability typically associated with rotator cuff tear. [57] (10.1053/otsm.2003.35895)
• [L1] The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. [58] (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. [59] (10.2147/oajsm.s76325)
• [L3] However, its usefulness for diagnosis of partial tears of the biceps tendon remains limited. [61] (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. [64] (10.1177/0363546514554193)
• [L5] Treatment of proximal biceps pathology is largely based on expert opinion and patient preferences rather than robust randomized evidence. [65] (10.1097/corr.0000000000002448)
• [L5] Biceps tendon pain in the absence of tears is associated with microscopic changes consistent with tendinopathy, which are often missed by MRI. [66] (10.1016/j.csm.2015.08.002)
• [L4] When measuring the long head of the biceps tendon, a mean of 2 measurements is recommended. [67] (10.2340/16501977-2095)
• [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. [69] (10.1016/j.csm.2015.08.001)
• [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. [70] (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)
• [L4] Conservative treatment remains the mainstay, with arthroscopic debridement reserved for cases where symptoms are not controlled by non-operative therapy. [73] (10.1177/1758573214567559)
• [L4] [77] (10.2106/jbjs.rvw.n.00020)
• [L1] [86] (10.1177/1758573220942923)
• [L5] [88] (10.1016/j.eats.2023.04.002)
• [L5] [91] (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. [93] (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. [95] (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. [105] (10.1016/j.jse.2008.06.003)
• [Paper] [108] (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. [116] (10.1016/j.arthro.2023.08.018)
• [L1] Both tenotomy and tenodesis are effective and equal for the treatment of long head biceps lesions. [118] (10.1007/s00167-013-2587-8)
• [L2] The supraspinatus tendon thickens in the presence of repetitive tasks, and it thickens the most in those who develop shoulder pain. [121] (10.1016/j.jse.2021.09.007)
• [L4] Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up. [123] (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. [124] (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. [127] (10.1016/j.arthro.2014.04.027)
• [L2] Concomitant biceps tenodesis appears to have a favorable effect on 1-year treatment success after total shoulder arthroplasty. [141] (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. [142] (10.1016/j.ejrad.2011.01.121)
• [L4] When indicated, biceps tenodesis offers an alternative to SLAP repair in young patients. [143] (10.1016/j.arthro.2018.10.151)
• [L5] The manuscript reviews current anatomic, functional, and clinical information regarding the long head of the biceps tendon, noting that while LHBT pathology is a significant cause of anterior shoulder pain, its exact role in shoulder stability remains controversial. [144] (10.2519/jospt.2009.2802)
• [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. [146] (10.1016/j.jse.2009.03.006)
• [L5] Arthroscopic biceps tenodesis is a safe and reliable treatment for managing intra-articular biceps tendon pathology. [148] (10.1016/j.eats.2024.103207)
• [L3] Tenotomy and open tenodesis are both safe options for treatment of biceps pathology. [149] (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. [152] (10.1007/s00264-018-3991-y)
• [L5] SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years. [153] (10.1016/j.jse.2024.09.040)
• [L3] [157] (10.1016/j.asmr.2021.10.020)
• [L5] Although comparative studies are lacking, tenotomy or tenodesis of the long head of the biceps seems a more reliable procedure than pulley repair. [158] (10.1016/j.csm.2015.08.003)
• [L5] [159] (10.1016/j.jse.2011.04.036)
• [L5] Clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other, though biceps tenodesis has proven more successful than tenotomy in non-isolated cuff tears. [160] (10.1016/j.arthro.2013.07.265)
• [L4] [162] (10.2106/00004623-199072050-00026)
• [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. [163] (10.1007/s00256-009-0720-z)
• [L2] Both high arthroscopic and mini-open subpectoral tenodesis of the long head of the biceps tendon produced reliably good functional results, but the ST group was associated with higher postoperative clinical outcomes. [165] (10.1016/j.jshs.2020.08.004)
• [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. [169] (10.1016/j.jisako.2026.101168)
• [L5] High-quality randomized controlled trials are necessary to understand how different biceps management techniques truly perform. [170] (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. [171] (10.1016/j.arthro.2013.04.001)
• [L3] Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. [172] (10.1016/j.jse.2019.04.001)
• [L3] The preoperative presence of an eccentrically positioned long head of the biceps tendon was associated with further changes of the tendon itself after rotator cuff repair. [181] (10.1302/0301-620x.102b9.bjj-2020-0076.r1)

See Also

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

References

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