Bicep Tenodesis Anchors: Fixation Methods and Recovery

A biceps tenodesis anchor is the hardware a surgeon uses to reattach the long head of the biceps tendon to the humerus after detaching it from its origin inside the shoulder joint. Several types of anchors exist, including interference screws, suture anchors, cortical buttons, and newer all-suture designs, and the choice among them affects fixation strength, complication profile, and the bone defect left behind. Understanding how these devices work and how they compare helps make sense of what your surgeon is recommending and what to expect afterward.

Why the Biceps Tendon Gets Moved in the First Place

The long head of the biceps tendon runs from the top of the shoulder socket (the glenoid), through the joint, and down a groove in the upper arm bone. It can become a source of pain when it is partially torn, unstable in its groove, or inflamed. A systematic review of surgical indications found that the most common reasons for tenodesis were partial tearing of the tendon (about half of cases), instability (about half), and inflammation of the tendon sheath (around 44%), with labral tears and painful clinical exams accounting for smaller shares.¹ Tenodesis is also frequently chosen when a labral tear (SLAP lesion) exists alongside biceps tendonitis, particularly when the labral tissue looks degenerative rather than healthy.²

Age and tissue quality strongly influence whether a surgeon repairs the labrum or simply moves the biceps tendon to a new home. Tenodesis tends to be favored in patients over 35, while younger patients with healthy-looking labral tissue are more likely to get a direct labral repair.³ That said, younger patients do undergo tenodesis, and outcomes in people 35 and under are generally favorable, with postoperative shoulder scores ranging from about 82 to 96 across nine studies.⁴

Why Anchor It at All? Tenodesis Versus Tenotomy

The simplest alternative to anchoring the biceps tendon is to just cut it loose, a procedure called tenotomy. Both approaches relieve the shoulder pain caused by the diseased tendon, and functional outcome scores are essentially equal. A meta-analysis of randomized controlled trials found no differences in shoulder scores, pain scales, or range of motion between the two.⁵ So why bother with an anchor?

The answer is cosmetic deformity and, to a lesser extent, strength. When the tendon is simply cut, the muscle belly can slide down the arm and bunch up, creating what is sometimes called a “Popeye” deformity. In the same meta-analysis, about 23% of tenotomy patients had this visible deformity compared with about 7% of tenodesis patients. A separate prospective randomized trial confirmed the pattern, finding that the risk of cosmetic deformity after tenotomy was roughly 3.5 times higher than after tenodesis, with one in three tenotomy patients affected versus one in ten tenodesis patients at two years.⁶ That same trial also found tenodesis patients had greater forearm supination strength, though this was the only strength difference among all the studies reviewed. For patients who care about arm appearance or who rely heavily on forearm rotation, an anchor-based tenodesis has a clear edge.

The Main Types of Fixation Devices

Once a surgeon decides to anchor the tendon rather than let it go, the choice of hardware matters. The four main categories each secure the tendon to bone in a different way.

Interference screws: A screw is inserted into a drilled bone tunnel alongside the rolled-up tendon, pressing the tendon against the tunnel wall. This is the most widely studied method and provides strong initial fixation.
Suture anchors: A small anchor is set into bone, and sutures attached to it are stitched through the tendon, holding it against the bone surface. This is an “onlay” approach because the tendon sits on top of the bone rather than inside it.
Cortical buttons: A small button passes through a hole in the bone and flips on the far cortex, acting like a toggle to hold sutures tied to the tendon.
All-suture anchors: A newer design that replaces the hard anchor body with tightly compressed suture material that expands inside a small drill hole, requiring less bone removal than a screw.

How the Anchors Compare Biomechanically

Surgeons and researchers have tested these devices head-to-head in cadaver and synthetic-bone studies, measuring how much force it takes to pull them out (load to failure) and how much the tendon shifts under repeated stress (cyclic displacement). The results are more nuanced than a simple ranking.

In one cadaver study, interference screws outperformed a specific suture anchor design by a wide margin, with about 170 newtons of load to failure versus about 69 for the suture anchors, roughly two and a half times the strength.⁷ But a different study using open suture anchors with closure of the transverse ligament found the opposite result: suture anchor fixation reached about 263 newtons compared with about 159 for interference screws.⁸ The technique and specific anchor model clearly matter as much as the category of device.

Cortical button fixation has shown mixed results. One study found similar load to failure compared with interference screws, with both around 210 to 220 newtons, though three of ten screw specimens failed from tendon slippage during cycling while all button specimens survived.⁹ However, another study found that a cortical button alone reached only about 99 newtons, far less than a 7-mm or 8-mm interference screw at roughly 276 to 277 newtons, and adding a button to the screw did not improve things.¹⁰

All-suture anchors, the newest entrant, have shown promise. One cadaver study found that an all-suture suture anchor achieved higher load to failure than a conventional interference screw while removing less cortical bone, creating a smaller stress riser in the humerus.¹¹ Another biomechanical study found comparable ultimate failure loads and stiffness between all-suture anchors and interference screws, though the all-suture anchors showed more displacement during cycling.¹² Drill angle also affects performance with all-suture anchors; a porcine model study concluded that 90 degrees is the optimal insertion angle.¹³

Onlay Versus Inlay Fixation

Beyond the specific device, a key distinction is whether the tendon is placed inside a bone tunnel (inlay, as with an interference screw) or on the bone surface (onlay, as with a suture anchor). The biomechanical data once seemed to favor inlay approaches for raw strength. But clinical healing tells a different story. A systematic review and meta-analysis noted that while lab studies showed higher load to failure for the inlay screw technique, one clinical study of 65 patients found the inlay method was associated with decreased healing. The decreased healing did not affect pain or function scores but did increase the rate of Popeye deformities. And at least one cadaver study found no difference in cyclic displacement or load to failure between onlay and inlay techniques performed at the same location.¹⁴ So the strongest anchor in the lab is not necessarily the one that heals best in a living shoulder.

Where the Anchor Is Placed on the Arm

The tenodesis can be done higher on the humerus (suprapectoral, at or above the pectoralis major muscle) or lower (subpectoral, below the muscle). Each has trade-offs related to the anchor and surrounding anatomy. A systematic review comparing the two positions when done alongside rotator cuff repair found that subpectoral tenodesis carried a higher incidence of temporary nerve injuries, while suprapectoral tenodesis was more often associated with persistent bicipital groove pain and Popeye deformity.¹⁵

The nerve risk with subpectoral placement is real and has been mapped anatomically. The musculocutaneous nerve, radial nerve, and deep brachial artery all pass within about one centimeter of the standard retractor position used during a subpectoral approach. Externally rotating the arm during surgery pushes the musculocutaneous nerve about 11 millimeters farther from the operative site, a simple maneuver that meaningfully improves the safety margin.¹⁶

Implant Material and Bone Reactions

Anchors are made from different materials, and these affect what happens in the bone over time. Bioabsorbable screws, designed to dissolve and be replaced by bone, can cause significant osteolysis, or bone loss around the implant. One study of bioabsorbable screws used for distal biceps repair found significant progressive bone erosion of the radius.¹⁷ A comparison between bioabsorbable (PLLA) and non-absorbable (PEEK) screws showed bone tunnel enlargement with both materials, around 43% for PLLA and 38% for PEEK.¹⁸ PEEK screws, being non-absorbable, stay in place permanently but avoid the inflammatory bone resorption sometimes triggered by dissolving polymers. All-suture anchors sidestep the issue partly because they leave a smaller hole and contain no rigid implant body, though they still require a pilot hole.

The Fracture Risk Question

Any time you drill a hole in a bone, you weaken it. For subpectoral tenodesis, the drilled unicortical hole sits in the upper arm bone at a location that already experiences substantial torsional forces. A biomechanical study specifically examined this issue and found that drilling an 8-mm hole for a subpectoral tenodesis reduced the torsional load to fracture by up to 28%. Adding a PEEK tenodesis screw alone reduced the maximum torque the bone could withstand by 30%, and adding a screw with the biceps tendon in place reduced it by 20%.¹⁹ The tendon partially offsets the weakening effect of the screw, but the bone is still weaker than before surgery. Screw malpositioning worsens things; one study showed a clear linear relationship between how oversized or misplaced the drill hole was and how much bone strength was lost.²⁰ This is one reason some surgeons prefer smaller-profile anchors or all-suture devices, especially in patients with lower bone density.

Clinical Results and Return to Sport

Lab-bench fixation strength matters, but what patients actually care about is whether their shoulder works again and whether they can get back to their activities. For overhead athletes with labral tears treated by tenodesis, a systematic review found an overall return-to-sport rate of 70%. Recreational athletes fared slightly better than professionals: recreational overhead athletes returned at 69%, competitive or collegiate athletes at 80%, and professionals at 60%.²¹ Another study focusing on isolated SLAP tears in overhead athletes found that about 82% returned to their sport, with 59% reaching the same or a higher level, at an average of about nine months postoperatively. No patients in that cohort needed revision surgery.²²

Professional baseball players present a specific and demanding case. A study of 14 professional baseball players who underwent tenodesis found that 86% returned to playing, but only 50% made it back to the same level or higher. Among pitchers specifically, all 12 returned to play, yet half returned at a lower level. For those who did return, it took about 245 days on average, and their subsequent performance metrics did not differ from matched controls.²³ The takeaway is that the anchor fixation generally holds up well enough for high-demand use, but the overall shoulder condition and sport demands often determine whether the athlete performs at the same level.

Recovery and How Soon You Can Ditch the Sling

Traditional protocols after biceps tenodesis keep the arm in a sling for four to six weeks to protect the healing tendon-to-bone interface. Surgeons have historically been cautious because early loading could theoretically pull the tendon off the anchor before biological healing occurs. But recent evidence suggests shorter immobilization may be safe. A study comparing an expedited protocol (sling discontinued within two weeks) to a standard protocol found no significant difference in complication rates, re-rupture, loss of fixation, or Popeye deformity between the two groups.²⁴ This was for isolated tenodesis, meaning no rotator cuff repair at the same time. If a cuff repair is done simultaneously, the rehab timeline is typically dictated by the cuff, not the tenodesis.

The Cost Difference Between Approaches

The anchor you choose affects the hospital bill. A study comparing open tenodesis, arthroscopic tenodesis, and simple tenotomy found that day-of-surgery costs were highest for open tenodesis (about $3,964), followed by arthroscopic tenodesis (about $3,427) and tenotomy (about $3,095). The fixation hardware itself accounted for much of the gap: anchor and screw costs averaged about $505 for open tenodesis versus about $238 for arthroscopic tenodesis, while tenotomy hardware cost was essentially zero. Despite the cost differences, functional outcomes did not significantly differ between the groups.²⁵ The cost premium for tenodesis is essentially buying a lower risk of cosmetic deformity and possibly a small strength advantage.

When the Anchor Fails and Revision Is Needed

Anchor failure, while uncommon, does happen. Systematic review data in younger patients showed complication rates ranging from 0% to 19%, with revision surgery rates of 0% to 18%.²⁶ A study of 25 revision tenodesis patients found that the most common reason for revision was failure of a suprapectoral tenodesis (56% of cases), followed by failed subpectoral tenodesis (36%) and patient dissatisfaction after tenotomy (8%). At an average of roughly six years of follow-up, the revision procedures produced acceptable results.²⁷

Revision surgery is more complex than the original procedure because the surgeon is working with a shorter tendon remnant, pre-existing bone holes, and sometimes scar tissue. One described technique uses two suture anchors placed about 1.5 centimeters apart in the bicipital groove, with the tendon stitched in a specific pattern and secured in an onlay fashion against freshened bone.²⁸ When the remaining tendon is too short, an allograft tendon can be used to bridge the gap, typically secured with a tenodesis screw in a new or reused bone tunnel.²⁹ The existence of reliable salvage options is reassuring, but avoiding the need for revision by choosing the right anchor, placing it accurately, and using appropriate postoperative precautions is obviously preferable.

Checking Whether the Anchor Held

After surgery, surgeons sometimes want to know whether the tendon has healed to the bone at the anchor site. This is typically assessed with MRI or ultrasound, looking for the tendon running continuously in the groove down to where the anchor was placed. A failed tenodesis on imaging shows the tendon absent from the expected fixation site.³⁰ In practice, imaging is usually only ordered when something seems clinically wrong, such as persistent pain, a new bulge in the arm, or cramping with elbow flexion. Many successful tenodeses are never imaged postoperatively because the patient is doing well and the answer would not change management.