The decision to intentionally cut the biceps tendon during a rotator cuff repair is a surgical step taken to ensure the procedure’s success. This intervention focuses specifically on the long head of the biceps tendon (LHB), one of the two tendons connecting the biceps muscle to the shoulder. The LHB travels directly into the shoulder joint, near the rotator cuff tendons, where it can become a separate source of pain. Addressing this tendon pathology concurrently with the rotator cuff repair is often necessary to eliminate persistent discomfort and improve long-term shoulder function.
Why the Biceps Tendon Becomes Painful
The long head of the biceps tendon (LHB) is anatomically vulnerable within the shoulder. It passes through a narrow channel in the humerus and attaches inside the shoulder socket, meaning the tendon is repeatedly rubbed and compressed during movement. This relationship with the rotator cuff makes it susceptible to secondary damage when the cuff is injured.
Chronic problems, such as a rotator cuff tear, disrupt normal shoulder mechanics and destabilize the biceps tendon’s position. This instability causes the tendon to fray, become inflamed, or partially tear, a condition known as tendinopathy. A damaged LHB acts as a persistent source of anterior shoulder pain, even after the rotator cuff tear is repaired. Leaving a damaged LHB in place could jeopardize recovery, as the tendon continues to generate pain and potentially compromise the repaired tissue.
The severity of LHB damage often correlates with the size of the rotator cuff tear. The LHB is forced to work harder as a stabilizer when the rotator cuff muscles are not functioning correctly, increasing stress and wear. This degenerative process can lead to the tendon becoming frayed, unstable, or even subluxing (popping out of its groove). Surgical intervention on the LHB is necessary to remove this pain generator and restore a stable, pain-free shoulder environment.
Surgical Options for Biceps Tendon Management
When the LHB is too damaged to be preserved, the surgeon chooses between two primary techniques to eliminate the pain source. The simplest approach is biceps tenotomy, which involves cutting the tendon at its attachment point inside the shoulder joint. The remaining portion of the tendon is allowed to retract naturally down the arm. This procedure is quick and effective at relieving biceps-related pain by removing the damaged section and the tension on the tendon.
Tenotomy is generally favored for older or less physically active patients, as it minimizes surgical time and complexity. However, the technique carries a higher risk of cosmetic alteration because the muscle belly can bunch up in the lower upper arm. This muscular bunching is a main factor influencing the choice of surgical method.
The second option, biceps tenodesis, is a more involved procedure. The LHB is cut, but the remaining tendon is then surgically reattached to the humerus bone further down the arm. This fixation prevents the muscle belly from retracting, maintaining a more normal muscle contour and tension. Tenodesis is often preferred for younger, more active individuals concerned about cosmetic appearance or who require maximum strength for heavy lifting.
While tenodesis is a longer operation, studies show it significantly reduces the likelihood of the muscle bunching deformity compared to tenotomy. The choice between tenotomy and tenodesis is a shared decision, weighing factors like age, activity level, and cosmetic outcomes. Both methods provide excellent relief from biceps-related shoulder pain.
Functional and Cosmetic Outcomes
A primary concern for patients is the impact on arm strength after the LHB is managed surgically. The biceps muscle has two heads: the long head and the short head. The short head, which has a separate attachment point outside the shoulder joint, remains fully intact and functional, compensating for the released long head.
For most patients, studies indicate no significant difference in overall elbow flexion strength between tenotomy and tenodesis. Elbow flexion is the biceps muscle’s main function. The expected outcome is substantial pain relief and improved shoulder mechanics, which is the main goal of the combined surgery. Minor strength differences are typically observed in forearm supination (turning the palm up), where tenodesis may result in slightly better strength than tenotomy.
The most notable difference between the two procedures is the cosmetic outcome. The “Popeye deformity,” a bulge in the lower biceps muscle, is a recognized side effect of tenotomy, occurring in a higher percentage of patients than with tenodesis. This deformity happens because the released tendon and muscle belly retract down the arm. While tenodesis significantly lowers the risk of this cosmetic issue, it does not eliminate it entirely, as fixation failure is possible.
The recovery time added by the biceps procedure to the overall rotator cuff repair timeline is minimal. Patients may experience some temporary cramping or tenderness in the biceps muscle post-surgery, which is more common after tenotomy, but this generally resolves. Successful management of the LHB ensures a more complete recovery and a better long-term result from the rotator cuff repair.