Biceps Tenotomy and Tenodesis

A patient's guide to understanding why these procedures are performed, how they are done, and what recovery looks like.

Why is surgery on the biceps tendon needed?

The long head of the biceps (LHB) is a tendon that originates inside the shoulder joint, attaches to the top of the socket (the labrum), and travels through a narrow groove in the front of the humerus before connecting to the biceps muscle. Because of its location, it is one of the most commonly injured tendons in the shoulder.

The biceps tendon’s unique problem

Unlike most tendons, the long head of the biceps runs through the shoulder joint. This makes it susceptible to irritation, tearing, and instability — often alongside other shoulder conditions such as rotator cuff tears.

Conditions involving the biceps:

1. Tendinitis & partial tearing. Chronic inflammation or partial-thickness tears cause deep, aching pain at the front of the shoulder, often worsening with overhead activity or lifting.

2. SLAP tears. The tendon's attachment to the labrum (called the biceps anchor) can tear, producing pain, clicking, and a sense of instability, especially in throwing athletes or after a fall.

3. Tendon instability. The tendon can slip out of its groove at the front of the shoulder (medial subluxation), causing pain and a snapping sensation with arm rotation.

4. Complete rupture. The tendon can rupture spontaneously — usually in the setting of pre-existing degeneration — causing sudden pain, bruising, and a visible bulge in the arm (the "Popeye" deformity).

When non-surgical treatment — rest, physical therapy, and injections — fails to relieve pain, surgery is considered. The two main surgical options are tenotomy and tenodesis.

Biceps Tenotomy: The tendon is simply cut at its attachment inside the shoulder and left to retract. No reattachment is performed.

Biceps Tenodesis: The tendon is cut at the top, then reattached to the bone at a lower point — eliminating the painful portion while preserving muscle function.

Biceps tenotomy — how it is performed

Tenotomy is almost always performed arthroscopically — using a tiny camera and instruments inserted through small incisions less than a centimeter in size. There is no large open incision.

Step 1 — Anesthesia

You will receive general anesthesia (asleep) and usually a nerve block to numb the shoulder and arm, which provides pain control for several hours after surgery.

Step 2 — Arthroscopic entry

Two or three small portals (incisions) are made around the shoulder. A camera is inserted to visualize the inside of the joint, including the biceps tendon and its attachment.

Step 3 — Tendon release

A small electrocautery device or arthroscopic scissors cuts the tendon at its attachment to the labrum at the top of the socket. The tendon releases immediately and retracts down into the arm.

Step 4 — Completion

Any remaining shoulder pathology (rotator cuff tears, labral damage, bone spurs) is addressed during the same procedure. Portals are closed with suture or skin tape. Total surgical time is typically 30–90 minutes depending on additional work performed.

Important: The "Popeye" deformity

After tenotomy, the biceps muscle belly shifts downward, creating a visible bulge in the lower arm — often called a "Popeye" sign. This occurs in most patients and is permanent. In older or less active patients, this is often cosmetically acceptable and causes minimal loss of strength.

Biceps tenodesis — how it is performed

Tenodesis is more involved than tenotomy because the tendon must be secured to bone in a new location. It can be performed arthroscopically, through a small open incision, or a combination of both.

Step 1 — Anesthesia

As with tenotomy: general anesthesia plus a nerve block for postoperative pain control.

Step 2 — Arthroscopic release

The diseased portion of the tendon is identified and cut at its attachment to the labrum. The free end of the tendon is brought out through or near the bicipital groove.

Step 3 — Preparation of the new attachment site

A small socket (called a tunnel or trough) is prepared in the upper arm bone (humerus), either in the bicipital groove (suprapectoral tenodesis) or just below the pectoral muscle (subpectoral tenodesis). The choice of location depends on the extent of tendon disease and your surgeon's preference.

Step 4 — Fixation

Fixation is achieved with one of or a combination of implants such as a small threaded screw called an interference screw or an anchor or metallic button that secures the tendon to the bone through suture.

Step 5 — Closure & completion

The portals and any small incision are closed. The tendon now lives at a new, lower attachment point on the arm bone, away from the diseased area inside the shoulder joint.

Recovery & rehabilitation

Tenotomy recovery

Weeks 1–2: Sling for comfort only. Begin gentle motion.

Weeks 2–4: Full active shoulder and elbow range of motion.

Weeks 4–6: Light resistance and progressive strengthening.

6–8 weeks: Return to full, unrestricted activity.

Tenodesis recovery

Weeks 0–6: Sling worn. No elbow flexion or supination against resistance. Gentle shoulder motion only.

Weeks 6–12: Sling off. Active motion. Begin gentle strengthening.

Months 3–4: Progressive resistance, including biceps curls.

Months 4–6: Return to full, unrestricted activity.

Why is tenodesis recovery longer?

After tenotomy, there is nothing left to heal — the tendon is simply gone. Recovery is just about managing comfort. After tenodesis, the reattached tendon must grow into the bone (a biological healing process that takes 6–12 weeks). Protecting this healing process is why elbow bending and lifting are restricted in the early weeks.

Which procedure is right for you?

The decision between tenotomy and tenodesis is individualized. Below are several considerations that should be weighed when making the decision.

Factor	Tenotomy	Tenodesis
Age	Typically preferred in older patients	Preferred in younger, active patients
Activity level	Lower-demand lifestyle or sedentary work	Higher-demand work, sport, or manual labor
Cosmetic concern	Popeye deformity acceptable	When cosmesis matters to the patient
Strength concerns	Minor supination strength loss tolerable	When preserving full biceps strength is a priority
Recovery tolerance	Patient prefers or requires faster return to activity	Patient accepts longer but more complete recovery

There is no universally "better" option — both procedures effectively relieve pain. Studies show similar patient satisfaction rates when the right procedure is matched to the right patient.

Call to book an appointment:

646-665-6784

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About the Author

C. Lucas Myerson, MD – Orthopedic surgeon specializing in shoulder and elbow surgery.

Disclaimer

This article is for educational purposes only. It is not a substitute for medical advice. Always talk to your doctor before starting or changing treatment.