What is the best management approach for a patient experiencing shoulder pain after a post tenodesis procedure?

Management of Shoulder Pain After Tenodesis

For patients experiencing shoulder pain after biceps tenodesis, a multimodal pain management approach combining NSAIDs, acetaminophen, physical therapy with gentle stretching focused on external rotation and abduction, and appropriate regional analgesia techniques is recommended. 1, 2

Initial Pain Assessment and Management

• First-line pharmacological treatment:

  • Regular acetaminophen (recommended as safer than other drugs) 1
  • NSAIDs (unless contraindicated) for both pain relief and anti-inflammatory effects 1, 2
  • Consider topical NSAIDs for fewer systemic side effects 2

• Pain assessment:

  • Use validated pain scales to guide treatment decisions 1
  • Regular reassessment at appropriate intervals based on intervention 1
  • Sudden increases in pain with tachycardia, hypotension, or hyperthermia warrant urgent evaluation for complications 1

Specific Interventions for Post-Tenodesis Pain

Physical Therapy

• Begin early physical therapy with gentle stretching and mobilization techniques 2
• Focus on external rotation and abduction exercises 2
• Gradually increase active range of motion exercises 2
• Avoid overhead pulley exercises as they may worsen pain 2
• Combine eccentric strengthening exercises with thermal therapy 2

Regional Analgesia Options

• Consider regional analgesia techniques if pain is severe:
  • Continuous interscalene block is preferred over single-shot block for prolonged analgesia 1
  • If interscalene block is not possible, axillary nerve block with or without suprascapular nerve block is recommended 1
  • For patients with contraindications to regional blocks, opioid patient-controlled analgesia (PCA) may be used 1

Injection Therapies

• Intra-articular corticosteroid injections (triamcinolone) for significant pain 2
• Consider methylprednisolone acetate 40mg with lidocaine 1% for more rapid pain relief 2
• Suprascapular nerve blocks may provide pain relief for up to 12 weeks 2

Common Complications After Biceps Tenodesis

Post-tenodesis pain may be related to specific complications:

• Persistent anterior shoulder pain (occurs in 10.8-12.9% of cases) 3
• Fixation-related issues:
  • Soft-tissue tenodesis: higher rates of new-onset anterior shoulder pain (11.9%) and subjective weakness (8.5%) 3
  • Implant tenodesis: lower rates of new-onset pain (2.6%) but higher revision rates (1.19%) 3
• Other complications:
  • Cosmetic deformity ("Popeye" sign)
  • Cramping or soreness in biceps muscle
  • Residual groove pain
  • Stiffness 4

Special Considerations

• Evaluate for surgical complications if pain is severe or worsening:

  • Loss of fixation
  • Infection
  • Hematoma
  • Neurologic or vascular injury 4

• Imaging considerations:

  • Plain radiography as initial imaging study (AP views in internal/external rotation, axillary view) 2
  • Consider MRI or ultrasound for soft tissue evaluation if symptoms persist 2

• Prognosis:

  • Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 2
  • Consider surgical referral if conservative management fails after 3-6 months 2

Cautions and Pitfalls

• Avoid complete immobilization as it may lead to muscular atrophy and worsening stiffness 2
• Ensure pain medications are administered at regular intervals, not just as needed 1
• Be aware that younger patients and female patients may experience more postoperative pain 1
• Pseudoparalysis of the shoulder is a contraindication to isolated biceps procedures 5

By following this structured approach to post-tenodesis shoulder pain, most patients can achieve significant pain relief and return to normal function.