Is biceps tenotomy indicated for patients with severe biceps tendonopathy who have not responded to conservative management, including physical therapy and pain management with nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections?

Biceps Tenotomy for Severe Biceps Tendonopathy

Yes, biceps tenotomy is indicated for patients with severe biceps tendonopathy who have failed 3-6 months of appropriate conservative management, including physical therapy, NSAIDs, and corticosteroid injections. 1

Conservative Management Must Be Exhausted First

Before considering surgical intervention, patients must complete an adequate trial of conservative therapy:

• Initial treatment should include relative rest (reducing repetitive loading activities without complete immobilization), cryotherapy (ice through wet towel for 10-minute periods), and eccentric strengthening exercises as the foundation of management 1, 2

• NSAIDs provide short-term pain relief but do not alter long-term outcomes or affect the underlying degenerative process 1

• Corticosteroid injections may offer better acute pain relief than oral NSAIDs but similarly do not change long-term outcomes and should be used with caution as they may inhibit healing and reduce tensile strength 1, 3

• Physical therapy with eccentric exercises is particularly effective for reversing degenerative changes and promoting tendon healing 1, 2

• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 1, 2

Surgical Indications

Surgery is reserved for carefully selected patients who have failed 3-6 months of well-managed conservative therapy 1, 2

When conservative management fails, both biceps tenotomy and tenodesis are effective surgical options:

• Both tenotomy and tenodesis show no substantial differences in functional scores or patient satisfaction at 2-year follow-up 4, 5

• Tenotomy provides earlier pain relief postoperatively, with 75% of tenotomy patients reporting no pain medication use at 2 weeks versus 33% for tenodesis 5

• Tenotomy has a higher incidence of cosmetic "Popeye" deformity (25% versus 7% for tenodesis), though this rarely affects function 4, 5

• Tenotomy is technically simpler and faster than tenodesis procedures 4

Clinical Decision-Making Algorithm

For patients with refractory biceps tendonopathy after 3-6 months of conservative treatment:

1. Consider patient priorities: If cosmetic appearance is a significant concern (younger, active patients, manual laborers who value arm appearance), tenodesis may be preferred 4

2. For older patients or those prioritizing faster recovery: Tenotomy offers quicker pain relief and simpler surgery with equivalent functional outcomes 5

3. Ensure concomitant shoulder pathology is addressed: Failed biceps procedures often result from unaddressed associated shoulder conditions rather than technical failure 6

Critical Pitfalls to Avoid

• Do not perform surgery before completing 3-6 months of appropriate conservative therapy unless there is complete tendon rupture 1, 2

• Avoid intratendinous corticosteroid injections; peritendinous injections are safer and reduce rupture risk 3

• Do not promise patients that tenotomy will avoid cosmetic deformity; thorough preoperative discussion of the 25% risk of Popeye deformity is essential to avoid patient dissatisfaction 4, 6

• Recognize that persistent pain after biceps surgery may indicate missed concomitant pathology (rotator cuff tears, labral pathology) rather than technical failure of the biceps procedure 6