Treatment of Intra-articular Long Head Biceps Tendon Tear with Distal Retraction After Rotator Cuff Surgery
Perform biceps tenotomy or tenodesis to address the torn long head of biceps tendon, as failure to treat this pathology results in persistent anterior shoulder pain and poor satisfaction after rotator cuff repair. 1
Primary Treatment Approach
The long head of biceps tendon (LHBT) is frequently involved in rotator cuff pathology and represents a significant pain generator that must be addressed surgically. 1, 2 When a tear with distal retraction occurs after rotator cuff surgery, the following algorithm should guide treatment:
Surgical Decision-Making
Both tenotomy and tenodesis are effective options for relieving pain from LHBT pathology in the setting of rotator cuff tears. 1, 2
Key factors determining the choice between tenotomy versus tenodesis:
Patient age and activity level: Younger, more active patients may benefit from tenodesis to preserve biceps muscle strength and avoid cosmetic deformity ("Popeye sign"). 2
Quality of rotator cuff tissue: If the rotator cuff repair is intact or reparable, either option is appropriate; if irreparable, isolated tenotomy or tenodesis can still provide substantial pain relief. 2
Patient compliance expectations: Tenodesis requires postoperative immobilization and rehabilitation compliance, while tenotomy has simpler recovery. 2
Acromiohumeral distance: Patients with preserved acromiohumeral distance >10 mm have significantly better outcomes with biceps procedures. 3
Specific Technical Recommendations
For biceps tenotomy:
- This is the simpler procedure with faster recovery. 3
- 78% of patients report pain improvement at 3 months, and 75% maintain improvement at 4+ years follow-up. 3
- Functional improvement occurs in 76% of patients at mid-term follow-up. 3
- Best results occur when acromiohumeral distance is normal (>10 mm preoperatively). 3
For biceps tenodesis:
- Arthroscopic technique involves detachment from glenoid origin, exteriorization through longitudinal opening of bicipital groove, and fixation with interference screw. 4
- Preserves 90% of biceps power compared to opposite side. 4
- Absolute Constant Score improves from 43 preoperatively to 79 at 2+ year follow-up. 4
Critical Prognostic Factors
Factors predicting worse outcomes that should modify treatment planning:
- Supraspinatus retraction Patte stage 3 is significantly associated with worse functional outcomes. 3
- Acromiohumeral distance <10 mm predicts significantly worse pain and functional improvement. 3
- Advanced rotator cuff arthropathy may necessitate consideration of alternative procedures beyond isolated biceps treatment. 2
Common Pitfalls to Avoid
Do not leave a torn, retracted LHBT untreated, as this is a well-established source of persistent anterior shoulder pain that undermines rotator cuff repair outcomes. 1
Do not assume the rotator cuff repair alone will address biceps pathology—the LHBT commonly exhibits hypertrophy, hourglass contracture, delamination, and instability that require direct surgical intervention. 1
Avoid tenodesis in patients unlikely to comply with postoperative rehabilitation, as early failures can occur; tenotomy is safer in this population. 2, 4
When Conservative Management May Be Considered
While the question addresses a post-surgical scenario requiring intervention, it should be noted that conservative treatment (NSAIDs, corticosteroid injections, physical therapy, activity modification) is typically attempted first for biceps pathology, though the evidence for these modalities in the setting of rotator cuff tears is inconclusive. 5, 2 However, with a tear and distal retraction already present after rotator cuff surgery, surgical intervention is indicated.