Arthroscopic Biceps Tenotomy/Tenodesis for Mild Subluxation with Tendinosis and Tenosynovitis
Yes, arthroscopic biceps tenotomy or tenodesis is indicated for a mildly subluxated long head of biceps tendon with tendinosis and mild tenosynovitis, particularly in younger, active patients where tenodesis is preferred to maintain elbow flexion/supination strength and avoid cosmetic deformity.
Clinical Decision Framework
The decision for surgical intervention hinges on identifying irreversible chronic changes to the biceps tendon that make spontaneous resolution of pain unlikely:
Absolute Indications for Tenodesis/Tenotomy
Your patient meets established criteria for surgical intervention based on the presence of:
- Subluxation/luxation of the biceps tendon from the bicipital groove (any degree qualifies as an absolute indication) 1
- Chronic inflammatory changes evidenced by tendinosis and tenosynovitis 2, 1
Additional absolute indications include (for reference):
- Greater than 25% partial thickness tearing 1
- Chronic atrophic changes or >25% reduction in tendon width 1
- Disruption of bicipital groove anatomy 1
Relative Indications
- Failed conservative management (rest, NSAIDs, physical therapy, corticosteroid injections) 3
- Biceps pathology in context of failed subacromial decompression 1
- Associated rotator cuff pathology requiring surgical repair 2
Tenodesis vs. Tenotomy: Making the Choice
For younger, active patients: Tenodesis is strongly preferred 4
Advantages of Tenodesis:
- Maintains elbow flexion and supination power 4
- Minimizes cosmetic deformity (no "Popeye" sign) 4, 5
- Reduces fatigue soreness after active flexion 4
- Particularly important for patients requiring supination strength 5
When Tenotomy May Be Acceptable:
- Older, sedentary patients where conservative treatment results in minimal functional loss 5
- Patients who prioritize simpler procedure with faster recovery over cosmetic concerns
Surgical Approach
All-arthroscopic biceps tenodesis with proximal interference screw fixation is the preferred technique 4
- Allows complete evaluation of glenohumeral joint and associated pathology 2
- Enables concurrent treatment of rotator cuff tears or SLAP lesions if present 4, 2
- Reproducible technique with satisfactory outcomes 2
Critical Pitfalls to Avoid
Do not perform routine tenodesis during all rotator cuff repairs - tenodesis should only be performed when chronic, irreversible changes are present 1
Do not rely solely on imaging - arthroscopic evaluation is essential for final decision-making, as findings like excessive fraying, atrophy, or partial rupture may only be fully appreciated intraoperatively 2
Do not ignore associated pathology - 95% of biceps tendinitis is secondary to impingement syndrome, requiring concurrent subacromial decompression 5
Evidence Quality Note
While the American Academy of Orthopaedic Surgeons guidelines state they "are unable to recommend for or against biceps tenotomy or tenodesis" in the specific context of shoulder arthroplasty for glenohumeral osteoarthritis 6, this reflects lack of high-quality evidence in that specific population, not in the general population with biceps pathology. The clinical literature consistently supports intervention for subluxation with chronic changes 4, 2, 1, 3, 5.