Clinical Outcomes After Biceps Tenodesis or Tenotomy Using Subpectoral Pain to Guide Management in Patients With Rotator Cuff Tears


      To assess whether preoperative subpectoral tenderness in patients with rotator cuff tears was associated with arthroscopic findings of tendinopathy of the long head of the biceps, as well as whether they had resolution of their subpectoral tenderness postoperatively after tenodesis or tenotomy.


      Patients presenting between 2011 and 2016 undergoing arthroscopic rotator cuff repair were evaluated preoperatively with the subpectoral biceps test (SBT). This test is performed with the arm adducted and internally rotated to allow palpation of the biceps as it courses under the pectoralis major tendon. Preoperative SBT findings determined operative management with either tenodesis or tenotomy during rotator cuff repair. Patients were followed up postoperatively to assess resolution of subpectoral tenderness with a repeated SBT. Preoperative and postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons, and Constant-Murley scores were recorded in all patients.


      A total of 128 patients were enrolled in the study, with a mean age of 58 years (range, 33-82 years). Patients with a positive preoperative SBT (n = 68) had significantly lower SANE and Constant-Murley scores preoperatively (P < .01) than patients with a negative SBT (n = 60). All patients with a positive preoperative SBT underwent either tenodesis or tenotomy, with 94% of patients (n = 64) having resolution of subpectoral pain and tenderness at final follow-up. Intraoperatively, 93% of patients with a positive SBT showed gross pathologic changes in the tendon (fraying, erythema, tears, or subluxation) compared with only 65% of patients with negative preoperative examination findings (P < .01). American Shoulder and Elbow Surgeons, Constant-Murley, and SANE scores were significantly increased postoperatively in all patients (P = .02).


      In this group of patients with rotator cuff tears surgically treated with concomitant biceps tenodesis or tenotomy, 94% had resolution of their subpectoral tenderness. A positive SBT was associated with gross pathologic changes of the biceps in 93% of patients.

      Level of Evidence

      Level III, prospective comparative study.
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        • Ahrens P.M.
        • Boileau P.
        The long head of biceps and associated tendinopathy.
        J Bone Joint Surg Br. 2007; 89: 1001-1009
        • Jordan R.W.
        • Saithna A.
        Physical examination tests and imaging studies based on arthroscopic assessment of the long head of biceps tendon are invalid.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 3228-3236
        • Boileau P.
        • Baque F.
        • Valerio L.
        • Ahrens P.
        • Chuinard C.
        • Trojani C.
        Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears.
        J Bone Joint Surg Am. 2007; 89: 747-757
        • Matsen III, F.A.
        • Kirby R.
        Office evaluation and management of shoulder pain.
        Orthop Clin North Am. 1982; 13: 453-475
        • Bennett W.F.
        Specificity of the Speed’s test: Arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove.
        Arthroscopy. 1998; 14: 789-796
        • Barber F.A.
        • Morgan C.D.
        • Burkhart S.S.
        • Jobe C.M.
        Point counterpoint: Labrum/biceps/cuff dysfunction in the throwing athlete.
        Arthroscopy. 1999; 15: 852-857
        • Tennent T.D.
        • Beach W.R.
        • Meyers J.F.
        A review of the special tests associated with shoulder examination: Part II: Laxity, instability, and superior labral anterior and posterior (SLAP) lesions.
        Am J Sports Med. 2003; 31: 301-307
        • McFarland E.G.
        • Kim T.K.
        • Savino R.M.
        Clinical assessment of three common tests for superior labral antero-posterior lesions.
        Am J Sports Med. 2002; 30: 810-815
        • Rol M.
        • Favard L.
        • Berhouet J.
        Diagnosis of long head of biceps tendinopathy in rotator cuff tear patients: Correlation of imaging and arthroscopy data.
        Int Orthop. 2018; 42: 1347-1355
        • Murthi A.M.
        • Vosburgh C.L.
        • Neviaser T.J.
        The incidence of pathologic changes of the long head of the biceps tendon.
        J Shoulder Elbow Surg. 2000; 9: 382-385
        • Wu P.T.
        • Jou I.M.
        • Yang C.C.
        • et al.
        The severity of the long head biceps tendinopathy in patients with chronic rotator cuff tears: Macroscopic versus microscopic results.
        J Shoulder Elbow Surg. 2014; 23: 1099-1106
        • Mazzocca A.D.
        • McCarthy M.B.
        • Ledgard F.A.
        • et al.
        Histomorphologic changes of the long head of the biceps in common shoulder pathologies.
        Arthroscopy. 2013; 29: 972-981
        • Jospeh M.
        • Maresh C.M.
        • McCarthy M.B.
        • et al.
        Histological and molecular analysis of the biceps tendon long head post-tenotomy.
        J Orthop Res. 2009; 27: 1379-1385
        • Mazzocca A.D.
        • Cote M.P.
        • Arciero C.L.
        • Romeo A.A.
        • Arciero R.A.
        Clinical outcomes after subpectoral biceps tenodesis with an interference screw.
        Am J Sports Med. 2008; 36: 1922-1929
        • Mazzocca A.D.
        • Rios C.G.
        • Romeo A.A.
        • Arciero R.A.
        Subpectoral biceps tenodesis with interference screw fixation.
        Arthroscopy. 2005; 21: 896
        • Conboy V.D.
        • Morris R.W.
        • Kiss J.
        • Carr A.J.
        An evaluation of the Constant-Murley shoulder assessment.
        J Bone Joint Surg Br. 1996; 78: 229-232
        • Kukkonen J.
        • Kauko T.
        • Vahlberg T.
        • Joukainen A.
        • Aärimaa V.
        Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery.
        J Shoulder Elbow Surg. 2013; 22: 1650-1655
        • Kocher M.S.
        • Horan M.P.
        • Briggs K.K.
        • Richardson T.R.
        • O’Holleran J.
        • Hawkins R.J.
        Reliability, validity, and responsiveness of the American Shoulder and Elbow Surgeons subjective shoulder scale in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis.
        J Bone Joint Surg Am. 2005; 87: 2006-2011
        • Godfrey J.
        • Hamman R.
        • Lowenstein S.
        • Briggs K.
        • Kocher M.
        Reliability, validity, and responsiveness of the simple shoulder test: Psychometric properties by age and injury type.
        J Shoulder Elbow Surg. 2007; 16: 260-267
        • Zhang Q.
        • Zhou J.
        • Ge H.
        • Cheng B.
        Tenotomy or tenodesis for long head biceps lesions in shoulders with reparable rotator cuff tears: A prospective randomised trial.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 464-469
        • Desai S.S.
        • Mata H.K.
        Long head of biceps tendon pathology and results of tenotomy in full-thickness reparable rotator cuff tear.
        Arthroscopy. 2017; 33: 1971-1976
        • Ditsios K.
        • Agathangelidis F.
        • Boutsiadis A.
        • Karataglis D.
        • Papadopoulos P.
        Long head of the biceps pathology combined with rotator cuff tears.
        Adv Orthop. 2012; : 405-472
        • Taylor S.A.
        • Khair M.M.
        • Gulotta L.V.
        • et al.
        Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex.
        Arthroscopy. 2015; 31: 215-224
        • Nuelle C.W.
        • Stokes D.C.
        • Kuroki K.
        • Crim J.R.
        • Sherman S.L.
        Radiologic and histologic evaluation of proximal bicep pathology in patients with chronic biceps tendinopathy undergoing open subpectoral biceps tenodesis.
        Arthroscopy. 2018; 34: 1790-1796
        • Taylor S.A.
        Editorial commentary: Thank you, thank you, thank you . . . for demonstrating histologic evidence of shoulder bicipital tunnel disease in the absence of magnetic resonance imaging findings.
        Arthroscopy. 2018; 34: 1797-1798
        • Meraner D.
        • Sternberg C.
        • Vega J.
        • Hahne J.
        • Kleine M.
        • Leuzinger J.
        Arthroscopic tenodesis versus tenotomy of the long head of biceps tendon in simultaneous rotator cuff repair.
        Arch Orthop Trauma Surg. 2016; 136: 101-106
        • Erickson B.J.
        • Basques B.A.
        • Griffin J.W.
        • et al.
        The effect of concomitant biceps tenodesis on reoperation rates after rotator cuff repair: A review of a large private-payer database from 2007 to 2014.
        Arthroscopy. 2017; 33: 1301-1307.e1
        • Taylor S.A.
        • Newman A.M.
        • Dawson C.
        • et al.
        The "3-pack" examination is critical for comprehensive evaluation of the biceps-labrum complex and the bicipital tunnel: A prospective study.
        Arthroscopy. 2017; 33: 28-38
        • Corpus K.T.
        • Garcia G.H.
        • Liu J.N.
        • et al.
        Long head of biceps tendon management: A survey of the American Shoulder and Elbow Surgeons.
        HSS J. 2018; 14: 34-40
        • Gulotta L.V.
        • Nho S.H.
        • Dodson C.C.
        • Adler R.S.
        • Altchek D.W.
        • MacGillivray J.D.
        Prospective evaluation of arthroscopic rotator cuff repairs at 5 years: Part I—Functional outcomes and radiographic healing rates.
        J Shoulder Elbow Surg. 2011; 20: 934-940
        • Godeneche A.
        • Nove-Josserand L.
        • Audebert S.
        • Toussaint B.
        • Denard P.J.
        • Ladermann A.
        Relationship between subscapularis tears and injuries to the biceps pulley.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2114-2120

      Linked Article

      • Editorial Commentary: Biceps Tendon Tenderness… Is It Enough to Guide Surgical Management?
        ArthroscopyVol. 35Issue 7
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          Pathology of the long head of the biceps tendon is often encountered concurrently with rotator cuff tears. Although both preoperative and intraoperative evaluations may play a role in the decision-making process of when and how to treat the biceps, it can still be a conundrum. The more straightforward tests and reliable evaluation methods we have in our repertoire, the more likely the appropriate treatment choice to address the pathology will be made. The subpectoral biceps test is a helpful examination maneuver as part of the preoperative biceps evaluation.
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