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Tendinopathy of the tendon of the long head of
the biceps
Umile Giuseppe Longo * MD, MSc, Mattia Loppini* MD, Gianluca Marineo* MD,
Wasim S Khan **, PhD, Nicola Maffulli MD, MS, PhD, FRCS (Orth) +,
Vincenzo Denaro * MD
* Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Via
Alvaro del Portillo, 200, 00128 Trigoria Rome, Italy
+ Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The
London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London
E1 4DG, England
Corresponding author:
Nicola Maffulli MD, MS, PhD, FRCS(Orth)
Centre Lead and Professor of Sports and Exercise Medicine
Consultant Trauma and Orthopaedic Surgeon
Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and
Dentistry
Mile End Hospital, 275 Bancroft Road, London E1 4DG England
Tel: + 44 20 8223 8839 Fax: + 44 20 8223 8930 n.maffulli@qmul.ac.uk
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Abstract
Pathologies of tendon of the long head of the biceps (LHB) are an important cause of
shoulder pain. They include tendinopathy, rupture, SLAP lesions, pulley tears and tendon
instability. Conservative management of symptomatic LHB tendinopathy is commonly
accepted as the first-line treatment. It consists of rest, nonsteroidal anti-inflammatory drugs,
corticosteroid injections and physical therapy. Biceps tenotomy and tenodesis are the most
common surgical procedures to manage both isolated LHB pathology and biceps-glenoid
complex tears combined with rotator cuff tears. However, controversy persists about the
superiority of one of them because there is no evidence of significant differences in
functional scores or patient satisfaction between the two techniques. This article provides an
overview on biomechanical function of the LHB and current strategies for treatment of LHB
disorders.
Key words: Long head of the biceps; Tendinopathy; Rupture; SLAP lesions; Pulley tears and
tendon instability
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Introduction
Shoulder pain is a common cause of pain and occupational disability, with significant impact
on patients’ quality of life, and marked functional impairment 1-4. Pathology of the tendon of
the long head of the biceps (LHB) is an important source of pain in the shoulder, often
causing associated loss of forward flexion. Tendinopathy of the LHB has inflammatory,
degenerative, overuse-related and traumatic causes 5. Although wide research has been
performed on LHB function and disorders, few level I studies have been conducted to guide
physicians in the best management option to adopt in such patients. Biceps tenotomy and
tenodesis are the most common procedures to manage both isolated LHB pathology and
rotator cuff combined with biceps-glenoid complex tears. However, controversy persists
about the superiority of one of them in terms of shoulder stability and motion 6.
This article provides an overview on biomechanical function of the LHB and current
strategies for the management of LHB disorders.
Anatomy
The tendon of the LHB consists of two different portions: intra-articular and extra-articular
tract. The intra-articular portion originates from the supraglenoid tubercle and superior
glenoid labrum. This portion is extrasynovial and passes through glenohumeral joint
anterosuperiorly to the humeral head. The extra-articular portion passes under the pulley and
enters into the bicipital groove. The proximal and distal parts of the tendon of the LHB are
different in term of morphologic features, innervation and vascularization patterns.
The tendon is approximately 5 mm wide and 10 cm long. The intra-articular tract, wide and
flat, is ribbon-shaped, while the extra-articular tract, rounder and smaller, is tubular 7.
The innervation pattern, defined a “net-like pattern” 8, consists of neuronal network
composed of sensory and sympathetic fibers, which are concentrated at the tendon origin and
attenuated at the musculotendinous junction. The blood supply is ensured by branches of the
anterior circumflex humeral artery, particularly at the proximal tract, whereas the distal tract
is relatively avascular. The fibrocartilaginous feature of distal portion of the tendon of the
LHB seems to favour its sliding motion into the groove.
A soft-tissue sling allows the LHB sliding movement maintaining the biceps within its
groove. The tendon can slide up to 18 mm in and out of the glenohumeral joint in forward
flexion and internal rotation 9. Moreover, it turns of 30° to 40° after exit of the joint 10. The
biceps reflection pulley (BRP) consists of coracohumeral ligament fibers, superior
glenohumeral ligament (SGHL), subscapularis and supraspinatus tendon and fibers of
glenohumeral joint capsule. A fibrous expansion from the sternocostal head (falciform
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ligament) envelops the tendon, by attaching to both sides of the bicipital groove 11. These
structures form the anterior reflection pulley of the LHB 12. Also, a posterior pulley of the
LHB has been detected. This structure consists of the large amount of the coracohumeral
ligament fibers which passes behind the LHB and insert at the greater tuberosity, blending to
the anterior fibers of the supraspinatus tendon 13, 14. This anteroposterior capsulo-
ligamentotendinous sling plays an important role stabilizing the distal tract of intra-articular
LHB tendon.
The bicipital groove is a corridor in which the medial wall is higher than the lateral wall. It is
narrowest and deepest at its mid portion, taking an hourglass-shape 12. The total opening
angle between the lateral and medial wall is 101° to 120° in most asymptomatic shoulders 15.
The bicipital groove plays a critical role, together with the soft tissue sling, in containing the
LHB tendon during its excursions.
Biomechanics of the LHB tendon
The biomechanical function of the LHB tendon has not been completely clarified. Several
cadaver and in vivo biomechanical studies have been performed to assess the role of the LHB
tendon in glenohumeral kinematics. An important function of the LHB tendon is to stabilize
the humeral head within the glenoid during elbow flexion and forearm supination 16. When
the LHB tendon is damaged, the head of the humerus migrates upward on the glenoid. In
addition, the LHB tendon plays a role as a stabilizer of the humeral head on the glenoid
during shoulder abduction in the scapular plane 17.
The LHB tendon contributes to the anterior stability of the shoulder by increasing the
resistance to torsional forces, especially in the abducted and externally rotated position 18.
Moreover, it seems to be able to reduce the stress placed on the inferior glenohumeral
ligament 18. Both the long and short heads of the biceps tendon have a role in the anterior
stabilizer function of the glenohumeral joint 19, helping to resist to anterior humeral head
displacement 19. When anterior shoulder instability occurs, the role of LHB became critical to
maintain the stability. Therefore, strengthening of the biceps is recommended during
rehabilitation in patients with anterior instability of the shoulder 20.
Biceps contraction also limits glenohumeral translation 21. A decreased humeral head
translations anteriorly, superiorly, and inferiorly at the middle and lower elevation angles of
the humerus was found 21. Biceps loading decreases markedly glenohumeral translation
(anterior, posterior, superior and inferior) and rotational range of motion in a simulated
position of 90° of arm abduction and different angles of internal and external rotation 22.
Also, loading of the LHB tendon limits significantly the anterosuperior and superior
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glenohumeral translation in the presence of rotator cuff tears 23.
Morphologic changes of LHB are often combined with rotator cuff tears 24. These findings
support the function of the tendon of the LHB of compensating for abnormal forces produced
in the shoulder when the rotator cuff is damaged. The more common reported anatomical
findings consist of increased size of the LHB. This enlargement leads to increased attrition
during tendon sliding into the bicipital groove and its deterioration.
Biomechanical studies confirmed the role of LHB in stabilizing the glenohumeral joint in all
directions. However, the load applied to the biceps varies widely through the studies.
Moreover, the results of some studies could be biased from non-physiological high loads
applied to the tendon.
Few EMG studies evaluating the effects of the biceps on the shoulder kinematics are
available. Sakurai et al 25 found that the activity of the LHB stabilized the humeral head. On
the other hand, Levy et al 26 found no electrical activity in the LHB tendon with isolated
shoulder motion. They proposed that the stabilizing role of LHB is passive or it is related to
biceps tension associated with elbow or forearm activity. No significant biceps activity was
found during shoulder motion both in patients with normal or torn rotator cuff 27, supporting
the passive function of the biceps tendon in shoulder motion.
Some authors assess the function of the LHB during specific shoulder movements.
Jobe et al 28 analysed throwing and pitching motions in five male subjects by dynamic
electromyography and high speed photography, showing that the biceps predominantly
activates during cocking to accomplish elbow flexion and then reactivates during follow-
through to decelerate the forearm. The muscle patterns observed during the cycle were
largely characteristic of attempts to decelerate the arm 28. The biceps activity was also higher
during windmill pitch than during overhead throw, especially before and after ball release
between 9 o’clock and the follow-through phase 29.
At present, the results of EMG studies do not allow definitive conclusions. Controversies on
the relationship between the activation of the biceps at the elbow and the activity of the
biceps during shoulder movements still needs to be clarified.
Pathologies of the tendon of the LHB
Disorders of the LHB can determine anterior shoulder pain and/or diminished shoulder
function. LHB pathologies include tendinopathy, rupture, SLAP lesions, pulley tears and
tendon instability.
Biceps tendinopathy and tendon rupture
The terminology of LHB tendon pathology has become inconsistent and confusing
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throughout the years. For proper research, assessment and treatment, a uniform and clear
terminology is necessary. The terms “tendinosis”, “paratendinitis”, and “tendinitis” should be
used only after excision biopsy had been examined by a pathologist as these imply specific,
histopathologically proven conditions, with inflammatory cells. The aforementioned terms
should not used in clinical practice.
In inflammatory tendinopathy of the tendon of the LHB, the tendon inflammation can
primary or secondary. Primary tendinitis is the inflammation of the biceps tendon within the
bicipital groove. It is rare, occurring just in 5% of patients with biceps pathology 30.
Therefore, LHB pathology is typically a secondary process, related to others shoulder
problems, such as degenerative rotator cuff lesions, SLAP lesions, impingement syndrome
and acromioclavicular joint disorders 31.
Inflammatory tendinopathy and degenerative tendinopathy usually are related to overuse
consisting of repetitive traction and friction of LHB and glenohumeral rotation, with resultant
pressure and shear forces occurring on the tendon 32. The intra-articular portion of LHB is
surrounded by a sheath originated from synovial lining of the glenohumeral joint.
Inflammation of this sheath can occur in association with inflammatory processes that affect
the rotator cuff tendons 33. The hourglass-shaped LHB tendon is a specific pathological
condition in which the intra-articular portion of tendon is hypertrophic and engages the
superior part of the groove during shoulder motion. The entrapment of LHB within the joint
causes shoulder pain related to tendinopathy and joint locking because of inability of the
tendon to slide into the groove during elevation of the arm 34.
An inflammatory tendinopathy can evolve from LHB tenosynovitis to LHB tendinopathy,
which is marked by specific macroscopic and microscopic features 5, 11, 33. In tenosynovitis,
the biceps tendon appears inflamed and hemorrhagic, but still mobile within the groove.
When the inflammatory process advances, features of early tendinopathy became evident.
The sheath surrounding LHB appears thickened, fibrotic and relatively avascular.
Microscopic findings include: round cell infiltration, mucopolysaccharide deposition and
collagen disorganization 5. The evolution of the degenerative process leads to advanced LHB
tendinopathy, characterized by degenerated tendon, fixed within the groove by scar tissue and
adhesions. A tendinopathic LHB tendon is more likely to rupture spontaneously.
A rupture of the tendon of the LHB is most common in people over 50 years and represents
96% of all biceps brachii injuries 35. Ruptures of the short head or the distal tendon are less
frequent. Traumatic ruptures of the LHB tendon have been reported. However, ruptures are
often spontaneous or associated with little trauma, because they take place in degenerated
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tendon resulting from tenosynovitic and tendinopathic processes 36. The most common sites
of tendon rupture include the tendon origin and the region near the musculotendinous
junction 37. The typical clinical sign of LHB rupture is Popeye deformity, because of the
muscle mass moved distally.
SLAP Lesions
The term “SLAP lesions” was introduced to describe the pathology of superior labrum
extending from anterior to posterior 38. Snyder et al also performed a classification of superior
glenoid and biceps anchor (SLAP) lesions, identifying 4 different types of lesions 38. A type I
SLAP consists of degenerated and frayed superior labrum with the edge still firmly attached
to the glenoid. A type II SLAP consists of the superior labrum and biceps anchor detachment
from the glenoid. A type III SLAP consists of a bucket-handle tear of the superior labrum,
without destabilization of remaining labrum and biceps anchor. A type IV SLAP consists of a
bucket-handle tear of the superior labrum with extension into the biceps tendon. Although
other authors have described further types of SLAP lesions, these are usually a combination
of the above standard types. Type II lesions are the most common, representing 55% of all
lesions, followed by type I lesions (21%), type III lesions (9%), and type IV lesions (10%) 39.
In 5% of the patients, lesions consist in a combinations of type II and III or type II and IV
lesions.
The incidence of SLAP lesions is close to 12% 40. However, data published in literature are
strictly related to experience of shoulder arthroscopists and their ability to recognize such
lesions.
SLAP lesions can be caused by recurrent micro-traumatic impairment, mainly in overhead
athletes, or by single traumatic events. Two different mechanisms of injury have been
proposed to understand the aetiology of superior labral injuries: superior compression and
inferior traction. The superior compression can result from an acute traumatic force occurring
in a fall on the arm with the shoulder positioned in an abducted and slightly forward-flexed
position at the time of impact 39. The superior compression can be also associated with lesions
of rotator cuff leading to a superior migration of the humeral head. Therefore, the superior
labrum and biceps anchor can be damaged and gradually lifted off the glenoid, because of
chronic repetitive superior translation of the humeral head.
74% of individuals with full-thickness rotator cuff tears had also intra-articular lesions,
particularly labral tears 41. Snyder et al 39 detected full- or partial-thickness rotator cuff tears
in 40% of patients with superior labral lesions. Other authors 40, 42, 43 proposed the association
of SLAP lesions with an inferior traction force, occurring with a traumatic, inferior pull on
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the arm, or repetitive micro-trauma, occurring in overhead sport activity with associated
instability.
Biceps instability and pulley tears
LHB instability is usually associated with a rotator cuff tear, especially subscapularis tendon
tears 44-46. The instability varies from subluxation to dislocation and can result in severe
shoulder pain. LHB instability has been reported with a frequency ranging from 6.5% to 20%
and has been observed most commonly in the anterior direction, related to subscapularis tears
46, 47. Although several classification systems for biceps instability have been described 10, 48,
the arthroscopic classification system proposed by Lafosse et al 49 seems to be very useful and
complete. The evaluation of LHB instability has been performed by arthroscopic assessment
with static and dynamic testing of the LHB in maximal external and internal rotation with
various degrees of abduction. This classification system allows to assess direction (anterior,
posterior, or combined anteroposterior) and extent of instability in relation to the bicipital
groove (subluxation or dislocation). Moreover, the macroscopic appearance of the LHB and
the integrity of rotator cuff tendons have been also assessed. The LHB lesions are classified
in grade 0 (no lesion), grade I (minor lesion), and grade II (major lesion). The concomitant
lesions of subscapularis and supraspinatus tendon are classified in three stages: A (intact), B
(partial thickness), and C (full thickness).
Lafosse et al 49 reported instability of the tendon of the LHB in 45% of patients with rotator
cuff tears. The instability direction pattern found was 16% anteriorly, 19% posteriorly and
10% anteroposteriorly. Moreover, the instability of the tendon of the LHB was associated
with LHB lesions in 85% of patients. In instability of the tendon of the LHB, the tendon
presents an increased pathologic anteroposterior movement over the tuberosities. The
“windshield wiper” movement, during internal and external rotation of the arm, produce an
increase of the friction area with subsequent damage of LHB tendon.
Braun et al 50 reported an incidence of pulley lesions of 32.4%. Moreover, they found a
significant correlation between pulley lesions and SLAP lesions, rotator cuff tears and LHB
pathologies 50. Some authors refer pulley lesions to forces on the pulley in external rotation–
abduction positions of the arm 10, 49. Other authors demonstrated that highest shear forces on
the pulley are present in forward flexion and internal rotation of the arm, neutral position of
the arm, neutral position and internal rotation of the arm 9.
Management
The management of LHB pathologies include conservative and surgical modalities.
Conservative management
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Although evidences are lacking, conservative management of symptomatic tendinopathy of
the LHB is commonly undertaken as the first-line treatment. Conservative management is
characterized by the same techniques used for the management of tendon disorders. The first
step consists of rest and nonsteroidal anti-inflammatory drugs. Moreover, physical therapy
can be prescribed to manage concomitant shoulder disorders 3.
When severe inflammation of the sheath of the tendon of the LHB occurs, corticosteroid
injections can be considered 51. Injections are usually performed in the subacromial space and
gleno-humeral joint, managing LHB tendinopathy associated with concomitant shoulder
pathologies. Moreover, injections can be performed within the bicipital groove to spread
corticosteroids in and around the groove without injecting the tendon itself.
Surgical management
The most common indications for surgical treatment of LHB pathologies include 11, 52, 53:
•partial-thickness tear of the LHB tendon (>25% to 50%)
•medial LHB subluxation
•LHB subluxation associated with lesions of the subscapularis tendon or biceps pulley/sling
•presence of associated shoulder pathology (rotator cuff and SLAP lesions)
•failure of conservative management of LHB tendinopathy.
The best surgical management of LHB tendon pathology has not been identified. The most
common procedures proposed are biceps tenotomy and tenodesis 6.
Biceps tenotomy is usually performed arthroscopicaally. This approach allows surgeon to
assess several aspects of LHB and gleno-humeral pathology. The surgeon should evaluate:
inflammation on surface of both intra-articular and extra-articular portions of tendon 53; shape
and hypertrophy condition of tendon (i.e. hourglass LHB tendon) 34; the stability of the LHB
within the biceps pulley by using a probe and by performing dynamic tests (internal and
external rotation) 49, 54; integrity of rotator cuff tendons (particularly subscapularis and
supraspinatus) and components of the biceps pulley/sling (i.e., CHL, SGHL) 49, 55.
Arthroscopic biceps tenotomy is an effective and reproducible technique providing relief of
shoulder pain arising from LHB pathology. Most patients are able to return to work and
sports 56. Sometimes postoperative pain can remain, because inflamed hypertrophic LHB is
not able to retract into the groove. In these cases, the proximal extremity of tendon should be
debrided 34. Some complications related to biceps tenotomy have been reported. The most
common complications described are Popeye deformity, occurring up to 70% of patients, and
fatigue discomfort in the biceps muscle, occurring in up to 38% of patients 57. Therefore,
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most authors perform tenotomy in older people, not labourers, and people who are unlikely to
be displeased with cosmesis.
Biceps tenodesis is generally performed in younger people, active patients (athletes and
labourers), and people who would avoid cosmetic deformity. The goal of tenodesis is to
preserve the length-tension relationship of the biceps muscle, which may avoid muscle
atrophy and Popeye deformity. Biceps tenodesis can be performed as an arthroscopic or open
procedure. In both instances, the tendon can be fixed within the bicipital groove 58, 59 or out of
this 60-63 (respectively proximal or distal fixation). Distal fixation techniques allow to excise
the intra-articular portion of the tendon by removing it from the bicipital groove. In this way,
it allows to prevent residual postoperative pain from inflammation of the sheath surrounding
the proximal tract of tendon 63. A lower risk of revision surgery has been reported with distal
fixation, outside the biceps groove, than proximal fixation (2.7% versus 12%) 63.
Multiple fixation techniques for LHB tenodesis have been described, including suture anchor
fixation, suture–to–adjacent tissue fixation, keyhole-to-bone fixation, interference screw
fixation, and soft tissue tenodesis 62, 64-71. Although several biomechanical studies comparing
different fixation methods has been described, controversy persists regarding the optimal
fixation technique. Some authors demonstrated superior biomechanical properties of
bioabsorbable interference screws compared with suture anchor 72, 73. Other authors did not
find statistically significant differences in ultimate failure strength among open subpectoral
bone tunnel biceps tenodesis, arthroscopic suture anchor tenodesis, open subpectoral
interference screw fixation, and arthroscopic interference screw fixation 74, 75. However, the
interference screw technique presents the least amount of displacement on cyclic loading
compared with other methods of fixation 76.
Several clinical studies comparing outcomes of tenotomy versus tenodesis have been
published (Tables 1-3). The incidence of Popeye deformity is higher after tenotomy than
tenodesis across all the studies. In a pool data analysis, the incidences were 41% with
tenotomy and 25% with tenodesis 6. Moreover, lower load to tendon failure in tenotomy
compared with tenodesis has been found. Although tenodesis seems to be better than
tenotomy, there is no evidence of significant differences in functional scores or patient
satisfaction between the two techniques. In addition, tenodesis is associated with a higher rate
of bicipital pain (RR 1.4) 77.
Further studies comparing tenotomy and tenodesis are needed. However, both procedures are
effective in the management of LHB tendinopathy.
When symptomatic pulley lesion occur, tenodesis or tenotomy can be performed instead of
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bicipital pulley repair. However, high quality level studies comparing these procedures are
not available.
Biceps tenodesis can be also proposed in patients with superior labral lesions. Boileau
reported higher satisfaction rate and functional outcomes with tenodesis comparing with
repair procedure in patients affected by type II SLAP lesions 78. Moreover, tenodesis or
tenotomy can be combined with rotator cuff repair when LHB pathology is associated with
rotator cuff tears. There is a lower rate of pain after the rotator cuff has been repaired when
the lesion of the tendon of the LHB has been addressed than when the tendon of LHB has
been preserved.
Pathology of the tendon of the LHB and impingement are commonly associated with rotator
cuff tears 4, 20, 71, 77, 79-103. There is significant crossover between rotator cuff tears and long head
of the biceps tendon testing.
Conclusions
The function of the LHB tendon has not been yet completely clarified. Several cadaver and in
vivo biomechanical studies have been performed to assess its role in glenohumeral
kinematics. Biomechanical studies confirmed a role of stabilizer of the glenohumeral joint in
all directions. However, the load applied to the biceps varies widely throughout the studies.
Moreover, the results of some studies could be biased from nonphysiologic high loads
applied to the tendon. Several clinical studies comparing the outcome of tenotomy versus
tenodesis have been published. Although tenodesis seems to be intuitively better than
tenotomy, there is no evidence of significant differences in functional scores or patient
satisfaction between the two techniques. In addition, tenodesis is associated with a higher rate
of bicipital pain. Even though, both procedures are effective for the management of LHB
tendinopathy, further studies comparing these techniques are needed.
Also, further biomechanical research should be focused on assessment of changes in
glenohumeral kinematics when tenotomy or tenodesis of the LHB have been performed.
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tendon after tenodesis or not: outcome analysis at the 4-year follow-up of two different
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107. Franceschi F, Longo UG, Ruzzini L, et al. Soft tissue tenodesis of the long head of the
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613
614
615
616
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618
619
620
621
622
623
624
625
626
627
628
629
630
631
632
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635
636
637
638
639
640
641
642
643
644
645
646
20
110. Koh KH, Ahn JH, Kim SM, et al. Treatment of biceps tendon lesions in the setting of
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techniques. Arthroscopy. 2005;21:861-866.
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in the stabilization of the head of the humerus. Clin Orthop Relat Res. 1989:172-175.
119. Pagnani MJ, Deng XH, Warren RF, et al. Role of the long head of the biceps brachii
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1996;5:255-262.
120. Su WR, Budoff JE, Luo ZP. The effect of posterosuperior rotator cuff tears and biceps
loading on glenohumeral translation. Arthroscopy.26:578-586.
21
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
21
Table 1
Author Study
Design
(Level of
evidence)
Sample
size (N°
di
patient)
Mean
age, y
(Range
or SD)
FOLLO
W-UP
(months
)
Surgical
Technique
Site of
tenodesis
self-rated
satisfaction
Pain
resolution
Rating
scale
score
pre
score
post
P value Complication
s
Concomitant Surgical
Procedures
Kelly et
al, 2005
104
Case
series /
4
40 48,0 31,0 arthrosopic
tenotomy
68% good,
32% fair
40/40 Insalata;
UCLA;
ASES
75.6;
27.6;
77.6
Not
reported
9 rotator cuff
repair, 5
instability/shrinkag
e, 7 degenerative
joint
disease/debrideme
nt, 8
acromioplasty, 2
manipulation
under anesthesia
for adhesive
capsulitis
Berlema
nn et al,
1995 64
Case-
control
study /3
14 44,6 84 keyhole
tenodesis
proximal
end
into a bal
7/14; Post and
Benca
7%
excellen
t, 67%
good,
14% fair
2 operated
tendons
ruptured;
1
pulmonary
embolisms
Impingement ???
Checchi
a et al,
2005 105
Case-
control
study /3
15 71,0 32,4 arthrosopic
tenodesis
glenoid
cavity
73,3%
excellent;
20 %
good; 6,6
% fair
6/14; UCLA 3,3 1 pz
Popeye
sign
rotator cuff tears in
all pz
Francesc
hi et al,
2007 106
Random
ized
controlle
d
trials / 1
11 58,1 42,7 arthrosopic
tenodesis with
tenotomy
anterior
leaf of
the
rotator
cuff
13/22 UCLA 11,1 32,9 P<0.05 rotator cuff tears in
all pz
11 60,3 arthrosopic
tenodesis
without
tenotomy
UCLA 10,5 33 P<0.05 rotator cuff tears in
all pz
Francesc
hi et al,
2008 107
Random
ized
Controll
ed Trial /
1
32 64,7 62,0 arthrosopic
tenotomy
0 to 4.6 (2-
4)
2.8 (1-4)
to 9.3
(6-10)
UCLA 10,1 32,1 P<0,00
1
8
pz=Popeye
sign
rotator cuff tears in
all pz
Walch et
al, 2005
108
Case-
control
study /3
30 64,3 57,0 Arthroscopic
tenotomy
87% good Constant
score
48.4 67,6 P<0,00
1
Not
reported
rotator cuff tears
Gumina
et al,
2011 109
Case-
control
study /3
30 32,0 31
years
Gilcreest
technique
(open)
suturing
to the
coracoid
tip
100%
good
Constant
score
74 No
complicatio
ns
excluded rotator
cuff tear
Koh et
al, 2010
110
Cohort
study / 2
43 65,0 27,1 Arthroscopic
Tenodesis
Using
a Suture
Anchor
prossimal
e
ASES
score;
Constant
score
84.70;
82.91
? rotator cuff tears,
instability
41 66,0 27,9 ASES
score
Constant
score
79.64;
78.27
? rotator cuff tears
Drakos
et al,
2008 111
Level IV,
therape
utic
case
series
40 38,5 28,0 Arthroscopic
Transfer of
the Long
Head of the
Biceps
Tendon
anterolat
eral
aspect of
the
conjoint
tendon
80% good;
20% fair
38/40 L’Insalata
; UCLA
ASES
75.57;
27.32;
78.72
postoperati
ve ropture
rotator cuff tears,
instability
Scheibel
et al,
2011 112
Cohort
study;
Level of
evidenc
e, 3
30 57,9 19,6 arthroscopic
soft tissue
tenodesis
rotator
interval
12.7 5-
15
Constant
score;
LHB
score
75 - 8 (P>0.05
) -
(P<0.05
)
21 subacromial
impingement, 8
symptomatic
osteoarthrosis of
the
acromioclavicular
joint, 8 Full-
thickness tears
22
675
676
22
27 61,0 22,4 arthroscopic
bony fixation
anchor
tenodesis
Bicipital
groove
13.9 (8-
15)
Constant
score;
LHB
score
78.3 -
11.3
2 SLAP II lesion,
24 rotator cuff
tears, subacromial
impingement, 5
symptomatic
osteoarthrosis
of the
acromioclavicular
joint
Maier et
al, 2011
31
Therape
utic
Level IV
21 51,0 20,2 open
tenodesis
Bicipital
groove
costant
score
26.3 79.3 p<0,01 recurrent
instability
(2PZ);
ROPTURE
(1 PZ)
traumatic
tear of the
subscapularis
tendon
23
677
23
Table 2
First author Technique Position of
tenodesis
Type Sample
size / No
Mean
age, y /
Range
or SD
Load to
tendon
failure / N
Statistically
significance
System machine
Wolf at al, 2005 113 Tenotomy in bicipital
groove
bioabsorbable
interference
screw
6 49 (41-
57)
110.7 P =0 .001 (Materials Testing System;
MTS Systems Corp,
Minneapolis,
MN
Tenodesis 10 310.8
Ahmad at al, 2007
114
Tenotomy -
Healthy Group
7 63.6 21,6 P=0.02 (Bionix 858; MTS, Eden
Prairie, MN)
Tenotomy-
Diseased
Group
7 33.0
Mazzocca at al,
2005 76
Tenodesis proximal
portion of the
bicipital groove
arthroscopic
interference
screw (AIS)
5 78 (18) 237.6 P =0.04 Instron testing
(Model 1321; Instron,
Canton, MA)
Tenodesis proximal
bicipital groove
arthroscopic
suture anchor
(SA)
5 164.8
Tenodesis 1 cm proximal
to where the
inferior border
of the
pectoralis
major tendon
subpectoral
interference
screw (SIS)
5 252.4
Tenodesis inferior border
of the
pectoralis
major tendon
subpectoral
bone tunnel
(SBT)
5 242.4
Richards et al,
2005 115
Tenodesis upper aspect
of the bicipital
groove
arthroscopic
interference
screw
5 52 (44-
57)
233.5 P= 0.007 Servohydraulic materials test
system (MTS) (MTS Model
858; Bionix, MTS Corp,
Minneapolis, MN)
Tenodesis proximal
portion of the
bicipital
arthroscopic
suture anchor
6 135.5
Patzer at al, 2011
116
Tenodesis suprapectoral
position
Bio-SwiveLock
suture anchor
(SSA sup)
7 63 111,2 P>0,05 MTS 858 Mini Bionix
materials testing machine
(MTS GmbH, Berlin,
Germany)
subpectoral
position
Footprint PK
suture anchor
(FSAsub)
7 99,1
suprapectoral
position
Bio-Tenodesis
screw
technique
(BTSsup)
7 218,3
subrapectoral
position
Bio-Tenodesis
screw
technique
(BTSsub)
7 200,7
suprapectoral
position
PEEK Biceptor
tenodesis
screw
(PBCsup)
7 173,9
subapectoral
position
PEEK Biceptor
tenodesis
screw
(PBCsub)
7 162,9
Table 3
Authors Type of study Number of
shoulders
type of test biceps loading Results CONCLUSIONS
Youm et, al 2009
22
cadaveric
study
6 glenohumeral rotational
range of motion,
translation
22 N (linear
bearing)
decrease in external
rotation= 5.0°, internal
rotation= 13.33, in anterior
(2.5 mm) translation
decrease anterioreposterior and
superioreinferior translation
Itoi et al, 1993 117 cadaveric
study
13 translation tests at 9O°
abduction
1,5 Kg (linear
bearing)
anterior displacementc
decreased with arm in 60°
or 90° of external rotation.
stabilised the humeral head for
anterior translation with the arm in
abduction and external rotation.
24
678
679
680
681
24
Kumar et al, 1989
118
cadaveric
study
15 Upward migration
humeral
3 Kg (linear
bearing)
decrease in the
acromiohumeral inter-
Val
long head is necessary to keep the
humeral
head in position during flexion and
supination
of the forearm.
Pagnani et al,
1996 119
cadaveric
study
7 glenohumeral translation
at 50 N forces in
anterior, posterior,
supenor,
and inferior position and
22 N joint compressive
load
50 N (linear
bearing)
translation reduce in all
positions of rotation
the long head of the biceps brachii
contributes to shoulder stability.
Application of a force to the biceps
tendon reduced both anteroposterior
and superoinferior translations
Su et al, 2010 120 cadaveric
study
10 glenohumeral translation
in the intact specimens
and in all sizes of
anterosuperior
and posterosuperior
rotor cuff tear
55 N (linear
bearing)
significant decrease in
both anterosuperior and
superior glenohumeral
translation
25
682
25
