The patient who is a candidate for biceps tenodesis complains of chronic shoulder pain. The dominant side is involved in 80% of the cases. The patient can be elderly and retired, over 65, with or without a history of massive and irreparable cuff tear. The patient can also be younger, around 30 or 40, with a history of an “overused
shoulder” because of his or her profession (mason, painter, gardener) or sports activity (throwing athlete). Onset is progressive in half of the cases; the other half has a history of more or less severe initial traumatic injury. The pain is localized at the anterior part of the shoulder, often radiates in the direction of the lateral part of the elbow, and sometimes can reach the dorsal part of the hand. The pain may occur typically with overhead activity but is often present at rest and may awaken the patient during the night. Most patients have already undergone conservative treatment with rehabilitation programs and corticosteroid injections without any success.

Looking at the patient from the back, atrophy of the supra- and infraspinatus is sometimes obvious and leads to the diagnosis of an associated massive cuff tear. Anterior palpation of the shoulder reveals localized pain in the area of the bicipital groove, and more importantly, the pain is recognized by the patient as “my pain.” In dislocations of the LHB, the tenderness is more medial on the lesser tuberosity, and the tendon can sometimes be rolled under the fingers. The cross-arm test is painful with the pain being in the anterior part of the shoulder instead of superior such as in acromioclavicular joint pathology. The impingement signs may be positive, but they are not very specific in our experience. We also find Speed’s test, or the “palm-up” test, useful in diagnosing biceps pathology.

While active and passive motions are usually preserved, loss of motion can alert the astute clinician to several scenarios, including an “hourglass biceps, a dislocated biceps, or a pseudoparalytic shoulder.” A hypertrophied and entrapped “hourglass biceps” often presents with loss of the terminal 10 to 20 degrees of active and passive elevation without loss of rotation. This represents true mechanical locking of the shoulder and should not be confused with a frozen shoulder (19). Patients with a dislocation of the LHB may also present with a very typical clinical picture. Dislocation is often traumatic and almost always associated with a tear of the upper subscapularis. The patient presents with a loss of active elevation above 90 degrees, and it is common to find a limitation of active and passive external rotation because the dislocated biceps tendon tethers the inferior part of the subscapularis. Most importantly, however, when a patient presents with a loss of active elevation, it is crucial to differentiate between true pseudoparalysis of the shoulder and painful loss of elevation. A shoulder with true pseudoparalysis is nonfunctional, exhibiting an ineffective shrug with attempted elevation of the arm, and will not respond to an isolated biceps procedure. A shoulder with painful loss of elevation is functional but active elevation is limited because of pain and often responds well to a biceps tenotomy or tenodesis. Performing the “landing test” can help to differentiate between the two entities (20). The examiner passively places the arm just above the horizontal level (between 90 and 120 degrees). A patient with true pseudoparalysis of the shoulder will not be able to actively maintain the arm in this position and it will fall down despite the patient’s efforts.

For all patients, the preoperative examination should include a radiographic evaluation with a true anteroposterior (AP) view in three rotations and a normalized supraspinatus outlet view. In case of a massive cuff tear involving the infra- and supraspinatus, the acromiohumeral distance, measured on the AP view in neutral rotation, is less than 6 mm. Computed tomography (CT arthrography) or magnetic resonance imaging (MRI) with gadolinium can demonstrate an “unstable” biceps tendon, being either subluxated or dislocated.

The principle of the arthroscopic biceps tenodesis is simple: After biceps tenotomy, the tendon is exteriorized and doubled on a suture and then pulled back into a humeral socket and fixed using a bioabsorbable interference screw. The fixation principle is similar to the interference screw fixation used with success for hamstring anterior cruciate ligament reconstruction of the knee. Doubling the biceps tendon has at least three advantages: (a) it reinforces the strength of the tendon, mitigating damage from the interference screw; (b) it prevents sliding of the tendon after screw insertion (stop-block effect); and (c) it allows optimal tensioning of the biceps muscle since its functional length is not changed.