Biceps Tenodesis versus Tenotomy: A Systematic Review and Meta-Analysis of Level I Randomized Controlled Trials

Belk JW, Kraeutler MJ, Houck DA, Chrisman AN, Scillia AJ, McCarty EC. Journal of Shoulder and Elbow Surgery. 2021. [Epub ahead of print.]

Take-Home Message

Patients who undergo biceps tenotomy are 3 times more likely than patients who undergo biceps tenodesis to develop a Popeye deformity while having similar patient-reported outcomes, range of motion, and strength.


Surgeons most commonly perform either biceps tenodesis (attaching the biceps tendon to the humerus instead of the labrum) or biceps tenotomy (simply cutting the biceps tendon off the labrum) to treat the long head of the biceps tendinopathy. Both techniques have their own advantages; however, the superiority of one treatment over the other remains unclear.

Study Goal

The authors performed a systematic review and meta-analysis to compare the complications and clinical outcomes between arthroscopic biceps tenodesis and biceps tenotomy.


The authors used the search phrase “biceps tenodesis tenotomy randomized” on several databases up to April 13th, 2020. Two reviewers independently screened 71 studies for high-quality randomized controlled trials that compared outcomes of people who underwent biceps tenodesis or biceps tenotomy. One reviewer extracted data and another reviewer confirmed the data from all the included studies. The author also assessed bias with the Cochrane Collaboration’s risk of bias tool (categories considered low risk, unclear, or high risk) and methodological quality with the Modified Coleman Methodology Score (scores range from 0-100, 100 being a perfect score). Finally, the authors collected post-operative patient-reported outcomes (American Shoulder and Elbow Surgeons [ASES] score, Visual Analog Scale [VAS] score, and Constant-Murley score), functional outcomes (range of motion, cosmetic deformity, strength), and rate of Popeye deformity.


The authors included 5 randomized controlled trials with 468 total participants (236 tenodesis, 232 tenotomy). Patients averaged 60 years of age, with 48% of participants being male and completing follow-up 23 months post-operatively. The authors found no differences in patient-reported outcomes, shoulder range of motion, nor shoulder or elbow strength between participants that underwent tenodesis vs. tenotomy. Participants who underwent tenotomy were more than 3 times more likely to develop a Popeye deformity after surgery (23% vs. 7%). Lastly,there were no differences in post-operative complications (e.g. biceps cramping, infection, stiffness) between groups.


The authors found that patients who undergo biceps tenotomy are more likely to develop a Popeye deformity, while patient-reported outcomes and range of motion do not differ. A previous group of researchers have shown that biceps tenotomy may allow for a quicker return to activity; however, this study did not assess return to activity time. Understanding the differences (if any) in return to activity time is important for counseling patients, as some patients may prefer to risk developing a Popeye deformity if it means return to prior levels of activity quicker. Also, future randomized controlled trials comparing biceps tenodesis vs. tenotomy in patients with shoulder instability and/or throwing athletes would be interesting, as the role of the long head of the biceps as an anterior shoulder stabilizer may be more important in these patients.

Clinical Implications

Surgeons should discuss the potential of Popeye deformity with patients before deciding on a procedure. Patients that do not want to risk developing a Popeye deformity would be better candidates for biceps tenodesis as opposed to biceps tenotomy. Besides the risk of Popeye deformity, patients can expect similar outcomes between biceps tenodesis and biceps tenotomy.

Questions for Discussion

Does time until return to activity differ between patients that undergo biceps tenodesis vs. biceps tenotomy? Do you think patients with shoulder instability are better candidates for biceps tenodesis as opposed to biceps tenotomy?

Related Posts

What is the Role of the Long Head of the Bicep Tendon?
What is the Role of the Long Head of the Bicep Tendon? Part II
Long Head of the Biceps Issues– Cut it or Move it?

Written by: Ryan Paul
Reviewed by: Jeffrey Driban

Upper Extremity EBP CEU Course