Biceps Tenotomy

Biceps tenotomy is a surgical procedure used to treat problems with the long head of the biceps tendon—one of the two tendons that connect the biceps muscle to the shoulder. In this technique, the tendon is simply released from its attachment in the shoulder joint. It is typically performed arthroscopically, meaning through small incisions using a camera and specialized instruments.

How Common It Is and Who Gets It? (Epidemiology)

Biceps tendon issues are a significant source of shoulder pain, particularly in older individuals or those with rotator cuff injuries. Biceps tenotomy is commonly performed when conservative treatments like physical therapy, anti-inflammatory medications, or steroid injections fail to relieve chronic shoulder pain. This procedure is often recommended for individuals who do not require tendon reattachment or for those seeking a simpler surgical option.

Why It Happens – Causes (Etiology and Pathophysiology)

The long head of the biceps tendon runs through the shoulder joint and plays a significant role in stabilizing the shoulder, as well as allowing for forearm movement like supination and elbow flexion. Over time, this tendon can become inflamed, torn, or degenerated due to overuse, injury, or age-related wear. When these issues occur, the tendon may become unstable or lead to painful inflammation, necessitating surgical intervention like biceps tenotomy.

How the Body Part Normally Works? (Relevant Anatomy)

The biceps brachii muscle has two heads: the long head and the short head. The long head originates from the top of the shoulder socket (glenoid) and passes through a groove in the upper arm bone (humerus). The tendon connects the muscle to the shoulder and aids in shoulder stability and movement. When the tendon becomes damaged or irritated, it can cause pain and weakness, particularly during overhead motions.

What You Might Feel – Symptoms (Clinical Presentation)

Patients with long head biceps tendon issues commonly report anterior shoulder pain, especially during overhead activities. Symptoms may include weakness in the arm, particularly with elbow flexion and forearm rotation, as well as visible muscle deformities, such as the “Popeye” sign, where the biceps muscle bulges. Persistent pain and limited range of motion are also common symptoms.

How Doctors Find the Problem? (Diagnosis and Imaging)

A thorough clinical examination is crucial for diagnosing biceps tendon issues. Special tests, such as the Speed’s test or Yergason’s test, can help localize pain to the biceps tendon. Imaging studies, such as MRI or ultrasound, are used to assess tendon tears, inflammation, and other abnormalities. MRI arthrograms may also be used to assess the integrity of the tendon and surrounding structures.

Classification

Biceps tendon injuries are classified based on the severity of the damage. Partial tears involve only a portion of the tendon, while complete tears involve a full rupture. Tenosynovitis refers to inflammation of the tendon sheath, while instability or subluxation occurs when the tendon becomes displaced from its normal position. These conditions can lead to chronic pain, weakness, and functional limitations.

Other Problems That Can Feel Similar (Differential Diagnosis)

Biceps tendonitis can be confused with other shoulder conditions, such as rotator cuff tears, SLAP tears (superior labrum anterior to posterior lesions), or impingement syndrome. Accurately diagnosing biceps tendon issues requires distinguishing them from other conditions that cause similar pain patterns, often through detailed imaging and clinical tests.

Treatment Options

Non-Surgical Care

• Rest and activity modification to reduce strain on the tendon
• Anti-inflammatory medications or corticosteroid injections for pain relief
• Physical therapy to improve shoulder and arm strength and restore mobility

Surgical Care

• Biceps tenotomy, which involves releasing the long head of the biceps tendon from its attachment at the shoulder and allowing it to retract and scar naturally
• In some cases, biceps tenodesis (re-anchoring the tendon) may be considered for patients with more severe tendon issues or cosmetic concerns

Recovery and What to Expect After Treatment

Recovery after biceps tenotomy typically involves wearing a sling for a few weeks to protect the shoulder. The rehabilitation process focuses on restoring range of motion and strength. Full recovery usually occurs within 2 to 3 months, with most patients returning to normal activities within 4 to 6 weeks. Athletes and labor-intensive workers may require additional time for full recovery.

Possible Risks or Side Effects (Complications)

While biceps tenotomy is generally a safe procedure, potential complications include infection, residual shoulder pain, weakness, cramping or spasms of the biceps, and cosmetic deformity, such as the “Popeye” sign. However, these complications are usually mild and rarely require revision surgery.

Long-Term Outlook (Prognosis)

The long-term prognosis for biceps tenotomy is positive, with most patients experiencing significant pain relief and improved function. The procedure provides an effective solution for shoulder pain caused by biceps tendon issues, especially in patients with minimal cosmetic concerns. Some residual weakness may occur, but most patients return to their usual activities with minimal limitations.

Out-of-Pocket Cost

Medicare

CPT Code 23405 – Biceps Tenotomy (Surgical Procedure to Sever the Biceps Tendon): $145.60

Medicare Part B typically covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover that remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans work with Medicare to fill the coverage gap and reduce your financial responsibility.

If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans typically cover any remaining balance, including coinsurance or small deductibles, which generally range from $100 to $300, depending on your plan and provider network.

Workers’ Compensation

If your biceps tenotomy is required due to a work-related injury, Workers’ Compensation will cover all associated medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly covers all approved treatments.

No-Fault Insurance

If your biceps tenotomy is needed due to an automobile accident, No-Fault Insurance will typically cover the full cost of your treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment, depending on your insurance policy.

Example

Sarah Robinson underwent biceps tenotomy (CPT 23405) after experiencing chronic shoulder pain. Her estimated Medicare out-of-pocket cost was $145.60. Since Sarah had supplemental insurance through AARP Medigap, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.

Frequently Asked Questions (FAQ)

Q. What is a biceps tenotomy?
A. A biceps tenotomy is a surgical procedure that involves cutting the long head of the biceps tendon from its attachment in the shoulder joint.

Q. When is a biceps tenotomy recommended?
A. It is typically recommended when the long head of the biceps tendon is torn, inflamed, or causing shoulder pain that has not improved with conservative treatments.

Q. What are common symptoms that may lead to a biceps tenotomy?
A. Symptoms may include persistent shoulder pain, especially in the front of the shoulder, pain with overhead activities, and a popping or catching sensation.

Q. What happens to the tendon after a biceps tenotomy?
A. After the tendon is released, it retracts down the arm and may form a bulge known as a “Popeye” muscle.

Q. What are the potential benefits of a biceps tenotomy?
A. The procedure can relieve pain, improve function, and eliminate mechanical symptoms such as catching or snapping.

Q. What are the potential risks of a biceps tenotomy?
A. Risks include muscle cramping, cosmetic deformity, weakness in elbow flexion and forearm supination, and persistent pain.

Q. What type of anesthesia is used for a biceps tenotomy?
A. The procedure is typically performed under general anesthesia, sometimes with a nerve block.

Q. How long does a biceps tenotomy procedure take?
A. The procedure usually takes less than 30 minutes.

Q. Is biceps tenotomy done alone or with other procedures?
A. It is often performed along with other shoulder procedures such as rotator cuff repair or shoulder debridement.

Q. What is the typical recovery time after a biceps tenotomy?
A. Most patients recover in a few weeks, with gradual improvement in pain and function.

Q. Will I need physical therapy after a biceps tenotomy?
A. Yes, physical therapy may be recommended to help regain range of motion and strength.

Q. Can the muscle deformity after a tenotomy be avoided?
A. A tenodesis, which involves reattaching the tendon to the bone, may be done instead to avoid cosmetic deformity in select patients.

Q. What is the difference between a biceps tenotomy and a tenodesis?
A. A tenotomy cuts and releases the tendon, while a tenodesis cuts and reattaches the tendon to the bone to preserve muscle contour and strength.

Q. Who is a good candidate for biceps tenotomy?
A. Older, less active individuals who are not concerned with cosmetic appearance or slight strength loss are typically good candidates.

Q. What is the recovery like compared to a biceps tenodesis?
A. Recovery from a tenotomy is generally quicker and easier compared to tenodesis, which has a longer healing period due to tendon reattachment.

Summary and Takeaway

Biceps tenotomy is a minimally invasive surgical solution for patients suffering from chronic biceps tendon pain and dysfunction. By releasing the tendon and allowing it to retract naturally, the procedure offers significant pain relief and restores shoulder function. While there are some potential risks, including cosmetic deformities and weakness, biceps tenotomy remains a reliable option, particularly for older, less active patients or those who require a quick recovery.

Clinical Insight & Recent Findings

A recent study compared the clinical outcomes of T-shaped versus conventional cylinder-shaped biceps tenotomy in patients with rotator cuff tears and concomitant long head of the biceps tendon (LHBT) lesions.

The study found that while both techniques led to significant postoperative improvements in pain and function, the T-shaped technique had a significantly lower incidence of Popeye deformity (6.7% vs. 22%) and a better anatomical outcome, with fewer cases of anatomic failure (11.1% vs. 31.7%). This technique, which involves releasing the LHBT with a portion of the superior labrum, helps avoid the typical deformity and cramping associated with standard tenotomy while still providing effective pain relief and function.

The study concluded that T-shaped tenotomy is a viable alternative, offering similar functional outcomes with fewer cosmetic complications compared to traditional biceps tenotomy. (“Study on biceps tenotomy – see PubMed.”)

Who Performs This Treatment? (Specialists and Team Involved)

Orthopedic surgeons specializing in shoulder conditions typically perform biceps tenotomy. Physical therapists play a key role in post-surgery rehabilitation to restore strength and mobility.

When to See a Specialist?

Consult a specialist if you have chronic shoulder pain related to the biceps tendon that has not improved with physical therapy or conservative treatments like injections.

When to Go to the Emergency Room?

Seek emergency care if you experience severe shoulder pain following a traumatic injury or if you notice signs of nerve damage, such as numbness or tingling in the arm.

What Recovery Really Looks Like?

After surgery, the patient will typically wear a sling for a short period, followed by rehabilitation focused on strengthening and restoring motion to the shoulder. Most patients can return to normal activities within 4 to 6 weeks, while athletes may need a few additional weeks for full recovery.

What Happens If You Ignore It?

If left untreated, biceps tendon issues can lead to chronic pain, decreased strength, and further damage to the shoulder, which may complicate recovery and require more extensive surgery.

How to Prevent It?

Preventing biceps tendon injuries involves strengthening the shoulder and forearm muscles, using proper lifting techniques, and avoiding repetitive overhead movements that strain the tendon.

Nutrition and Bone or Joint Health

A diet rich in calcium, vitamin D, and omega-3 fatty acids can support joint and tendon health, reduce inflammation, and promote healing following surgery.

Activity and Lifestyle Modifications

To prevent recurrence, patients should avoid activities that place undue strain on the shoulder, especially overhead lifting or repetitive movements. Regular exercise to strengthen the rotator cuff and surrounding muscles is key to maintaining shoulder stability.