Long Head of Biceps Tenodesis

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What’s the problem?

The biceps muscle has two tendons, one of which (the long head) passes through the shoulder. In this location, it can be squashed by the shoulder during movement, and over many years, this leads to tendon inflammation. Sometimes, biceps instability can occur where the tendon flicks in and out of the groove of bone it normally lies in. This can lead to pain which is typically felt at the front of the shoulder, and is very tender to palpation.

How can you treat it?

Not all biceps tendinitis needs surgery. If symptoms are mild, a corticosteroid injection into the biceps sheath at the front of the shoulder may help to reduce symptoms. Otherwise, surgery is recommended – a long head of biceps tenotomy or tenodesis

The Operation

The operation is mostly arthroscopy (or keyhole). A few small keyhole incisions are made around the shoulder, and then the biceps tendon is released from its attachment within the shoulder. This is called the “tenotomy” and in some patients, this is all that is required. In others, the tendon is reattached further down the arm – the “tenodesis” via another small incision just to the side of the armpit, and this removes the inflamed segment of tendon, as well as preventing it from recurring in the future

The Other Parts of the Operation

In addition to the biceps tendon, there are often other parts of the shoulder that may be painful, and these can be addressed at the same time arthroscopically. They include:

• Under the acromion is a bursa which can be inflamed. This can be surgically removed (a subacromial decompression). Part of the bone on the under surface of the acromion can also be removed if it is rubbing or impinging on the rotator cuff muscle beneath it (acromioplasty)
• The ACJ (acromioclavicular joint) can be arthritic and painful. It can be removed at the same time as a rotator cuff repair

The Anaesthetic

You will be asleep for the duration of the operation (ie a general anaesthetic). The anaesthetist will talk to you about a nerve block before the operation, which helps with pain relief and generally lasts 24-48 hours. This is normally done while you are sedated/half asleep just prior to the operation.

What are the Risks of this Operation?

• Ongoing pain and slow recovery:
  Levels of pain felt after surgery vary, depending on the patient and type of tear. However, most patients will have significant improvement in the pain they feel in their shoulder in the long term.
• Stiffness:
  This can occur as a combination of pre-existing stiffness, surgical scarring and immobilisation in a sling. Although a physiotherapy program will be instituted afterwards, some stiffness can occur. It is very uncommon to see significant stiffness of the shoulder in the long term.
• Infection:
  If it occurs, it will usually only be a superficial wound infection to the top most layer of the skin. It is very rare after arthroscopic surgery (less than 0.2%)
• Popeye sign:
  This can occur with a tenotomy, where there is bunching of the biceps muscle in your arm. In some particularly muscular patients, this change in muscle contour may not be to their liking and so a tenodesis would be preferred. In addition, in patients who use their arms for heavy and manual work, some cramping of the biceps might occur

Benefits

Most patients are able to achieve a pain free shoulder with functional range of motion. You should be able to freely reach the top of your head and toilet behind your back. Higher level activities like sports are usually able to be returned to.

What can I expect?

You will wake up with your arm in a sling after your surgery. If you have had a nerve block, you shouldn’t feel any pain till the next day. The nurses will provide you pain relief and the next morning a physio will see you to go through some exercises you can do. These exercises will change over the next few months but you should try to do them regularly to maximise your rehabilitation.

Most patients stay overnight in hospital after surgery, before going home. A number of allied health staff (physios, occupational therapists) will make sure you have adequate support at home before discharge. An appointment will be made for you for a wound check at 2 weeks, and another appointment with Mr Lau at 6 weeks.

What should I avoid doing?

Although your biceps tendon has been rerouted, it still takes time to heal fully. In particular, in the first two weeks, it is very important to keep your arm in the sling most of the time (you can come out for hygiene reasons) to allow the tendon the best chance to heal back to bone.

Other than this, your physiotherapist will arrange a specific programme of rehabilitation, including exercises, restrictions and progression based on how well you are performing.

Return to…?

• Work
  Depends what you do. Desk based work can be done from 2 weeks post operatively, if you can do these tasks single handedly. Otherwise generally 6-8 weeks before you can use both hands freely whilst seated.
  For manual work, it depends on what kind of lifting/pushing you do, but generally not before 3 months
• Drive
  In Australia, you can’t drive unless you are in full control of both your arms. Therefore, whilst you’re in a sling, you cannot drive. Generally 6 weeks post operatively.
• Sports/Hobbies (may vary depending on the size/nature of your rotator cuff tear):
• Gentle swimming: after 12 weeks
• Gardening (light tasks only): 8-12 weeks
• Heavy lifting: after 3 months
• Golf, tennis, badminton, squash: after 3-6 months

Concerns or questions?

If you have any concerns post operatively, or you would like further information, please contact Mr Lau through the VBJS on 03 5752 5020 or via email at admin@vbjs.com.au

If you need urgent medical help, call 000 or go to your nearest emergency department.

Rehabilitation protocol

• Long Head of Biceps Tenodesis

These notes have been prepared by Mr Simon Lau. They are general overviews and information aimed for use by his patients. They reflect Mr Lau’s views, opinions and recommendations. They do not constitute medical advice. The contents are provided for information and education purposes only. Please seek Mr Lau’s specific advice with any questions regarding medical conditions and treatment.