Biceps Tenodesis in Dallas: Treating Long Head Biceps Pain in the Shoulder

What is a biceps tenodesis? It is a surgery that moves the long head of the biceps tendon out of the shoulder joint and reattaches it to the arm bone just below, so it no longer slides in and out of the tight groove at the front of the shoulder where it causes pain. Dr. Brett Raynor usually performs biceps tenodesis arthroscopically, through four or sometimes five small poke holes, as an outpatient surgery. When it is done on its own, most patients wear a sling for comfort for a week or two, start moving the shoulder right away, avoid curls and carrying with the elbow bent for about 12 weeks, avoid heavy lifting for 3 to 4 months, and have no real restrictions after 3 to 4 months.

Dr. Raynor almost always performs a biceps tenodesis as part of a rotator cuff repair, and he often performs it on its own for shoulder pain coming from the biceps tendon, including calcific biceps tendinitis. He also often uses it to treat a SLAP tear. He is a fellowship-trained orthopaedic sports medicine surgeon at Texas Orthopaedic Associates in Dallas.

This page is about the biceps at the shoulder, not the elbow. The biceps has two tendons at the top, in the shoulder, and one at the bottom, at the elbow. Dr. Raynor treats the long head tendon at the shoulder. He does not treat the elbow end (the distal biceps tendon). If your pain or injury is at the front of the elbow, call the office at (214) 265-3211 and you will be scheduled with the appropriate specialist in the group.

Key points

• The long head of the biceps tendon runs up a groove at the front of the arm bone and makes a sharp turn into the shoulder joint. That turn is where it gets inflamed, frays, slips out of place, or pulls on the top of the socket.

• Diagnosis is an examination and X-rays, and often an MRI.

• Treatment usually starts without surgery. One or two steroid injections can be part of that; more than two can damage the tendon.

• A biceps tenodesis releases the tendon from the top of the socket and reattaches it lower on the arm bone. Reattaching it, rather than simply cutting it, keeps the muscle from balling up in the arm.

The long head of the biceps tendon, and what goes wrong

The biceps muscle on the front of the arm splits into two tendons at the top. The short head attaches to a knob of bone at the front of the shoulder blade, outside the joint, and rarely causes trouble. The long head is the one that matters here. It travels up a groove in the front of the arm bone (the bicipital groove), passes through a tight sleeve of tissue at the top of that groove, turns about ninety degrees, and crosses over the ball of the shoulder to attach at the top of the socket, where it blends into the labrum, the rim of tissue around the socket.

Every time the arm moves, the tendon slides through that groove and around that turn. It sits right next to the rotator cuff, so the two are often injured together. The long head can cause pain in several ways:

• Tendinitis. The tendon becomes inflamed and thickened where it runs through the groove.

• Calcific tendinitis. Calcium builds up in the tendon and inflames it.

• Partial tears and fraying. Wear, or an injury, frays the tendon or tears part of its thickness.

• Instability in the groove. The tissue that holds the tendon in its groove stretches or tears, so the tendon slips toward the edge of the groove or out of it. This often goes along with a tear of the subscapularis, the rotator cuff tendon at the front of the shoulder.

• SLAP-type problems. The tendon pulls on its attachment at the top of the socket and tears the labrum there (a SLAP tear, for superior labrum anterior to posterior).

These problems are common alongside a rotator cuff tear, and they also happen on their own. For more on the cuff itself, see rotator cuff tears.

Symptoms of a long head biceps problem

• Pain at the front of the shoulder, often felt along the groove at the top of the arm, sometimes spreading down toward the biceps muscle

• Pain that gets worse with lifting, reaching overhead, carrying, or pulling

• Tenderness when the front of the shoulder is pressed

• A click, snap or catch at the front of the shoulder with certain motions, which can mean the tendon is slipping in its groove

• Aching at night, especially when lying on that side

When the long head tears all the way through, the muscle can slide down the arm and form a bulge above the elbow, often called a "Popeye" deformity. That is different from the pain-generating problems above, and an evaluation sorts out which one you have. Dr. Raynor sometimes treats a complete tear with surgery when it happened recently, especially when a rotator cuff tear already needs surgery. He also considers surgery when the look of the bulge bothers you, or when your job involves a screwdriver motion all day.

How a biceps problem is diagnosed

Dr. Raynor starts with the history and an examination: where the pain is, what makes it worse, and a set of tests that load the biceps tendon and the rotator cuff separately, since the two often hurt together. X-rays are taken to look at the bones and joint. An MRI is often needed to show the tendon, the labrum at the top of the socket, and the rotator cuff, and to show whether a cuff tear or a SLAP tear is part of the picture.

Treatment without surgery

Most long head biceps pain is treated without surgery first. Non-surgical care typically includes:

• Rest from the motions that hurt. Cutting back on heavy lifting, overhead work and the activity that set it off while the tendon settles down.

• Physical therapy. Exercises for the rotator cuff and the shoulder blade muscles, which take load off the front of the shoulder.

• Anti-inflammatory medicine, when it is safe for you to take.

• A steroid injection. One or two injections can be part of non-operative care and can calm an inflamed tendon. Dr. Raynor limits steroid injections because more than two can damage the tendon, and a damaged tendon is harder to treat later.

When surgery makes sense

Surgery is worth considering when:

• Pain from the long head of the biceps keeps coming back or does not improve after a reasonable course of non-surgical care

• The MRI or the examination shows a partial tear, significant fraying, or a tendon that is slipping out of its groove

• Calcific biceps tendinitis, where calcium builds up in the tendon, keeps causing pain. When it needs surgery, Dr. Raynor usually treats it with a biceps tenodesis.

• A SLAP tear at the top of the socket keeps causing pain. For a SLAP tear on its own, Dr. Raynor usually performs a biceps tenodesis.

• A recent complete tear of the tendon with a "Popeye" bulge, especially when a rotator cuff tear already needs surgery, or when the bulge bothers you or your job involves a screwdriver motion all day

• You are having a rotator cuff repair. Dr. Raynor almost always performs a biceps tenodesis at the same time, because the biceps is a common source of pain after an otherwise good repair if it is left alone. How Dr. Raynor performs rotator cuff repair covers that combined surgery.

When the labrum is torn by a shoulder dislocation, that is a different problem with a different repair; see shoulder stabilization.

How Dr. Raynor performs a biceps tenodesis

Dr. Raynor usually performs biceps tenodesis arthroscopically, with a camera and small instruments, as an outpatient surgery. The tendon is released from the top of the socket and reattached in the groove just to the outside of the upper border of the subscapularis tendon, with a small anchor. These are the steps, in the order they happen.

1. Nerve block and general anesthesia. In the operating room, just before you go to sleep, an anesthesiologist places an interscalene nerve block, which numbs the shoulder and arm. You then have general anesthesia, typically with a breathing tube, because the surgery is done sitting upright in what is called the beach chair position. The block keeps the arm comfortable for the first part of the recovery.

2. Four small poke holes. Dr. Raynor works through four small poke-hole incisions, sometimes five. One carries the camera; the others carry the instruments.

3. A look inside. He examines the whole joint first: the biceps tendon, the labrum, the cartilage and the rotator cuff, and treats anything else that needs it.

4. Lassoing the tendon. A looped suture is passed around the biceps tendon, and the loop is passed through itself so it cinches down on the tendon like a lasso.

5. A second stitch so it cannot roll off. Another stitch is placed through the tendon just above the lasso, toward the socket, so the loop cannot slide off the end.

6. Releasing the tendon. The tendon is cut between that stitch and its attachment at the top of the socket. It no longer crosses the joint, so it no longer has to slide around the turn into the shoulder.

7. Preparing the new spot. A spot at the top of the groove, just to the outside of the upper border of the subscapularis, is roughened, and a small socket is made in the bone.

8. Dunking the tendon into the anchor. The suture limbs are loaded into a small anchor, which pushes the tendon down into the socket in the bone and locks it there. The tendon now heals to the bone at its new spot.

9. Closing. Each poke hole is closed with a single stitch, and the stitches are removed at your first post-op visit, 7 to 14 days after surgery. You go home the same day.

The armpit approach. Most of Dr. Raynor's biceps tenodeses are now arthroscopic, but sometimes he still performs an open subpectoral tenodesis instead: through a small incision near the armpit, the tendon is reattached a little lower on the arm bone, below the chest muscle tendon. The goal is the same.

What about pain afterward? It varies a lot from person to person. A biceps tenodesis is not an operation where you feel good right away: the nerve block covers the first part, and the tendon then needs time to heal into the bone.

Biceps tenodesis or tenotomy?

There are two ways to deal with a painful long head biceps tendon. A tenotomy simply cuts the tendon from the top of the socket and lets it go. A tenodesis cuts it and then reattaches it lower on the arm bone. Dr. Raynor rarely performs a tenotomy: if he is cutting the biceps, he prefers to tenodese it.

The research supports both procedures for pain relief, and the main difference is the shape of the arm. In a combined analysis of five high-quality randomized trials (468 patients), 23.3 percent of patients who had a tenotomy developed a visible bulge in the arm (the Popeye deformity), compared with 6.8 percent after tenodesis, and pain and shoulder function scores were similar between the groups (Belk et al., J Shoulder Elbow Surg, 2021). A larger meta-analysis of 11 randomized trials (860 patients) reached the same conclusion: similar pain and function, with a lower rate of the Popeye deformity after tenodesis (Hartland et al., BMJ Open, 2022).

Reattaching the tendon keeps the biceps muscle where it belongs. That is why Dr. Raynor prefers it.

Recovery after biceps tenodesis

How you recover depends on whether the tenodesis was done on its own or together with a rotator cuff repair. When it is part of a cuff repair, the cuff sets the pace.

Biceps tenodesis on its own

There is a physical therapy protocol for this, and your therapist and Dr. Raynor's team will walk you through it.

The biceps tenodesis recovery roadmap walks through each stage, including sleeping, showering, pain medication and incision care.

Biceps tenodesis with a rotator cuff repair

The rotator cuff protocol governs: a sling for six weeks, active-assisted motion starting around six weeks, strengthening at about three months, and the tendon healed at about four months. Those rules already keep you from curls and carrying with the elbow bent while the biceps tendon heals. The rotator cuff repair page and its recovery roadmap cover that timeline in detail.

Frequently asked questions about biceps tenodesis

Expand any question below.

Why patients choose Dr. Raynor for biceps tenodesis

• Fellowship-trained in sports medicine at the Steadman Philippon Research Institute in Vail, Colorado

• Board-certified orthopaedic surgeon; D Magazine Best Doctor every year since 2019

• Team physician for the U.S. Ski and Snowboard Team, Highland Park High School, St. Mark's School of Texas, Hockaday and Ursuline Academy

• Instructor at national arthroscopy courses and reviewer for the American Journal of Sports Medicine

• More than 800 five-star Google reviews

If your biceps problem comes with a rotator cuff tear, you can also read why patients choose Dr. Raynor as their Dallas rotator cuff surgeon.

Written and medically reviewed by M. Brett Raynor, M.D., board-certified orthopaedic sports medicine surgeon. Last reviewed October 2026. General information for patients; your own surgical plan and post-operative instructions come first.