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Subpectoral Biceps Tenodesis: Surgical Technique and Clinical Considerations
Subpectoral biceps tenodesis is performed through a deltopectoral approach with the patient in beach chair position. The procedure involves detachment of the long head of biceps tendon from its origin, creation of a socket in the proximal humerus beneath the pectoralis major muscle, and fixation of the biceps tendon within this socket using various methods such as interference screws, suture anchors, or cortical buttons.
Anatomically, the location is typically 1-2 cm distal to pectoralis major tendon insertion. This preserves the anatomic length-tension relationship of the biceps muscle and maintains proper cosmetic appearance and function of the biceps muscle.
The procedure is indicated for biceps tendinopathy, SLAP tears in older patients, biceps instability, failed conservative management, partial or complete biceps tendon tears, and concomitant rotator cuff repairs.
The advantages include elimination of pain from the bicipital groove, maintenance of muscle length-tension relationship, better cosmetic results compared to tenotomy, lower risk of cramping and Popeye deformity, preservation of supination strength, and reliable return to activities.
Important technical considerations include careful identification and protection of neurovascular structures, proper tensioning of the biceps tendon, accurate socket preparation and placement, secure fixation method, and appropriate post-operative rehabilitation protocol.
Potential complications include infection, nerve injury, fracture, hardware failure, persistent pain, failed tendon healing, and cosmetic deformity.
The post-operative protocol consists of initial immobilization period, progressive passive range of motion, gradual strengthening program, return to activities at 4-6 months, with full recovery typically by 6 months.
Outcomes generally show high patient satisfaction rates, good to excellent functional outcomes, reliable pain relief, restoration of biceps function, low complication rates, and successful return to sports and activities.
Contraindications include active infection, insufficient bone stock, severe osteoporosis, unrealistic patient expectations, and medical comorbidities precluding surgery.
Surgical planning requires consideration of patient age and activity level, concomitant shoulder pathology, quality of remaining tendon, bone quality, patient goals and expectations, and surgeon experience and preference.
The immediate post-operative phase spanning the first six weeks requires sling immobilization as needed for pain with specific range of motion restrictions. Flexion should be limited to 60 degrees, and external rotation should not exceed 20 degrees with the arm at the side. Active biceps contraction is prohibited during this period. Beginning at week two, gentle pendulum exercises are introduced along with active range of motion for elbow, wrist, and hand, complemented by isometric deltoid exercises without resistance.
During the intermediate phase from weeks 4-8, sling weaning is enforced, accompanied by the initiation of passive range of motion exercises and active-assisted range of motion. Exercise progression includes light isotonic exercises without biceps loading at week four, advancing to submaximal biceps isometrics by week six. Heavy lifting and resistance exercises remain restricted during this phase.
The strengthening phase occurs between weeks 8-16, focusing on achieving full active range of motion and implementing gradual biceps strengthening. This phase emphasizes restoring normal scapulohumeral rhythm through progressive resistive exercises, light biceps curls, scapular stabilization, and rotator cuff strengthening.
The return to activity phase extends from months 3-6. Criteria for return include achieving full pain-free range of motion, normal strength (5/5), normal scapular control, and successful functional testing. This phase incorporates sport-specific training, work simulation activities, and progressive resistance training.
Important precautions include avoiding heavy lifting for four months, preventing sudden forceful biceps contractions, and restricting resistance to biceps for 4-6 weeks The protocol should be individualized based on surgical technique, tissue quality, patient age and activity level, occupational demands, and individual healing response.
A. Immobilization
• Sling for comfort
• Range of motion restrictions:
Flexion limited to 60 degrees
External rotation limited to 20 degrees with arm at side
No active biceps contraction
B. Exercises (Week 2)
• Gentle pendulum exercises
• Active range of motion for elbow, wrist, and hand
• Isometric deltoid exercises without resistance
A. Week 4
• Stop using Sling
• Initiate passive range of motion
• Begin active-assisted range of motion
B. Exercise Progression
• Week 4: Light isotonic exercises (no biceps loading)
• Week 6: Begin submaximal biceps isometrics
• No heavy lifting or resistance
A. Goals
• Progress to full active range of motion
• Gradual biceps strengthening
• Restore normal scapulohumeral rhythm
B. Exercise Program
• Progressive resistive exercises
• Begin light biceps curls
• Scapular stabilization
• Rotator cuff strengthening
A. Criteria for Return
• Full pain-free range of motion
• Normal strength (5/5)
• Normal scapular control
• Successful functional testing
B. Therapeutic Interventions
• Sport-specific training
• Work simulation activities
• Progressive resistance training
V. Precautions
• No heavy lifting for 4 months
• Avoid sudden forceful biceps contractions
• No resistance to biceps for 8 weeks
Individualize based on:
©2025 Dr Frank McCormick All Rights Reserved.
©2025 Dr Frank McCormick All Rights Reserved.
