Management of Biceps Tendon Pathology: From the Glenoid to the Radial Tuberosity

Double Trouble: Combined Neurogenic Thoracic Outlet Syndrome and Superior Labrum Anterior Posterior Tear

Neurogenic thoracic outlet syndrome and superior labrum anterior posterior tears are usually treated in a staged manner due to different post-operative therapy needs. This case describes successful combined surgery with expedited physical therapy.

Arthroscopic Anatomic Knotless Coracoclavicular Ligament Repair Without Coracoid Drilling

Acromioclavicular joint injuries are common in young active patients. A wide variety of surgical techniques exist to address specific complications associated with surgery. Complications after surgery include loss of reduction, fracture of the clavicle or coracoid, failure of fixation, and prominent and symptomatic hardware. This technique aims to reduce these complications with an arthroscopic anatomic coracoclavicular ligament repair using knotless adjustable loop buttons with fifth-generation suture tape and no drilling of the coracoid.

Arthroscopic Suprapectoral Biceps Tenodesis Using Standard Portals

The long head of the biceps (LHB) tendon is a common cause of shoulder pain. Biceps tenodesis is commonly used to address biceps and superior labrum pathology, reducing pain and restoring function. There are numerous techniques for biceps tenodesis, and it is unclear as to which single technique and approach provides significantly superior outcomes. In this technical note, we present an arthroscopic suprapectoral approach with release of the LHB from the bicipital groove and subsequent fixation with suture anchor. This technique simplifies the technique to be performed from standard arthroscopic portals and aims to maximize outcomes and minimize common complications associated with biceps tenodesis.

Krackow Stitch and Whipstitch Use in Distal Biceps Tendon Rupture Repair: A Porcine Composite Bone Biomechanical Study

The suture combination of a Krackow stitch plus a whipstitch can be used to strengthen a tendon rupture repair. We compared biomechanical outcomes of suture repair techniques for distal biceps tendon ruptures using a single Krackow stitch with and without a whipstitch and a whip-stitch alone. Data were obtained from 36 thawed porcine flexor profundus tendons. A cortical button was secured to fourth-generation composite bone using No. 2 FiberWire (Arthrex) and No. 2 FiberLoop (Arthrex). The primary outcome was maximum load to failure. Secondary outcomes were displacement at the bone-tendon interface, total construct elongation, and stiffness. The Krackow plus whipstitch group (mean, 493.82 N; SD, 209.44 N) had a greater maximum load to failure as compared with the single Krackow group (mean, 333.71 N; SD, 172.32 N) (P=.01) and single whipstitch group (mean, 207.27 N; SD, 66.42 N) (P<.001). The single Krackow group (mean, 1.67 mm; SD, 0.89 mm) had a greater bone-tendon interface displacement (P=.01) after preloading and before cyclic loading than the single whipstitch group (mean, 0.83 mm; SD, 0.58 mm). There were no other secondary outcome differences between groups. A repair using Krackow plus whipstitch is biomechanically stronger with no difference in bone-tendon interface displacement, total construct elongation, or stiffness when compared with a single Krackow or single whipstitch. We recommend this repair technique for distal biceps tendon rupture repair, which may accelerate rehabilitation and decrease re-rupture rate. [Orthopedics. 2023;46(4):224-229.].

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

Revision Distal Biceps Tendon Repair Using Original Intramedullary Buttons

There are several techniques used for tendon fixation in distal biceps tendon repair. Intramedullary unicortical button fixation has the advantage of high biomechanical strength, minimal proximal radial bone removal, and low risk of injury to the posterior interosseous nerve. One disadvantage in revision surgery is retained implants in the medullary canal. This article describes a novel technique for revision distal biceps repair initially fixed with intramedullary unicortical buttons, using the original implants.

Arthroscopic Identification and Management of Hourglass Biceps

The hourglass biceps is a condition in which the intra-articular portion of the biceps tendon becomes inflamed and hypertrophies relative to the remaining tendon. This condition can be seen in association with rotator cuff and labral pathology and may lead to anterior shoulder pain. Diagnosis requires careful visualization and inspection of the biceps tendon during shoulder arthroscopy, as the presentation may be subtle. Surgical treatment includes tenotomy or tenodesis, depending on patient factors and surgeon preference.

Clinical implications of the distinct anatomy and innervation of the long head biceps tendon

The proximal long head of the biceps tendon (LHBT) has been recognized as a well-known cause of anterior shoulder pain. Previous studies have identified a heterogeneous distribution of nerve fibers in the tendon, with a higher abundance of fibers in the proximal and distal thirds of the tendon. This suggests that the proximal portion of the long head biceps tendon may have a different source of innervation than the distal portion. The purpose of this study was to review the innervation of the superior shoulder and identify the proximal source of sensory innervation of the LHBT. The relevant hypothesis was that the suprascapular nerve (SSN) was the proximal source of sensory innervation to the LHBT. Gross and microdissection of eight fresh human cadaver shoulders were performed, with a focus on the distal articular branches of suprascapular nerve (SSN). Utilizing 3.5× magnification loupes, the medial subacromial branch (MSAb), lateral subacromial branch (LSAb), and posterior glenohumeral branch (PGHb) were identified and followed distally to their terminal branches. In all specimens, terminal branches of the lateral subacromial branch supplied the proximal LHBT and the superior labrum. Terminal branches of the posterior glenohumeral branch supplied the posterosuperior labrum and, to a lesser extent, the labral attachment of the LHBT. These findings confirm branches of the suprascapular nerve as the proximal source of sensory innervation to the LHBT. Identification of the suprascapular nerve as a source of proximal innervation of the LHBT may influence clinical decisions related to nonsurgical and surgical intervention, nerve blocks, and nerve ablation procedures.

Return to Play After Distal Biceps Tendon Repair

PURPOSE OF REVIEW

Distal biceps tendon ruptures (DBTR) are uncommon injuries in 40- to 50-year-old men but occur at a younger age in the athlete population. The distal biceps tendon is an important supinator of the forearm and flexor of the elbow. A complete injury results in limiting function in the upper extremity. The current review evaluates the different options in management and the current literature on return to play in athletes.

RECENT FINDINGS

The distal biceps tendon inserts on the posterior aspect of the radial tuberosity as two independent heads. The long head footprint is more proximal and posterior giving it a better lever arm for supination. The short head footprint is more distal and anterior giving it a better lever arm for flexion. Surgical anatomic repair is highly recommended among the athlete population, to restore proper function of the upper extremity. There is scarce literature on return to play among athletes. The most recent studies on high-performance athletes are on National Football League (NFL) players. These studies showed that 84-94% of NFL players returned to play at least one game after distal biceps repair. Compared to matched control groups, there was no difference in the player's performance after surgery. Anatomic repair of DBTR results in excellent outcomes, high return to work, and high rate of return to play among athletes. When compared to matched control groups, NFL players have the performance score and play the same number of games after surgery.

Management of proximal biceps tendon pathology

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

How to Report: Elbow MRI

The elbow is the least common of the main joints examined with magnetic resonance imaging (MRI), thus radiologists may be less familiar with writing these reports. This article addresses the main pathologies encountered in and around the elbow, emphasizing the specific features that need reporting and providing examples of terminology to use when describing these abnormalities.

Isolated Biceps Tenodesis and Tenotomy: A Systematic Review of Indications and Patient Satisfaction

Biceps tenodesis and tenotomy are increasingly being used as treatment options for shoulder pathology, but patient satisfaction remains largely unstudied. A systematic review of the MEDLINE database was conducted to identify clinical outcome studies on isolated biceps tenodesis or tenotomy that reported patient satisfaction. Within the 15 investigations that were included, the indication for tenotomy was rotator cuff pathology, whereas the indication for tenodesis was biceps pathology or type 2 superior labral tear from anterior to posterior. Patients undergoing tenotomy were 13.6 years older than those undergoing tenodesis (P<.001). Patient satisfaction was high following both procedures, at 85.6% following tenotomy and 92.3% following tenodesis. [Orthopedics. 2021;44(6):333-340.].

Return to sport and weightlifting analysis following distal biceps tendon repair

BACKGROUND

Rupture of the distal biceps tendon is an increasingly frequent injury sustained predominantly by middle-aged men. Despite the prevalence of sport in this age group, little is known regarding return to sport outcomes following surgery.

METHODS

Patients undergoing distal biceps tendon repair (DBR) between January 2015 and January 2017 were contacted electronically via e-mail and via telephone to administer a previously validated and standard return to sport survey. Patients self-reported preinjury and current level of sport and activity as well as preinjury and current level of select weightlifts.

RESULTS

A total of 77 of 124 patients were available for follow-up (62.1%). Of these patients, 61 endorsed preoperative sport and were included for analysis. Average follow-up was 38.7 ± 6.7 months. The mean age at surgery was 47.5 ± 8.8 years, and the mean body mass index was 30.3 ± 5.1. The dominant side was affected in 25 of 61 cases. Of the 61 included patients, 57 (93.4%) were able to return to sport at any level (lower, same, or higher intensity than preinjury activity level). Forty of the patients (65.6%) were able to return to sport at same or higher intensity. Mean time to return to sport was 6.0 ± 2.8 months. Days from injury to surgery (odds ratio [OR] 0.999, 95% confidence interval [CI] 0.998-0.999), suture anchor fixation in comparison to suture button (OR 0.602, 95% CI 0.427-0.850), and dominant-side surgery (OR 0.749, 95% CI 0.582-0.963) were associated with a decreased likelihood to return to sport at same or higher level of duty. Single-sided incision in comparison to double (OR 5.209, 95% CI 1.239-20.903) and dominant-side surgery (OR 6.370, 95% CI 1.639-24.762) were associated with increased duration to return to sport.

CONCLUSION

Distal biceps tendon rupture is a significant injury; however, patients can expect high levels of return to sport following DBR with some residual impairment compared with baseline. It is important to counsel patients on their expectations while taking into account the results of this study: that there will be a small but appreciable decrease in strength compared with preinjury levels.

Arthroscopic Tenotomy of the Long Head of the Biceps Tendon and Section of the Anterior Joint Capsule Produce Moderate Osteoarthritic Changes in an Experimental Sheep Model

Osteoarthritis (OA) of the glenohumeral (GH) joint is a common cause of shoulder pain, resulting in considerable invalidity. Unfortunately, the study of its pathogenesis is challenging. Models of OA are necessary to identify specific targets for therapy and to be able to interfere with the development and evolution of OA. This study aims to assess the effect of an arthroscopic tenotomy of the long head of the biceps tendon (LHBT) and section of the anterior glenohumeral joint capsule on the ovine glenohumeral joint. In addition, the authors aim to validate and evaluate the reliability of a modified semi-quantitative MRI score to assess joint degeneration in a sheep’s shoulder. Eight skeletally mature sheep received an arthroscopic tenotomy of the LHBT and section of the anterior joint capsule and were euthanized four months after surgery. All animals tolerated the surgery well, and no complication was recorded for six weeks. Moderate degenerative changes to the ovine shoulder joint were found on MRI and histological evaluation. The arthroscopic tenotomy of the LHBT and the anterior glenohumeral joint capsule section caused moderate degenerative changes to the ovine shoulder joint.

Utility of the FABS MRI sequence in the evaluation of distal biceps pathology

OBJECTIVE

The flexed elbow, abducted shoulder, forearm supinated (FABS) position has been described as a method of imaging the distal biceps tendon on its long axis. The purpose of this study is to evaluate whether obtaining additional MR imaging in the FABS position changes the radiologist's assessment of the distal biceps tendon compared with traditional sequences only.

MATERIALS AND METHODS

Blinded review of 46 elbow MRIs when viewed without (-F) and with (+F) FABS sequences available was performed by two independent readers. The biceps tendon was graded in each case using a 0-3 scale, and a confidence level of 0-10 was assigned. -F and +F reads were compared. Reads were also compared with the surgical reference standard when available, 12 patients.

RESULTS

Pooled intra rater reliability was 0.800 (0.714, 0.886) between the -F and +F groups. Pooled mean confidence was 7.163 (1.252) for the -F group and 8.370 (1.264) for the +F group (p < 0.001). Pooled diagnostic accuracy was 0.651 (0.420, 0.882) for the -F group and 0.615 (0.456, 0.875) for the +F group compared with the surgical reference standard.

CONCLUSION

The FABS sequence changed the radiologist's impression of the distal biceps tendon in the minority of cases and did not significantly change diagnostic accuracy. We do not recommend its use in the majority of cases. In challenging cases of high-grade partial vs complete tendon tear, FABS may be helpful to identify subtle residual tendon fibers.

The Flexion Initiation Test and an Evidence-Based Diagnostic Algorithm for Distal Biceps Tendon Tears

Purpose

The purpose of this study was (1) to assess the flexion initiation test’s (FIT) ability to detect distal biceps tendon tears (DBTT) in a cohort of consecutive patients presenting with elbow pain and (2) to generate a reliable evidence-based diagnostic algorithm using a combination of both the FIT and hook tests.

Methods

We performed a retrospective review of 125 consecutive patients who presented with elbow pain, all of which had the FIT and hook test performed prior to imaging/further intervention. The integrity of the tendon was determined during surgery or by magnetic resonance imaging. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for the FIT and hook test.

Results

Our evidence-based diagnostic algorithm showed that when both test results are in agreement, there is a 100% diagnostic accuracy for detecting what prior authors have termed surgically indicated tears (complete ruptures and high-grade partial tears) and biceps pathology that can be treated with nonoperative management. The FIT demonstrated 100% sensitivity for surgically indicated tears. The hook test demonstrated 100% sensitivity for complete ruptures, but 18% sensitivity for diagnosing partial tears.

Conclusions

The FIT, which is aimed at improving diagnostic acuity of high-grade partial thickness tears, demonstrated a 93% sensitivity and 96% specificity overall and a 100% sensitivity for complete ruptures and high-grade partial tears. The evidence-based diagnostic algorithm using the combination of the FIT and hook test demonstrates high accuracy for the diagnosis of both complete and high-grade partial DBTTs. The methodology may help to prevent diagnosis delays, improve patient education, and preserve the option for timely primary surgical repair in the treatment of DBTTs.

Level of Evidence

Level IV, diagnostic.

Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic

Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.

Acute distal biceps tendon ruptures: anatomy, pathology and management - state of the art

All patients with acute complete distal biceps tendon ruptures who are not low demand or medically unfit to proceed with surgery are offered operative repair. This restores arm shape, supination strength and function, and decreases their cramping symptoms. Surgical repair technique varies significantly depending on location and training centre. Nuances in technique and appropriate implant selection need to be noted in order to achieve a strong repair allowing early active range of motion. Intimate knowledge of distal biceps tendon anatomy is key to avoid complications associated with the different approaches. The cumulative body of evidence on complications, coupled with knowledge of the different biomechanical construct strengths of the alternative methods of fixation, points to the use of the cortical button technique without the addition of an interference screw. Subtle variations in drill hole positioning on the bicipital tuberosity secures either an anatomic or non-anatomic repair. Anatomic repair results in greater supination peak torque and fatigue strength, and in greater flexion fatigue strength. It is advisable to perform an anatomic repair in elite athletes or those patients who significantly rely on supination strength and endurance for their livelihood. A universal postoperative protocol is suggested for all repairs.

Biomechanical Evaluation of Humerus Fracture After Subpectoral Biceps Tenodesis With Interference Screw Versus Unicortical Button

PURPOSE

To compare the torsional failure strength of the humerus after subpectoral biceps tenodesis with an interference screw versus a unicortical button in a human cadaveric model.

METHODS

Thirteen matched pairs of fresh-frozen human cadaveric upper extremities were randomized to receive either 2.6 × 12 mm unicortical button or 6.25-mm interference screw subpectoral biceps tenodesis. After the procedure, the humeri were loaded into a materials testing machine. The humeri were loaded in external rotation with respect to the elbow at 1.0°/s until failure. Rotation angle to failure, failure torque, energy absorbed, and stiffness were compared by paired t-tests with alpha set at 0.05.

RESULTS

Humeri that were fixed with unicortical buttons showed statistically significant higher rotation to failure (26.87 ± 5.83 vs 19.04 ± 3.86°, P < .001), failure torque (54.11 ± 22.01 vs 44.95 ± 17.47 Nm, P < .001), and energy absorbed (883.93 ± 582.28 vs 451.40 ± 216.19 Nm-Deg, P = .002) than humeri fixed with interference screws.

CONCLUSIONS

In a cadaveric biomechanical model, at time 0, the use of a 2.7 × 12-mm unicortical button fixation in biceps tenodesis resulted in higher loads required to fracture the humerus when compared with a 6.25-mm interference screw fixation in a torsion model.

CLINICAL RELEVANCE

This study demonstrates a significant biomechanical difference with regards to fracture of the humerus, between 2 commonly used fixations methods and implant sizes, interference screw, and unicortical button. The results of this study can aid surgeons in implant selection as well as help to improve patient education prior to surgery.

Biceps tenotomy versus tenodesis: patient-reported outcomes and satisfaction

Background

Biceps tenotomy and tenodesis are surgical treatments for pathology of the proximal tendon of the long head of the biceps. There is debate over which procedure provides better patient outcomes.

Purpose

Compare patient-reported outcomes and satisfaction between biceps tenotomy and tenodesis.

Methods

This retrospective cohort study including all patients undergoing arthroscopic biceps tenodesis or tenotomy as part of more extensive shoulder surgery with a single surgeon. Concomitant procedures included rotator cuff repair, subacromial decompression, acromioclavicular joint resection, and debridement. Patients 36–81 years old were contacted by phone at > 2-year post-operatively to complete a biceps-specific outcome questionnaire. Subject decision not to participate was the sole exclusion criterion. Satisfaction scores and frequencies of potential biceps-related downsides (biceps cramping/spasms, biceps pain, shoulder pain, weakness, cosmetic deformity) were analyzed for the effects of procedure, sex, and age.

Results

Satisfaction score distributions were similar between patients with tenodesis and patients with tenotomy (χ² = 8.34, P = 0.08), although slightly more patients with tenodesis than patients with tenotomy reported being satisfied or very satisfied (96% versus 91%). Perceived downsides occurred more frequently among patients with tenotomy than in patients with tenodesis: 59% of patients with tenotomy reported ≥ 1 downside, versus 37% of patients with tenodesis (P < 0.01). In patients reporting ≥ 1 downside, distributions of total downsides differed between procedures (χ² = 10.04, P = 0.04): patients with tenotomy were more likely to report multiple concurrent downsides than were patients with tenodesis (31% versus 16%). Each individual downside tended to be reported as present by a greater proportion of patients with tenotomy than patients with tenodesis. Sex had no effect on satisfaction or downsides, but there was a trend for older patients to report higher satisfaction and fewer downsides.

Conclusions

Biceps tenotomy and tenodesis are both viable treatments for proximal biceps tendon pathology, yielding high patient satisfaction. There were trends toward greater satisfaction and fewer problems in patients with tenodesis. Still, younger patients with tenodesis did report perceived downsides. Alternatively, older patients tended to be more satisfied with both procedures overall. Regardless of procedure, most patients receiving either tenotomy or tenodesis would undergo their respective surgery again.

Level of Evidence

Level III evidence, retrospective comparative cohort study

Open Biceps Tenodesis Associated With Slightly Greater Rate of 30-Day Complications Than Arthroscopic: A Propensity-Matched Analysis

PURPOSE

To compare the early complication risk associated with open biceps tenodesis (OBT) and arthroscopic biceps tenodesis (ABT) and determine which preoperative factors may influence complication rate.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively queried from 2008 to 2016 for all procedures with CPT codes for ABT (29828) and OBT (23430). Patients were excluded if they received concomitant rotator cuff repair or shoulder arthroplasty. Patients undergoing OBT and ABT were matched by propensity scores based on age, body mass index, operative time, proportion of smokers, and proportion of concomitant subacromial decompression, distal clavicle excision, SLAP, and debridement. The incidence of adverse events in the 30-day postoperative period was compared.

RESULTS

A total of 8,032 patients met the inclusion and exclusion criteria. Prior to propensity match, patients receiving OBT and ABT, respectively, differed with respect to age (49.4 ± 13.8 vs 51.4 ± 13.2; P < .001), body mass index (29.6 ± 6.8 vs 29.9 ± 7.0; P = .029), and operative time (91.2 ± 51.3 vs 85.3 ± 43.4; P < .001). Following propensity match, 6,330 remained in the study (3,165 ABT and 3,165 OBT). OBT had significantly greater incidence of any adverse events (1.58% vs 0.95%; P = .032) and anemia requiring transfusion (0.35% vs 0%; P = .001). Multivariate analysis suggested that OBT (relative risk [RR] = 1.7, 95% confidence interval [CI], 1.1-2.7; P = .020), old age (RR = 1.6, 95% CI, 1.0-2.5), history of dyspnea (RR = 3.8, 95% CI, 1.8-7.7; P < .001), and congestive heart failure (RR = 5.5, 95% CI, 1.3-22.7; P = .019) were associated with developing a postoperative adverse event within 30 days of surgery.

CONCLUSIONS

Both procedures were found to have a low rate of complications, although OBT had a slightly greater (1.58% vs 0.95%) rate of 30-day complications than ABT. Early complication rate should not serve as impetus to direct surgical technique as number needed to treat is high, although ABT may be considered in more high-risk individuals.

LEVEL OF EVIDENCE

Level III, retrospective comparative database study.

Biceps tenodesis versus biceps tenotomy for biceps tendinitis without rotator cuff tears

Disorders of the long head of the biceps tendon (LHB) are a well-recognised cause of shoulder pain despite the function of the long head of the biceps remaining poorly understood. There has been a dramatic rise in the number of biceps tenodesis procedures being performed in the last decade. This may partly be attributed to concerns regarding residual cosmetic deformity and pain after biceps tenotomy though there is little evidence to suggest that functional outcomes of tenodesis are superior to biceps tenotomy. Current literature focuses on LHB disorders with concomitant rotator cuff tears. The aim of this review is to discuss the anatomy of the LHB, the pathogenesis of tendinopathy of the LHB, indications of biceps tenodesis and tenotomy and compare the current literature on the functional outcomes of these procedures for LHB disorders in the absence of rotator cuff tears.