Biceps Tenodesis Versus Tenotomy

in the Treatment of Lesions of the Long

Head of the Biceps Tendon in Patients
Undergoing Arthroscopic Shoulder Surgery
A Prospective Double-Blinded Randomized Controlled Trial
Peter MacDonald,*y MD, Fleur Verhulst,y MD, Sheila McRae,y PhD, Jason Old,y MD,
Greg Stranges,y MD, Jamie Dubberley,y MD, Randy Mascarenhas,z MD, James Koenig,y MD,
Jeff Leiter,y PhD, Mark Nassar,y MD, and Peter Lapner,§ MD
Investigation performed at Pan Am Clinic, Winnipeg, Manitoba, Canada,
and Ottawa Hospital, Ottawa, Ontario, Canada

Background: The biceps tendon is a known source of shoulder pain. Few high-level studies have attempted to determine
whether biceps tenotomy or tenodesis is the optimal approach in the treatment of biceps pathology. Most available literature
is of lesser scientific quality and shows varying results in the comparison of tenotomy and tenodesis.
Purpose: To compare patient-reported and objective clinical results between tenotomy and tenodesis for the treatment of lesions
of the long head of the biceps brachii.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: Patients aged 18 years undergoing arthroscopic surgery with intraoperative confirmation of a lesion of the long head
of the biceps tendon were randomized. The primary outcome measure was the American Shoulder and Elbow Surgeons (ASES)
score, while secondary outcomes included the Western Ontario Rotator Cuff Index (WORC) score, elbow and shoulder strength,
operative time, complications, and the incidence of revision surgery with each procedure. Magnetic resonance imaging was per-
formed at postoperative 1 year to evaluate the integrity of the procedure in the tenodesis group.
Results: A total of 114 participants with a mean age of 57.7 years (range, 34 years to 86 years) were randomized to undergo either
biceps tenodesis or tenotomy. ASES and WORC scores improved significantly from pre- to postoperative time points, with
a mean difference of 32.3% (P \ .001) and 37.3% (P \ .001), respectively, with no difference between groups in either outcome
from presurgery to postoperative 24 months. The relative risk of cosmetic deformity in the tenotomy group relative to the tenod-
esis group at 24 months was 3.5 (95% CI, 1.26-9.70; P = .016), with 4 (10%) occurrences in the tenodesis group and 15 (33%) in
the tenotomy group. Pain improved from 3 to 24 months postoperatively (P \ .001) with no difference between groups. Cramping
was not different between groups, nor was any improvement in cramping seen over time. There were no differences between
groups in elbow flexion strength or supination strength. Follow-up magnetic resonance imaging at postoperative 12 months
showed that the tenodesis was intact for all patients.
Conclusion: Tenotomy and tenodesis as treatment for lesions of the long head of biceps tendon both result in good subjective
outcomes but there is a higher rate of Popeye deformity in the tenotomy group.
Registration: NCT01747902 (ClinicalTrials.gov identifier)
Keywords: long head of biceps; tenodesis; tenotomy; MRI; randomized trial; shoulder joint

The long head of the biceps brachii tendon is a common

source of shoulder pain and dysfunction in patients with
The American Journal of Sports Medicine
rotator cuff pathology.10,27,31 Tenotomy and tenodesis
1–11
DOI: 10.1177/0363546520912212 have been shown to produce favorable and comparable
Ó 2020 The Author(s) results in treating lesions of the long head of the biceps,

1
2 MacDonald et al The American Journal of Sports Medicine

but controversy still exists regarding the treatment of
choice. On the basis of anecdotal evidence, some suggest
that tenotomy should be reserved for older, low-demand
patients, while tenodesis should be performed in younger
patients and those who engage in heavy labor.19 Proponents
of tenotomy suggest that this is a technically easy procedure
that leads to easy rehabilitation and fast return to activity
with a low complication and reoperation rate.12,35 However,
those who support biceps tenodesis list good preservation of
elbow flexion and supination strength, improvement of
functional scores, elimination of pain, and avoidance of cos-
metic deformity as benefits of the procedure.2
Several case series’ in the literature have evaluated
biceps tenotomy versus tenodesis, demonstrating that
both are effective procedures in treating biceps tendon
lesions.1,30 Findings regarding more detailed aspects of
each procedure, however, are varied. With respect to the
incidence of a cosmetic deformity, some studies indicate
a significant difference in cosmetic deformity (Popeye
sign),19,30 while others show no difference.26 Meanwhile,
comparative studies and systematic reviews have shown
a significant predisposition to the development of a Popeye
deformity in patients undergoing biceps tenotomy, but it
has also been shown that this is well-tolerated by
patients.1,8,35 Additionally, not all patients undergoing
biceps tenotomy develop a cosmetic deformity, leading
some to say that the tendon may be entrapped in the bicip-
ital groove after being cut rather than retracting down the
arm.38 There is also a disparity in evidence regarding the
effect of the different approaches on strength, with some
studies finding no difference in elbow flexion strength or
supination strength,12,19 while others found that strength
decreased with tenotomy.36 A systematic review also
showed no statistical difference in postoperative biceps
pain, with a prevalence of 24% in the tenodesis group as
compared with 19% with tenotomy.30 Alternatively,
a meta-analysis found significantly less cramping pain in
patients undergoing tenodesis than tenotomy (P = .04).13
Most of these findings, however, come from lower-level
studies, such as retrospective studies5,14,24,26 or cohort
studies.4,11,19,37 The value of systematic reviews concern-
ing these studies12,17,27,30 is therefore limited as well.
There are only a few prospective randomized controlled tri-
als directly comparing biceps tenotomy and tenode-
sis,3,6,20,40 all of which show multiple similar outcomes
but also some fundamental differences. More well-designed
prospective level 1 studies are needed to compare tenotomy
and tenodesis to more adequately guide the decision-
making process and maximize patient outcomes.
The primary research objective of this randomized clin-
ical trial was to determine whether patients who undergo
biceps tenodesis have improved disease-specific quality of
life, as measured by the American Shoulder and Elbow
Surgeons (ASES) score at 2 years postoperatively, when
compared with patients who undergo biceps tenotomy. Sec-
ondary outcomes measures included the Western Ontario
Rotator Cuff Index (WORC), incidence of a Popeye defor-
mity, visual analog scale (VAS) pain scores, incidence of
cramping, elbow strength, and operative time. It was
hypothesized that there would be no difference between
subjective patient-reported outcomes at postoperative 24
months. Secondary hypotheses were that there would be
a greater incidence of Popeye deformity after tenotomy
than tenodesis and that surgery involving tenodesis would
be longer. Finally, it was hypothesized that there would be
no difference between approaches regarding pain or
cramping, as measured on VASs, or isometric elbow flexion
and supination strength, as measured with a handheld
dynamometer. These hypotheses are confirmed in certain
previous studies and not supported in others, with the
majority of the available literature on this topic of lower
scientific value. This level 1 study is intended to settle
the long-standing discussion of tenotomy versus tenodesis.
METHODS
Study Design
This parallel 1:1 double-blinded randomized controlled tri-
al was conducted at 2 academic centers. Five fellowship-
trained upper extremity surgeons (4 at 1 center [P.M.,
J.O., G.S., J.D.], 1 at the second center [P.L.]), each with
.5 years of experience, performed all surgery. Participants
completed questionnaires and underwent a clinical assess-
ment by a trained assessor (research physiotherapist or
athletic therapist) preoperatively and at 3, 6, 12, and 24
months postoperatively. Neither participants nor outcome
assessors were privy to group allocation until all data
were collected in the trial. Assessors did not have access
to patient operative or chart data before or during the
assessments and were also blinded regarding any addi-
tional procedures performed, but patients were not.
Although there was a difference in incision for patients

*Address correspondence to Peter MacDonald, MD, Pan Am Clinic and University of Manitoba, Pan Am Clinic, 75 Poseidon Bay, Winnipeg, MB R3M
3E4, Canada (email: pmacdonald@panamclinic.com).
y
Pan Am Clinic and University of Manitoba, Winnipeg, Manitoba, Canada.
z
McGovern Medical School, University of Texas Health Sciences Center, Houston, Texas, USA.
§
Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada.
Submitted June 24, 2019; accepted January 27, 2020.
One or more of the authors has declared the following potential conflict of interest or source of funding: A research grant was received for this project
from the Arthroscopy Association of North America, Conmed Linvatec, University of Manitoba Department of Surgery, and Alexander Gibson Chair Fund.
Pan Am Clinic Foundation, in which P.M. and J.O. are board members and S.M. is an employee and F.V. is a fellow, receives general funds and funds for
education from Arthrex, Ossur, and Conmed. R.M. receives hospitality support from Stryker and Zimmer Biomet and educational support from Vericel, Med
Inc of Texas, Arthrex, and Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an
independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
AJSM Vol. XX, No. X, XXXX
undergoing subpectoral tenodesis, if chosen, patients were
not informed of what the subpectoral incision was for.
Approval to conduct this study was obtained from the appro-
priate local research ethics boards before commencement of
any study activities. The trial was registered at Clinical-
Trials.gov (NCT01747902).
Participants
The target population included patients 18 years of age
undergoing arthroscopic shoulder surgery with intraopera-
tive confirmation of a lesion of the long head of the biceps
tendon. Participants with repairable rotator cuffs, irrepa-
rable rotator cuffs, and no rotator cuff tears were included.
Patients who were referred to the participating surgeons
with shoulder pain attributed to rotator cuff and/or biceps
lesions were screened for eligibility. All patients who had
magnetic resonance imaging (MRI) and/or physical exami-
nation findings consistent with a lesion of the long head of
the biceps were approached by the research coordinator,
who explained the study and provided the opportunity to
consent. Patients were excluded if they had any significant
comorbidities, including previous surgery on the affected
shoulder, active or previous joint or systemic infection, sig-
nificant muscle paralysis, Charcot arthropathy, significant
medical comorbidity that could alter the effectiveness of
the surgical intervention (eg, cervical radiculopathy, poly-
myalgia rheumatica), major medical illness (life expec-
tancy \1 year or unacceptably high operative risk),
inability to speak or read English, psychiatric illness that
precluded informed consent, or unwillingness to be fol-
lowed for 2 years. Randomization to either tenodesis or
tenotomy was carried out intraoperatively by a research
assistant or circulating nurse using sealed opaque enve-
lopes. A computer-based random number generator was
used to create the randomization envelopes, in blocks of
10, before any patients were consented. The envelopes
were made by a research assistant uninvolved in the intra-
operative randomization or postoperative evaluation pro-
cess. Patients remained blinded to their allocation until
their involvement in the study was complete.
Sample Size Calculation
A difference of 9.7 points on the ASES was the minimal clin-
ically detectable difference, with a typical standard deviation
of 16.5 points.25 With alpha set at .05 and power at 0.80, the
sample size was determined to be 45 per group. With a fore-
seen dropout rate of 25%, the target sample size was
increased to 57 patients per group for a total of 114 patients.
Outcome Measures
The primary outcome measure was the ASES standardized
assessment of shoulder function.28 Participants also com-
pleted the WORC subjective questionnaire.18 Although
these outcomes were initially designed and validated for
use with patients with rotator cuff pathology, both are
used to evaluate patients with biceps pathology, as there
is substantial crossover between rotator cuff and biceps
Biceps Tenotomy vs Tenodesis 3
symptoms. In addition, WORC has been validated for use
in patients with subacromial disease requiring surgery,
including biceps pathology.39 Participants were also asked
to report if they had pain in their upper arm, using a
10-cm VAS from ‘‘no pain’’ to ‘‘extreme pain,’’ as well as if
they had cramping in their upper arm, from ‘‘no cramping’’
to ‘‘extreme cramping.’’ Additional secondary outcomes
monitored during the postoperative course included the
presence/absence of a Popeye deformity as noted by the out-
come assessor, operative times of the 2 procedures, compli-
cations (tenodesis failure, infection, adhesive capsulitis,
neurologic complications), and the incidence of revision sur-
gery for each procedure. Popeye deformity was assessor
reported and defined as a more distal and prominent muscle
belly of the biceps as compared with the other arm, which
becomes more obvious with active or resisted elbow flexion.
Elbow isometric flexion strength and supination strength
at 90° of elbow flexion were measured with a handheld
dynamometer (Commander Echo 1700). Elbow and shoulder
range of motion were assessed with a goniometer. MRI was
performed at a minimum 12 months postoperatively to eval-
uate the integrity of the procedure and whether biceps fixa-
tion was intact or not in the tenodesis group.
Surgical Technique
Shoulder arthroscopy was conducted with the patient in the
lateral decubitus or beach-chair position based on surgeon
preference. Diagnostic arthroscopy was performed with
a standard posterior portal, and the biceps tendon was
assessed via an arthroscopic probe with a standard anterior
interval portal. Final study eligibility was confirmed via iden-
tification of tearing, instability, degeneration, or inflamma-
tion of the long head of the biceps tendon or superior
labrum attachment. If the patient was eligible, randomization
was carried out by the research assistant or circulating nurse.
For patients who underwent biceps tenotomy, the long
head of the biceps tendon was detached from its proximal
anchor to the superior labrum with an arthroscopic biter,
an electrothermal device, or a scalpel, according to surgeon
preference.
For those patients undergoing biceps tenodesis, this was
performed via either an arthroscopic suprapectoral approach
with an interference screw or an open subpectoral approach
with a button (Arthrex) based on surgeon preference.
Once the long head of biceps tendon pathology had been
addressed, the scope was switched to a standard lateral
portal to assess subacromial pathology and the rotator
cuff. Subacromial decompression was performed with a cut-
ting block technique if required, and the rotator cuff was
repaired if necessary via standard antero- and posterolat-
eral accessory portals based on tear configuration.
Postoperative Care and Physiotherapy
Postoperative care and immobilization were identical for
the 2 groups and consisted of the use of a sling for 4 to 6
weeks. Patients were allowed to remove the sling for activ-
ities of daily living in which the arm was not elevated
4 MacDonald et al
actively, and only gentle nonresisted elbow flexion and
supination were allowed. Active range of motion was
started at 4 to 6 weeks, and resistance exercises were
begun when maximal range of motion was achieved. No
at-risk work activities or sports were allowed for 6 months.
This postoperative protocol was also used in patients with
irreparable cuff tears.
Data Analysis
Descriptive statistics were generated for all variables:
means (standard deviations) for continuous variables and
frequencies for nominal data. An intention-to-treat analysis
was undertaken, so all patients’ data were analyzed accord-
ing to the group to which they were allocated. A series of
mixed effect model analyses were run with 1 between-group
(study group) and 1 within-patient (time) variable to exam-
ine the main effects as well as any interaction. These were
run for ASES, WORC, and strength at preoperative and
24-month time points and 3 and 24 months for pain and
cramping scores. Analyses were also conducted including
each of the following variables as covariates: age, sex,
presence/absence of rotator cuff tear, presence/absence of
rotator cuff repair, and type of tenodesis. To maintain ade-
quate power, interim time points (3, 6, 12 months) were
not included in these analyses, owing to occasional missing
values. However, post hoc comparisons involving interim
time points were performed—specifically, 2-group indepen-
dent t tests at each time point and repeated measures t tests
between time points by group, adjusted for multiple compar-
isons. These were added to show general improvement by
group and time point from pre- to postsurgery. A 2-group
independent t test was performed to compare surgery
time. Chi-square was used to compare incidence of Popeye
deformity between groups at 3 and 24 months. Post hoc
analyses to compare sub- and suprapectoral tenodeses
were undertaken through a series of independent t tests
for subjective outcomes and strength. The 5% significance
level was used for all comparisons.
RESULTS
A total of 114 participants were randomly assigned to
either biceps tenodesis (n = 57) or biceps tenotomy (n =
57) between May 2013 and January 2016. Patient flow
through the study is presented in the CONSORT (Consoli-
dated Standards of Reporting Trials) diagram (Figure 1).
Three patients in the tenodesis group were excluded intra-
operatively, 1 because of a preexisting biceps rupture and
2 because of anesthesia issues that made completion of their
shoulder procedure infeasible, leaving 54 for inclusion in
study follow-up. Sixty-nine percent (n = 37) of the tenodesis
procedures were performed with the suprapectoral tech-
nique, with the remaining 31% (n = 17) undergoing subpec-
toral tenodesis. Groups were similar with respect to
demographics, preoperative subjective scores, intraopera-
tive findings, and concomitant procedures (Table 1). A total
of 48 patients in the tenodesis group and 52 in the tenotomy
The American Journal of Sports Medicine
group returned for final follow-up, yielding 90% retention in
the trial at 24 months. The mean (SD) operative time was 74
(40) minutes in the tenodesis group as compared with 69
(39) minutes in the tenotomy group (P = .539).
Subjective Scores
A summary of subjective and functional scores by group and
time point is presented in Table 2. ASES scores significantly
improved from baseline to postoperative 24 months in
patients who underwent tenotomy and tenodesis, with
a mean difference of 32.3% (95% CI, 27.6-37.1; F1,91 =
182.3; P \ .001). There was no main effect based on group
(P = .46), and there was no interaction effect between group
and time (P = .43). Between-group differences remained
nonsignificant when controlling for age, sex, presence/
absence of rotator cuff tear, and presence/absence of rotator
cuff repair. Significant improvement was observed from
baseline to 6 months, with no improvement after this
time. Similarly, WORC scores improved from presurgery
to postoperative 24 months with a mean difference of
37.3% (95% CI, 32.0-42.7; F1,82 = 193.4; P \ .001), with no
main effect of group (P = .25) or interaction effect (P =
.89). WORC scores followed a similar pattern of improve-
ment from presurgery to postoperative 6 months in both
groups, with no further significant change after 6 months.
Pain improved significantly from 3 to 24 months postop-
eratively with a mean decrease of 1.8 cm on a 10-cm VAS
(95% CI, –1.1 to –2.5; F1,86 = 24.1; P \ .001), with no
main effect of group (P = .86) or interaction effect (P =
.29). In contrast, there was no significant change in cramp-
ing over the same period, with a mean difference of 0.02 cm
on a 10-cm VAS (95% CI, –0.70 to 0.74; F1,87 = 0.002; P =
.962). There was no main effect of group (P = .44) and no
interaction effect between group and time (P = .32).
Popeye Deformity
Popeye sign was defined as a bulge on the medial side of
the upper arm that becomes more prominent with active
or resisted elbow flexion and has a different aspect than
the other arm (Figure 2). There was a significant difference
in the presence of a Popeye deformity between groups. At
postoperative 3 months, 5 (11.4%) patients in the tenodesis
group had a Popeye deformity, as opposed to 17 (39%) in
the tenotomy group (P = .003), with a relative risk (RR)
that was significantly higher for patients undergoing
tenotomy (RR = 3.4; 95% CI, 1.37-8.41; P = .008). This out-
come remained relatively unchanged at postoperative 24
months, with 4 (10%) and 15 (33%) patients with deform-
ities in the tenodesis and tenotomy groups, respectively
(RR = 3.5; 95% CI, 1.26-9.70; P = .016).
Strength
There were no main effects of group or time in elbow flex-
ion strength of the affected limb. Supination strength
improved significantly from presurgery to 24 months post-
operatively in both groups, with a mean difference of 1.2 kg
AJSM Vol. XX, No. X, XXXX Biceps Tenotomy vs Tenodesis 5

Assessed for eligibility (n = 321)

Excluded (n = 122)
Reasons:
- Worker’s Compensation Board (n = 2)
- had prior surgery (n = 13)
- opted not to have surgery (n = 5)
- major medical illness (n = 2)
- severe glenohumeral osteoarthritis (n = 3)
- could not return for study visits (n = 2)
- no biceps pathology (n = 95)

Not consented (n = 85)

Randomized (n = 114)

Allocated to tenodesis (n = 57) Allocated to tenotomy (n = 57)

Excluded post-randomization (n = 3)
1 ruptured biceps tendon
2 anesthesia issues

Lost to follow-up after: Lost to follow-up after:

Surgery (n = 1) Surgery (n = 2)
3 months (n = 1) 3 months (n = 0)
6 months (n = 2) 6 months (n = 1)
12 months (n = 2) 12 months (n = 1)

Withdrawn - unrelated to surgery/study:

6 months (n = 1)

Analyzed of 54 included participants: Analyzed of 57 included participants:

Baseline (n = 51; 94%) Baseline (n = 53; 93%)
3 months (n = 48; 89%) 3 months (n = 46; 81%)
6 months (n = 47; 87%) 6 months (n = 46; 81%)
12 months (n = 42; 78%) 12 months (n = 46; 81%)
24 months (n = 48; 89%) 24 months (n = 52; 91%)
Excluded from analysis (n = 0) Excluded from analysis (n = 0)

Figure 1. Patient flow through the study following the CONSORT (Consolidated Standards of Reporting Trials) diagram.

(95% CI, 0.43-2.02; F1,31 = 9.87; P = .004). There was no Complications

main effect of group or interaction effect.
MRI Findings
Mean (SEM) time from surgery to postoperative MRI was
18.4 (1.3) months in the tenotomy group and 17.2 (1.2)
months in the tenodesis group (P = .50). Of 39 patients
who underwent MRI in the tenodesis group, all demon-
strated an intact tenodesis on imaging. In the tenotomy
group, 44 patients underwent MRI.
There were 4 reoperations in the tenodesis group, of which
2 underwent revision tenodesis, each initially performed
with a suprapectoral technique (Table 3). In both cases,
the revisions were performed for persistent anterior shoul-
der pain. There were 5 reoperations in the tenotomy group,
including 2 patients who underwent a tenodesis. One
patient fell on an outstretched arm approximately 2
months postsurgery and subsequently had severe anterior
shoulder pain with radiation to the midhumeral area. The
6 MacDonald et al The American Journal of Sports Medicine

TABLE 1
Demographic and Intraoperative
Findings and Proceduresa

Tenodesis Tenotomy
(n = 57) (n = 57)

Demographics
Sex, men:women 47:10 45:12
Age, y 58.7 6 10.9 56.3 6 8.1
Body mass index 29.7 6 4.9 29.3 6 4.3
Smoker 12 (25) 11 (22)
Surgical side: dominant 34 (63) 34 (60)
Baseline scores, %
ASES 48.2 6 17.6 47.3 6 15.9
WORC 34.0 6 15.4 37.1 6 13.2
Intraoperative findings
SLAP tears 7 (13) 3 (5)
Suprainfraspinatus tear
No tear 13 (25) 18 (33)
Partial 7 (13) 3 (5)
Complete 32 (62) 34 (62)
Subscapularis tear
No tear 25 (69) 25 (68)
Partial 6 (17) 5 (14)
Complete 5 (14) 7 (19)
Any rotator cuff tear 42 (79) 40 (73)
Additional surgical procedures
Acromioplasty 19 (36) 19 (37)
Rotator cuff repair 34 (64) 37 (66) Figure 2. Patient with Popeye deformity after tenotomy
Operative time, min 74 6 40 69 6 39 procedure.
a
Data presented as mean 6 SD or n (%), unless otherwise
stated. ASES, American Shoulder and Elbow Surgeons; SLAP, compared with tenodesis. Otherwise, no significant differ-
superior labrum anterior and posterior; WORC, Western Ontario ences in pain, cramping, elbow flexion, and supination
Rotator Cuff Index. strength were found.
There have been many varying reports in the litera-
second patient developed postoperative capsulitis. After ture regarding Popeye deformity after either biceps
resolution of the capsulitis, this patient continued to tenotomy or tenodesis. In 2005, Wolf et al38 performed
have persistent severe anterior shoulder pain, and he ulti- a biomechanical analysis of the biceps after tenotomy
mately underwent revision to tenodesis to address this. versus tenodesis and found a significant risk of distal
One of these patients had no study follow-ups, and the biceps tendon migration and a lower load to failure after
other had an ASES score of 66.7 at postoperative 5 months tenotomy. In a review of the literature, Frost et al12
as compared with the mean of 75.5 for the tenodesis group found that the incidence of Popeye deformity after biceps
at 6 months. Other reasons for reoperations are shown in tenotomy varied from 3% to 70%, which is in keeping
Table 3. Two additional patients in the tenotomy group with the findings of our study showing an incidence of
developed adhesive capsulitis that resolved over time. Popeye deformity of 38.6% after biceps tenotomy.
Numerous studies have shown an increased incidence
of cosmetic deformity after biceps tenotomy as compared
Subpectoral vs Suprapectoral Tenodesis with tenodesis.3,4,6,7,13,17,20,21,30
Duff and Campbell8 performed a study of patient accep-
Subjective and objective outcome measures by tenodesis
tance after biceps tenotomy and found that only 3% of
type are presented in Table 4. There was no difference
patients had concerns about their biceps deformity. Clem-
between tenodesis types on any outcome.
ent et al5 found no statistically significant difference in
deformity between groups. Interestingly, a recent retro-
DISCUSSION spective study by Godenèche et al14 showed no deformity
at all after biceps tenodesis or tenotomy at 10-year
There was no difference in subjective outcomes between follow-up. The occurrence of a Popeye deformity in 11.4%
patients undergoing tenodesis and tenotomy in the treat- of those patients who underwent a tenodesis in the current
ment of biceps pathology at postoperative 24 months, sup- study may have been due to undertensioning of the biceps
porting the primary hypothesis of this study. The most tendon, or the patients could have tenodesed in a position
important finding of this study was a 3.5-times higher where there was too much slack in the biceps tendon. The
risk of cosmetic Popeye deformity after tenotomy as surgical technique used was performed exactly as
AJSM Vol. XX, No. X, XXXX Biceps Tenotomy vs Tenodesis 7

TABLE 2
Subjective and Functional Outcomes by Group at Each Time Pointa

Tenodesis Tenotomy Between-Group P Value

ASES, %
Preoperative 48.2 6 17.6 47.3 6 15.9 .795
3 mo 65.2 6 19.7 61.1 6 22.0 .348
6 mo 74.5 6 17.9 72.7 6 23.2 .526
12 mo 79.0 6 18.8 80.0 6 18.5 .819
24 mo 79.4 6 21.8 82.3 6 17.8 .471
Comparison between time points within groups
Baseline–3 mo \.001b \.001b
3 mo–6 mo .002b \.001b
6 mo–12 mo .203 .363
12 mo–24 mo .495 .074
WORC, %
Preoperative 34.0 6 15.4 37.1 6 13.2 .293
3 mo 54.4 6 20.2 54.1 6 21.0 .935
6 mo 69.2 6 19.7 63.4 6 22.6 .187
12 mo 71.6 6 22.4 72.2 6 20.5 .893
24 mo 73.3 6 25.9 73.6 6 22.8 .959
Pairwise comparison between time points within groups
Baseline–3 mo \.001b \.001b
3 mo–6 mo \.001b .015b
6 mo–12 mo .056 .085
12 mo–24 mo .623 .163
Pain, cm
3 mo 4.7 6 3.2 4.1 6 3.0 .400
6 mo 3.7 6 3.0 3.4 6 3.5 .728
12 mo 2.4 6 2.7 2.8 6 2.9 .471
24 mo 2.3 6 2.9 2.9 6 3.0 .309
Pairwise comparison between time points within groups
3 mo–6 mo .059 .121
6 mo–12 mo .012b .744
12 mo–24 mo .647 .312
Cramping, cm
3 mo 2.5 6 3.0 2.0 6 2.6 .421
6 mo 2.3 6 2.7 2.2 6 2.9 .882
12 mo 1.7 6 2.4 2.1 6 2.8 .584
24 mo 2.1 6 2.9 2.3 6 2.9 .726
Pairwise comparison between time points within groups
3 mo–6 mo .820 .784
6 mo–12 mo .056 .540
12 mo–24 mo .573 .999
Flexion strength, kg
Preoperative 15.3 6 7.8 16.7 6 9.7 .436
3 mo 13.5 6 7.8 13.4 6 6.1 .935
6 mo 16.8 6 8.2 14.0 6 6.3 .064
12 mo 16.9 6 7.3 14.3 6 5.3 .052
24 mo 14.9 6 6.6 15.9 6 7.5 .549
Supination strength, kg
Preoperative 2.1 6 1.0 2.1 6 1.4 .962
3 mo 2.3 6 1.5 2.3 6 1.3 .882
6 mo 3.0 6 1.9 2.9 6 1.7 .853
12 mo 2.7 6 1.3 2.5 6 1.1 .347
24 mo 2.8 6 1.5 2.9 6 2.0 .747

a
Data presented as mean 6 SD or P value. ASES, American Shoulder and Elbow Surgeons; WORC, Western Ontario Rotator Cuff Index.
b
P \ .05.

described in other articles, and every effort was made to deformity after tenodesis,6,14,24,37 other numbers range
tenodese the tendon under proper tension. Available liter- from 5.5% to as high as 24%.3,11,19,20,40
ature is divided about the incidence of Popeye deformity The significant improvement in ASES and WORC
after tenodesis, and although some studies show no scores at 3 and 6 months after either biceps surgery found
8 MacDonald et al The American Journal of Sports Medicine

TABLE 3
Revision Surgery by Groupa

24 mo

Patient Time 1, mob Additional Biceps Surgery Additional Procedures Time 2, moc ASES WORC

Tenodesis group
1 6 Tenodesis revision Rotator cuff exploration
15 Tenodesis revision Rotator cuff exploration, debridement/synovectomy 9 68.3 32.4
2 15 Rotator cuff repair redo 9 50.7 22.4
3 18 Distal clavicle exision, rotator cuff exploration, 6 100 98
debridement/synovectomy
4 20 Tenodesis revision Rotator cuff exploration, debridement/synovectomy 4 45 37
Tenotomy group
1 7 Rotator cuff repair, subacromial decompression 17 92.7 77.2
2 7 Tenodesis Rotator cuff exploration, debridement/excision ND ND
3 14 Revision decompression 10 69.7 36.5
4 19 Tenodesis (open) Rotator cuff exploration, debridement/synovectomy 5 66.7 ND
5 22 Subacromial decompression, distal clavicle excision 2 29.2 28.1

a
ASES, American Shoulder and Elbow Surgeons; ND, no data; WORC, Western Ontario Rotator Cuff Index.
b
Time 1: time from initial surgery to additional surgery.
c
Time 2: time from additional surgery to 24-month study follow-up.

TABLE 4
Subjective and Functional Outcomes by Tenodesis Type at Postoperative 24 Monthsa

Subpectoral (n = 14) Suprapectoral (n = 34) P Value

ASES, % 81.5 6 22.3 78.6 6 21.9 .680

WORC, % 71.6 6 29.9 74.0 6 24.5 .772
Pain, % 2.4 6 3.0 2.3 6 2.9 .853
Cramping, % 2.3 6 2.9 2.0 6 2.9 .781
Strength, affected/unaffected ratio
Flexion 0.92 6 0.22 0.98 6 0.29 .541
Supination 0.96 6 0.25 0.98 6 0.22 .878

a
Data are presented as mean 6 SD. ASES, American Shoulder and Elbow Surgeons; WORC, Western Ontario Rotator Cuff Index.

in the current study is similar to that seen in previous
studies,1,3-7,12,17,20,30,35,40 although the outcome metrics
were different. In contrast, Godenèche et al,14 Meraner
et al,24 and Ge et al13 all found significantly better out-
comes after biceps tenodesis than after tenotomy based
on the Constant score. Leroux et al21 also found a signifi-
cantly higher Constant score 25.5 months after tenodesis;
however, this difference was less than the reported mini-
mal clinically important difference of 10.4 points. These
outcome scores are influenced by the concomitant rotator
cuff pathology as well. However, since patients were ran-
domized and there were no significant differences in rota-
tor cuff pathology and surgery between groups, this was
not considered a confounding factor for group comparison.
The fact that the current study did not show any functional
differences between groups is probably due to its double-
blinded and randomized character, which, in contrast to
most of the available literature, minimizes bias. Age, sex,
presence/absence of rotator cuff tear, presence/absence of
rotator cuff repair, and type of tenodesis were included
as covariates in the statistical analysis and made no differ-
ence to the findings.
In the current study, no differences in biceps pain and
cramping were found between patient treated with tenot-
omy or tenodesis. Interestingly, pain improved incremen-
tally over time, while cramping remained unchanged up
to postoperative 24 months. This is an interesting finding,
as most studies describe cramping as a temporary compli-
cation, recovering within a few months. Only Wittstein
et al37 described 11% of patients in their tenotomy group
experiencing cramping with activities of daily living at
a mean follow-up of 56 months. The studies of Osbahr
et al,26 Cho et al,4 and Castricini et al3 also did not show
any difference in pain or cramping between groups. Mera-
ner et al24 found no difference in pain and no cramping in
either group. Boileau et al1 and Zhang et al40 found more
pain and cramping after tenotomy, but this difference
was not significant. Similarly, in a review of the literature,
Hsu et al17 concluded there was more pain after tenotomy
but no differences in postoperative patient satisfaction,
AJSM Vol. XX, No. X, XXXX
indicating that the differences were not clinically signifi-
cant. Virk and Nicholson33 and Ge et al13 reviewed the lit-
erature on this topic and found an overall lower risk of pain
and cramping after tenodesis. Clement et al5 found that
pain on biceps palpation was significantly more frequent
in the tenodesis group, and the studies of Friedman
et al11 and Wittstein et al showed more cramping after
tenotomy but more pain over the tenodesis site after
tenodesis.
Reports on postoperative elbow flexion and supination
strength are variable as well. This might in part be due
to the fact that isolated supination strength is difficult to
measure. In the current study, no differences in elbow flex-
ion strength or supination strength were found after biceps
tenotomy versus tenodesis. Castricini et al3 found elbow
flexion strength at 6 months to be lower on the operated
side than the contralateral side, but there was no differ-
ence between those undergoing tenotomy and those under-
going tenodesis. Also, the difference between the affected
and contralateral sides was no longer seen at 24 months.
Similar results were found by Shank et al29 and Zhang
et al.40 Also, Clement et al5 found no difference between
groups. They suggested that the self-locking effect of the
‘‘T’’ tenotomy may conserve muscle strength better than
classic tenotomy techniques. Lee et al20 found a signifi-
cantly greater side-to-side difference in supination
strength after tenotomy than after tenodesis based on iso-
metric testing at postoperative 12 months. In addition,
Wittstein et al37 found peak supination torque was signif-
icantly less on the operative side in patients undergoing
tenotomy versus tenodesis, with no difference in peak flex-
ion torque or endurance in either motion. Unfortunately,
fatiguability and endurance were not tested in the current
study. The et al32 performed a long-term strength and
function study after biceps tenotomy in active working
men. They found significant reductions in peak elbow flex-
ion and forearm supination strength, but clinical function
remained good. This could be explained by compensatory
muscle changes in the upper arm. The range of outcomes
with respect to strength could be attributable to a number
of factors, including patient position, time postoperative,
and isokinetic versus isometric testing. Detailed descrip-
tion of testing protocol is lacking in many studies, making
it difficult to compare findings directly. The systematic
review done by Ge et al13 showed better overall function
after tenodesis, and the recent study by Godenèche
et al14 also showed similar findings. As was the case in
the current study, most of the available literature fails to
show a difference in outcome between biceps tenodesis
and tenotomy, regardless of level of evidence. A possible
explanation could be that the long head of the biceps is
more a shoulder-stabilizing structure than an elbow-mov-
ing structure, and functional testing is therefore limited.
Elbow flexion strength and supination strength probably
do not truly assess the role of the long head of the biceps.
Since tenodesis and tenotomy both eliminate any shoul-
der-stabilizing effects, the functional outcomes of the 2 pro-
cedures would likely be similar.
Recent studies have reported postoperative MRI find-
ings primarily examining rotator cuff retear rate and
Biceps Tenotomy vs Tenodesis 9
found no difference between biceps tenotomy and tenodesis
groups.3,14 In a prospective randomized controlled study,
Lee et al20 performed MRI at postoperative 12 months
and found that in the tenotomy group, 80.4% of the biceps
tendons were still in the biceps groove. The overall success
rate of biceps tenodesis according to the maintenance of
the fixed tendon was 90.3%. Postoperative MRI evaluation
in the current study did not reveal any failures on imaging
in the tenodesis group, and 68% of the tenotomy group had
a biceps tendon that was still in the groove.
In a review of complications after biceps tenodesis or
tenotomy, Virk and Nicholson33 found a high rate of post-
operative cosmetic deformity, as well as cramping or sore-
ness in the biceps muscle after tenotomy. Complications
after tenodesis tended to be more severe, such as neuro-
logic injuries, proximal humerus fracture, and infection.
In the current study, no such complications occurred. How-
ever, 2 patients from the tenotomy group eventually under-
went biceps tenodesis to address symptoms of ongoing
anterior shoulder pain. In addition, 2 patients developed
adhesive capsulitis. A risk factor analysis of biceps tenot-
omy by Lim et al22 showed that male sex was the only fac-
tor correlated with occurrence of a Popeye deformity. Other
factors did not show any correlation with deformity, elbow
flexion strength, and cramp-like arm pain. Voss et al34
recently found no increased rate of complication after
biceps tenodesis when comparing patients aged .65 and
\65 years. In the current study, neither age nor sex was
a confounding factor for outcome.
A large database review on the effect of biceps tenodesis
on reoperation rates after rotator cuff repair demonstrated
significantly higher reoperation rates at 1 year in patients
who had concomitant biceps tenodesis when compared
with those who did not.9 No such conclusion could be
drawn for the current study. However, the rate of reopera-
tion in this study is clinically significant in both groups,
which is partly due to the fact that patients with rotator
cuff surgery were included in this study. The often chronic
character of cuff and impingement pathology sometimes
necessitates follow-up surgery.
A possible limitation of the current study may be that
patients were included who had concomitant shoulder
pathology, and the study did not consist of a cohort of
patients with isolated biceps pathology. The majority of
patients had concomitant rotator cuff tears for which a rotator
cuff repair was carried out in the same setting. However, we
believe that inclusion of these patients makes the study more
generalizable, as this best represents surgical practice, where
the number of patients undergoing surgical intervention for
isolated biceps pathology is low. Loss to follow-up was 10%,
but the sample size was increased by 25% to account for
this. The study was thus adequately powered to detect a clin-
ically meaningful difference if one existed. Regarding tenod-
esis surgical technique, sub- and suprapectoral approaches
were both utilized in the current study, which may have
affected the results. The effect was thought to be negligible
given that there was 100% healing in all tenodesis cases,
and no statistical differences were found in subjective out-
comes or strength. Although the post hoc analyses were
likely underpowered (14 subpectoral and 34 suprapectoral),
10 MacDonald et al
the findings are consistent with the literature, which also
states no significant difference in outcome measures between
techniques.15,16,23,36 While there are certainly differences
between the techniques, there is no definitive guiding litera-
ture available for one technique over the other.
Not all patients agreed to return for postoperative imag-
ing (68%), so there is a potential for bias related to healing
status because of this loss to follow-up. Another possible
limitation was related to the duration of follow-up of 2
years. It is possible that longer follow-up would be of value.
However, as soft tissue healing can be considered complete
by 12 months, it seems likely that further changes in heal-
ing status would be related to chronic intrinsic tendon
pathology, which should be similar between groups. A final
limitation could be that the effect alone of tenodesis and
tenotomy on shoulder and elbow function is difficult to
determine in this study because of the concomitant rotator
cuff tears and repairs. However, with an equal number of
cuff tears and repairs in each group, the difference in
shoulder and elbow function between the groups can be
measured adequately.
CONCLUSION
Tenotomy and tenodesis as treatment for lesions of the
long head of the biceps tendon both result in good outcomes
with no significant differences identified between groups in
patient-reported outcomes or elbow strength. The choice of
one procedure over the other should take into consider-
ation the higher risk of cosmetic deformity in tenotomy
as compared with tenodesis.
ACKNOWLEDGMENT
The authors thank Leeanne Gullet, Holly Brown, Katie
McIlquham, and Sara Ruggiero for their assistance in coor-
dinating this study.
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