There is debate among orthopedic surgeons about the optimal method to treat biceps-labral complex (BLC) injuries in young athletes. Typically, operative treatment is indicated after at least 3 months of unsuccessful nonoperative management for BLC disorders ranging from biceps tendinitis and chondromalacia to superior labrum anterior and posterior (SLAP) tears.1 Historically, SLAP repair was the preferred surgical treatment method for young, active patients with healthy labral tissue and glenohumeral cartilage, and biceps tenodesis and labral debridement has been the preferred procedure for older patients who have more BLC degeneration.2 However, there has been an increase in the use of biceps tenodesis in the management of BLC injury, and Patterson et al3 reported an increase from 1.9% to 18.8% in the use of biceps tenodesis for patients with isolated SLAP lesions from 2002 to 2011. As the management algorithm shifts, with increased recognition of the biceps and labrum as a complex, it is important to measure clinical and functional outcomes after operative treatment for BLC.
The initial treatment recommendations for BLC injury included arthroscopic debridement and SLAP repair.4–6 Early results showed poor long-term outcomes after debridement alone; therefore, arthroscopic repair of the biceps anchor became the gold standard for operative management. Studies of arthroscopic repair initially reported excellent results, based on various patient-reported, shoulder-specific outcome measures, with rates of successful outcomes ranging from 75% to 97%.4,7–10 However, some studies reported poor outcomes for specific subsets of patients, particularly athletes playing overhead throwing sports.5,7,11,12 Return to play rates for younger athletes playing overhead throwing sports ranged from 22% to 84%, depending on the activity and position played.5,7,11–15 Additionally, there is concern about restriction of motion after SLAP repair, sometimes even 5 years postoperatively.16–18
Because of these concerns about return to play and stiffness after SLAP repair, biceps relocation procedures, including biceps tenodesis and transfer, offered an alternate treatment for SLAP lesions and other types of BLC injury in younger, more active patients. Bio-mechanical studies and clinical case reports19–21 described successful outcomes and return to activities after biceps tenodesis, although these studies focused primarily on older patient populations (>40 years old).16,19–23 Few studies have reported on the use of biceps tenodesis or transfer for the treatment of BLC injuries in a cohort of young, competitive athletes. Of the few studies available, Griffin et al24 investigated a population of athletes with a mean age of 19.8 years who underwent biceps tenodesis for biceps tendinopathy or BLC injury. Of this group, 66% returned to play, with 48% returning to the same level of play. Of athletes playing overhead throwing sports, 76% returned to play, and no difference was found between patient-reported outcome measure scores of athletes playing overhead throwing sports and those playing non-overhead throwing sports.
The goal of this study was to investigate the level of play that can be expected in a young, athletic population after biceps tenodesis or transfer. The primary outcomes were rate of return to play and postoperative level of play compared with preoperative level. Secondary outcomes included improvement in clinical function and pain scores. The authors hypothesized that both rates of return to play and clinical improvement would be high after biceps tenodesis or transfer in young athletes.
Materials and Methods
This study received institutional review board approval. The authors conducted a retrospective review of patients who underwent biceps tenodesis or transfer surgery with a minimum follow-up of 24 months. All procedures were performed by 1 of the 3 fellowship-trained sports medicine orthopedic surgeons (D.W.A., S.J.O., J.S.D.). Eligible patients were identified with Current Procedural Terminology25 billing codes for biceps tenodesis (29828 and 23430), and further chart review was used to include only patients between 14 and 35 years who actively participated in sports. To limit potential confounding surgical factors, patients who had concomitant rotator cuff repair or adhesive capsulitis were excluded. However, patients who underwent biceps transfer or a combination of SLAP repair and biceps tenodesis were included.
The study included 2 procedure groups because 1 of the 3 operating surgeons performed exclusively soft tissue to soft tissue subdeltoid biceps transfers, whereas the other 2 surgeons performed only tendon to bone subpectoral biceps tenodesis. The biceps transfer procedure is an arthroscopic technique in which the long head of the biceps tendon is transferred to the anterior lateral conjoint tendon.26 This form of tenodesis allows for soft tissue healing and reproduces the natural pull of the biceps tendon as well as the “bungee” effect of the BLC complex.
The screening process identified 65 eligible patients who had undergone biceps tenodesis or transfer. Demographic data were recorded and operative notes were reviewed to identify secondary procedures performed with the biceps tenodesis or transfer, such as SLAP repair. Eligible patients were contacted for consent to participate in the study and were asked to complete a questionnaire on patient-reported, shoulder-specific outcome measure scores (Kerlan-Jobe Orthopaedic Clinic [KJOC], Disabilities of the Arm, Shoulder and Hand [DASH]-Sports, Conway-Jobe, Single Assessment Numeric Evaluation [SANE], and Numeric Rating Scale [NRS] pain). For the KJOC, a higher score indicates greater disability. For the other instruments, a lower score indicates greater disability. The questionnaire also addressed surgical history, preoperative sport participation, postoperative sport participation, satisfaction with surgery, and level of return to play. Patients who underwent bilateral procedures were asked to complete the survey twice to include both shoulders.
Descriptive statistics were reported, with mean and standard deviation for continuous outcomes and frequency for categorical outcomes. Comparisons of mean outcomes for biceps tenodesis and transfer were performed with t tests. Statistical significance was defined by an alpha level of 0.05. All analyses were performed with Stata software, version 14 (StataCorp LLC).
Of the 65 patients who were identified initially, 39 (60%) successfully completed the follow-up survey, for a total of 41 shoulders (2 patients underwent bilateral treatment). Patient age at the time of surgery ranged from 15 to 34 years, with a mean age of 21.3 years. Of the study participants, 13 were female and 28 were male (Table 1). Of the 41 procedures performed, 28 (68%) involved the dominant shoulder. In addition, 5 patients (12%) required revision surgery.
Mean follow-up time for this study was 52±28 months, ranging from 21 months to 149 months. Patients returned to sport after 39 of the 41 procedures (95%), and only 1 patient who underwent bilateral surgery (counted as 2 procedures) did not return. At the time of the survey, patients reported playing their respective sports for a mean of 14.5±6 years. Preoperatively, the highest level of play achieved included professional (n=4), collegiate (n=17), high school (n=16), middle school (n=2), competitive adult (n=1), and recreational (n=1). Postoperatively, the highest level of play achieved included professional (n=4), collegiate (n=14), high school (n=11), and recreational (n=10) (Table 2). Of those who returned to play, 26 of 39 (67%) returned to their preoperative level or higher. Of the 15 who did not return or returned at a lower level, 7 (47%) did so for reasons other than their shoulder.
Preoperative Versus Postoperative Level of Play
Evaluation of patient-reported outcome measures showed that patients reported a mean KJOC score of 71.7±26.4, a mean DASH-Sports score of 21.3±30.9, a mean SANE score of 79.4±24.2, and a mean NRS pain score of 1.8±2.5. According to the Conway-Jobe classification, 20 (49%) patients reported excellent treatment results, 10 (24%) reported good treatment results, and 5 (12%) reported fair treatment results, whereas 6 (15%) reported poor treatment results (Table 3).
Patient-Reported Outcome Measures of Subgroups and Overall Sample
Athletes Playing Overhead Versus Non-Overhead Throwing Sports
The study cohort included 26 athletes playing overhead throwing sports and 15 playing non-overhead throwing sports. All (100%) athletes playing overhead throwing sports and 87% of those playing non-overhead throwing sports returned to play after surgery. Of those who returned to play, 65% of athletes who played overhead throwing sports and 69% of those who played non-overhead throwing sports returned to their preoperative level of play. Athletes playing overhead throwing sports had a mean SANE score of 77±3, KJOC score of 66.8±29, DASH-Sports score of 24.5±33, and NRS pain score of 1.9±2.7. For those playing non-overhead throwing sports, these values were 83±23 for SANE, 80.3±18.0 for KJOC, 15.8±26.4 for DASH-Sports, and 1.6±2.2 for NRS pain score. Additionally, 69% of athletes playing overhead throwing sports and 80% of those playing non-overhead throwing sports reported excellent or good satisfaction with the treatment results. These differences were not statistically significant (P>.05).
Baseball was the most common primary sport, reported by 15 (37%) patients; followed by lacrosse, with 4 (10%) patients; and then basketball, golf, softball, tennis, and swimming, with 3 (7%) patients each. A total of 26 (63%) patients played overhead throwing sports (Table 4). All baseball players reportedly returned to play, with 80% returning to their preoperative level of play or higher.
Primary Sports of Participants
Biceps Tenodesis Versus Transfer
This study included 24 (59%) biceps transfer and 17 (41%) biceps tenodesis procedures. Although no patients who underwent biceps transfer had concomitant SLAP repair, 5 of the 17 (29%) patients who underwent biceps tenodesis procedures also underwent SLAP repair. The 5 SLAP repairs were performed with biceps tenodesis if the superior labral tissue was unstable after the biceps was detached to prevent bucket handling and propagation of the labral tear. Patients who underwent biceps tenodesis had a return to play rate of 100%, whereas those who underwent biceps transfer had a return rate of 92%. In addition, 53% of those who underwent tenodesis and 73% of those who underwent transfer returned to their preoperative level of play. All patient-reported outcome measure scores were statistically improved for patients who underwent biceps transfer compared with biceps tenodesis (P<.05). Additionally, 59% of patients who underwent biceps tenodesis and 83% of those who underwent biceps transfer reported satisfaction with the results of treatment as excellent or good; however, this difference was not statistically significant (P=.12).
This study found a high overall rate of return to play, with nearly all patients returning to their original sport. Most returned to the same level of play or higher. Most patient-reported outcome measure scores were better for patients who underwent biceps transfer. However, both procedures had similar reports of excellent or good results. Although athletes who play overhead throwing sports may have additional strain as a result of overhead throwing movements, comparisons with athletes who played non-overhead throwing sports did not show significantly worse outcomes.
Few studies have evaluated return to play after biceps tenodesis compared with SLAP repair, although the few existing studies suggest promising results. Ek et al22 found no difference in American Shoulder and Elbow Surgeons score between patients undergoing SLAP repair and those undergoing biceps tenodesis but did find that patients undergoing biceps tenodesis had a return to play rate of 73% compared with a lower rate of 60% for those undergoing SLAP. Griffin et al24 evaluated return to play rates among patients younger than 25 years who underwent biceps tenodesis and found that 67% returned, with 73% of those returning to their pre-operative level of play. In the current study, the return to play rate was 95%, with 63% returning to their preoperative level of play or higher. Additionally, 73% of patients reported excellent or good satisfaction with the results of treatment. The high return to play rate in these patients suggests that biceps relocation procedures such as tenodesis and transfer may have successful functional outcomes, even in younger athletes.
In the study by Griffin et al,24 athletes playing overhead throwing sports had a return to play rate of 76%, with no apparent difference in patient-reported outcome measure scores compared with those playing non-overhead throwing sports. The current study also found no significant differences between these groups of athletes, despite the increased strain placed on the BLC by overhead activities, such as throwing. In the current study, every patient whose sport involved overhead throwing returned to play after biceps tenodesis; however, only 17 (65%) returned to their preoperative level or higher. Of the 9 who returned to a lower level of play, 5 (56%) reported that their shoulder injury was the reason for the decrease.
Baseball was the most frequently played sport in this study cohort (37%), and all baseball players returned to play. In addition, 80% of them returned to their preoperative level of play or higher. Chalmers et al27 found that professional baseball players who underwent isolated biceps tenodesis had a return to play rate of 44%, whereas those who underwent concomitant biceps tenodesis and labral repair had a return rate of only 25%. In the current study, 9 patients underwent simultaneous biceps tenodesis and labral repair. All reported returning to play, but only 22% returned to the same level of play or higher. Any differences in findings could be related to the inclusion of fewer professional-level athletes in the current study.
The biceps tenodesis and biceps transfer groups also showed differences in outcomes. The biceps transfer group generally reported statistically better patient-reported outcome measure scores than the biceps tenodesis group. A possible explanation for this discrepancy is the difference in postoperative rehabilitation protocols for these procedures. After biceps transfer, the patient is encouraged to perform active and active-assisted range of motion movements, with no specific restrictions on flexion at the elbow, whereas the biceps tenodesis group typically has a restriction on active elbow flexion. Another possible reason why the biceps transfer group had better patient-reported outcome measure scores is that biceps transfer involves only soft tissue and does not require a drill hole of any size to be placed in the humerus. Finally, differing diagnoses may have played a role in the different patient-reported outcome measure scores between the 2 groups. In the current study, most patients in the biceps tenodesis subgroup were diagnosed with labral tears. However, only a few in the biceps transfer group were diagnosed with labral tears, and most of the diagnoses involved creasing at the labral insertion and biceps tendinitis or chondromalacia.
Of the 5 patients who underwent revision surgery, 3 were in the biceps tenodesis group and 2 were in the biceps transfer group. Of the revision procedures, 3 involved debridement or removal of painful scar tissue, and all 3 patients returned to their preoperative level of play. The other 2 patients, 1 in the biceps tenodesis group and 1 in the biceps transfer group, underwent revision biceps tenodesis and SLAP repair because of a repeat injury multiple years after retirement from competitive play.
This study had limitations. Of the 3 surgeons, 1 performed subdeltoid biceps transfer and the other 2 performed sub-pectoral biceps tenodesis. Although both are types of biceps relocation procedures, the fact that the surgeons were split in their preferred operative methods limits the external validity of the results. A second limitation was poor recall as a result of the retrospective nature of this study, although return to play is a relatively clear self-reported outcome. The current study would have been stronger if data collection had been prospective rather than retrospective. Further, because the authors focused primarily on isolated biceps tenodesis procedures for BLC injury, they excluded patients who underwent common concomitant procedures, such as rotator cuff repair. Although these restrictions were necessary for the purposes of this study, they limited the number of patients who were eligible. Larger, prospective, multicenter studies are needed to further validate outcomes for successful return to play after procedures involving relocation of the long head of the biceps, such as tenodesis and transfer.
Previously, biceps tenodesis was used primarily for older patients with BLC injury, but this case series showed that biceps tenodesis or transfer can be an effective surgical treatment option for younger athletes. Nearly all of the patients who participated in this study successfully returned to their primary sport after biceps tenodesis or transfer, and more than half returned to their preoperative level of play or higher. Patient-reported outcome measures showed relatively high functional outcomes as well, particularly for patients undergoing biceps transfer, and scores were not significantly different between athletes who played overhead throwing vs non-overhead throwing sports. All athletes who played overhead throwing sports returned to play, with 65% returning to their previous level or higher. These findings suggest that biceps tenodesis or transfer may be a reliable option for athletes with BLC injuries.
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| Female||13 (31.7%)|
| Male||28 (68.3%)|
|Type of surgery|
| Transfer||24 (58.5%)|
| Tenodesis||17 (41.5%)|
| Right||26 (63.4%)|
| Left||15 (36.6%)|
|Total time playing sport at time of survey, y|
| 1–5||4 (11.8%)|
| 6–10||7 (20.6%)|
| 11–15||8 (23.5%)|
| 16–20||13 (38.2%)|
| 21–25||2 (5.9%)|
Preoperative Versus Postoperative Level of Play
|Level of play||No.|
Patient-Reported Outcome Measures of Subgroups and Overall Sample
|Patient-reported outcome measure||Mean||P||Mean||P||Total|
|Overhead||Non-overhead||Biceps tenodesis||Biceps transfer|
Primary Sports of Participants
|Overhead throwing sports|
| Baseball||15 (36.6%)|
| Softball||3 (7.3%)|
| Basketball||3 (7.3%)|
| Tennis||3 (7.3%)|
| Volleyball||1 (2.4%)|
| Beach volleyball||1 (2.4%)|
|Non-overhead throwing sports|
| Wrestling||2 (4.9%)|
| Crew||2 (4.9%)|
| Golf||3 (7.3%)|
| Swimming||3 (7.3%)|
| Lacrosse||4 (9.8%)|
| Football||1 (2.4%)|