Preservation of the long head of the biceps tendon is a viable option in rotator cuff repair: a retrospective comparative study using Biceps Inflammation Section Integrity classification

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Clin Shoulder Elb. 2026;29(3):311-315

Publication date (electronic) : 2026 August 3

doi : https://doi.org/10.5397/cise.2025.01319

Stefano Gumina¹, Matteo Cantore¹, Marco Rionero¹, Alessandro Calistri², Vittorio Candela^,1

¹Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, Rome, Italy

²Department of Orthopaedics and Traumatology, Paideia International Hospital, Rome, Italy

Corresponding Author: Vittorio Candela Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome 00185, Italy Tel: +39-6-49-1672 Fax: +39-6-49-1703 E-mail: vittorio.candela@yahoo.it

Received 2025 November 16; Revised 2026 February 7; Accepted 2026 March 1.

Abstract

INTRODUCTION

Historically, the long head of the biceps tendon (LHBT) has been considered one of the main sources of shoulder pain in the context of shoulder pathology, as its structure is compromised in 36% to 88% of rotator cuff tears (RCTs), as well as in labral lesions and shoulder instability [1-4]. Several studies have hypothesized that there is a correlation between the severity of RCTs and LHBT inflammation and degeneration [4-6]. These alterations are thought to result from repetitive traction, friction, and rotational forces [7,8] exerted by the humeral head on the LHBT, ultimately leading to macroscopic and microscopic tendon changes [9].

Multiple prior studies support the idea that both tenotomy and tenodesis of the LHBT are highly effective in reducing pain and improving symptoms and active range of motion in patients with concomitant RCTs [3,10-13]. However, in recent years, a new school of thought has gained traction, emphasizing the importance of preserving the LHBT due to its stabilizing and depressing effect on the humeral head, as well as its potential role during arthroscopic rotator cuff repair (RCR) and shoulder stabilization [14,15]. A recent study suggests that in patients younger than 55 years with a posterosuperior medium-sized or smaller cuff tear, a healthy LHBT may safely be preserved [16]. Furthermore, a systematic review by the Francophone Arthroscopy Society reported that three-quarters of the included studies found no significant differences in outcomes between patients undergoing RCR alone and those undergoing RCR with concomitant tenotomy or tenodesis [17].

Despite these emerging findings, the decision to preserve or sacrifice the LHBT remains a matter of debate, as no clear consensus or objective criterion currently exists to determine whether the tendon should be considered expendable. Recently, the Biceps Inflammation Section Integrity (BISI) classification system was introduced to describe and quantify LHBT pathology in patients with concomitant RCT [6]. The BISI considers the presence of LHBT inflammation, section alteration and loss of integrity according to three intraarticular zones.

The aim of this study was to compare two groups of patients matched for age and RCT size who were treated with either tenotomy (±tenodesis) or debridement (shaver and radiofrequency) using a BISI score treatment algorithm. Our hypothesis was that no significant clinical differences would be found between the two groups.

METHODS

According to a written determination issued by the Institutional Review Board of Sapienza University of Rome (No. 127/2026), this retrospective observational study did not require prior Ethics Committee approval because it involved the analysis of anonymized clinical data collected during routine clinical practice without any additional intervention or deviation from standard clinical care. Written informed consent was obtained from all patients.

We performed a retrospective comparative study. Group I was initially composed of 86 patients aged between 60 and 70 years who were consecutively treated between January 2023 and June 2024 by the same surgeon (SG) for a type II (large) RCT according to the Southern California Orthopedic Institute (SCOI) [18] classification on the dominant arm. The diagnosis of RCT was established through physical examination, plain radiographs, and magnetic resonance imaging. Exclusion criteria for all patients included: primary moderate or severe osteoarthritis of the operated or contralateral shoulder, traumatic etiology of the RCT, previous shoulder surgery, history of shoulder dislocation, concomitant or previous frozen shoulder, inflammatory joint disease, and agenesis or prior tenotomy/tenodesis of the LHBT.

All surgeries were performed under general anesthesia combined with an interscalene block, with the patient positioned in the beach-chair position. The size of the RCT was confirmed intraoperatively according to the SCOI classification. RCTs were repaired in all cases using a single-row technique with two 5-mm double-loaded metal anchors. Before RCT repair, attention was focused on the LHBT. The LHBT was tenotomized (8 cases) only if dislocation or high-grade delamination (<50% residual tendon thickness; BISI score [6], 5–15) was present. In all other cases (BISI score <5; inflammation and/or delamination and/or flattening in one of the three portions), the LHBT underwent debridement and radiofrequency ablation to treat pathological signs.

Debridement was performed using a cross blade dual-edge cutter (Stryker), restoring the tendon to a cylindrical shape by removing irregularities such as villi and protruding laminae. Any remaining irregularities after motorized blade treatment were further smoothed with a 90-S radiofrequency ablation probe (Serfas, Stryker) applied tangentially to the LHBT, and the superficial hyperemic layer was ablated in areas exhibiting inflammation until its macroscopic disappearance (Fig. 1). At the 1-year follow-up, the Constant-Murley score [19] and visual analog scale (VAS; no pain=0, worst possible pain=10) were recorded, along with any complications. In cases of pain, the precise location of shoulder pain was documented according to dermatome distribution.

Fig. 1.

Right shoulder viewed from the posterior portal. (A, B) Long head biceps tendon (LHBT) with inflammation and delamination in zones A (tendon insertion) and C (bicipital groove); debridement is performed using a cross blade dual-edge cutter (C); a 90-S radiofrequency ablation probe applied tangentially to the LHBT eliminates irregularities and the superficial hyperemic layer (D, E); final LHBT appearance (F). G: glenoid, H: humeral head.

Clinical outcomes obtained in our patient cohort were compared to those of patients who underwent repair of a large RCT between January 2021 and December 2022 on the dominant arm associated with tenotomy (±tenodesis) for a BISI score < 5 (group II). Tenodesis was performed in active patients who were engaged in overhead sport activity despite advancing age. These latter patients were extracted from our database comprising patients who underwent RCT, with known demographic characteristics, intra-articular and subacromial pathoanatomical findings, and clinical outcomes (VAS and Constant-Murley scores at 3, 6, and 12 months postoperatively). The same exclusion and inclusion criteria were applied. All patients were treated by the same surgeon and submitted to the same postoperative protocol considering the severity of the RCT (type II according to the SCOI classification). Using the binary yes/no question “Are you satisfied with your shoulder surgery?” patients were categorized over time into two simple subgroups: satisfied and unsatisfied.

RESULTS

The final study group was composed of 75 patients in group I and 86 patients in group II (82 tenotomies and 4 tenodesis). Baseline characteristics are shown in Table 1. No difference was found between groups (P>0.05). At the 1-year follow-up, the mean Constant score obtained by patients in whom the LHBT was preserved (group I) and those who underwent tenotomy (± tenodesis) (group II) passed from 49 to 76 and from 50 to 78, respectively. No statistically significant differences were found between the two groups (P>0.05). Considering group II, no differences were found regarding the mean Constant score between patients submitted to tenotomy (n=82) and tenodesis (n=4)

Table 1.

Baseline characteristics of the two groups

The mean VAS was 2 (range, 0–3) in both groups. The relative strength deficit (mean score, 10/25; range 6–12) and a partial limitation in shoulder rotations (mean external rotation score, 7/10; range, 5–10; internal rotation score, 6/10; range, 4–8) represented the lowest values of the CS, in both groups. Considering group II, Popeye deformity was present in 20 (19 tenotomy; 1 tenodesis) out of 86 patients (23%). However, only 4 patients had cosmetic complaints. No patients in the present series complained about strength deficit or cramping pain. Seventy-nine percent and 81% (P>0.05) of patients with preserved or sacrificed LHBT, respectively, were satisfied with the outcomes of their surgical procedures.

DISCUSSION

The principal finding of the present study is that, within our series, no differences were observed in pain, functional outcomes, or patient-reported satisfaction among individuals within the same decade of life who underwent repair of large RCTs, regardless of whether the LHBT was preserved or sacrificed. This finding related to patient satisfaction is particularly relevant, as this outcome measure is not influenced by the primary confounding factor affecting clinical results, namely patient age [20].

This study is of practical importance because it suggests that preservation of the LHBT, when only mildly to moderately degenerated, does not result in inferior clinical outcomes compared to sacrifice. Furthermore, preservation of the LHBT is an additional treatment option for future surgeries, as its role in augmentation in cases of re-tear is expanding.

However, our findings leave some interpretive doubts regarding the genesis of shoulder pain in patients with a large RCT with LHBT exposure, given the possible presence of multiple pain generators. Boesmueller et al. [21] observed a cord-like fiber arrangement throughout the superior labrum with nociceptive fibers present in this region. Therefore, the presence and abundance of nociceptors suggests a significant association with pain generation from the biceps tendon. The tendon tract near the insertion should receive branches of the suprascapular nerve. However, the same authors noted a paucity of fibers in the middle third of the biceps, which usually corresponds to the most exposed area in large RCTs. They observed that the portion near the intertubercular groove would instead be richly innervated by branches from the musculocutaneous nerve.

Four possible hypotheses can be formulated to explain our results. (1) Exposure of the LHBT: a cuff tear exposes the LHBT, placing it in potential contact with the anteroinferior margin of the acromion. However, it is highly unlikely that the most exposed area of the bicipital tendon in cuff tears, but paradoxically less rich in nociceptors, could be the primary pain generator. If this hypothesis were correct, cuff repair should restore the covering of the bicipital tendon, protecting it from direct contact with the acromion, and debridement and thermoablation of the LHBT would be a useless practice. (2) Role of debridement and ablation: debridement with the cross blade, but especially RF ablation, which acts tangentially to the course of the LHBT, could destroy the nerve endings responsible for the pain [22]. (3) Limited role of the LHBT in the genesis of shoulder pain in patients with cuff tears: the pain of patients with cuff tears is primarily related to the cuff tear margins, which are composed of inflammatory tissue [23], subacromial bursitis, and synovitis [24]. If this is the case, LHBT tenotomy is both a traditional and useful practice, while debridement and thermal ablation of the LHBT would be useless. (4) Restoration of correct joint biomechanics: cuff repair alone would restore correct joint biomechanics to the shoulder, reducing the possibility that the LHBT could further degenerate and become inflamed again after debridement.

This study has limitations that need to be addressed. These include the short-term follow-up, the absence of structural healing assessment, and the fact that comparable outcomes may be attributable to differences in baseline tendon pathology rather than a true causal effect of the treatment strategy itself (tenotomy versus debridement).

CONCLUSIONS

Our findings demonstrate that LHBT preservation during RCR is a reasonable option in patients with large RCTs. Biceps status should be intraoperatively evaluated using the BISI classification, and tendon preservation is a valid option for mild to moderate degeneration (BISI <5). LHBT preservation may help maintain shoulder biomechanics and offer advantages for future revision surgeries. However, these findings should be interpreted within the context of a retrospective design and short-term follow-up.

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