Tenodesis is a surgical procedure in which a tendon is detached from its original anchor point and reattached to a new location, usually bone. The term comes from the Greek words for “tendon” and “binding,” and it is most commonly performed on the long head of the biceps tendon in the shoulder. But tenodesis is not limited to one body part. Surgeons use variations of this technique in the wrist, ankle, and knee, each with its own specific goals and trade-offs.
Why Surgeons Perform Tenodesis
The most frequent reason for tenodesis is a problem with the long head of the biceps tendon, the cord of tissue that runs from the top of the shoulder socket down through a bony groove in the upper arm. When this tendon becomes partially torn, inflamed, or unstable, it can cause deep shoulder pain that does not respond to rest, physical therapy, or injections. A systematic review of 39 studies found that the most common reasons surgeons performed biceps tenodesis were partial tearing of the tendon, instability, or inflammation of the tendon sheath.
Tenodesis is also commonly performed alongside rotator cuff repairs, since damage to the biceps tendon and rotator cuff often coexist. In those cases, the surgeon addresses both problems in a single operation. Another frequent scenario involves a specific type of injury to the labrum, the ring of cartilage around the shoulder socket. For tears at the biceps anchor in patients under 40, surgeons may repair the labral tear but still perform a tenodesis on the biceps tendon. In patients over 40, where labral tissue tends to be more worn and degenerative, tenodesis with debridement of the torn labrum is the dominant approach.
Tenodesis Versus Tenotomy
When the long head of the biceps tendon is damaged beyond repair in its current position, surgeons face a choice between two procedures: tenodesis (reattaching the tendon to a new point on the bone) or tenotomy (simply cutting the tendon and letting it retract). Both relieve pain effectively, and randomized trials have shown equivalent functional outcomes for both techniques. The practical differences show up in side effects and cosmetic results.
Tenotomy is quicker and technically simpler, but it carries a higher risk of the so-called Popeye deformity, a visible bulge in the lower arm caused by the biceps muscle bunching up after the tendon retracts. One large study found that about 20% of patients who had a tenotomy developed this deformity, compared to roughly 6% of those who had a tenodesis. Patients who developed the deformity also reported lower subjective satisfaction with their shoulder.
The downsides extend beyond appearance. A study comparing patient-reported outcomes found that about 59% of tenotomy patients reported at least one negative effect, versus 37% of tenodesis patients. Tenotomy patients were more than twice as likely to experience muscle spasms and cramping, and almost twice as likely to report ongoing shoulder pain. They were also more likely to report multiple problems at once.
These differences explain why surgeons tend to recommend tenodesis for younger, more active patients and those who care about arm appearance or strength. Tenotomy remains a reasonable choice for older or less active patients who want a simpler procedure with a shorter operating time. The decision often comes down to a conversation about cosmetic concerns, activity level, and tolerance for a slightly longer recovery.
Where on the Arm the Tendon Gets Reattached
Even once a surgeon has decided on tenodesis, there is a second decision to make: where exactly to fix the tendon. The two main options are suprapectoral (above the chest muscle, closer to the shoulder joint) and subpectoral (below the chest muscle, farther down the arm bone). Both approaches produce good clinical results, and the functional scores patients report afterward are similar.
The differences lie in the types of complications each location tends to produce. A systematic review of over 3,700 cases found that subpectoral tenodesis carried a higher rate of temporary nerve irritation, while suprapectoral tenodesis was more likely to cause persistent pain in the bicipital groove and Popeye deformity. A separate meta-analysis found a small statistical advantage for subpectoral tenodesis in one functional score, though the difference was not large enough to be meaningful in practice.
The choice between open and arthroscopic approaches adds another layer. In an open subpectoral tenodesis, the surgeon makes a small incision on the front of the arm and works directly on the bone. In an arthroscopic approach, the surgeon works through small portals near the shoulder joint using a camera. One study comparing these two approaches found that arthroscopic patients had shorter hospital stays, but open patients had less tenderness around the bicipital groove in the first three months after surgery. By the time patients were fully healed, the outcomes were comparable.
How the Tendon Is Fixed to Bone
Surgeons use several types of hardware to anchor the tendon to its new location. The two most common are interference screws (small screws that press the tendon into a bone tunnel) and suture anchors (devices embedded in bone with sutures that tie the tendon down). A biomechanical study comparing all-suture anchors to interference screws found that both had comparable strength in terms of how much force they could withstand before failing. The main difference was that suture anchors allowed slightly more movement under repeated loading, meaning the tendon could shift a bit more before the construct failed entirely.
A third option, sometimes called a bridge or soft-tissue tenodesis, secures the tendon using sutures passed through surrounding tissue rather than hardware drilled into bone. A review of over 1,500 shoulders found that soft-tissue fixation was associated with higher rates of new-onset pain and subjective weakness compared to implant-based fixation, but it also had a lower revision rate.
The fracture risk associated with drilling a hole in the arm bone is a question patients often ask about. A systematic review looking specifically at this found a cumulative fracture incidence of about 0.5% across nearly 700 tenodesis cases that reported complications. The overall non-fracture complication rate was around 13%, which includes things like persistent pain, stiffness, and cosmetic deformity.
Tenodesis Beyond the Shoulder
While biceps tenodesis dominates the conversation, the same basic principle of fixing a tendon to bone or rerouting it to stabilize a joint shows up in several other parts of the body.
Wrist and Hand
In the wrist, tenodesis is used to treat instability between two small bones called the scaphoid and lunate. When the ligament connecting these bones tears completely and cannot be repaired directly, surgeons can reroute a strip of tendon through the bones to act as a replacement stabilizer. A study of 203 patients who underwent this three-ligament tenodesis technique found that most reported meaningful improvements in both pain and function at one year, though about 20% of wrists did not improve.
Ankle
Chronic ankle instability, where the ankle repeatedly gives way despite bracing and physical therapy, is another area where tenodesis has been used. In these procedures, a tendon graft is threaded through bone tunnels in the fibula and heel bone to recreate the function of the damaged lateral ligaments. One advantage of using an allograft (donor tissue) for this is that the patient does not lose any of their own tendons, preserving the strength needed to turn the foot outward. However, a systematic review and meta-analysis found that tenodesis-style reconstructions of the ankle carried a higher complication risk compared to anatomic repair techniques, with roughly twice the odds of complications.
Knee
In younger patients with torn anterior cruciate ligaments, surgeons sometimes add a lateral extra-articular tenodesis alongside the standard ACL reconstruction. This additional procedure anchors a strip of tissue on the outer side of the knee to help control rotational instability. Long-term follow-up data in skeletally immature athletes who received this combination procedure showed that patient-reported outcome scores remained above acceptable thresholds at an average of 11 years, though more data is still needed to know whether the added tenodesis reduces the risk of post-traumatic arthritis in the long run.
What Happens Biologically After Surgery
When a tendon is fixed to bone, the body has to create a new attachment from scratch. This healing process unfolds in four phases: inflammation, proliferation, remodeling, and maturation. The early inflammatory phase clears damaged tissue and recruits repair cells. Proliferation fills the gap with new tissue. Remodeling and maturation gradually transform that tissue into something that resembles the original tendon-to-bone connection, though the process takes months and the repaired site may never fully replicate the original structure.
How the tendon is fixed affects how the biology plays out. A study in a rabbit model comparing bone tunnel fixation to cortical surface fixation found that both approaches developed early signs of the specialized transition zone (a fibrocartilage layer) that characterizes healthy tendon-bone junctions. However, minimal bonding was observed inside the bone tunnels, suggesting that the outer surface of the bone may be a more active site for biological healing. This finding has implications for hardware choices and technique refinements, since the biology of healing may favor certain fixation methods over others.
Recovery and Rehabilitation
After a biceps tenodesis, the repaired tendon needs protection while it heals to bone. The early weeks typically involve a sling and restricted movement, followed by a gradual progression through passive range of motion, active motion, strengthening, and eventually return to full activity. A case report detailing a progressive physiotherapy program for biceps tenodesis recovery emphasized that the rehabilitation is specifically tailored to the challenges of tendon-to-bone healing, with a focus on gradually increasing strength, range of motion, and functional capacity.
Most patients can expect meaningful improvement in pain and function. In patients 35 and younger, a systematic review found that postoperative functional scores were generally high at an average follow-up of about five years, with pain scores dropping substantially from preoperative levels. Return-to-sport rates varied widely depending on the type of athlete: overhead athletes (throwers, swimmers, tennis players) returned at lower rates than non-overhead athletes. For the overall group, return-to-sport rates ranged from 35% to 100% across the included studies, reflecting how much the outcome depends on the specific demands being placed on the shoulder.
Timing also matters when the tenodesis is being done to address a tendon that has already ruptured. A study of patients who underwent tenodesis more than three months after their biceps tendon ruptured found that 90% still had good to excellent outcomes, though two patients experienced a second rupture. All patients who had surgery within three months of rupture had good to excellent results with no re-ruptures, suggesting that earlier intervention may offer a slight edge.
Pain Management During and After Surgery
Shoulder surgery is notoriously painful in the first day or two, and adding a tenodesis to an arthroscopic shoulder procedure can increase discomfort because the fixation site is further from the joint than the structures addressed arthroscopically. A randomized controlled trial tested whether adding a specific nerve block targeting the chest wall (called a Pecs II block) to the standard nerve block used for shoulder surgery could improve pain control. Patients who received the additional block had significantly better pain relief after surgery and needed fewer opioids in the recovery room.
This finding is relevant for patients who want to discuss pain management options with their anesthesiologist before surgery. Nerve blocks are not mandatory, but they can meaningfully reduce the amount of narcotic medication needed in the first hours after the procedure.
How Surgeons Monitor the Repair Afterward
After a tenodesis, imaging is sometimes used to check that the tendon remains attached and is healing properly. MRI has traditionally been the standard, but ultrasound is emerging as a practical alternative. A case report evaluating a subpectoral biceps tenodesis at one year found that ultrasound accurately showed an empty bicipital groove (confirming the tendon had been moved), preserved tendon structure, and stable fixation at the subpectoral site. These findings matched what MRI showed, while offering the advantages of being cheaper, faster, and available at the bedside for real-time assessment.
For most patients with an uncomplicated recovery, routine imaging is not necessary. Imaging tends to be reserved for patients who have ongoing pain, new symptoms, or a concern about hardware failure. If your shoulder feels good and is progressing through rehabilitation on schedule, your surgeon is unlikely to order a scan just to check.
The Tenodesis Grasp in Spinal Cord Injury
The word “tenodesis” has a completely separate meaning in the world of spinal cord injury rehabilitation. People with certain levels of cervical spinal cord injury lose the ability to actively close their fingers, but they can still extend their wrist. When the wrist is pulled back into extension, the finger tendons on the palm side naturally tighten and the fingers curl inward. This passive closing of the hand is called a tenodesis grasp, and it allows people with quadriplegia to pick up and hold objects without any active finger movement.
The mechanics of this grasp have been studied in detail. Research on individuals with C6-level quadriplegia found that the grasp involves a characteristic sequence: the wrist flexes during the reaching phase, then extends during the grasping phase, with the whole movement taking longer than a normal grasp because the person must carefully position the wrist to engage the tendon mechanism. These findings have informed rehabilitation strategies, since therapists can train patients to maximize the effectiveness of this natural tendon action.
Reconstructive hand surgery can take this concept further. Surgeons can surgically tighten or reroute tendons in the hand and wrist of patients with spinal cord injuries to create a stronger, more reliable version of the tenodesis grasp, sometimes restoring enough hand function for daily tasks like eating, writing, and self-care. These single-stage reconstructions rely on a detailed understanding of how muscle, tendon, and joint mechanics interact when voluntary control is absent.