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Relieve pain or improve function? Tenodesis should be selected on the basis of demand

This study concludes that both arthroscopic intertubercular groove and suprapectoral tenodesis combined with rotator cuff repair effectively treat small supraspinatus tears with long head of biceps tendon lesions, though the choice between techniques should be guided by patient-specific demands given the early functional advantages of the intertubercular approach and the distinct pathological characteristics of the tendon zones.

Original authors: Yue Geng, Xusheng Bo, Jiangtao Gao, Zhihua Wang, Ye Tian, Yi Zheng, Zhuangdai Zhang, Jiangtao Dong

Published 2026-07-02

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CC BY 4.0

Original authors: Yue Geng, Xusheng Bo, Jiangtao Gao, Zhihua Wang, Ye Tian, Yi Zheng, Zhuangdai Zhang, Jiangtao Dong

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine your shoulder is a complex pulley system, like the rigging on a sailboat. One of the most important ropes in this system is the long head of the biceps tendon (LHBT). Sometimes, this rope gets frayed, inflamed, or damaged, causing pain and making it hard to lift your arm. Often, this happens at the same time the main sail (the rotator cuff) gets a small tear.

When surgeons fix the torn sail, they also have to deal with the damaged rope. The big question is: Where should we re-attach the rope to stop the pain and get the arm working again?

This study compares two different ways to re-attach that rope:

The "Intertubercular Groove" (IT) Method: This is like re-tying the rope in its original, natural groove on the bone. It's a quicker, simpler job.
The "Supraopectoral" (ST) Method: This is like moving the rope attachment point further down the bone, past the "transverse humeral ligament" (a little strap holding the rope). This allows the surgeon to cut away a longer, more damaged section of the rope before re-tying it.

The Experiment

The researchers looked at 139 patients who had small tears in their main shoulder cable (rotator cuff) and a damaged biceps rope. Half got the "IT" fix, and half got the "ST" fix. They followed them for two years, checking their pain levels, how well they could move their arms, and even looking at tiny samples of the cut rope under a microscope.

What They Found

1. Both methods work great in the long run.
By the end of the two-year follow-up, almost everyone felt much better. Their pain went down, and they could lift their arms higher. Whether you chose the "IT" method or the "ST" method, the final result was a happy, functional shoulder.

2. The "ST" method is better at killing pain early on.
Think of the damaged rope as a frayed, splintered stick.

The IT method ties the rope up high, but it might leave a little bit of that "splintered" part behind.
The ST method cuts off a longer piece of the rope, removing almost all the damaged, inflamed tissue.

Because the ST method removes more of the "bad stuff," patients in this group reported less pain at the 6-month mark compared to the IT group. It's like removing the entire rotten section of a tree branch versus just trimming the very tip; the former stops the rot from hurting you sooner.

3. The "IT" method helps you get moving sooner.
While the ST group had less pain, the IT group seemed to regain their strength and range of motion a bit faster in the early months.

The IT method is less invasive (smaller cut, less disturbance to the front of the shoulder).
The ST method, while thorough, involves more work in the front of the shoulder, which can cause some temporary stiffness or discomfort that slows down the "getting moving" phase slightly.

4. The Microscope Mystery: Where is the damage?
The researchers cut the removed rope into three sections to look at them under a microscope:

Zone 1 & 2 (The top parts): These sections were full of inflammation, degeneration, and "pain signals" (chemical markers). They were the most damaged.
Zone 3 (The bottom part): This section was surprisingly healthy and clean.

This confirms that the "bad stuff" is concentrated in the upper parts of the rope (inside the joint and under the ligament strap). This explains why the ST method (which cuts off the top two zones) is so good at stopping pain—it removes the "hot zone" of inflammation.

The Bottom Line: It Depends on Your Goal

The study concludes that there is no single "perfect" surgery. It depends on what the patient needs most:

If your main goal is to stop the pain as quickly as possible: The ST (Supraopectoral) method is likely the better choice because it removes the most damaged tissue.
If your main goal is to get your arm moving and functioning as fast as possible: The IT (Intertubercular Groove) method might be the better choice because it is less invasive and allows for quicker functional recovery.

In short: Both methods fix the shoulder, but they take different paths. One path clears out the damage more thoroughly (better for pain), while the other path is less disruptive to the surrounding area (better for quick movement). The surgeon should pick the path based on what the patient needs most.

Technical Summary: Intertubercular vs. Suprapectoral Tenodesis for Small Rotator Cuff Tears with LHBT Lesions

Problem Statement
Long head of biceps tendon (LHBT) lesions frequently co-occur with rotator cuff tears (RCT), particularly supraspinatus tendon tears, contributing to anterior shoulder pain and dysfunction. While arthroscopic rotator cuff repair (RCR) combined with biceps tenodesis is a standard treatment, the optimal fixation location remains debated. The two primary techniques are Intertubercular Groove Tenodesis (IT), which is technically simpler but may leave residual pathological tissue, and Suprapectoral Tenodesis (ST), which allows for more extensive resection of the pathological tendon but carries higher surgical complexity and potential risks. Previous literature has yielded conflicting results regarding pain relief and functional outcomes, and there is a paucity of data quantifying regional histologic differences within the LHBT to guide surgical selection based on patient-specific needs (pain relief vs. functional restoration).

Methodology
This retrospective cohort study analyzed 139 patients (75 in the IT group, 64 in the ST group) who underwent arthroscopic RCR combined with either IT or ST for small-sized supraspinatus tendon tears (<1 cm) complicated by LHBT lesions. Inclusion criteria strictly limited the cohort to isolated small RCTs and LHBT lesions to minimize confounding variables from concomitant injuries.

Surgical Technique: All procedures were performed by a single senior surgeon. IT involved fixation at the upper portion of the transverse humeral ligament (THL), while ST involved fixation at the upper edge of the suprapectoral region, allowing for resection of the tendon proximal to the pectoralis major insertion.
Clinical Evaluation: Patients were followed for a minimum of 24 months. Outcomes were assessed using the Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CMS), University of California at Los Angeles (UCLA), and Simple Shoulder Test (SST) scores, alongside active range of motion (flexion and abduction). MRI was used to evaluate rotator cuff healing (Sugaya classification).
Histopathological Analysis: A subset of 10 resected LHBT specimens was analyzed. Tendons were sectioned into three zones: Zone 1 (intra-articular), Zone 2 (THL-covered), and Zone 3 (upper edge of suprapectoral). Sections were stained with H&E for Bonar scoring and subjected to immunohistochemistry for Substance P (SP), Calcitonin Gene-Related Peptide (CGRP), and Matrix Metalloproteinase-13 (MMP-13) to quantify pathological changes and degeneration markers.

Key Results

Clinical Outcomes: Both groups demonstrated significant improvements in all clinical scores and range of motion from preoperative to 24-month follow-up ( $P < 0.001$ $P < 0.001$ ).
- Pain Relief: At 6 months postoperative, the ST group showed significantly lower VAS scores (better pain relief) compared to the IT group ( $P = 0.039$ ).
- Functional Recovery: The IT group demonstrated earlier functional gains. The UCLA score in the IT group improved significantly by 3 months ( $P = 0.01$ ), whereas the ST group showed significant improvements in SST and active abduction between 6 and 12 months. By 24 months, there were no statistically significant differences in final functional scores or range of motion between the two groups, although the ST group's ASES score was slightly higher at the final follow-up.
Complications and Healing: MRI confirmed well-healed rotator cuffs in all patients (94.2% Sugaya Type I-II). No cases of Popeye deformity, fracture, or neurovascular injury were reported in either group.
Histopathology: The Bonar scores and specific variables (tenocytes, ground substance, collagen, vascularity) were significantly higher in Zone 1 and Zone 2 compared to Zone 3 ( $P < 0.05$ ). Immunohistochemical analysis revealed significantly higher positive cell counts for SP, CGRP, and MMP-13 in Zones 1 and 2 compared to Zone 3 ( $P < 0.05$ ), indicating that the most severe inflammation and degeneration occur in the intra-articular and THL-covered regions.

Key Contributions

Regional Pathology Quantification: The study provides histological evidence that LHBT pathology is not uniform; the intra-articular and THL-covered zones (Zones 1 and 2) exhibit significantly higher inflammation and degeneration markers than the suprapectoral zone (Zone 3).
Differentiated Surgical Indications: The data suggests a divergence in early postoperative trajectories: ST offers superior early pain relief (likely due to complete resection of the highly pathological proximal tissue), while IT offers potential advantages in early functional recovery.
Long-term Equivalence: The study confirms that despite different early recovery profiles, both techniques yield comparable long-term functional outcomes and healing rates at 24 months for small RCTs.

Significance and Claims
The authors conclude that both IT and ST combined with RCR are effective treatments for small supraspinatus tears with LHBT lesions. The significance of the study lies in its recommendation to select the surgical technique based on the patient's primary demand:

For patients prioritizing pain relief, particularly in the early postoperative period, Suprapectoral Tenodesis (ST) is suggested as the preferred option due to the complete removal of the highly pathological tissue identified in Zones 1 and 2.
For patients prioritizing functional improvement and range of motion, Intertubercular Groove Tenodesis (IT) may be advantageous, showing earlier functional gains, though long-term outcomes are equivalent.

The paper emphasizes that while pain does not significantly impede rehabilitation, the choice of technique should align with the patient's specific goals, acknowledging that ST involves a more extensive resection of pathological tissue which correlates with the observed histological findings. The authors note limitations including the retrospective nature of the study and the relatively short follow-up period compared to the need for 5-year data, but assert that the 24-month window covers the critical rehabilitation transition period.

The Experiment

What They Found

The Bottom Line: It Depends on Your Goal

Technical Summary: Intertubercular vs. Suprapectoral Tenodesis for Small Rotator Cuff Tears with LHBT Lesions

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