Editorial Commentary: Failure Following Biceps Long Head Tenodesis Includes Popeye Sign, Cramping, and Tendon Migration

The long head of the biceps tendon (LHBT) is often referred to as a “pain generator” around the shoulder, and tenodesis of the LHBT is a commonly used surgical method for treating pathologies of the tendon. Current literature indicates that tenodesis of the LHBT can lead to reduced pain, improved shoulder function, and a low failure rate. However, the definition of failure following LHBT tenodesis varies. Clinically, postoperative cramping is generally considered a sign of treatment failure, while the appearance of a Popeye sign is usually regarded as a mechanical failure. In addition, recent research shows increased migration of the tenodesed biceps tendon is associated with inferior clinical outcome. While some degree of tendon migration can occur as a physiological response to the shortening of the muscle-tendon unit, excessive migration may be caused by loosening at the tendon-implant interface or suture cut-through. This can lead to painful cramping or weakness in the shoulder. The findings explain why some patients experience cramping or pain in the bicipital groove after LHBT tenodesis, even in the absence of a Popeye sign. When evaluating biomechanical studies, it is essential to consider not only the ultimate load failure but also the elongation that occurs with cyclic loading. Biomechanical study shows cyclic displacement was greater in both all-suture anchor and all-suture button groups versus interference screw fixation. If this results in clinical tendon migration, these fixation methods might result in inferior outcome, illustrating the importance of cyclic loading.