Musculoskeletal
Gregory D. Bello, Jr., DO
Resident
University of Louisville
Jeffersonville, Indiana, United States
Alexandra Jensen, DO
Physician
U of L Frazier Rehab
Louisvilled, Kentucky, United States
Tyler Lindsey, BS
Medical Student
Idaho College of Osteopathic Medicine
Louisville, Kentucky, United States
Gregory d. Bello, Jr., DO
University of Louisville
Jeffersonville, Indiana, United States
Biceps tenodesis is an established orthopedic surgical treatment for long head of the biceps tendon pathology. Reported failure rates are low, typically under 2%, yet complications such as fixation loss, persistent anterior shoulder pain, or recurrent tendon rupture remain clinically relevant. Symptomatic failed tenodesis is uncommon but important, as it may leave orthopedic surgeons with management challenges given altered anatomy of the retracted muscle, scar tissue formation, and limited options for revision fixation. We report 3 patient cases of painful recurrent biceps symptoms following failed biceps tenodesis to highlight a therapeutic option in the form of botulinum toxin A (BoNT-A) injection to the biceps brachii.
Case Description:
We report three patients with persistent symptomatic biceps pain after failed surgical management. A 52-year-old female experienced severe spasms following failed revision subpectoral biceps tenodesis, with BoNT-A reducing pain from 10/10 to 6/10. A 52-year-old male developed painful “Popeye” deformity after shoulder arthroplasty with failed tenodesis but showed no benefit from BoNT-A. A 69-year-old female who sustained a proximal humerus fracture and underwent reverse shoulder arthroplasty without tenodesis given retracted nature of tendon had marked improvement, with bicep pain decreasing from 8/10 to 2/10.
Discussions:
Failed biceps tenodesis can present with persistent pain, cramping, or deformity that is challenging to manage surgically. Our cases demonstrate variable response to BoNT-A, with some patients achieving meaningful relief and others deriving no benefit. These findings suggest BoNT-A may be a selective adjunct in refractory biceps pain.
Conclusions:
BoNT-A may provide significant pain relief for selected patients with failed biceps tenodesis or rupture, though outcomes are inconsistent. Further study is warranted to define patient factors predicting response and to establish its role as an adjunct in managing refractory postoperative biceps pain.
