Long Head of Biceps Tenodesis: Fixation Constructs and Tenodesis Level-A Narrative Review

Disorders of the long head of the biceps tendon (LHBT) are a common source of anterior shoulder pain and are frequently encountered in patients undergoing shoulder surgery. Biceps tenodesis has gained popularity because it addresses biceps-related symptoms while preserving muscle contour and function. This narrative review summarizes contemporary evidence on LHBT tenodesis, with particular emphasis on fixation constructs and tenodesis level, and integrates current evidence into a practical framework for surgical decision-making. A literature review was performed using PubMed/MEDLINE, Scopus, and Google Scholar, incorporating clinical studies, biomechanical investigations, systematic reviews, and meta-analyses evaluating tenodesis techniques, fixation methods, outcomes, and complications. Current evidence indicates that top-of-groove, suprapectoral, and subpectoral tenodesis can provide favorable pain and functional outcomes, with comparative clinical studies generally demonstrating limited clinically meaningful differences between levels. Subpectoral tenodesis may more completely address groove-related pathology but is associated with approach-specific risks, whereas biomechanical differences among interference screws, suture anchors, cortical buttons, and onlay constructs have not consistently translated into differences in clinical outcomes. Rehabilitation protocols vary considerably and are commonly influenced by concomitant procedures. The available evidence is limited by heterogeneous techniques and patient populations, relatively few randomized comparisons, and limited long-term follow-up. Accordingly, no single tenodesis level or fixation construct can currently be considered universally superior. Patient-specific factors, groove pathology, surgical context, and the strength and applicability of the available evidence should inform individualized surgical decision-making.