November 11, 2025

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Maxwell C. Park, MD, and colleagues have defined the anterior cable and noted the anterior supraspinatus accounts for 70% of the muscle’s cross-sectional area, despite a similar tendon cross-sectional area to the posterior supraspinatus.

This relationship between the tendon and muscle accounts for nearly 300% more stress, force transmission and strain anteriorly. This region can withstand such stress as the superior capsule is tightly bonded to the anterior tendon cord of the supraspinatus, which shares the same attachment on the supraspinatus. This confluence has been termed the anterior cable. It provides superior stability and a functional fulcrum to the shoulder, transmitting and dissipating force through the rotator cuff in much the same way as a suspension bridge. The anterior cable is a keystone of the greater tuberosity as it supports a large contractile force through a relatively small anterior footprint.

Figure 1. An arthroscopic view of the right shoulder from the lateral portal, beach chair position, showing an anterior L-shaped rotator cuff tear with the supraspinatus tendon retracted to the glenoid rim, infraspinatus retracted posteriorly and biceps tendon exposed (LHBT, long head of biceps tendon; GT, greater tuberosity; SS, supraspinatus; IS, infraspinatus).

Source: Cory Meixner, MD; Gregory L. Cvetanovich, MD; Julie Y. Bishop, MD; and Surena Namdari, MD

Tears of the anterior cable can lead to L-shaped rotator cuff tears with increased tendon retraction, fatty degeneration, higher retear rates and posterior/superior humeral head translation (Figure 1). As such, these are tears that the senior authors of this article are more apt to recommend surgery to fix despite the MOON Shoulder Group showing efficacy of physical therapy for full-thickness degenerative rotator cuff tears.

Gregory Colbath, MD, MS, and colleagues demonstrated that the long head of the biceps tendon (LHBT) has tendon-derived stem cells regardless of inflammation status, supporting its use as a biologic anterior cable reconstruction or, essentially, a biological superior capsular reconstruction based on where the biceps is rerouted, when available. Moreover, Park and colleagues found it to be as effective as semitendinosus allograft in limiting superior translation of the humeral head without impairing glenohumeral kinematics.

The senior authors of this article utilize this technique when there is a disruption to the anterior cable, the LHBT is present and there is an intact or reparable subscapularis. This procedure is most often performed in the setting of preserved preoperative overhead elevation with a chief complaint of pain being the indication for surgery. If the infraspinatus is not repairable to the biceps (in a margin convergence fashion), the authors of this article consider augmentation through a traditional superior capsular reconstruction, interpositional graft or a lower trapezius transfer. It is also possible to incorporate the LHBT into a repair of the supraspinatus when there is concern that the tendon quality could negatively impact healing.

Surgical technique

Patients can be positioned per surgeon preference for arthroscopic rotator cuff repair — either beach chair or lateral decubitus — after induction of general anesthesia combined with or without an interscalene block. The procedure is performed using the same standard rotator cuff repair portals. Diagnostic arthroscopy is first performed with a 30 arthroscope through a standard posterior viewing portal and anterior working portal. The intra-articular portion of the LHBT is examined. The arthroscope is moved to the subacromial space through the posterior portal and a bursectomy is performed via a lateral portal, which can then be utilized as the viewing portal. An anterolateral portal is made posterior to the bicipital groove and serves as the primary working portal. Evaluation of rotator cuff retraction and degeneration is performed with a tendon grasper. The retracted supraspinatus and infraspinatus tendons are mobilized. The footprint is exposed and decorticated with an arthroscopic shaver. An additional incision is made off the lateral border of the acromion for suture anchor insertion and suture management after localizing with a spinal needle.

There are several methods to mobilize the biceps, which are shown in the video portion. To access the bicipital sheath, the arm is placed in abduction and external rotation, and a thorough anterolateral bursectomy is performed to expose the bicipital groove. The lateral border of the biceps sheath is opened with electrocautery, allowing centralization of the LHBT — moving it out of the groove to reach the desired location on the greater tuberosity footprint. Once the biceps is out of the groove, remaining adhesions can be released for complete tendon mobility.

Figure 2. An arthroscopic view of the right shoulder from the lateral portal with the patient in the beach chair position is shown. The anterolateral portal serves as the working portal. The long head of the biceps is tagged with two suture tapes with a luggage-tag technique using a suture lasso or self-retrieving suture passer (LHBT, long head of biceps tendon; GT, greater tuberosity).

Source: Cory Meixner, MD; Gregory L. Cvetanovich, MD; Julie Y. Bishop, MD; and Surena Namdari, MD

Two suture tapes with a loop are then passed around the LHBT with a luggage-tag technique, and then each suture tail is passed back through the biceps with a suture lasso or a self-retrieving suture passer (Figure 2).

The authors of this article believe leaving the biceps intact once moved out of the groove is acceptable as it does not appear to be a pain generator or restrict motion after surgery. However, there is a need for studies to evaluate this further. Alternatively, the video shows that a biceps tenotomy can be performed maintaining the attachment on the glenoid and ensuring enough length for the tendon to be moved posteriorly and reach the desired position on the supraspinatus footprint. If this approach is taken, a mini-open subpectoral biceps tenodesis with the tendon that remains attached to the biceps muscle will typically be performed at the conclusion of the surgery.

Figure 3. An arthroscopic view of the right shoulder from the posterior portal, beach chair position, showing the anterior cable reconstruction prior to rotator cuff repair, with the biceps fixed using an independent suture anchor. Maintain arm in 30° of abduction/external rotation to avoid over-constraint. In the image, the greater tuberosity has not been fully prepared for the rotator cuff repair (LHBT, long head of biceps tendon; GT, greater tuberosity; HH, humeral head).

Source: Cory Meixner, MD; Gregory L. Cvetanovich, MD; Julie Y. Bishop, MD; and Surena Namdari, MD

Importantly, the arm is maintained at 30° of abduction and external rotation to limit over-constraint when determining the best position to secure the biceps to the footprint (Figure 3). The suture tapes can then be loaded into a suture anchor, which is placed at the predetermined position on the footprint. Typically, the anchor will be placed in a lateral position on the footprint to allow tendon compression over the prepared bone bed. Once this step is complete, the rotator cuff can be repaired in the manner the tear type necessitates. Margin convergence is performed between the repaired rotator cuff and biceps tendon with side-to-side sutures, employing a loop-around technique for the biceps for a strong margin convergence construct.

A slightly different construct to centralize the biceps places anchors on the footprint, one posterior and one anterior to the rerouted biceps. This construct has been described as a biceps transposition for a biological superior capsular reconstruction. A double pulley is created by taking one suture from each anchor around the biceps and a limb passed through the rotator cuff (typically the superior edge of the infraspinatus) and then tying these limbs in a margin convergence fashion. The sutures from the medial anchors that are through the remaining rotator cuff can then be tied and taken to a lateral row anchor, if possible, thus completing the repair (Figure 4).

Figure 4. An arthroscopic view of the right shoulder from the lateral portal, beach chair position, showing the completed rotator cuff repair with anterior cable reconstruction (ACR, anterior cable reconstruction; GT, greater tuberosity; IS, infraspinatus).

Source: Cory Meixner, MD; Gregory L. Cvetanovich, MD; Julie Y. Bishop, MD; and Surena Namdari, MD

The morphology of the rotator cuff tear will truly dictate the repair method and incorporate the remaining rotator cuff. Sometimes, a lateral row may not be possible and only a margin convergence to the rerouted biceps is feasible.

Rehabilitation

Postoperative restrictions and rehabilitation are similar to standard rotator cuff repair protocols and, in these cases, typically utilize a larger/massive repair protocol that starts between 2 and 6 weeks postoperatively.

Patients utilize an abduction brace for 6 weeks and start with passive motion, progressing to active assisted motion and then active motion per protocol. Typically, strengthening will begin at 3 months postoperatively.

For more information:

Julie Y. Bishop, MD**, and Gregory L. Cvetanovich, MD****,** can be reached at the department of orthopedic surgery and sports medicine and the Sports Medicine Research Institute at The Ohio State University Wexner Medical Center in Columbus, Ohio.** Cory Meixner, MD,** can be reached at Community Health Network in Westfield, Indiana.** ****Surena Namdari, MD, **can be reached at the shoulder and elbow division at Rothman Orthopaedics in Philadelphia. Bishop’s email: julie.bishop@osumc.edu. Cvetanovich’s email: gregory.cvetanovich@osumc.edu. Meixner’s email: cmeixner@ecommunity.com. Namdari’s email: surena.namdari@rothmanortho.com.

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