Without a clear understanding of the functional role for the long head of the biceps tendon, treatment recommendations have remained the subject of controversy. Some investigators have suggested that the tendon has only a vestigial function; others believe that it may play a critical role in shoulder stability. More recently, previously accepted theories of the function of the long head of the biceps tendon have been re-examined because of increased awareness of the significance of a retained symptomatic tendon. This tendon can be an important source of shoulder pain and disability when not specifically addressed, and functional consequences more negative than loss of the tendon are likely. Disorders affecting the long head of the biceps tendon can be classified as inflammatory, instability related, or traumatic, on the basis of the original initiating event. However, because of the close association of biceps tendon lesions with other abnormalities, a thorough evaluation of the shoulder is essential. Our surgical approach has been to employ arthroscopy, with special emphasis on discovering and treating any associated disorders. A decision on appropriate surgical management for the long head of the biceps tendon is made at the time of arthroscopy. Tenotomy or tenodesis is recommended for irreversible structural changes in the tendon, such as significant atrophy or hypertrophy, partial tearing greater than 25% of the width of the tendon, any luxation of the tendon from the groove, and for certain disorders of the biceps origin. Tenodesis is preferred for the younger patient. An acceptable alternative in the older patient is tenotomy without tenodesis. It should be emphasized that routine tenotomy or tenodesis is not recommended.