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SLAP and Biceps Pathology

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Superior labral (SLAP) tears and disorders of the long head of biceps — assessment and treatment.

Updated Aug 2026
Illustration of a baseball pitcher mid-throw, wincing with pain in the throwing shoulder.
SLAP and biceps-anchor problems often cause deep shoulder pain during overhead throwing and other overhead activity. Kieran Hirpara 4.0

What you're feeling

You may feel a deep ache in the front of your shoulder. This pain often sits right where the long head of the biceps tendon attaches to the top of your shoulder socket. Because SLAP lesions can mimic other issues, you might also feel a sense of instability or catching in the joint. The pain can sometimes radiate down your arm.

Certain movements tend to make the discomfort worse. You might notice sharp pain when you lift your arm above your head, such as reaching for a high shelf or placing a bag in the boot of your car. Overhead activities like throwing a ball or swimming put extra stress on the injured area. You may also feel pain when you rotate your arm outward, like when you are putting on a jacket or reaching into a back pocket.

The pain often flares up after you have been active. You might feel stiff and sore the morning after a day of heavy lifting or sports. Nighttime pain is common, especially if you roll onto the affected side. This can disrupt your sleep and leave you feeling tired. Simple daily tasks can become difficult. You might struggle to lift a heavy grocery bag or pour water from a tall jug.

It is important to know that clinical tests alone cannot confirm this diagnosis. Your surgeon will look at your full history and symptoms. If you have pain in the front of the shoulder, your surgeon may check for other issues like calcific tendinitis, which involves calcium deposits in the tendon. Sometimes, a SLAP lesion occurs alongside other problems, such as a pulley lesion, though this combination is relatively rare.

Your surgeon will discuss the best path forward with you. For some patients, particularly younger active individuals, biceps tenodesis may be a reliable option. This procedure involves reattaching the biceps tendon to the upper arm bone. It can provide improved functional results and may allow for an earlier return to activity compared to repairing the labrum directly. We will tailor the treatment plan to your specific needs and activity levels.

What's actually happening

Your shoulder joint relies on a ring of cartilage called the labrum to keep the ball of your upper arm bone seated securely in the socket. Think of this labrum as a shock absorber or a gasket that seals the joint. The long head of your biceps tendon attaches directly to the top of this ring. When you have a SLAP lesion, that attachment point is damaged or torn. This disrupts the stability of your shoulder and puts extra strain on the biceps tendon.

This injury often causes pain and a feeling of instability. You might notice that your shoulder muscles do not fire in the usual order. Your body may try to compensate by activating other muscles, like the serratus anterior, earlier than normal. This is your body’s way of trying to protect the joint from further movement or injury. Because of these changes, your shoulder may feel weak or unsteady, especially when you lift your arm or rotate it.

The symptoms can be tricky to pinpoint. A SLAP lesion can mimic other shoulder problems, such as impingement or general wear-and-tear arthritis. This is because the pain signals travel through similar pathways. In some cases, the tear is subtle and does not significantly change how the joint moves during passive motion. However, it still creates increased tension on the biceps tendon and alters how the joint loads weight. This ongoing strain can lead to further irritation or damage if left untreated.

Understanding what is happening helps explain why simple rest may not be enough. The mechanical issue at the anchor point needs to be addressed to restore normal function. Your surgeon will assess the specific nature of the tear and your activity level to determine the best path forward. Whether that involves repairing the labrum or reattaching the biceps tendon elsewhere, the goal is to relieve the tension and restore stability to your shoulder joint.

What we can do about it

The approach Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, takes in our clinic focuses on a clear path from simple care to advanced options. Patients reach our clinic by GP or physiotherapist referral. A clinic assessment (history, examination, and imaging where needed) establishes the diagnosis. For degenerative or long-standing problems we usually try non-operative care — activity change, physiotherapy or hand therapy, splinting, and injections — and consider surgery when that has not given enough improvement. For structural or acute problems, surgery may be recommended straight away, without a preceding non-operative trial.

We start with self-management and physiotherapy. You can try changing activities to avoid painful overhead movements. Physiotherapy aims to strengthen the muscles around your shoulder to support the joint. This helps reduce strain on the torn labrum and biceps tendon. We recommend giving this approach a fair chance before moving to other treatments. Treatment decisions for SLAP lesions are driven primarily by the presence of pain, your overhead activity level, and prior non-operative management. A clinical prediction model consisting of variables describing patient characteristics, specific symptoms, and the type of non-operative treatment modalities utilized was found to predict failure of non-operative management of SLAP tears with moderate accuracy. This means some patients may need more than just exercise to find relief.

If pain persists, we discuss medical management. This may include pain medication and anti-inflammatories to help you manage discomfort. Injections can also be considered. Cortisone injections reduce inflammation and can provide relief for a limited time. Hyaluronic acid injections may help lubricate the joint. Platelet-rich plasma (PRP) injections use your own blood components to promote healing. The effect of these injections varies, but they are often used to buy time for physiotherapy to work or to avoid surgery. Non-operative treatment with an appropriate regimen provided satisfactory clinical outcomes in middle-aged patients with symptomatic SLAP lesions and should be considered before recommending operative treatment.

Surgery is considered when conservative care has reached its limit. This means you have tried rest, therapy, and injections without getting enough improvement. A decision to operate on a shoulder for a suspected SLAP lesion should not be made on the basis of clinical assessment tests alone. We look at your overall picture, including your age and activity goals. If surgery is needed, we discuss the best option for you. For active patients under 30, primary biceps tenodesis provides improved functional results in active patients under 30 when compared to SLAP repair at minimum 2 year follow-up. For others, arthroscopic repair or biceps tenodesis may be suitable. Biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears. We make the decision individually with you, weighing the specific advantages and disadvantages of each path.

What to expect

Your outlook depends on the specific type of tear and your age. For active patients under 30, biceps tenodesis (relocating the biceps tendon) often provides better long-term function than SLAP repair (reattaching the torn cartilage). In competitive overhead athletes, 81% return to their previous level of play at an average of 4.1 months postoperatively after subpectoral biceps tenodesis for symptomatic SLAP tear.

If you are middle-aged or over 40, biceps tenodesis is a reliable option. It provides satisfactory outcomes for the treatment of Type II and Type IV SLAP lesions in middle-aged patients. The procedure significantly decreases pain and increases shoulder function. Over the past 10 years, the total number of biceps tenodeses has increased, whereas the number and relative percentage of SLAP repairs within the practice have decreased.

Female patients who underwent surgical treatment of SLAP lesions with SLAP repair or biceps tenodesis show comparable minimum two-year results with respect to level of function, self-reported pain, and ability to return to sports after these procedures. Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up.

If left alone, symptoms may persist. Risk factors for revision surgery after SLAP repair include age greater than 40 years, female sex, obesity, smoking, and diagnosis of biceps tendinitis or long head of the biceps tearing. Your surgeon will discuss which path fits your lifestyle and goals.

When to see someone

Ask for a specialist review if you have persistent shoulder pain that does not improve with rest. Seek care if you notice weakness, instability, or a feeling of locking or giving way. Symptoms that interfere with sleep or work also warrant evaluation. Sudden worsening of pain is another clear sign. Note that SLAP lesions may mimic other issues like impingement or rotator cuff problems. Therefore, clinical assessment tests alone are not enough to confirm a diagnosis. Your surgeon will look at the full picture to decide if surgery, such as biceps tenodesis, is right for you.

Reviewed by AI synthesis (v2) — pending human review · 18 May 2026.

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For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

Overview

  • Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions [1].
  • Biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears [4].
  • SLAP repairs are generally favored in younger, active patients [6].
  • Treating the biceps is preferred in lower-demand patients aged >30 years [6].
  • Biceps tenodesis has been increasingly used for the management of SLAP lesions [7].
  • Recent studies report high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes with biceps tenodesis in carefully selected athletes [7].
  • SLAP repair and biceps tenodesis both present viable treatment options but come with specific advantages and disadvantages [8].
  • The decision between SLAP repair and biceps tenodesis is ultimately made individually with the patient [8].
  • Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the long head of the biceps tendon provides significant improvement in shoulder outcomes [9].
  • Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the long head of the biceps tendon provides a reliable return to activity level with low risk for complications [9].
  • Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up [10].
  • Treatment of proximal biceps pathology is largely based on expert opinion and patient preferences rather than robust randomized evidence [20].
  • Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment [24].
  • Primary biceps tenodesis has lower costs than primary SLAP repair [24].
  • The indications and technique of biceps tenodesis in the elite pitcher still need to be defined [26].
  • High-demand patients with biceps tendonitis in the setting of a SLAP lesion with labral instability who undergo combined tenodesis and labral repair have significantly worse outcomes than patients who undergo either isolated labral repair for type II SLAP tears or isolated biceps tenodesis for a SLAP tear and biceps tendonitis [44].

Anatomy & Pathophysiology

  • Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of patients with shoulder pathology [12].
  • In the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity [17].
  • Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions [28].
  • In vivo studies have not yet established the stabilizing effect of the long head of the biceps on the glenohumeral joint [28].
  • The physiologic load required for the long head of the biceps to stabilize the glenohumeral joint remains unknown [28].
  • The long head of the biceps has a pertinent biomechanical role in glenohumeral stability regardless of the condition of the superior labrum [32].
  • Validity for strength testing of the serratus anterior muscle is optimal with subjects in a seated position and the shoulder flexed at 90° in the scapular plane [33].
  • Treatment of scapular dyskinesis is directed at managing underlying causes and restoring normal scapular muscle activation patterns by kinetic chain–based rehabilitation protocols [35].
  • Both proposed superior labral reconstruction techniques increased the force needed for humeral head superior migration in the setting of a labral tear [36].
  • The long head of the biceps tendon serves as a source of local autograft with biological and biomechanical properties that aid outcomes of complex primary and revision shoulder surgery procedures [40].
  • Potential prognostic variables associated with final subscapularis strength remain elusive [42].
  • The ultimate load to failure and stiffness for unicortical button fixation and the compared method in proximal subpectoral biceps tenodesis were not different [43].

Classification

  • Arthroscopic repair and biceps tenotomy/tenodesis both provide benefits for type II SLAP lesions [1].
  • Calcific tendinitis of the long head of the biceps brachii at its origin may be associated with a concurrent SLAP lesion [2].
  • A positive subpectoral biceps test is associated with gross pathologic changes of the biceps in 93% of patients [3].
  • Biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair for type II and IV SLAP tears [4].
  • Biceps tenodesis yields consistent and reliable results for operative treatment in overhead athletes, whereas return to play after SLAP repair can be unpredictable [5].
  • SLAP repair and biceps tenodesis are both viable treatment options with specific advantages and disadvantages, with the decision made individually with the patient [8].
  • Appropriate treatment for biceps pathology, whether conservative or surgical, should be based on established pathology [11].
  • There is no single pattern of pain that distinguishes biceps conditions from other shoulder abnormalities [16].
  • In the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues rather than a single entity [17].
  • Biceps tenodesis may be considered a valid primary or revision surgery for symptomatic type II SLAP tears due to no detrimental effect on glenohumeral stability [21].
  • Biceps tenodesis remains a reliable treatment for pathologic abnormality of the long head of the biceps [50].

Clinical Presentation

  • A positive subpectoral biceps test was associated with gross pathologic changes of the biceps in 93% of patients [3].
  • There is no single pattern of pain that distinguishes biceps conditions from other shoulder abnormalities [16].
  • In the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity [17].
  • Diagnosis of long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology can be challenging due to limitations in MRI and arthroscopic visualization [22].
  • Surgeons should maintain a high level of suspicion and utilize specific techniques to prevent missing pathology when diagnosing long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology [22].
  • The concomitant presence of SLAP and pulley lesions is significantly rare, occurring in only about 10% of all patients with SLAP and pulley lesions [25].
  • If calcific tendinitis of the long head of the biceps brachii at its origin is suspected, it may be helpful to consider the presence of a concurrent SLAP lesion and its management [2].
  • A 10.1% incidence of subsequent surgery after isolated SLAP repair was identified, often related to an additional diagnosis [14].
  • Clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions [14].

Investigations

  • A positive subpectoral biceps test was associated with gross pathologic changes of the biceps in 93% of patients [3].
  • There is no single pattern of pain that distinguishes biceps conditions from other shoulder abnormalities [16].
  • Biceps tendon pain in the absence of tears is associated with microscopic changes consistent with tendinopathy, which are often missed by MRI [46].
  • MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes in patients with chronic long head biceps tendinopathy undergoing open subpectoral tenodesis [19].
  • Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders [47].
  • Bicipital groove morphology measured by MRI has no correlation to intra-articular biceps tendon pathology [48].
  • Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with a systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies [51].
  • Diagnosis of long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology can be challenging due to limitations in MRI and arthroscopic visualization [22].
  • In approximately 80% of intra-articular biceps tears evaluated, a 'hidden lesion' was observed going beyond the bicipital groove and extending to the distal extra-articular portion [55].
  • The myotendinous junction (MTJ) of the biceps begins further proximal than may be appreciated intraoperatively [56].
  • If calcific tendinitis of the long head of the biceps brachii at its origin is suspected, it may be helpful to consider the presence of a concurrent SLAP lesion [2].
  • Clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions, as there is a 10.1% incidence of subsequent surgery after isolated SLAP repair often related to an additional diagnosis [14].

Treatment

Operative Management: SLAP Repair vs. Biceps Tenodesis/Tenotomy

  • Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions [1].
  • Biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears [4].
  • For operative treatment, biceps tenodesis has consistent and reliable results, whereas return to play after SLAP repair can be unpredictable [5].
  • SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years [6].
  • Biceps tenodesis has been increasingly used for the management of SLAP lesions, with recent studies reporting high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes in carefully selected athletes [7].
  • SLAP repair and biceps tenodesis both present viable treatment options but come with specific advantages and disadvantages, with the decision ultimately made individually with the patient [8].
  • Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair [13].
  • Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair [24].
  • The treatment option of biceps tenodesis is an appealing alternative to SLAP repair, but the indications and technique of biceps tenodesis in the elite pitcher still need to be defined [26].

Biceps Tenodesis vs. Tenotomy

  • Treatment of proximal biceps pathology is largely based on expert opinion and patient preferences rather than robust randomized evidence [20].
  • Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes [23].
  • Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis [49].

Subpectoral Biceps Tenodesis Outcomes

  • Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the LHBT provides significant improvement in shoulder outcomes with a reliable return to activity level with low risk for complications [9].
  • Short-term follow-up of 20 procedures has not shown any failure of fixation or residual biceps discomfort [15].
  • Subpectoral biceps tenodesis utilizing a dual suture anchor technique is a treatment option for SLAP lesions, partial thickness tears, subluxation, and tenosynovitis of the long head of the biceps with high rates of postoperative patient satisfaction, a low failure rate, and improved outcome scores [31].
  • Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up [10].
  • Although revision to subpectoral biceps tenodesis may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized [54].

Nonoperative Management

  • Appropriate treatment for biceps pathology, whether conservative or surgical, should be based on established pathology [11].
  • Diagnosis and nonoperative management of long head of biceps tendon disorders are categorized as inflammation, instability, and rupture, requiring specific protocols [41].

Associated Pathology

  • If calcific tendinitis of the long head of the biceps brachii at its origin is suspected, it may be helpful to consider the presence of a concurrent SLAP lesion and its management [2].

Complications

  • A positive subpectoral biceps test was associated with gross pathologic changes of the biceps in 93% of patients [3].
  • The incidence of subsequent surgery after isolated arthroscopic SLAP repair is 10.1% [14].
  • Subsequent surgery after isolated SLAP repair is often related to an additional diagnosis [14].
  • Risk factors for revision surgery after SLAP repair include age >40 years [18].
  • Risk factors for revision surgery after SLAP repair include female sex [18].
  • Risk factors for revision surgery after SLAP repair include obesity [18].
  • Risk factors for revision surgery after SLAP repair include smoking [18].
  • Risk factors for revision surgery after SLAP repair include diagnosis of biceps tendinitis or long head of the biceps tearing [18].
  • Short-term follow-up of 20 procedures using an all-suture anchor fixation for subpectoral biceps tenodesis has not shown any failure of fixation [15].
  • Short-term follow-up of 20 procedures using an all-suture anchor fixation for subpectoral biceps tenodesis has not shown any residual biceps discomfort [15].
  • In patients with chronic long head biceps tendinopathy undergoing open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes [19].

Recovery

  • Arthroscopic repair and biceps tenotomy/tenodesis both provide benefits for type II SLAP lesions [1].
  • Biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair for type II and IV SLAP tears [4].
  • Biceps tenodesis yields consistent and reliable results for operative treatment in overhead athletes, whereas return to play after SLAP repair can be unpredictable [5].
  • Biceps tenodesis is increasingly used for SLAP lesions, with recent studies reporting high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes in carefully selected athletes [7].
  • SLAP repair and biceps tenodesis are both viable treatment options with specific advantages and disadvantages, with the decision made individually with the patient [8].
  • Primary subpectoral open biceps tenodesis for SLAP tears or long head of the biceps pathology provides significant improvement in shoulder outcomes, reliable return to activity level, and low risk for complications [9].
  • Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up [10].
  • Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair [13].
  • There is a 10.1% incidence of subsequent surgery after isolated SLAP repair, often related to an additional diagnosis [14].
  • Short-term follow-up of 20 procedures using an all-suture anchor fixation for subpectoral biceps tenodesis showed no failure of fixation or residual biceps discomfort [15].
  • Risk factors for revision surgery after SLAP repair include age >40 years, female sex, obesity, smoking, and diagnosis of biceps tendinitis or long head of the biceps tearing [18].
  • Biceps tenodesis may be considered a valid primary or revision surgery for symptomatic type II SLAP tears due to no detrimental effect on glenohumeral stability [21].
  • Superior clinical outcomes are seen in nonsmokers, those with only 1 tendon affected, and those who undergo tenotomy instead of tenodesis for a damaged long head of biceps tendon [58].

Key Evidence

  • [L1] Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions. [1] (10.1186/s13018-019-1096-y)
  • [L4] The authors conclude that if calcific tendinitis of the long head of the biceps brachii at its origin is suspected, it may be helpful to consider the presence of a concurrent SLAP lesion and its management. [2] (10.1007/s00167-007-0323-y)
  • [L3] A positive subpectoral biceps test was associated with gross pathologic changes of the biceps in 93% of patients. [3] (10.1016/j.arthro.2019.02.017)
  • [L4] Based on these results, biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears. [4] (10.1177/0363546514540273)
  • [L5] For operative treatment, biceps tenodesis has consistent and reliable results, whereas return to play after SLAP repair can be unpredictable. [5] (10.1016/j.csm.2015.08.009)
  • [L5] SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years. [6] (10.1016/j.jse.2024.09.040)
  • [L5] Biceps tenodesis has been increasingly used for the management of SLAP lesions, with recent studies reporting high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes in carefully selected athletes. [7] (10.5435/jaaos-d-21-01199)
  • [L5] SLAP repair and biceps tenodesis both present viable treatment options but come with specific advantages and disadvantages, with the decision ultimately made individually with the patient. [8] (10.1016/j.arthro.2019.02.026)
  • [L4] Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the LHBT provides significant improvement in shoulder outcomes with a reliable return to activity level with low risk for complications. [9] (10.1016/j.arthro.2019.06.035)
  • [L4] Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up. [10] (10.1177/0363546513520122)
  • [Paper] The article outlines that appropriate treatment for biceps pathology, whether conservative or surgical, should be based on established pathology. [11] (10.1016/j.csm.2009.12.003)
  • [L5] Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of the patient with shoulder pathology. [12] (10.5435/jaaos-d-15-00258)
  • [L3] Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair. [13] (10.1177/0363546514534939)
  • [L3] We identified a 10.1% incidence of subsequent surgery after isolated SLAP repair, often related to an additional diagnosis, suggesting that clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions. [14] (10.1016/j.arthro.2016.01.053)
  • [L5] Short-term follow-up of 20 procedures has not shown any failure of fixation or residual biceps discomfort. [15] (10.1007/s00167-014-3348-z)
  • [L5] There is no single pattern of pain that distinguishes biceps conditions from other shoulder abnormalities. [16] (10.1016/j.csm.2015.08.004)
  • [L4] In the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity. [17] (10.1016/j.jse.2008.05.044)
  • [L3] Risk factors for revision surgery after SLAP repair include age >40 years, female sex, obesity, smoking, and diagnosis of biceps tendinitis or long head of the biceps tearing. [18] (10.1177/0363546517691950)
  • [L4] In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes. [19] (10.1016/j.arthro.2018.01.021)
  • [L5] Treatment of proximal biceps pathology is largely based on expert opinion and patient preferences rather than robust randomized evidence. [20] (10.1097/corr.0000000000002448)
  • [L5] Biceps tenodesis may be considered a valid primary or revision surgery for patients suffering from symptomatic type II SLAP tears due to no detrimental effect on glenohumeral stability. [21] (10.1016/j.jse.2013.07.036)
  • [L5] Diagnosis of long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology can be challenging due to limitations in MRI and arthroscopic visualization; surgeons should maintain a high level of suspicion and utilize specific techniques to prevent missing pathology. [22] (10.1016/j.arthro.2017.09.005)
  • [L1] Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes. [23] (10.1016/j.jse.2020.11.012)
  • [L3] Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair. [24] (10.1016/j.arthro.2018.01.029)
  • [L4] The concomitant presence of SLAP and pulley lesions is significantly rare, occurring in only about 10% of all patients with SLAP and pulley lesions. [25] (10.1016/j.arthro.2011.01.005)
  • [L5] The treatment option of biceps tenodesis is an appealing alternative to SLAP repair, but the indications and technique of biceps tenodesis in the elite pitcher still need to be defined. [26] (10.1016/j.arthro.2018.01.001)
  • [L5] Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions, though in vivo studies have yet to establish this stabilizing effect and the physiologic load required remains unknown. [28] (10.1016/j.arthro.2010.10.014)
  • [L4] Subpectoral biceps tenodesis utilizing a dual suture anchor technique is a treatment option for SLAP lesions, partial thickness tears, subluxation, and tenosynovitis of the long head of the biceps with high rates of postoperative patient satisfaction, a low failure rate, and improved outcome scores. [31] (10.1007/s00402-017-2810-z)
  • [L5] The long head of the biceps has a pertinent biomechanical role in glenohumeral stability regardless of the condition of the superior labrum. [32] (10.1016/j.arthro.2025.05.022)
  • [L4] Validity for strength testing of the serratus anterior muscle is optimal with subjects in a seated position and the shoulder flexed at 90° in the scapular plane. [33] (10.1186/s12891-019-2741-7)
  • [L5] Treatment is directed at managing underlying causes and restoring normal scapular muscle activation patterns by kinetic chain–based rehabilitation protocols. [35] (10.5435/00124635-200303000-00008)
  • [L5] Both proposed superior labral reconstruction techniques increased the force needed for humeral head superior migration in the setting of a labral tear. [36] (10.1016/j.arthro.2018.08.049)
  • [L5] This review examines the role of the LHBT as a source of local autograft, with biological and biomechanical properties, in aiding outcomes of complex primary and revision shoulder surgery procedures. [40] (10.1016/j.jse.2023.04.009)
  • [L5] Diagnosis and nonoperative management of long head of biceps tendon disorders are categorized as inflammation, instability, and rupture, requiring specific protocols. [41] (10.1016/j.csm.2015.08.006)
  • [L4] Potential prognostic variables associated with final subscapularis strength remain elusive. [42] (10.1016/j.jse.2014.06.042)
  • [L5] The ultimate load to failure and stiffness for the two methods were not different. [43] (10.1007/s00167-013-2775-6)
  • [L3] High-demand patients with biceps tendonitis in the setting of a SLAP lesion with labral instability who undergo combined tenodesis and labral repair have significantly worse outcomes than patients who undergo either isolated labral repair for type II SLAP tears or isolated biceps tenodesis for a SLAP tear and biceps tendonitis. [44] (10.1007/s00167-015-3774-6)
  • [L5] Biceps tendon pain in the absence of tears is associated with microscopic changes consistent with tendinopathy, which are often missed by MRI. [46] (10.1016/j.csm.2015.08.002)
  • [L3] Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. [47] (10.1016/j.jse.2019.04.001)
  • [L1] We do not find any value in bicipital groove morphology measured by MRI as a predictor of biceps tendon or rotator cuff pathology at the time of surgery. [48] (10.1016/j.jse.2010.04.044)
  • [L4] Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis. [49] (10.1016/j.arthro.2016.04.022)
  • [L3] Biceps tenodesis remains a reliable treatment for pathologic abnormality of the long head of the biceps. [50] (10.1177/0363546515570024)
  • [L3] Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with the described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies. [51] (10.1016/j.arthro.2012.04.142)
  • [L4] Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. [54] (10.1177/0363546519892922)
  • [L4] In approximately 80% of the intra-articular biceps tears evaluated in this study, a 'hidden lesion' was observed going beyond the bicipital groove and extending to the distal extra-articular portion. [55] (10.1177/0363546514554193)
  • [L5] The MTJ of the biceps begins further proximal than may be appreciated intraoperatively. [56] (10.1177/0363546513482297)
  • [L4] Superior clinical outcomes are seen in nonsmokers, those with only 1 tendon affected, and those who undergo tenotomy instead of tenodesis for a damaged long head of biceps tendon. [58] (10.1016/j.jse.2019.12.011)

References

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Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.09.005 [23] Biceps tenodesis versus tenotomy: a systematic review and meta-analysis of level I randomized controlled trials. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.11.012 [24] Treatment for Symptomatic SLAP Tears in Middle‐Aged Patients Comparing Repair, Biceps Tenodesis, and Nonoperative Approaches: A Cost‐Effectiveness Analysis. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.01.029 [25] Is There an Association Between SLAP Lesions and Biceps Pulley Lesions?. Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.01.005 [26] Editorial Commentary: The Shoulder Biceps Tendon and Baseball Continue Their Controversial Relationship. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.01.001 [28] Anatomy, Function, Injuries, and Treatment of the Long Head of the Biceps Brachii Tendon. Arthroscopy. 2011. 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