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SLAP and Biceps Pathology

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

107 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

For patients with SLAP III or IV lesions, the most commonly accepted approach is tenotomy or tenodesis of the long head of biceps tendon [1]. While SLAP repairs are generally favored in younger, active patients [10], primary biceps tenodesis provides improved functional results in active patients under 30 when compared to SLAP repair at minimum 2 year follow-up [4]. In patients under the age of 30 years with a symptomatic isolated SLAP tear, open subpectoral biceps tenodesis may be a reliable alternative to arthroscopic repair [2]. Conversely, treating the biceps is preferred in lower-demand patients aged >30 years [10]. Biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears [18]. In a young active population, biceps tenodesis may be a viable surgical alternative for type II SLAP lesions [13] and may facilitate earlier return to activity compared to repair [13].

Recent studies report high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes for biceps tenodesis in carefully selected athletes [11]. Patients undergoing arthroscopic suprapectoral biceps tenodesis for either SLAP tears or long head of biceps tendon abnormalities had similar outcome scores and complication rates compared with those undergoing open subpectoral biceps tenodesis [12]. Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the long head of biceps tendon provides significant improvement in shoulder outcomes, a reliable return to activity level, and carries a low risk for complications [29]. 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 [39].

Long-term data indicate that at the minimum 10-year follow-up, 40% of the military cohort younger than 35 years of age treated with SLAP repair experienced treatment failure and underwent subsequent revision to biceps tenodesis [8]. No revisions occurred in patients who underwent biceps tenodesis as the index procedure in the military cohort younger than 35 years of age at minimum 10-year follow-up [8]. Reoperation rates are higher for patients undergoing SLAP repair [147]. Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment [63] and offers lower costs than primary SLAP repair [63]. In patients aged ≤50 years with isolated SLAP tears, open biceps tenodesis provides cost savings over arthroscopic methods of treatment [45]. Although SLAP repair and biceps tenodesis both present viable treatment options [64], the decision between them is ultimately made individually with the patient [64]. Treatment of proximal biceps pathology is largely based on expert opinion and patient preferences rather than robust randomized evidence [46]. Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied [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 [146]. The indications and technique of biceps tenodesis in the elite pitcher still need to be defined [70].

Anatomy & Pathophysiology

Bony and Soft Tissue Anatomy

The long head of the biceps originates from the bicipital tubercle at the superior rim of the glenoid and along the posterior superior rim of the glenoid and labrum [31]. The short head originates from the coracoid tip, lateral to and in common with the coracobrachialis [31]. Insertion occurs laterally on the posterior part of the radial tuberosity and medially via an aponeurotic passage across and into the deep fascia of the volar forearm muscles [31]. The glenoid labrum consists of parallel collagen fibers coursing around the glenoid circumference [49]. The superior labrum inserts on the superior glenoid rim, medial to the articular cartilage margin, through a transitional zone of fibrocartilage [49]. A normal synovial recess exists between the meniscoid or triangular superior labrum and the articular cartilage extension over the superior glenoid rim [49]. While usually triangular, the superior labrum can exhibit a meniscoid shape and commonly attaches medial to the articular margin of the glenoid rim [50]. The inner portion of the labrum is avascular, with the superior labrum being less vascular than the inferior and posterior labrum [50]. The sub-supraspinatus recess is a definable anatomic entity typically measuring 5 mm to 10 mm in depth [106]. The posterosuperior labrum exhibits physiological motion (roll back) during glenohumeral motion, most pronounced in external rotation in abduction [106].

Biceps Tendon Anatomy and Vascularity

Of the biceps tendon, 40% to 60% attaches to the supraglenoid tubercle 5 mm medial to the superior glenoid rim, while the remainder attaches directly to the superior glenoid labrum [49]. The tendon typically attaches entirely (type I) or predominantly posterior (type II) on the superior labrum [49]. It is an intra-articular but extrasynovial structure within the glenohumeral joint [49]. Vascularity is provided primarily by the ascending branch of the anterior humeral circumflex artery, which travels within the bicipital groove [49]. An avascular zone exists at the proximal portion of the tendon, close to the superior glenoid [49]. The tendon passes through the bicipital (intertubercular) groove between the greater and lesser tuberosities [49]. Stability within this groove is afforded by the biceps sling (pulley), consisting of fibers from the subscapularis tendon, supraspinatus tendon, coracohumeral ligament, and superior glenohumeral ligament [49]. The long head of the biceps (LHB) tendon is innervated by thinly myelinated sensory neurons, with most innervation occurring at the LHB origin [50]. Blood supply also derives from the thoracoacromial and brachial arteries via the osteotendinous and musculotendinous junctions, respectively [50]. A hypovascular zone near the tendon origin at the superior glenoid attachment corresponds to where it commonly tears at the LHB pulley near the proximal groove [50]. The bicipital tendon does not move up and down in the groove; rather, the humerus moves down and up with adduction and abduction relative to the tendon [31]. The tendon is retained within the groove by a pulley made up of fibers from the coracohumeral and superior glenohumeral ligaments, with some reinforcement from adjacent tendons [31]. The tendon is sometimes divided into intra-articular and intratubercular portions, but the portions that are intracapsular or within the groove depend on the position of the arm [95]. With the arm in full abduction, 1.3 cm of the LHB tendon lies within the shoulder joint, increasing to 5 cm when the arm is adducted and externally rotated [95].

Anatomic Variants

Anatomic variants in the superior labrum include a sublabral foramen or absence of the superior labrum, often seen together with a cordlike middle glenohumeral ligament (MGHL) [50]. In a cohort of 73 shoulders, 3.3% had a sublabral foramen, 8.6% had a sublabral foramen with cordlike MGHL (Buford complex), and 1.5% had an absent anterosuperior labrum [50]. The superior labrum has a high degree of normal variation, typically either rounded or meniscoid, with the meniscal component overlying but not attached to the glenoid articular surface [100]. In one series, 49 of 191 patients demonstrated a mobile meniscoid type of superior labrum at arthroscopy and were treated with observation alone [100]. Only one of these patients became clinically symptomatic [100]. The sublabral recess represents a small potential space under the biceps anchor and the anterosuperior labrum, often present at the 12 o'clock position [100]. The Buford complex is a normal variant consisting of a cordlike MGHL that originates directly from the superior labrum at the base of the biceps tendon, resulting in an absence of anterosuperior labral tissue [100]. The sublabral foramen involves a cordlike MGHL that attaches directly to the anterosuperior labrum, creating a hole between the ligament and the glenoid [100]. Inappropriate surgical attachment of a cord-like MGHL to a void on the anterosuperior glenoid results in painful restriction of external rotation and elevation [100]. The incidence of the cordlike MGHL in isolation is 18%, which is more common than its combination with the Buford complex (1% to 2%) [100].

Biceps-Labral Complex Zones

The biceps-labral complex (BLC) consists of the superior glenoid labrum (SGL) and the long head of the biceps (LHB) tendon [96]. The BLC is classified into three distinct zones: Inside, Junction, and Extra-articular [50]. The Inside zone consists of the SGL and the LHB anchor, which is closely associated with the SGL [50]. The Junction zone includes the intra-articular portion of the LHB, as well as the stabilizing biceps pulley [50]. The LHB pulley is a capsuloligamentous complex comprising the superior glenohumeral ligament, the coracohumeral ligament, and fibers from the subscapularis and supraspinatus tendons [50]. The Extra-articular zone consists of the bicipital tunnel and is further divided into three zones: zone 1 (bony groove), zone 2 (“No Man’s Land”), and zone 3 (subpectoralis) [50]. Zone 1 and zone 2 of the bicipital tunnel contain synovial tissue, which may generate pain [50]. Zone 2 of the bicipital tunnel cannot be visualized by arthroscopy from above or with an open approach from below the zone [50].

Pathophysiology of SLAP Lesions

SLAP tears can be caused by forceful traction to the arm, direct compression loads, and repetitive overhead throwing [35]. Increased external rotation of the shoulder in the late cocking phase increases torsional force at the LHB root, resulting in a peel-back injury to the posterosuperior labrum [35]. Injuries can result from repetitive contact of the posterosuperior labrum with the undersurface of the rotator cuff in the late cocking phase, known as internal impingement [35]. SLAP tears are seen more frequently in the late cocking position, occurring because of an adaptive posterior capsular contracture [35]. Throwing athletes demonstrate increased shoulder external rotation and decreased internal rotation in abduction, which causes posterosuperior migration of the humeral head in the late cocking phase [35]. Increased external rotation results in greater torsional loads across the superior labrum from the more posteriorly oriented LHB tendon, causing the labrum and LHB tendon to displace medially over the glenoid rim [35]. The primary inciting event in the "peel-back" mechanism is a deficit of glenohumeral internal rotation secondary to scarring and contracture of the posterior and inferior capsule as a result of recurrent microtrauma of overhead activity [36]. Capsular restriction is associated with a posterior and superior shift of the humeral head during the cocking phase of throwing [36]. The shift in contact forces posterosuperiorly may lead to increased shear forces at the posterosuperior labrum [36]. With progressive labral separation, the biceps tendon assumes a more vertical and posterior angle in the cocking position, creating a "vicious cycle" that increases the torsional force on the posterosuperior labrum [36]. A cadaver study has shown that SLAP tears are more commonly created when the shoulder is forward flexed compared with when it is in an extended position [27]. Traction on the biceps tendon is capable of producing type-II SLAP lesions, and inferior subluxation significantly facilitates the generation of type-II SLAP lesions [27]. Superior labral complex lesions demonstrated 20% less strength in the late cocking phase than in the early deceleration phase [27]. SLAP tears may represent an adaptive process, because the peel-back of the SGL permits increased humeral external rotation needed to participate in overhead sporting activity [96]. The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage [116]. SLAP lesions lead to increased glenohumeral translation and concurrently LHB tension and load in at most anterior direction [164].

Pathophysiology of Biceps Tendon Instability

Pathology of the LHB tendon includes tendinitis, tendinopathy, tears, subluxation, entrapment, delamination, and dislocation out of the bicipital groove [35]. Because of the relatively anterior position of the bicipital groove along the humeral head combined with humeral retroversion, the tendon is exposed to medial instability, which can increase the risk of tendon degeneration [35]. Variations of bicipital groove morphology can also increase the risk of LHB tendon pathology [35]. Isolated LHB tendon pathology can occur but frequently is associated with other shoulder pathologies, especially rotator cuff pathology [35]. When seen in isolation, primary LHB tendinitis usually occurs in younger patients who participate in overhead activities such as volleyball and baseball [35]. With LHB tendon instability, the patient describes a clicking or snapping with overhead motions [35]. A subscapularis tear is associated with LHB medial instability and a supraspinatus tear is associated with posterolateral instability [35]. Bicipital instability is usually associated with rotator interval injury or subscapularis tendon injury, or both [56]. 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 [21]. Shoulder long head biceps tendon pathology is associated with increasing rotator cuff tear size [14]. Biceps tendinitis is rarely the primary cause of shoulder pain and is usually secondarily involved as a part of an impingement syndrome or degenerative lesions of the rotator cuff [56]. The proximal LHB tendon has been recognized as a source of substantial anterior shoulder pain [35]. This clinical entity can be difficult to diagnose because it is known to occur with other pathologies including SLAP lesions, rotator cuff disorders impingement, bursitis, and acromioclavicular joint disorders [35]. There is no single pattern of pain that distinguishes biceps conditions from other shoulder abnormalities [16]. No single physical examination finding is completely accurate for the diagnosis of a SLAP tear [20].

Biomechanical Function

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 [94]. The role of the biceps tendon on the static and dynamic stability of the shoulder is controversial [95]. Andrews noted a dynamic tensioning of the biceps-labral complex with electric stimulation of the biceps tendon [95]. The dynamic relationship between the biceps tendon and superior labral complex and their combined role in glenohumeral stability remains unclear [95]. The long head of the biceps is important in stabilizing the humeral head in the glenoid during powerful elbow flexion and forearm supination [95]. Severing the long head of the biceps tendon while both heads were tensed caused significant upward migration of the humeral head [95]. Both the long and short heads of the biceps function as anterior stabilizers of the glenohumeral joint with the arm in abduction and external rotation [95]. With increasing instability from sectioning of the inferior glenohumeral ligament, both heads of the biceps have an increased stabilizing function to resist anterior displacement of the humeral head [95]. The long head of the biceps has a pertinent biomechanical role in glenohumeral stability regardless of the condition of the superior labrum [117]. All 3 labral zones assessed in a study have important biomechanical contributions to biceps anchor displacement [129]. Loss of the long head attachment is manifested mainly as loss of supination strength (20%) with a smaller loss (8%) of elbow flexion strength [31]. Lucas reported a 20% loss of elevation strength in external rotation with rupture of the long head of the biceps [31]. In internal rotation, no loss of strength was evident following rupture of the long head of the biceps [31]. The long head of the biceps is hypertrophied in certain conditions, particularly when paralysis or rupture of the supraspinatus has occurred, probably because the patient is using the muscle as a depressor of the humeral head [31]. The long head of the biceps can act as a dynamic humeral head depressor [95]. The biceps can potentially act as a static humeral head depressor, preventing migration of the humeral head into the acromion with contraction of the deltoid [95]. The function of the biceps tendon as a humeral head depressor increased in the context of a chronic rotator cuff tear [95]. The long head of the biceps contributes to joint stability, which is increased in external rotation and decreased in internal rotation [31].

Classification

SLAP Lesion Classification

Snyder Classification: The Snyder classification is a reliable system for identifying SLAP lesions among experienced shoulder surgeons [102]. Type I lesions are defined as significant fraying [23]. Type II lesions are defined as complete detachment of the biceps tendon and superior labrum from the glenoid [23]. Type III lesions are defined as a "bucket-handle" tear of the superior labrum [23]. Type IV lesions are defined as a central superior labrum tear with extension into the biceps [23].

Management Implications: The management of type II lesions should include stabilization of the detached biceps tendon-superior labrum complex [81]. Suture repair of many type IV lesions is appropriate if there is extensive involvement of the superior labrum and biceps tendon [81]. Repair of type IV SLAP lesions can be anticipated to be successful provided no more than 30% of the biceps root is compromised by the injury [76]. Symptomatic type II SLAP lesions in patients aged < 40 yr with normal biceps tendons are an indication for the Double-Pulley Anatomic Technique for repair [15].

Biceps Tendon Disorder Classification

Long head of the biceps tendon disorders are classified into inflammatory, unstable, or traumatic categories based on the original initiating event [23]. This classification helps with the organization of pathogenesis and formulation of protocols for appropriate management [23].

Inflammatory Disorders: These include biceps tendinitis concurrent with rotator cuff disease and primary bicipital tendinitis [23].

Unstable Disorders: These include subluxation and dislocation [23]. Subluxation is classified into Type I (superior subluxation), Type II (unstable at proximal portion of groove), and Type III (subluxation following melanin or nonunion of lesser tuberosity) [23]. Dislocation is classified into Type I (extraarticular, combined with partial tear of subscapularis) and Type II (intraarticular, combined with full-thickness tear of subscapularis) [23].

Traumatic Disorders: These include traumatic rupture and superior labral tears (SLAP lesions) [23]. Traumatic rupture is classified into Type I (partial) and Type II (complete) [23].

Diagnostic Reliability and Concordance

Interobserver concordance for the Snyder classification was 85% for debridement, 70% for repair of labrum, and 59% for repair of labrum or biceps tenodesis [157]. The chance-corrected κ value for interobserver agreement on debridement was 0.75, indicating moderate agreement [157]. The chance-corrected κ value for interobserver agreement on repair of labrum was 0.68 [157]. The chance-corrected κ value for interobserver agreement on repair of labrum and/or biceps tenodesis was 0.32 [157]. Interobserver concordance for no treatment was 94.4%, with a κ value of 0.95 [157].

Other Considerations

The distinction between inflammatory, unstable, and traumatic biceps tendon disorders is not always clear, as degenerated and inflamed tendons are more prone to trauma and repeated trauma may result in changes indistinguishable from inflammation [23].

Clinical Presentation

History and Mechanism

The clinical history for SLAP tears varies between acute traumatic events and insidious overuse. Acute trauma, characterized by sudden traction or compression to the affected extremity, may be present, and SLAP tears can be associated with a previous subluxation or dislocation event [58]. Conversely, insidious onset is most common in overhead throwing athletes [58]. Symptomatic SLAP lesions secondary to overuse are most frequent in the dominant arm of young male high-performance overhead athletes [36]. Pain from a SLAP tear is often localized deep within the glenohumeral joint and can be associated with mechanical symptoms, fatigue, or a “dead arm” sensation during overhead activities [58]. In the presence of a concomitant paralabral cyst, pain may be associated with frank weakness of the rotator cuff [58].

Patients with biceps instability describe a clicking or snapping sensation with overhead motions [35]. The proximal long head of the biceps tendon is a recognized source of substantial anterior shoulder pain [35]. Clinical diagnosis of long head biceps tendon pathology is difficult because it occurs with other pathologies including SLAP lesions, rotator cuff disorders, impingement, bursitis, and acromioclavicular joint disorders [35]. In the context of rotator cuff disease, 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 [21]. Primary bicipital tendinitis usually occurs in younger patients who participate in overhead activities such as volleyball and baseball [35]. Pain and tenderness in biceps tendinitis are localized to the bicipital groove, and stressing the tendon via resisted elbow flexion and supination provokes pain [74].

A ruptured long head of the biceps tendon presents with a prominent lump in the front of the arm that becomes more prominent when the patient contracts the biceps against resistance [74]. Patients may present for the first time with a “lump” in the arm that is easily mistaken for a tumor [74]. Function is usually little disturbed by a ruptured long head of the biceps tendon, and treatment is unnecessary unless associated rotator cuff symptoms require attention [74]. Isolated traumatic tears of the long head of the biceps tendon are generally treated nonsurgically, with the rare exception of tenodesis for the dominant arm of a laborer or an individual who cannot tolerate deformity [112].

Physical Examination

Clinical diagnosis of a SLAP tear or symptomatic long head biceps tendinopathy is challenging because examination findings are similar to other pathologies within the glenohumeral joint [20, 110]. No single physical examination finding produces a consistently accurate SLAP tear diagnosis [20, 110]. Clinical examination alone has been shown to be unreliable in diagnosing SLAP tears when multiple physical examination tests have been compared with intraoperative findings [110]. The current literature and practice for making the SLAP diagnosis are variable and inconsistent [109]. Diagnosis of long head biceps tendon pathology remains challenging due to vague complaints and unreliable physical examination maneuvers [55].

Special Tests for SLAP Tears: The O’Brien active compression test is the most commonly used maneuver to evaluate for a possible SLAP tear [110]. It is positive if pain occurs deep within the shoulder in maximum internal rotation and improves with maximum external rotation [58]. The crank test is positive if pain, clicking, or catching is reproduced when axial force is applied to the extremity while the humerus is passively rotated at 160° elevation [58]. The biceps load I and II tests are positive if pain or apprehension worsens with resisted elbow flexion in 90° to 120° abduction and maximum external rotation [58]. The anterior slide test is positive if pain, a pop, or a click is reproduced when the patient resists an anterior and axial force applied to the elbow [58]. The dynamic labral shear test is positive if a reproducible painful click deep in the shoulder is characterized in the mid-arc of abduction while the arm is externally rotated and progressively abducted [58].

Special Tests for Biceps Pathology: The Speed test is positive if pain is experienced in the anterior shoulder or glenohumeral joint when resisting downward pressure at 90° elevation in full supination [58]. The Yergason test is positive if pain is experienced in the bicipital groove or glenohumeral joint when supinating against resistance with the elbow flexed to 90° [58]. Speed and Yergason tests demonstrate poor sensitivity, moderate specificity, and poor accuracy for detecting biceps pathology and SLAP lesions [58]. Both the Yergason and Speed tests are specific but not sensitive in detecting long head biceps tendinitis, rupture, and SLAP lesions [110]. Including two sensitive tests (active compression and crank tests) and a specific test (Speed test) increases the overall accuracy of diagnosis [58]. A decision to operate on a shoulder for a suspected SLAP lesion should not be made on the basis of provocative tests alone [38].

The 3-Pack Examination: The 3-pack examination consists of the active compression test, the throwing test, and bicipital tunnel palpation [110]. The 3-pack tests were highly sensitive (73% to 98%) for biceps-labrum complex disease [30]. A negative active compression test coupled with the absence of pain on bicipital tunnel palpation correlated with a negative predictive value of 93% to 96% for hidden extra-articular bicipital tunnel disease [110]. The active compression test was reported to have a sensitivity of 95.7% and tenderness to palpation 97.8% when assessing the ability of these physical examination techniques to detect bicipital tunnel pathology [110].

Inspection, Palpation, and General Findings: The most common physical examination finding for long head biceps pathology is tenderness caused by palpating the tendon within the bicipital groove [110]. A deformity of the long head biceps tendon such as a Popeye sign indicates tendon rupture [110]. A painful click or tenderness to palpation at full abduction and external rotation indicates medial long head biceps instability [110]. If the long head biceps tendon is dislocated, it can be rolled under the examiner’s fingers [110]. Isolated atrophy of the infraspinatus can indicate the presence of suprascapular neuropathy caused by a spinoglenoid cyst, which is often associated with a superior labral tear [110]. Range of motion and rotator cuff strength are usually preserved in patients with SLAP tears [110]. Overt instability in the setting of an isolated SLAP tear is rare [110]. Glenohumeral internal rotation deficit should be assessed in overhead athletes, as extreme deficits greater than 25° to 30° can predispose patients to internal impingement and SLAP tears [110]. A positive subpectoral biceps test was associated with gross pathologic changes of the biceps in 93% of patients [6].

Imaging and Diagnostic Confirmation

MRI is the imaging modality of choice for SLAP tears [58]. Diagnostic accuracy of MRI may be improved by positioning the arm in abduction and external rotation [58]. Magnetic resonance arthrography improves the diagnostic performance of MRI for the detection of a SLAP tear [58]. MRA helps diagnose long head biceps pathology and SLAP tears because it is more specific and more sensitive than MRI alone [20]. Diagnostic accuracy of MRI ranges widely in the literature, and overdiagnosis of SLAP tears is common as normal anatomy can be misconstrued as pathologic [58]. Accurate diagnosis of a SLAP tear is predicated on clinical examination and concordant MRI findings and cannot be confirmed until the time of surgery [58]. Definitive diagnosis of suspected SLAP tears is confirmed on arthroscopic examination [52].

Ultrasonography can be useful in the dynamic assessment of the biceps tendon [58]. 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 [5]. 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 [61]. Arthroscopic examination is limited to the intra-articular long head biceps tendon as well as the proximal groove, missing less common distal biceps groove lesions [112].

Investigations

Clinical Examination

A combined physical examination approach aids in the diagnosis of SLAP or long head of biceps (LHB) pathology [20]. Clinical diagnosis and physical examination of a SLAP tear or symptomatic LHB tendinopathy is often challenging because the findings are similar to other pathologies within the glenohumeral joint [20]. The 3-pack examination for biceps-labrum complex disease consists of the active compression test, throwing test, and bicipital tunnel palpation [30].

Imaging

Plain radiography: Plain radiographs (scapular Y, AP, and axillary lateral views) should be obtained to assess the glenohumeral joint for abnormalities [101].

MRI: MRI may be used to assess the LHB tendon, associated fluid and possible synovitis, and the morphology of the bicipital groove [101]. It can help identify concomitant shoulder and acromioclavicular joint pathologies [101]. However, studies have demonstrated poor correlation between MRI and arthroscopic findings regarding LHB pathology [101]. MRI has poor to moderate sensitivity for inflammation, partial-thickness tendon tears, and tendon ruptures of the LHB [101]. Proton density–weighted sequences with fat suppression have the greatest sensitivity for detecting tendon degeneration [51]. Tendon caliber change is more specific than signal intensity for detecting tendon degeneration [51]. Diagnosing partial tears of the biceps tendon at the entrance to the bicipital groove can be challenging on MRI or MRA without directed effort [51]. Half of biceps tendon partial tears at the groove entrance have an associated caliber change [51]. Evaluation in all imaging planes aids in the identification of a biceps groove entrance lesion [51]. In patients with chronic long head biceps tendinopathy, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes [44]. Biceps tendon pain in the absence of tears is associated with microscopic changes consistent with tendinopathy, which are often missed by MRI [153]. Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders [158]. An increasing prevalence of MRI-based SLAP tears was observed with increasing patient age [166]. High prevalence of superior labral tears diagnosed by MRI in middle-aged patients with asymptomatic shoulders emphasizes the need for supporting clinical judgment when making treatment decisions [177]. Bicipital groove morphology measured by MRI has no value as a predictor of biceps tendon or rotator cuff pathology at the time of surgery [162]. Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons with a described systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears [174].

Magnetic Resonance Arthrography (MRA): MRA is more specific and sensitive for LHB pathology and SLAP tears than MRI [20, 101]. MRA helps diagnose LHB pathology and SLAP tears because it is more specific and more sensitive than MRI alone [20]. MRA in patients with no pathology shows the tendon surrounded by contrast fluid, resembling a kidney bean [101]. Both MRI and MRA should be performed in the sagittal oblique and axial planes because LHB subluxation and dislocation are often associated with partial-thickness and full-thickness subscapularis tendon tears [101]. MR arthrography is an important diagnostic modality for suspected SLAP lesions which helps to formulate preoperative planning [75]. MR arthrography may save patients from undergoing diagnostic arthroscopy [75]. MR arthrography is a helpful technique for the diagnosis and preoperative evaluation of suspected SLAP lesions [156]. MR arthrography can help avoid unnecessary diagnostic arthroscopy [156]. MRA was found to have a sensitivity of 82% to 89% and a specificity of 87% to 98% in the evaluation of the biceps pulley [51]. Diagnostic criteria for biceps pulley pathology on MRA include nonvisualization or discontinuity of the superior glenohumeral ligament, medial subluxation of the biceps tendon on axial images, biceps tendinopathy, and inferior displacement on oblique sagittal images [51]. The rotator cuff interval is best assessed with MRA because joint distension can separate the components of the rotator cuff interval [51]. Three specific findings on MR arthrography were more commonly seen in patients with type II SLAP lesion than in patients with sublabral recess, and the difference was statistically significant (p < 0.05) [179].

Ultrasonography: Ultrasonography is accurate and cost-effective in the diagnosis of LHB dislocation, subluxation, and rupture [101]. Ultrasonography is not as accurate as other modalities in diagnosing partial-thickness tendon tears [101]. The exact role of ultrasonography for the diagnosis of tendon inflammation has not been fully defined [101].

CT: A contrast-filled gap between the labrum and glenoid on neutral CT arthrography after SLAP repair is frequently observed even in patients with satisfactory clinical outcomes [170].

Diagnostic Challenges and Associated Pathology

Surgeons should maintain a high level of suspicion and utilize specific techniques to prevent missing long head biceps tendon and subscapularis pathology [61]. 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 [5]. A 10.1% incidence of subsequent surgery after isolated SLAP repair was identified, often related to an additional diagnosis [41]. Clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions [41]. There are several morphologic factors related to the lesser tuberosity and intertubercular groove that are associated with subscapularis tendon tears and biceps tendon pathology [181]. In approximately 80% of the intra-articular biceps tears evaluated, a 'hidden lesion' was observed going beyond the bicipital groove and extending to the distal extra-articular portion [182].

Treatment

Non-Operative

Initial management for suspected SLAP lesions is non-operative, comprising cooling, anti-inflammatory drugs, rest from sports, and physical therapy [111]. Conservative management, including rest, activity modification, anti-inflammatory medications, and physical therapy, should be attempted for a minimum of 3 months for most SLAP lesions [108]. In overhead athletes, nonoperative treatment remains the mainstay and has achieved good success [69]. For middle-aged patients with symptomatic SLAP lesions, non-operative treatment with an appropriate regimen provides satisfactory clinical outcomes and should be considered before recommending operative treatment [145]. Physical therapy for superior labral tears consists of rotator cuff strengthening, periscapular muscular strengthening, and posteroinferior capsular stretching [137]. In throwers who fail initial nonoperative treatment, a second course of physical therapy specifically designed to improve glenohumeral internal rotation deficit, scapular dyskinesia, posterior capsular contracture, and concomitant injuries demonstrates reasonable success [69].

Injection of local anesthetic with corticosteroid into the glenohumeral joint or bicipital groove serves both diagnostic and therapeutic roles for SLAP lesions [137]. Intra-articular injection of anesthetic agents or steroids may help determine if the SLAP tear is the pain generator [69]. For biceps tendinitis, initial management includes strengthening exercises and local corticosteroid injection into the biceps sheath [134]. Aspiration of the spinoglenoid notch cyst can be performed to treat suprascapular nerve compression associated with SLAP lesions [137].

Predictive factors for failure of nonsurgical management in the general population include a history of trauma, a positive compression-rotation test, and participation in overhead sports [137]. In baseball players, advanced age, prolonged symptoms, pitching, the presence of an exostosis of the posterior band of the inferior glenohumeral ligament (Bennett lesion), and the presence of a partial articular rotator cuff tear have been associated with failure of conservative management [137]. A clinical prediction model consisting of variables describing patient characteristics, specific symptoms, and the type of non-operative treatment modalities utilized predicts failure of non-operative management of SLAP tears with moderate accuracy [159].

Operative

Indications: Surgical management is considered in patients with persistent symptoms following a 3-month period of nonsurgical treatment [59]. Operative treatment is reserved for failure of nonoperative treatment [99]. Treatment decisions for SLAP lesions are driven primarily by the presence of pain, overhead activity level, and prior non-operative management [93]. The decision to perform surgical management of long head of the biceps pathology depends on clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment [7]. A decision to operate on a shoulder for a suspected SLAP lesion should not be made on the basis of specific clinical tests alone [38]. Examination under anesthesia is an important diagnostic tool and should be incorporated into the operative plan for SLAP lesions [69]. Arthroscopic diagnosis of SLAP tears is confirmed using the Snyder criteria, which includes separation of the chondrolabral junction, erythema at the LHB anchor junction, and a minimum 5 mm of labral excursion [59].

Surgical Approach / Technique: Arthroscopic shoulder surgery for SLAP tears can be performed in the lateral decubitus or beach-chair position [59]. Type I SLAP tears are usually managed with a débridement back to a stable base [59]. Type I degenerative tears typically demonstrate fraying with an intact biceps anchor, and débridement alone is sufficient [137]. Type II lesions should be repaired when the history and examination suggest a SLAP tear and the arthroscopic examination confirms existence of a type II tear [59]. Type II tears are unstable due to the involvement of the biceps anchor, and reattachment of the labrum to the superior glenoid rim is indicated [137]. Type III SLAP tears are managed with either repair of the bucket handle or, depending on size and tissue quality, a resection of the unstable labral fragment and repair of the MGHL if it is attached to the torn fragment [59]. Type III tears are managed by débriding the unstable bucket-handle labral tear [137].

Management of type IV tears depends on the patient age and the extent of LHB tendon involvement [59]. If less than 30% of the tendon is involved in a type IV tear, these tears are usually managed with débridement [59]. Tears of more than 30% of the LHB tendon in type IV lesions are usually managed with LHB tenodesis [59]. If less than 25% to 50% of the biceps tendon is involved in a type IV tear, the tear and its extension into the tendon are débrided [137]. If 25% to 50% or more of the biceps tendon is involved in a type IV tear, biceps tenodesis or tenotomy with labral débridement or repair is indicated [137]. In patients older than 40 years, biceps tenodesis may be preferred over SLAP repair secondary to concerns for complications such as retear and excessive stiffness [137]. Degenerative type II tears associated with concomitant shoulder lesions in older patients do not require repair but can be better addressed with débridement, tenodesis, or tenotomy [59].

Implant Selection: Bioabsorbable tacks are no longer used because of concerns about synovitis and cartilage damage caused by the degradation and release of loose bodies [59]. Bulky suture knots should be avoided during SLAP repair to prevent shoulder pain, impingement, and chondral injury [59]. A horizontal mattress suture pattern using knotless anchors was used to anatomically repair the superior labrum and restore the meniscoid shape of the superior labrum [59]. Significantly better range of motion was noted in patients whose SLAP was repaired with a knotless anchor horizontal mattress suture technique [59].

Other Considerations: SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years [10]. Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair [28]. SLAP repairs have had more beneficial results in patients younger than 40 years and if they are not associated with a rotator cuff repair [20]. SLAP repairs have proved more beneficial than tenodesis in patients younger than 40 years and may be even more successful if not associated with rotator cuff repair [20]. The indications of SLAP repair should be narrowed to avoid overtreatment [127]. SLAP repair should continue to be considered as an option for SLAP tear treatment only after nonsurgical management has failed [175]. Both the surgical treatments, SLAP repair and the biceps tenodesis, are efficacious in pain alleviation and recovery of shoulder function [57]. 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 [64].

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 [11]. Biceps tenodesis is gaining popularity due to encouraging functional outcomes and return-to-sport rates [99]. Subpectoral biceps tenodesis provides satisfactory outcomes for the treatment of Type II and Type IV SLAP lesions in middle aged patients [9]. In a young active population, biceps tenodesis may be a viable surgical alternative for type II SLAP lesions and may facilitate earlier return to activity compared to repair [13]. 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 [39]. In patients with non-communicated type II SLAP lesions combined with Bankart lesions, Bankart repair and SLAP debridement yielded satisfactory results without affecting shoulder stability [140]. An effective arthroscopic technique for managing combined anterior shoulder instability and type IV SLAP lesions involves repairing all pathoanatomy present, including the superior labrum and biceps tendon split [40].

Biceps Tenodesis vs. Tenotomy: Both tenotomy and LHB tenodesis are acceptable treatment options, but the literature has not clearly demonstrated which surgery is superior [20]. No clear clinical advantage has been reported when comparing LHB tenodesis and tenotomy [20]. An increase in Popeye deformities is seen with biceps tenotomy [20]. Current indications proposed for LHB tenodesis include patients with high levels of physical activity, patients concerned with cosmesis, and workers’ compensation cases [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 [62]. Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis [167].

Tenotomy without tenodesis is associated with subjective cramping and potential for cosmetic deformity ("Popeye deformity"), but weakness is not associated with tenotomy [134]. Tenodesis may result in "groove pain" if the technique of the tenodesis retains a portion of the tendon in the intertubercular groove [134]. A subpectoral tenodesis technique reduces the risk of groove pain [134]. Tenodesis is favored over tenotomy in active patients for cosmesis and prevention of biceps cramping [72]. Biceps tenotomy has the advantage of being a fast and relatively simple procedure, with fewer restrictions on postoperative rehabilitation and the avoidance of potential complications associated with further surgical dissection and hardware placement involved in the tenodesis [73]. The benefits of biceps tenodesis over tenotomy are the avoidance of a "Popeye deformity," which can occur in up to 70% of patients after a tenotomy, and the avoidance of persistent biceps spasm and fatigue that can be seen in up to 40% of patients [73]. Recent literature suggests no difference in the outcome from biceps tenodesis and tenotomy procedures [73]. Some authors recommend tenodesis in young or athletic patients in order to restore the length-tension relationship and maximize the function of the elbow, although there is limited evidence to support this [73].

Biceps tenotomy benefits include technical ease of the procedure and postoperative rehabilitation, and advantages in elderly, less active patients who are less likely to be negatively affected by cosmetic deformity, cramping, or fatigue [137]. Biceps tenodesis involves removal of the intra-articular portion of the tendon with more distal reinsertion to maintain the length-tension relationship of the biceps muscle [137]. Concern exists that proximal tenodesis may be associated with a higher incidence of persistent pain due to the preservation of a potentially pathologic tendon and tenosynovium within the bicipital groove [137]. Distal tenodesis, below the groove in a suprapectoral or subpectoral region, removes the biceps tendon from the joint and bicipital groove, thus mitigating the risk of persistent postoperative pain [137]. Patients undergoing arthroscopic suprapectoral biceps tenodesis for either SLAP tears or LHBT abnormalities had similar outcome scores and complication rates compared with those undergoing open subpectoral biceps tenodesis [12]. Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair in middle-aged patients [63].

Concomitant Pathology: In patients aged 50 years and older with a degenerative SLAP tear, a combined LHB tenotomy or tenodesis and rotator cuff repair has shown superior outcomes compared with rotator cuff and SLAP repair combined [59]. It is generally preferable to perform a biceps procedure, rather than a SLAP repair, when a concomitant rotator cuff repair is performed [137]. Concomitant repair of rotator cuff tears and SLAP tears have shown good clinical outcomes with high patient satisfaction [59]. In a patient with concomitant rotator cuff and superior labral tears, it is imperative to determine whether the SLAP tear is an incidental finding or if both lesions contribute to the patient’s symptoms [137].

Paralabral ganglion cysts often accompany SLAP tears and should be recognized on preoperative MRI [137]. Paralabral ganglion cysts can cause suprascapular nerve compression and resultant rotator cuff weakness [137]. Paralabral ganglion cysts can be decompressed using aspiration at the time of surgery [137]. Earlier intervention can be offered to patients with evidence of suprascapular nerve compression from a spinoglenoid cyst, because delay in surgical intervention may lead to irreversible infraspinatus atrophy and weakness [59]. Subacromial procedures performed in conjunction with a superior labral repair should be done with caution because they may increase the risk of postoperative stiffness [137]. Indications for biceps surgery include a symptomatic SLAP tear with biceps involvement, tearing of the tendon of 25% to 50% or more of the tendon, tendon subluxation or dislocation due to disruption of the biceps pulley, or intraoperative findings consistent with tenosynovitis or tendinosis with concordant preoperative examination and imaging [137]. In biceps tendon instability, acceptable outcomes have not been achieved with pulley repair or reconstruction [137].

Revision: Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up [32]. Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum two-year follow-up [33]. At the minimum 10-year follow-up, 40% of the military cohort younger than 35 years of age treated with SLAP repair experienced treatment failure and underwent subsequent revision to biceps tenodesis, compared with no revisions in patients who underwent biceps tenodesis as the index procedure [8]. A revision surgery rate of 6.3%, with a 4.3% rate of revision SLAP repair, has been reported [59]. Revision surgery and failure after index SLAP repair correlated with the use of absorbable poly-l/d-lactic acid suture anchors [59]. An 81% return to sport and active duty was reported for patients who underwent open subpectoral tenodesis for a failed repair of type II SLAP tears in a military cohort [59].

Complications

Concomitant Pathology: SLAP lesions present a major association with other shoulder lesions in 96% of cases [60]. In patients aged under 40 years, SLAP lesions are associated with labral lesions [60]. In patients aged 40 years or over, SLAP lesions are associated with impact syndrome with or without rotator cuff lesions [60]. The concomitant presence of SLAP and pulley lesions is significantly rare, occurring in only about 10% of all patients with SLAP and pulley lesions [67].

Revision Surgery: The incidence of subsequent surgery after isolated SLAP repair is 10.1% [41]. Subsequent surgery after isolated SLAP repair is often related to an additional diagnosis [41]. Risk factors for revision surgery after SLAP repair include age >40 years [43], female sex [43], obesity [43], smoking [43], and diagnosis of biceps tendinitis or long head of the biceps tearing [43].

Failed Repair Outcomes: The reason for unsatisfactory outcomes after some SLAP repairs is not well understood and remains the subject of debate [66]. Overconstraining or shortening the biceps tendon during repair is likely detrimental [66]. In overhead athletes, chronic attritional loads placed on the superior labrum in the late cocking stage of throwing may be too high for even a repaired labrum to withstand [66]. The pain associated with SLAP lesions in overhead athletes is likely multifactorial and related to pitch counts, throwing mechanics, internal rotation deficits, and rotator cuff internal impingement [66].

Other Considerations: 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 [44]. Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the long head of the biceps tendon provides a low risk for complications [29]. Biceps tenodesis is a safe treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up [32]. Biceps tenodesis is a safe treatment for failed arthroscopic SLAP tears at a minimum two-year follow-up [33]. Biceps tenodesis is a safe alternative to primary SLAP repair in patients with type II and IV SLAP tears [18]. Patients undergoing arthroscopic suprapectoral biceps tenodesis for either SLAP tears or long head of the biceps tendon abnormalities had similar complication rates compared with those undergoing open subpectoral biceps tenodesis [12]. At the minimum 10-year follow-up, no revisions occurred in patients who underwent biceps tenodesis as the index procedure [8].

Recovery

Outcomes of Primary Biceps Tenodesis: Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the long head of the biceps tendon provides significant improvement in shoulder outcomes with a reliable return to activity level and low risk for complications [29]. In competitive overhead athletes, 81% of patients returned to their previous level of play at an average of 4.1 months postoperatively after subpectoral biceps tenodesis for symptomatic SLAP tear [185]. Biceps tenodesis for the treatment of Type II and Type IV SLAP repairs results in a significant decrease in pain and increase in shoulder function [77]. Patients undergoing arthroscopic suprapectoral biceps tenodesis for either SLAP tears or long head of the biceps tendon abnormalities had similar outcome scores and complication rates compared with those undergoing open subpectoral biceps tenodesis [12]. Both SLAP repair and biceps tenodesis are efficacious in pain alleviation and recovery of shoulder function [57].

Outcomes of SLAP Repair: Predictable short-term surgical results and return to activity can be expected after repair of type II SLAP lesions in patients younger than 50 years who have coexistent rotator cuff tear [79].

Risk Factors and Complications: 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 [43].

Key Evidence

• [L4] For patients with SLAP III or IV lesions the most commonly accepted approach is tenotomy or tenodesis of the long head of biceps tendon. [1] (10.2174/1874325001812010288)
• [L3] In patients under the age of 30 years with a symptomatic isolated SLAP tear, open subpectoral biceps tenodesis may be a reliable alternative to arthroscopic repair. [2] (10.1016/j.arthro.2021.07.028)
• [L4] The findings suggest that patients who undergo subpectoral biceps tenodesis as a salvage procedure for failed type II SLAP repair demonstrate improved results. [3] (10.1177/2325967113s00088)
• [L3] Our results suggest that primary biceps tenodesis provides improved functional results in active patients under 30 when compared to SLAP repair at minimum 2 year follow‐up. [4] (10.1177/2325967117s00395)
• [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. [5] (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. [6] (10.1016/j.arthro.2019.02.017)
• [L4] The decision to perform surgical management of long head of the biceps pathology depends on clinical presentation, physical examination, associated pathologies, and failure of nonsurgical treatment. [7] (10.1177/2325967114s00246)
• [L3] At the minimum 10-year follow-up, 40% of the military cohort younger than 35 years of age treated with SLAP repair experienced treatment failure and underwent subsequent revision to biceps tenodesis, compared with no revisions in patients who underwent biceps tenodesis as the index procedure. [8] (10.1177/03635465261429405)
• [L4] Subpectoral biceps tenodesis provides satisfactory outcomes for the treatment of Type II and Type IV SLAP lesions in middle aged patients. [9] (10.1177/2325967114s00062)
• [L5] SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years. [10] (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. [11] (10.5435/jaaos-d-21-01199)
• [L4] Patients undergoing arthroscopic suprapectoral biceps tenodesis for either SLAP tears or LHBT abnormalities had similar outcome scores and complication rates compared with those undergoing open subpectoral biceps tenodesis. [12] (10.1177/2325967120945322)
• [L3] In a young active population, biceps tenodesis may be a viable surgical alternative for type II SLAP lesions and may facilitate earlier return to activity compared to repair. [13] (10.1177/2325967117s00394)
• [L3] Shoulder long head biceps tendon pathology is associated with increasing rotator cuff tear size. [14] (10.1016/j.asmr.2021.07.013)
• [Paper] [15] (10.1016/j.eats.2015.05.009)
• [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] 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. [18] (10.1177/0363546514540273)
• [L1] Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions. [19] (10.1186/s13018-019-1096-y)
• [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. [21] (10.1016/j.jse.2008.05.044)
• [L4] Arthroscopic biceps tenodesis can be considered an effective alternative to reinsertion in the treatment of isolated type II SLAP lesions. [22] (10.1016/j.arthro.2007.03.068)
• [L1] Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied. [26] (10.1136/bjsports-2016-097098)
• [L5] [27] (10.1302/2058-5241.4.180033)
• [L3] Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair. [28] (10.1177/0363546514534939)
• [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. [29] (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. [32] (10.1177/0363546513520122)
• [L2] Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum two-year follow-up. [33] (10.1016/j.arthro.2014.04.026)
• [Paper] [36] (10.1016/j.csm.2008.06.002)
• [L3] A decision to operate on a shoulder for a suspected SLAP lesion should not be made on the basis of these tests alone. [38] (10.1177/03635465020300061001)
• [L3] 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. [39] (10.1177/2325967123s00164)
• [L4] The authors present an effective arthroscopic technique for managing combined anterior shoulder instability and type IV SLAP lesions by repairing all pathoanatomy present, including the superior labrum and biceps tendon split. [40] (10.1016/j.arthro.2009.04.075)
• [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. [41] (10.1016/j.arthro.2016.01.053)
• [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. [43] (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. [44] (10.1016/j.arthro.2018.01.021)
• [L3] In patients aged ≤50 years with isolated SLAP tears, open biceps tenodesis provides cost savings over arthroscopic methods of treatment. [45] (10.1016/j.asmr.2020.09.020)
• [L5] Treatment of proximal biceps pathology is largely based on expert opinion and patient preferences rather than robust randomized evidence. [46] (10.1097/corr.0000000000002448)
• [L5] [52] (10.5435/00124635-200910000-00005)
• [L5] Diagnosis of long head biceps tendon pathology remains challenging due to vague complaints and unreliable physical examination maneuvers. [55] (10.1136/jisakos-2017-000128)
• [L1] Both the surgical treatments, SLAP repair and the biceps tenodesis, are efficacious in pain alleviation and recovery of shoulder function. [57] (10.1016/j.jot.2018.09.002)
• [L4] SLAP lesions presented a major association with other shoulder lesions (96%): labral lesions in patients aged under 40 years and impact syndrome with or without rotator cuff lesions in patients aged 40 years or over. [60] (10.1016/s2255-4971(15)30176-2)
• [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. [61] (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. [62] (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. [63] (10.1016/j.arthro.2018.01.029)
• [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. [64] (10.1016/j.arthro.2019.02.026)
• [L5] [66] (10.1016/j.jse.2010.11.013)
• [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. [67] (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. [70] (10.1016/j.arthro.2018.01.001)
• [L4] MR Arthrogram is an important diagnostic modality for suspected SLAP lesions which not only helps to formulate the preoperative planning but may also save patients from undergoing diagnostic arthroscopy. [75] (10.1016/j.surge.2010.06.006)
• [L4] Repair of type IV SLAP lesions can be anticipated to be successful provided no more than 30% of the biceps root is compromised by the injury. [76] (10.1016/j.arthro.2008.04.014)
• [L4] Biceps tenodesis for the treatment of Type II and Type IV SLAP repairs results in a significant decrease in pain and increase in shoulder function. [77] (10.1016/j.arthro.2014.04.030)
• [L3] Predictable short-term surgical results and return to activity can be expected after repair of type II SLAP lesions in patients younger than 50 years who have coexistent rotator cuff tear. [79] (10.1177/0363546509347364)
• [L5] The management of type II lesions should include stabilization of the detached biceps tendon-superior labrum complex, and suture repair of many type IV lesions is also appropriate if there is extensive involvement of the superior labrum and biceps tendon. [81] (10.5435/00124635-199803000-00007)
• [L5] Treatment decisions for SLAP lesions are driven primarily by the presence of pain, overhead activity level, and prior non-operative management. [93] (10.1016/j.jisako.2026.101087)
• [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. [94] (10.1016/j.arthro.2010.10.014)
• [L5] Operative treatment is reserved for failure of nonoperative treatment, with biceps tenodesis gaining popularity due to encouraging functional outcomes and return-to-sport rates. [99] (10.1016/j.arthro.2022.08.005)
• [L3] For experienced shoulder surgeons, the Snyder classification is a reliable system for identifying SLAP lesions. [102] (10.1177/0363546510392332)
• [L4] The sub-supraspinatus recess is a definable anatomic entity typically measuring 5 mm to 10 mm in depth, and the posterosuperior labrum exhibits physiological motion (roll back) during glenohumeral motion, most pronounced in external rotation in abduction. [106] (10.1177/1758573218757169)
• [L4] [108] (10.1016/j.arthro.2018.01.031)
• [L4] The current literature and practice for making the SLAP diagnosis are variable and inconsistent. [109] (10.1016/j.arthro.2015.06.033)
• [L5] [111] (10.1007/s00167-015-3966-0)
• [L5] The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage. [116] (10.1016/j.jse.2024.12.023)
• [L5] The long head of the biceps has a pertinent biomechanical role in glenohumeral stability regardless of the condition of the superior labrum. [117] (10.1016/j.arthro.2025.05.022)
• [L3] Therefore, we believe the indications of SLAP repair should be narrowed to avoid overtreatment. [127] (10.4055/cios.2018.10.3.358)
• [L5] All 3 labral zones assessed in this study have important biomechanical contributions to biceps anchor displacement. [129] (10.1177/0363546509343468)
• [L4] In patients with non-communicated type II SLAP lesions combined with Bankart lesions, Bankart repair and SLAP debridement yielded satisfactory results without affecting shoulder stability. [140] (10.5397/cise.2018.21.1.37)
• [L4] 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. [145] (10.1007/s00167-016-4226-7)
• [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. [146] (10.1007/s00167-015-3774-6)
• [L3] Reoperation rates are higher for patients undergoing SLAP repair, which is a likely driver behind the increased utilization of biceps tenodesis. [147] (10.1016/j.jseint.2022.11.001)
• [L5] Biceps tendon pain in the absence of tears is associated with microscopic changes consistent with tendinopathy, which are often missed by MRI. [153] (10.1016/j.csm.2015.08.002)
• [L2] MR arthrography is a helpful technique for the diagnosis and preoperative evaluation of suspected SLAP lesions; it can help avoiding unnecessary diagnostic arthroscopy. [156] (10.1016/j.ejrad.2011.07.006)
• [L2] [157] (10.1177/0363546508314795)
• [L3] Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. [158] (10.1016/j.jse.2019.04.001)
• [L3] 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. [159] (10.1177/2325967121s00328)
• [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. [162] (10.1016/j.jse.2010.04.044)
• [L5] SLAP lesions lead to increased glenohumeral translation and concurrently LHB tension and load in at most anterior direction. [164] (10.1007/s00167-011-1423-2)
• [L3] An increasing prevalence of MRI-based SLAP tears was observed with increasing patient age. [166] (10.1177/2325967118797065)
• [L4] Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis. [167] (10.1016/j.arthro.2016.04.022)
• [L4] A contrast-filled gap between the labrum and glenoid on neutral CT arthrography after SLAP repair is frequently observed even in patients with satisfactory clinical outcomes. [170] (10.1007/s00167-014-3350-5)
• [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. [174] (10.1016/j.arthro.2012.04.142)
• [L4] SLAP repair should continue to be considered as an option for SLAP tear treatment only after nonsurgical management has failed. [175] (10.1177/0363546517728256)
• [L3] These shoulder MRI findings in middle-aged populations emphasize the need for supporting clinical judgment when making treatment decisions for this patient population. [177] (10.1177/2325967115623212)
• [L4] These three findings were more commonly seen on MR arthrography in patients with type II SLAP lesion than in patients with sublabral recess, and the difference was statistically significant (p < 0.05). [179] (10.2214/ajr.05.0955)
• [L3] There are several morphologic factors related to the lesser tuberosity and intertubercular groove that are associated with subscapularis tendon tears and biceps tendon pathology. [181] (10.1016/j.arthro.2015.11.035)
• [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. [182] (10.1177/0363546514554193)
• [L4] In the current series of competitive overhead athletes, 81% of patients returned to previous level of play at an average of 4.1 months postoperatively after subpectoral biceps tenodesis for symptomatic SLAP tear. [185] (10.1016/j.arthro.2022.07.017)

See Also

• Biceps Tenodesis
• Rotator Cuff
• Rotator Cuff Disorders
• Suprascapular neuropathy
• Calcific Tendinitis
• Rotator cuff repair
• Shoulder Instability

References

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