Skip to content

SLAP and Biceps Pathology

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

Overview

Primary biceps tenodesis has emerged as a definitive alternative to primary SLAP repair for type II and IV lesions, offering superior functional outcomes in active patients under 30 years of age [3]. In this demographic, tenodesis may facilitate earlier return to activity compared to repair [4] and serves as a reliable alternative to arthroscopic reinsertion for isolated type II tears [5, 7]. For middle-aged patients, primary tenodesis demonstrates increased effectiveness over both SLAP repair and nonoperative treatment, while also incurring lower costs [11]. Even in patients aged ≤50 years with isolated SLAP tears, open tenodesis provides cost savings over arthroscopic methods [41].

Biceps tenodesis is a safe, effective, and technically straightforward intervention for symptomatic SLAP lesions, with recent data reporting high rates of return to sport and patient satisfaction in carefully selected athletes [6, 14]. Female patients undergoing either SLAP repair or biceps tenodesis show comparable two-year results regarding function, pain, and return to sports [16]. While both arthroscopic repair and tenodesis/tendonectomy interventions offer benefits for type II SLAP lesions [9], the choice between them involves specific advantages and disadvantages that must be individualized with the patient [19]. Furthermore, subpectoral tenodesis serves as a salvage procedure for failed type II SLAP repair, demonstrating improved results in this setting [1].

Anatomy & Pathophysiology

Osseous and Labral Morphology: The human glenoid labrum exhibits compressive behavior that varies around its circumference [29]. The sub-supraspinatus recess is a definable anatomic entity typically measuring 5 mm to 10 mm in depth [30]. Patients older than 50 years were significantly more likely to have superior labral abnormalities regardless of other shoulder injury or disease [18]. Isolated tears of the anterosuperior labrum represent a subtle cause of shoulder pain and dysfunction that is very difficult to diagnose clinically [64].

Kinematics and Biomechanics: The posterosuperior labrum exhibits physiological motion (roll back) during glenohumeral motion, most pronounced in external rotation in abduction [30]. Simulated Type II Superior Labral Anterior Posterior Lesions do not alter the path of glenohumeral articulation [43]. The small amounts of increased external rotation and translation found with arthroscopically created type II superior labral anterior posterior lesions do not significantly affect glenohumeral kinematics in this passive motion model as quantified by the path of glenohumeral articulation [43]. In shoulders with a SLAP lesion there is a trend towards delay in activation time of Biceps and other muscles with the exception of an associated earlier onset of activation of Serratus anterior [46]. SLAP lesions lead to increased glenohumeral translation and concurrently LHB tension and load in at most anterior direction [49]. All 3 labral zones assessed have important biomechanical contributions to biceps anchor displacement [39]. Repair of the labrum restored stability for superior subluxation but also changed the kinematics of the subluxation event [61].

Pathophysiology and Clinical Presentation: SLAP lesions may mimic impingement, rotator cuff pathology, or anterior instability [23]. The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage [33].

Classification

Snyder: The Snyder classification is a reliable system for identifying SLAP lesions among experienced shoulder surgeons [27]. 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 [25]. Arthroscopic repair is an effective 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 [8].

Other Considerations: Biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears [6]. Subpectoral biceps tenodesis provides satisfactory outcomes for the treatment of Type II and Type IV SLAP lesions in middle-aged patients [10]. 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 [26]. 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 [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 [5]. Arthroscopic biceps tenodesis can be considered an effective alternative to reinsertion in the treatment of isolated type II SLAP lesions [7]. Patients who undergo subpectoral biceps tenodesis as a salvage procedure for failed type II SLAP repair demonstrate improved results [1]. Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions [9]. Biceps tenotomy and rotator cuff repair may be a more reliable method to address concomitant type II SLAP lesions and large to massive rotator cuff tears in patients [12]. 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].

Clinical Presentation

Diagnosing superior labrum and biceps anchor disorders requires a nuanced approach, as the current literature and practice for making the SLAP diagnosis remain variable and inconsistent [31]. Clinical assessment tests alone are insufficient to justify surgical intervention for a suspected SLAP lesion [13]. Furthermore, SLAP lesions frequently mimic other pathologies, including impingement, rotator cuff pathology, or anterior instability [23].

Pathoanatomy and Variants: Calcific tendinitis of the long head of the biceps brachii at its origin may be associated with a concurrent SLAP lesion [2]. Superior glenoid rim fractures involving the biceps anchor are extremely rare and represent a bony variant within the spectrum of SLAP lesions [17]. The concomitant presence of SLAP and pulley lesions is significantly rare, occurring in only about 10% of all patients with SLAP and pulley lesions [15].

Diagnostic Consensus: An evidence-based, updated, and consensus statement on the pathoanatomy and diagnosis of clinically relevant superior labrum and biceps anchor disorders has been provided by the American Shoulder and Elbow Surgeons SLAP/Biceps Anchor Study Group [21].

Management Outcomes and Indications: Outcomes following surgical treatment of SLAP lesions vary depending on the method of treatment, associated pathology, and patient characteristics [34]. Primary biceps tenodesis provides improved functional results in active patients under 30 years old compared to SLAP repair at minimum 2-year follow-up [3]. In a young active population, biceps tenodesis may facilitate earlier return to activity compared to repair for type II SLAP lesions [4]. Open subpectoral biceps tenodesis may be a reliable alternative to arthroscopic repair for symptomatic isolated SLAP tears in patients under 30 years of age [5]. Arthroscopic biceps tenodesis can be considered an effective alternative to reinsertion for isolated type II SLAP lesions [7]. Subpectoral biceps tenodesis provides satisfactory outcomes for the treatment of Type II and Type IV SLAP lesions in middle-aged patients [10]. Biceps tenotomy and rotator cuff repair may be a more reliable method to address concomitant type II SLAP lesions and large to massive rotator cuff tears [12]. Subpectoral biceps tenodesis as a salvage procedure for failed type II SLAP repair demonstrates improved results [1]. An effective arthroscopic technique exists for managing combined anterior shoulder instability and type IV SLAP lesions by repairing all pathoanatomy present, including the superior labrum and biceps tendon split [8]. 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 [14]. Patients undergoing arthroscopic suprapectoral biceps tenodesis for SLAP tears or long head of the biceps abnormalities had similar outcome scores and complication rates compared with those undergoing open subpectoral biceps tenodesis [20].

Risk Factors: 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 [22].

Investigations

Plain radiography: Superior glenoid rim fractures involving the biceps anchor are extremely rare and represent a bony variant within the spectrum of SLAP lesions [17].

MRI: 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 for this patient population [58]. Patients older than 50 years were significantly more likely to have superior labral abnormalities regardless of other shoulder injury or disease [18]. 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].

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 [52].

Other Considerations: A decision to operate on a shoulder for a suspected SLAP lesion should not be made on the basis of clinical assessment tests alone [13]. The concomitant presence of SLAP and pulley lesions is significantly rare, occurring in only about 10% of all patients with SLAP and pulley lesions [15]. The SLAP lesion can be diagnosed only arthroscopically and may be treated successfully by arthroscopic techniques alone in many patients [56]. 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 [25]. Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions [9]. An evidence-based, updated, and consensus statement on the pathoanatomy and diagnosis of clinically relevant superior labrum and biceps anchor disorders suggests future directions for research [21].

Treatment

Non-Operative

Non-operative treatment with an appropriate regimen provides satisfactory clinical outcomes in middle-aged patients with symptomatic SLAP lesions and should be considered before recommending operative treatment [42]. A clinical prediction model consisting of variables describing patient characteristics, specific symptoms, and non-operative treatment modalities can predict failure of non-operative management of SLAP tears with moderate accuracy [48]. Treatment decisions for SLAP lesions are driven primarily by the presence of pain, overhead activity level, and prior non-operative management [44]. A decision to operate on a shoulder for a suspected SLAP lesion should not be made based on clinical assessment tests alone [13].

Operative

Indications: Primary biceps tenodesis provides improved functional results in active patients under 30 years old compared to SLAP repair at minimum 2-year follow-up [3]. In a young active population, biceps tenodesis may facilitate earlier return to activity compared to repair for type II SLAP lesions [4]. Primary biceps tenodesis offers increased effectiveness compared to both primary SLAP repair and nonoperative treatment, with lower costs than primary SLAP repair, for symptomatic SLAP tears in middle-aged patients [11]. Biceps tenotomy and rotator cuff repair may be a more reliable method to address concomitant type II SLAP lesions in patients with large to massive rotator cuff tears [12]. If calcific tendinitis of the long head of the biceps brachii at its origin is suspected, the presence of a concurrent SLAP lesion should be considered [2].

Surgical Approach / Technique: Open subpectoral biceps tenodesis may be a reliable alternative to arthroscopic repair for symptomatic isolated SLAP tears in patients under 30 years of age [5]. Arthroscopic biceps tenodesis can be considered an effective alternative to reinsertion for the treatment of isolated type II SLAP lesions [7]. Both arthroscopic repair and biceps tenotomy/tenodesis interventions offer benefits for type II SLAP lesions [9]. An effective arthroscopic technique exists for managing combined anterior shoulder instability and type IV SLAP lesions by repairing all pathoanatomy present, including the superior labrum and biceps tendon split [8]. 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 [45]. Surgeons should perform careful capsulotomy with minimal resection during arthroscopic, isolated decompression of ganglion cysts of the shoulder to prevent labral damage and the development of new SLAP lesions [66].

Implant Selection: SLAP repair and biceps tenodesis both present viable treatment options with specific advantages and disadvantages, with the decision made individually with the patient [19]. Some SLAP repair techniques can disrupt vascularization of the long head of the biceps tendon, whereas the technique using 2 anchors with simple sutures can preserve vascularization [51].

Other Considerations: Subpectoral biceps tenodesis as a salvage procedure for failed type II SLAP repair demonstrates improved results [1]. Biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears [6]. Biceps tenodesis for the treatment of Type II and Type IV SLAP lesions results in a significant decrease in pain and increase in shoulder function [26]. In a young active population, primary arthroscopic biceps tenodesis is a viable surgical alternative to labral repair for type II SLAP lesions with minimum 2-year outcomes [28]. Female patients who underwent surgical treatment of SLAP lesions with SLAP repair or biceps tenodesis show comparable minimum two-year results regarding function, self-reported pain, and ability to return to sports [16]. Patients undergoing arthroscopic suprapectoral biceps tenodesis for SLAP tears or LHBT abnormalities had similar outcome scores and complication rates compared to those undergoing open subpectoral biceps tenodesis [20]. Patients who underwent an open Latarjet procedure with an associated SLAP tear more frequently reported postoperative pain than those without a SLAP lesion [65]. Superior glenoid rim fractures involving the biceps anchor represent a rare bony variant within the spectrum of SLAP lesions [17].

Complications

Revision Surgery: Reoperation rates are significantly higher for patients undergoing SLAP repair compared to other treatments [24], with isolated SLAP repair independently associated with unplanned reoperation [67]. Risk factors for revision surgery after SLAP repair include age greater than 40 years [22], female sex [22], obesity [22], smoking [22], and a diagnosis of biceps tendinitis or long head of the biceps tearing [22]. Patients older than 50 years are significantly more likely to have superior labral abnormalities regardless of other shoulder injury or disease [18].

Stiffness / Arthrofibrosis: Subpectoral biceps tenodesis may emerge as a primary alternative for treating young athletes with unstable SLAP tears due to high rates of postoperative stiffness after modern arthroscopic shoulder SLAP repair [75].

Functional Outcomes and Reoperation Risk: Meta-analysis showed more frequent favorable outcomes with biceps tenodesis compared to repair for isolated type II SLAP tears [70], and arthroscopic and open biceps tenodesis demonstrated slightly lower risk for reoperation than SLAP repair [73]. Primary biceps tenodesis provides improved functional results in active patients under 30 years old compared to SLAP repair at minimum 2-year follow-up [3]. In patients under the age of 30 with isolated SLAP tear pathology, biceps tenodesis is a reliable alternative to arthroscopic repair with a low rate of revision surgery [72] and demonstrates excellent patient reported outcomes [72]. Primary biceps tenodesis offers increased effectiveness compared with both primary SLAP repair and nonoperative treatment for symptomatic SLAP tears in middle-aged patients [11]. In 87% of cases, a good or excellent functional outcome can be anticipated after arthroscopic repair of type II SLAP lesions [74].

Other Considerations: Subpectoral biceps tenodesis is used as a salvage procedure for failed type II SLAP repair and demonstrates improved results [1]. Subpectoral biceps tenodesis may emerge as a primary alternative for treating young athletes with unstable SLAP tears due to high rates of revision reoperation after modern arthroscopic shoulder SLAP repair [75]. Subpectoral biceps tenodesis may emerge as a primary alternative for treating young athletes with unstable SLAP tears due to inconsistent functional outcomes after modern arthroscopic shoulder SLAP repair [75]. Primary biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears [6]. Primary biceps tenodesis has lower costs than primary SLAP repair for symptomatic SLAP tears in middle-aged patients [11]. Calcific tendinitis of the long head of the biceps brachii at its origin may be associated with a concurrent SLAP lesion [2]. The concomitant presence of SLAP and pulley lesions occurs in only about 10% of all patients with SLAP and pulley lesions [15]. Single-portal SLAP lesion repair is described as a very uncomplicated and easily reproducible procedure [68]. The total number of biceps tenodeses has increased over the past 10 years while the number and relative percentage of SLAP repairs have decreased [71].

Recovery

Light activity (weeks): Evidence regarding specific timelines for desk work, driving, or light ADLs is not provided in the current evidence base; however, return to activity is noted to be facilitated earlier with biceps tenodesis compared to repair in young active populations [4].

Full activity (months): In competitive overhead athletes, 81% returned to their previous level of play at an average of 4.1 months postoperatively following subpectoral biceps tenodesis for symptomatic SLAP tears [60]. Return to sport remains completely unpredictable for throwers due to massive variability in outcomes and a lack of robust comparative literature [47]. Overall successful outcomes favor tenodesis regarding return to play in athletes [69], though rates of return to play in younger patients show no significant difference between biceps tenodesis and SLAP repair [59]. For elite overhead athletes, the return to preinjury level of competition after type II SLAP lesion repairs was 57% [63].

Complete recovery / outcome plateau (months): Female patients undergoing surgical treatment of SLAP lesions with either SLAP repair or biceps tenodesis show comparable minimum two-year results regarding level of function, self-reported pain, and ability to return to sports [16]. Primary biceps tenodesis provides improved functional results in active patients under 30 years old compared to SLAP repair at minimum 2-year follow-up [3]. Primary biceps tenodesis offers increased effectiveness compared with both primary SLAP repair and nonoperative treatment for symptomatic SLAP tears in middle-aged patients [11]. Subpectoral biceps tenodesis provides satisfactory outcomes for the treatment of Type II and Type IV SLAP lesions in middle-aged patients [10].

Rehabilitation protocol: No specific rehabilitation protocols, immobilisation durations, or weight-bearing progressions are detailed in the provided evidence.

Functional milestones: Primary biceps tenodesis as a salvage procedure for failed type II SLAP repair demonstrates improved results [1]. Arthroscopic biceps tenodesis is an effective alternative to the repair of a type II SLAP lesion, allowing patients to return to a presurgical level of activity and sports participation [38]. Athletes undergoing biceps tenodesis for a symptomatic, isolated SLAP tear had a high rate of return to play, good functional outcomes, and a low rate of revision surgery [54]. Biceps tenodesis is 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 [14].

Other Considerations: Reoperation rates are higher for patients undergoing SLAP repair compared to biceps tenodesis [24]. Arthroscopic revision type II SLAP repairs yield worse results than primary repairs, with workers' compensation patients and overhead athletes doing especially worse [53]. Primary biceps tenodesis has lower costs than primary SLAP repair for symptomatic SLAP tears in middle-aged patients [11]. Biceps tenodesis has no significant difference in rates of revision surgery compared to SLAP repair in younger patients [59].

Key Evidence

  • [L4] The findings suggest that patients who undergo subpectoral biceps tenodesis as a salvage procedure for failed type II SLAP repair demonstrate improved results. (10.1177/2325967113s00088)
  • [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. (10.1007/s00167-007-0323-y)
  • [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. (10.1177/2325967117s00395)
  • [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. (10.1177/2325967117s00394)
  • [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. (10.1016/j.arthro.2021.07.028)
  • [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. (10.1177/0363546514540273)
  • [L4] Arthroscopic biceps tenodesis can be considered an effective alternative to reinsertion in the treatment of isolated type II SLAP lesions. (10.1016/j.arthro.2007.03.068)
  • [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. (10.1016/j.arthro.2009.04.075)
  • [L1] Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions. (10.1186/s13018-019-1096-y)
  • [L4] Subpectoral biceps tenodesis provides satisfactory outcomes for the treatment of Type II and Type IV SLAP lesions in middle aged patients. (10.1177/2325967114s00062)
  • [L3] Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair. (10.1016/j.arthro.2018.01.029)
  • [L2] Biceps tenotomy and rotator cuff repair may be a more reliable method to address concomitant type II SLAP lesions and large to massive rotator cuff tears in patients. (10.1177/0363546512462678)
  • [L3] A decision to operate on a shoulder for a suspected SLAP lesion should not be made on the basis of these tests alone. (10.1177/03635465020300061001)
  • [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. (10.5435/jaaos-d-21-01199)
  • [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. (10.1016/j.arthro.2011.01.005)
  • [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. (10.1177/2325967123s00164)
  • [L4] Superior glenoid rim fractures involving the biceps anchor are extremely rare and represent a bony variant within the spectrum of SLAP lesions. (10.1177/0363546509336341)
  • [L3] Patients older than 50 years were significantly more likely to have superior labral abnormalities regardless of other shoulder injury or disease. (10.1177/2325967118797065)
  • [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. (10.1016/j.arthro.2019.02.026)
  • [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. (10.1177/2325967120945322)
  • [L5] The purpose of this review is to provide an evidence-based, updated, and consensus statement on the pathoanatomy and diagnosis of clinically relevant superior labrum and biceps anchor disorders and suggests future directions for research. (10.1016/j.jse.2022.12.015)
  • [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. (10.1177/0363546517691950)
  • [L4] SLAP lesions may mimic impingement, rotator cuff pathology, or anterior instability. (10.1016/j.arthro.2011.03.007)
  • [L3] Reoperation rates are higher for patients undergoing SLAP repair, which is a likely driver behind the increased utilization of biceps tenodesis. (10.1016/j.jseint.2022.11.001)
  • [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. (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. (10.1016/j.arthro.2014.04.030)
  • [L3] For experienced shoulder surgeons, the Snyder classification is a reliable system for identifying SLAP lesions. (10.1177/0363546510392332)
  • [L3] In a young active population, primary arthroscopic biceps tenodesis is a viable surgical alternative to labral repair for type II SLAP lesions. (10.1007/s00167-020-05971-0)
  • [L5] This study has shown that the human glenoid labrum's compressive behavior varies around its circumference. (10.1016/j.arthro.2008.12.012)
  • [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. (10.1177/1758573218757169)
  • [L4] The current literature and practice for making the SLAP diagnosis are variable and inconsistent. (10.1016/j.arthro.2015.06.033)
  • [L5] The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage. (10.1016/j.jse.2024.12.023)
  • [L5] Outcomes following surgical treatment vary depending on the method of treatment, associated pathology, and patient characteristics, with biceps tenodesis receiving increasing attention as a treatment option. (10.1302/2058-5241.4.180033)
  • [L3] Arthroscopic biceps tenodesis can be considered an effective alternative to the repair of a type II SLAP lesion, allowing patients to return to a presurgical level of activity and sports participation. (10.1177/0363546508330127)
  • [L5] All 3 labral zones assessed in this study have important biomechanical contributions to biceps anchor displacement. (10.1177/0363546509343468)
  • [L3] In patients aged ≤50 years with isolated SLAP tears, open biceps tenodesis provides cost savings over arthroscopic methods of treatment. (10.1016/j.asmr.2020.09.020)
  • [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. (10.1007/s00167-016-4226-7)
  • [L5] The small amounts of increased external rotation and translation found with arthroscopically created type II superior labral anterior posterior lesions do not significantly affect glenohumeral kinematics in this passive motion model as quantified by the path of glenohumeral articulation. (10.1177/0363546507312169)
  • [L5] Treatment decisions for SLAP lesions are driven primarily by the presence of pain, overhead activity level, and prior non-operative management. (10.1016/j.jisako.2026.101087)
  • [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. (10.5397/cise.2018.21.1.37)
  • [L4] This study shows that in shoulders with a SLAP lesion there is a trend towards delay in activation time of Biceps and other muscles with the exception of an associated earlier onset of activation of Serratus anterior, possibly due to a coping strategy to protect glenohumeral stability and thoraco-scapular stability. (10.1186/1749-799x-5-12)
  • [L5] Return to sport for throwers after SLAP repair or biceps tenodesis remains completely unpredictable due to massive variability in outcomes and a lack of robust comparative literature. (10.1016/j.arthro.2025.03.022)
  • [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. (10.1177/2325967121s00328)
  • [L5] SLAP lesions lead to increased glenohumeral translation and concurrently LHB tension and load in at most anterior direction. (10.1007/s00167-011-1423-2)
  • [L5] Some SLAP repair techniques can disrupt vascularization; however, the technique using 2 anchors with simple sutures can preserve the vascularization of the long head of the biceps tendon. (10.1016/j.jse.2020.07.014)
  • [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. (10.1007/s00167-014-3350-5)
  • [L4] Arthroscopic revision type II SLAP repairs yield worse results than primary repairs as reported in the literature, with workers' compensation patients and overhead athletes doing especially worse. (10.1177/0363546511398648)
  • [L4] Athletes undergoing biceps tenodesis as the treatment for a symptomatic, isolated SLAP tear had a high rate of return to play, good functional outcomes, and a low rate of revision surgery. (10.1177/2325967121s00553)
  • [L4] The SLAP lesion can be diagnosed only arthroscopically and may be treated successfully by arthroscopic techniques alone in many patients. (10.1016/j.arthro.2010.06.004)
  • [L3] These shoulder MRI findings in middle-aged populations emphasize the need for supporting clinical judgment when making treatment decisions for this patient population. (10.1177/2325967115623212)
  • [L1] This study found that biceps tenodesis has no significant difference in rates of return to play in athletes, as well as in functional outcome scores and rates of revision surgery in younger patients compared to SLAP repair. (10.1016/j.jisako.2023.09.007)
  • [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. (10.1016/j.arthro.2022.07.017)
  • [L5] Repair of the labrum restored stability for superior subluxation but also changed the kinematics of the subluxation event. (10.1016/j.arthro.2014.06.012)
  • [L3] Return to preinjury level of competition for elite overhead athletes after type II SLAP lesion repairs was 57%, despite high American Shoulder and Elbow Surgeons scores. (10.1177/0363546510379971)
  • [L4] Isolated tears of the anterosuperior labrum represent a subtle cause of shoulder pain and dysfunction that is very difficult to diagnose clinically. (10.1016/j.arthro.2010.05.022)
  • [L3] Patients who underwent an open Latarjet procedure with an associated SLAP tear more frequently reported postoperative pain than those without a SLAP lesion. (10.1177/23259671231185199)
  • [L4] Surgeons should be aware of this uncommon cause of shoulder pain and perform careful capsulotomy with minimal resection to prevent labral damage. (10.1007/s00167-009-0851-8)
  • [L3] Isolated SLAP repair is independently associated with unplanned reoperation. (10.1007/s00167-020-06397-4)
  • [L4] The simple modification described makes SLAP repair a very uncomplicated and easily reproducible procedure. (10.1016/j.arthro.2006.05.033)
  • [L5] Overall successful outcomes are seen in both SLAP repair and biceps tenodesis, with results favouring tenodesis in terms of return to play in athletes, though there is a paucity of Level I studies comparing the two. (10.1136/jisakos-2020-000537)
  • [L1] Meta-analysis showed more frequent favorable outcomes with biceps tenodesis. (10.1016/j.arthro.2022.05.005)
  • [L4] Over the past 10 years, the total number of biceps tenodeses has increased, whereas the number and relative percentage of SLAP repairs within our practice have decreased. (10.1016/j.arthro.2015.11.044)
  • [L3] In patients under the age of 30 with isolated SLAP tear pathology, BT is a reliable alternative to AR, with a low rate of revision surgery, and excellent patient reported outcomes. (10.1177/2325967121s00332)
  • [L4] Arthroscopic and open BT demonstrated slightly lower risk for reoperation than SLAP repair. (10.1016/j.arthro.2021.11.049)
  • [L4] In 87% of cases, a good or excellent functional outcome can be anticipated after arthroscopic repair of type II SLAP lesions with the described techniques. (10.1016/j.arthro.2011.09.005)
  • [L5] Subpectoral biceps tenodesis may emerge as a primary alternative for treating the young athlete with unstable SLAP tears due to high rates of postoperative stiffness, revision reoperation, and inconsistent functional outcomes after modern arthroscopic shoulder SLAP repair. (10.1016/j.arthro.2021.10.019)

See Also

References

[1] Subpectoral Biceps Tenodesis for Failed Type II SLAP Repair. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113s00088

[2] A SLAP lesion associated with calcific tendinitis of the long head of the biceps brachii at its origin. Knee Surgery, Sports Traumatology, Arthroscopy. 2007. DOI: 10.1007/s00167-007-0323-y

[3] Biceps Tenodesis vs. Repair for Type II SLAP Tears in Patients Under 30 years-old. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00395

[4] Arthroscopic Treatment of Type II Superior Labral Anterior to Posterior (SLAP) Lesions in a Younger Population: Traditional Repair versus Biceps Tenodesis with Accelerated Rehabilitation. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00394

[5] Open Subpectoral Biceps Tenodesis May Be an Alternative to Arthroscopic Repair for SLAP Tears in Patients Under 30. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.07.028

[6] Subpectoral Biceps Tenodesis for the Treatment of Type II and IV Superior Labral Anterior and Posterior Lesions. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514540273

[7] Arthroscopic Treatment of Type II SLAP Lesions: Biceps Tenodesis as an Alternative to Reinsertion (SS‐54). Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.03.068

[8] Combined Arthroscopic Repair of a Type IV SLAP Tear and Bankart Lesion. Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.04.075

[9] Is arthroscopic repair superior to biceps tenotomy and tenodesis for type II SLAP lesions? A meta-analysis of RCTs and observational studies. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1096-y

[10] Subpectoral Biceps Tenodesis For The Treatment Of Type Two And Four Slap Lesions. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00062

[11] 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

[12] Arthroscopic Repair of Concomitant Type II SLAP Lesions in Large to Massive Rotator Cuff Tears. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512462678

[13] Clinical Assessment of Three Common Tests for Superior Labral Anterior-Posterior Lesions. The American Journal of Sports Medicine. 2002. DOI: 10.1177/03635465020300061001

[14] Surgical Treatment of Superior Labral/Biceps Pathology in the Overhead Thrower. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-21-01199

[15] Is There an Association Between SLAP Lesions and Biceps Pulley Lesions?. Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.01.005

[16] Poster 178: Outcomes of SLAP Repair vs. Biceps Tenodesis of SLAP Lesions in Females: A Retrospective Review. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00164

[17] Superior Glenoid Fracture Involving the Biceps Anchor. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509336341

[18] Imaging-Based Prevalence of Superior Labral Anterior-Posterior Tears Significantly Increases in the Aging Shoulder. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118797065

[19] Editorial Commentary: Which to Fix—the Biceps or the Labrum? The Shoulder SLAP Tear Is Still Controversial. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.02.026

[20] Outcomes and Complications After Primary Arthroscopic Suprapectoral Versus Open Subpectoral Biceps Tenodesis for Superior Labral Anterior-Posterior Tears or Biceps Abnormalities: A Systematic Review and Meta-analysis. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120945322

[21] American Shoulder and Elbow Surgeons SLAP/Biceps Anchor Study Group evidence review: pathoanatomy and diagnosis in clinically significant labral injuries. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.12.015

[22] Risk Factors for Revision Surgery After Superior Labral Anterior-Posterior Repair: A National Perspective. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517691950

[23] Clinical Presentation and Follow‐up of Isolated SLAP Lesions of the Shoulder (SS‐04). Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.03.007

[24] SLAP repair and bicep tenodesis: a comparison of utilization and revision rates for SLAP tears. JSES International. 2023. DOI: 10.1016/j.jseint.2022.11.001

[25] Surgical Management of Type IV SLAP Lesions (SS‐13). Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.04.014

[26] Results of Subpectoral Biceps Tenodesis for the Treatment of Type II and IV SLAP Lesions. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.04.030

[27] Reproducibility and Reliability of the Snyder Classification of Superior Labral Anterior Posterior Lesions Among Shoulder Surgeons. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546510392332

[28] Arthroscopic treatment of type II superior labral anterior to posterior (SLAP) lesions in a younger population: minimum 2‐year outcomes are similar between SLAP repair and biceps tenodesis. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-05971-0

[29] The Compressive Behavior of the Human Glenoid Labrum May Explain the Common Patterns of SLAP Lesions. Arthroscopy. 2009. DOI: 10.1016/j.arthro.2008.12.012

[30] The sub-supraspinatus recess and superior labral motion: an arthroscopic analysis. Shoulder & Elbow. 2018. DOI: 10.1177/1758573218757169

[31] Current Practice for the Diagnosis of a SLAP Lesion: Systematic Review and Physician Survey. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.06.033

[33] 2025 Basic Science Neer Award Winner: The impact of posterior and posterior superior labral injuries and the effect of their treatment on glenohumeral kinematics in the deceleration and follow-through phase of throwing: a biomechanical study. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.023

[34] SLAP lesions: current controversies. EFORT Open Reviews. 2019. DOI: 10.1302/2058-5241.4.180033

[38] Arthroscopic Treatment of Isolated Type II SLAP Lesions. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546508330127

[39] Effects of Zone-Specific Superior Labral Detachment on Biceps Anchor Stability. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509343468

[41] Cost Comparison of Open and Arthroscopic Treatment Options for SLAP Tears. Arthroscopy, Sports Medicine, and Rehabilitation. 2021. DOI: 10.1016/j.asmr.2020.09.020

[42] Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4226-7

[43] Simulated Type II Superior Labral Anterior Posterior Lesions Do Not Alter the Path of Glenohumeral Articulation. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546507312169

[44] Factors influencing surgeons’ decision-making in the treatment of SLAP lesions: A case-vignette study. Journal of ISAKOS. 2026. DOI: 10.1016/j.jisako.2026.101087

[45] Arthroscopic Treatment of a Type II Superior Labrum Anterior to Posterior (SLAP) Lesion Combined with a Bankart Lesion: Comparative Study between Debridement and Repair of Type II SLAP Lesion by the Status of Lesion. Clinics in Shoulder and Elbow. 2018. DOI: 10.5397/cise.2018.21.1.37

[46] Does a SLAP lesion affect shoulder muscle recruitment as measured by EMG activity during a rugby tackle?. Journal of Orthopaedic Surgery and Research. 2010. DOI: 10.1186/1749-799x-5-12

[47] Editorial Commentary: Outcomes After SLAP Repair and Biceps Tenodesis Are Unpredictable for Throwing Athletes With SLAP Lesions. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.03.022

[48] Developing a Clinical Prediction Model for Failed Nonoperative Management of SLAP Tears (220). Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00328

[49] Increased glenohumeral translation and biceps load after SLAP lesions with potential influence on glenohumeral chondral lesions: a biomechanical study on human cadavers. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1423-2

[51] Effects of type II SLAP lesion repair techniques on the vascular supply of the long head of the biceps tendon: a cadaveric injection study. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.07.014

[52] External rotation and active supination CT arthrography for the postoperative evaluation of type II superior labral anterior to posterior lesions. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3350-5

[53] Outcomes of Revision Arthroscopic Type II Superior Labral Anterior Posterior Repairs. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511398648

[54] Paper 15: Return to Play after Biceps Tenodesis for Isolated SLAP Tears in Overhead Athletes. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00553

[56] SLAP Lesions of the Shoulder. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2010.06.004

[58] High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967115623212

[59] Similar outcomes between biceps tenodesis and SLAP repair for SLAP tears in younger patients – A meta-analysis. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2023.09.007

[60] High Rate of Return to Sporting Activity Among Overhead Athletes With Subpectoral Biceps Tenodesis for Type II SLAP Tear. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2023. DOI: 10.1016/j.arthro.2022.07.017

[61] Effects of Varying Locations for Biceps Tendon Tenotomy and Superior Labral Integrity on Shoulder Stability in a Cadaveric Concavity‐Compression Model. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.06.012

[63] Outcome of Type II Superior Labral Anterior Posterior Repairs in Elite Overhead Athletes. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510379971

[64] Anterosuperior Labral Tear Without Biceps Anchor Involvement: A Subtle Isolated Cause of a Painful Shoulder. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2010.05.022

[65] Outcomes After Open Latarjet in Patients With or Without SLAP Lesions. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/23259671231185199

[66] Development of new SLAP lesion after the arthroscopic, isolated decompression of ganglion cyst of the shoulder. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-0851-8

[67] Isolated type II SLAP tears undergo reoperation more frequently. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-020-06397-4

[68] Single‐Portal SLAP Lesion Repair. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.05.033

[69] SLAP tears and return to sport and work: current concepts. Journal of ISAKOS. 2021. DOI: 10.1136/jisakos-2020-000537

[70] Biceps Tenodesis Has Greater Expected Value Than Repair for Isolated Type II SLAP Tears: A Meta‐analysis and Expected‐Value Decision Analysis. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.05.005

[71] SLAP Lesions: Trends in Treatment. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2015.11.044

[72] Open Subpectoral Biceps Tenodesis versus Arthroscopic Repair for SLAP Tears in Patients under 30 (224). Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00332

[73] Biceps Tenodesis Demonstrates Lower Reoperation Rates Compared to SLAP Repair for Treatment of SLAP Tears in a Large Cross‐Sectional Population. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.11.049

[74] Long‐Term Outcome After Arthroscopic Repair of Type II SLAP Lesions: Results According to Age and Workers' Compensation Status. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2011.09.005

[75] Editorial Commentary: Subpectoral Biceps Tenodesis Is a Safe Alternative to Arthroscopic Repair for Unstable SLAP Tear in the Young Athlete: Should We Do the Last Operation First?. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2021.10.019

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.