SLAP ਅਤੇ ਬਾਈਸੈਪਸ ਦੀਆਂ ਸਮੱਸਿਆਵਾਂ ਜਾਣਕਾਰੀ In-depth

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• For operative treatment of proximal biceps pathology in overhead athletes, biceps tenodesis yields consistent and reliable results, whereas return to play after SLAP repair can be unpredictable [1].
• Biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears [2].
• Both arthroscopic repair and biceps tenotomy and tenodesis interventions provide benefits for type II SLAP lesions [3].
• SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years [4].
• 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 [5].
• SLAP repair and biceps tenodesis are both viable treatment options with specific advantages and disadvantages, with the decision ultimately made individually with the patient [6].
• Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up [7].
• Appropriate treatment for biceps pathology, whether conservative or surgical, should be based on established pathology [10].
• Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair [11].
• The number of isolated SLAP repairs performed has decreased over time [12].
• Management of failed SLAP repair has shifted toward biceps tenodesis or tenotomy over revision SLAP repair in more recent years [12].
• Short-term follow-up of 20 subpectoral biceps tenodesis procedures using an all-suture anchor fixation has not shown any failure of fixation or residual biceps discomfort [13].
• In a young active population, primary arthroscopic biceps tenodesis is a viable surgical alternative to labral repair for type II SLAP lesions [14].
• Biceps tenodesis may be considered a valid primary or revision surgery for patients suffering from symptomatic type II SLAP tears due to no detrimental effect on glenohumeral stability [15].
• Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment [18].
• Primary biceps tenodesis offers lower costs than primary SLAP repair [18].
• 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 [19].
• Treatment of proximal biceps pathology is largely based on expert opinion and patient preferences rather than robust randomized evidence [28].
• Adjuvant biceps procedures are not required when repairing isolated supraspinatus tears unless biceps pathology is observed intraoperatively, for which tenodesis grants better function and strength than tenotomy [29].
• The indications and technique of biceps tenodesis in the elite pitcher still need to be defined [57].
• 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 [60].
• Biceps tenotomy is well accepted by most patients with good overall results [71].
• The choice between biceps tenotomy and tenodesis for pathology of the proximal biceps tendon can continue to be based on surgeon and patient preference [73].

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 of the biceps originates from the coracoid tip lateral to and in common with the coracobrachialis [31].
• The biceps tendon is an intra-articular but extrasynovial structure within the glenohumeral joint [43].
• 40% to 60% of the biceps tendon attaches to the supraglenoid tubercle 5 mm medial to the superior glenoid rim, with the remainder attaching directly to the superior glenoid labrum [43].
• The biceps tendon typically attaches entirely (type I) or predominantly posterior (type II) on the superior labrum [43].
• The biceps tendon may have equal anterior and posterior contributions (type III) or, less commonly, predominantly anterior (type IV) attachment [43].
• The glenoid labrum consists of parallel collagen fibers that course around the circumference of the glenoid [43].
• The superior labrum inserts on the superior glenoid rim, medial to the articular cartilage margin, through a transitional zone of fibrocartilage [43].
• A normal synovial recess exists between the meniscoid or triangular superior labrum and the articular cartilage extension over the superior glenoid rim [43].
• The superior labrum is usually triangular but can have a meniscoid shape [44].
• The superior labrum is less vascular compared with the inferior and posterior labrum [44].
• Vascularity to the glenoid labrum originates from the scapular, circumflex scapular, and posterior circumflex humeral arteries via capsular or periosteal vessels [43].
• The inner portion of the labrum is avascular [44].
• The biceps tendon passes through the bicipital groove, or intertubercular groove, between the greater and lesser tuberosities [43].
• Stability of the biceps within the bicipital groove is afforded by the biceps sling, or pulley, consisting of fibers from the subscapularis tendon, supraspinatus tendon, coracohumeral ligament, and superior glenohumeral ligament [43].
• 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 bicipital 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].
• A shallow bicipital groove and supratubercular ridge above the lesser tubercle were thought to predispose to biceps tendon pathology [31].
• The medial wall of the bicipital groove was higher, with an opening angle of 30 to 40 degrees in the largest fraction of patients [31].
• The biceps tendon is innervated by thinly myelinated sensory neurons, with most innervation occurring at the LHB origin [44].
• Blood is supplied to the LHB tendon from the thoracoacromial and brachial arteries via the osteotendinous and musculotendinous junctions, respectively [44].
• A hypovascular zone exists at the proximal portion of the LHB tendon, close to the superior glenoid [43].
• The biceps muscle has two distal tendinous insertions: a lateral insertion to the posterior part of the tuberosity of the radius and a medial aponeurotic insertion into the deep fascia of the volar forearm [31].
• Loss of the long head attachment is manifested mainly as a 20% loss of supination strength and an 8% loss of elbow flexion strength [31].
• The biceps labral complex (BLC) consists of the superior glenoid labrum (SGL) and the long head of the biceps (LHB) tendon [89].
• The BLC is classified into three distinct zones: Inside, Junction, and Extra-articular [44].
• The Inside zone of the BLC consists of the SGL and the LHB anchor [44].
• The Junction zone includes the intra-articular portion of the LHB and the stabilizing biceps pulley [44].
• The Extra-articular zone consists of the bicipital tunnel, divided into zone 1 (bony groove), zone 2 (“No Man’s Land”), and zone 3 (subpectoralis) [44].
• Zone 1 and zone 2 of the bicipital tunnel contain synovial tissue, which may generate pain [44].
• Zone 2 of the bicipital tunnel cannot be visualized by arthroscopy from above or with an open approach from below [44].

Anatomic Variants

• A sublabral foramen was identified in 3.3% of shoulders in a cohort of 73 [44].
• A sublabral foramen with a cordlike middle glenohumeral ligament (Buford complex) was identified in 8.6% of shoulders in a cohort of 73 [44].
• An absent anterosuperior labrum was identified in 1.5% of shoulders in a cohort of 73 [44].
• The sublabral recess represents a small potential space under the biceps anchor and the anterosuperior labrum, often present at the 12 o’clock position [92].
• The Buford complex is a normal variant consisting of a cordlike middle glenohumeral ligament originating directly from the superior labrum at the base of the biceps tendon, resulting in an absence of anterosuperior labral tissue [92].
• The sublabral foramen involves a cordlike middle glenohumeral ligament attaching directly to the anterosuperior labrum, creating a hole between the ligament and the glenoid [92].
• Inappropriate surgical attachment of a cord-like middle glenohumeral ligament to a void on the anterosuperior glenoid results in painful restriction of external rotation and elevation [92].
• The incidence of the cordlike middle glenohumeral ligament in isolation is 18%, which is more common than its combination with the Buford complex (1% to 2%) [92].
• The superior labrum has a high degree of normal variation, typically either rounded or meniscoid [92].
• In one series, 49 of 191 patients demonstrated a mobile meniscoid type of superior labrum at arthroscopy and were treated with observation alone [92].
• Only one of the patients with a mobile meniscoid type of superior labrum became clinically symptomatic [92].

Pathophysiology and Mechanisms

• SLAP tears can be caused by forceful traction to the arm, direct compression loads, and repetitive overhead throwing [33].
• 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 [33].
• 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 [33].
• SLAP tears are seen more frequently in the late cocking position because of an adaptive posterior capsular contracture [33].
• Throwing athletes demonstrate increased shoulder external rotation and decreased internal rotation in abduction, causing posterosuperior migration of the humeral head in the late cocking phase [33].
• 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 [33].
• The proximal LHB tendon is a source of substantial anterior shoulder pain [33].
• Pathology of the LHB tendon includes tendinitis, tendinopathy, tears, subluxation, entrapment, delamination, and dislocation out of the bicipital groove [33].
• The relatively anterior position of the bicipital groove along the humeral head combined with humeral retroversion exposes the tendon to medial instability [33].
• Variations of bicipital groove morphology can increase the risk of LHB tendon pathology [33].
• Isolated LHB tendon pathology frequently is associated with other shoulder pathologies, especially rotator cuff pathology [33].
• Primary LHB tendinitis usually occurs in younger patients who participate in overhead activities such as volleyball and baseball [33].
• A subscapularis tear is associated with LHB medial instability [33].
• A supraspinatus tear is associated with posterolateral instability of the LHB tendon [33].
• SLAP lesions lead to increased glenohumeral translation and concurrently increased LHB tension and load in the anterior direction [127].
• 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 [35].
• The dynamic relationship between the biceps tendon and superior labral complex and their combined role in glenohumeral stability remains unclear [88].
• The biceps tendon does not slide in the groove; rather, the humerus moves on the stationary biceps tendon during shoulder motion [88].
• From full adduction to full elevation of the arm, the groove moves a distance of up to 2 to 5 cm along the tendon [88].
• Maximal excursion of the humeral head along the tendon results when the shoulder is in a position of maximal external rotation [88].
• Minimal excursion of the humeral head along the tendon is seen when the shoulder is in a position of maximal internal rotation [88].
• The synovial pouch extends from the shoulder joint, lining the greater part of the intertubercular groove [88].
• With the arm in full abduction, 1.3 cm of the long head of the biceps tendon lies within the shoulder joint [88].
• When the arm is adducted and externally rotated, the length of tendon within the joint increases to 5 cm [88].
• In external rotation, the long head of the biceps acts as a head depressor at the shoulder to enhance abduction strength [88].
• 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 [88].
• The function of the biceps tendon as a humeral head depressor increases in the context of a chronic rotator cuff tear [88].
• Electrical stimulation of the biceps tendon results in superior lifting of the labrum and compression of the glenohumeral joint [88].
• The long and short heads of the biceps function as anterior stabilizers of the glenohumeral joint with the arm in abduction and external rotation [88].
• 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 [88].
• Severing the long head of the biceps tendon while both heads are tensed causes significant upward migration of the humeral head [88].
• The long head of the biceps is important in stabilizing the humeral head in the glenoid during powerful elbow flexion and forearm supination [88].
• 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 [89].
• 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 [46].
• Bicipital instability is usually associated with rotator interval injury or subscapularis tendon injury, or both [46].
• In the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity [17].
• The distinction between inflammatory, unstable, or traumatic biceps 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 [25].
• Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders [41].
• There is no single pattern of pain that distinguishes biceps conditions from other shoulder abnormalities [23].
• 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 [24].
• No single physical examination finding is completely accurate for the diagnosis of a SLAP tear [24].
• The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals [62].

Classification

• Long head of biceps tendon disorders are classified into inflammatory, unstable, or traumatic categories based on the original initiating event [25].
• 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 can result in changes indistinguishable from inflammation [25].
• Inflammatory biceps tendon disorders include biceps tendinitis concurrent with rotator cuff disease and primary bicipital tendinitis [25].
• Instability biceps tendon disorders include subluxation and dislocation [25].
• Subluxation of the long head of the biceps tendon 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) [25].
• Dislocation of the long head of the biceps tendon is classified into Type I (extraarticular, combined with partial tear of subscapularis) and Type II (intraarticular, combined with full-thickness tear of subscapularis) [25].
• Traumatic biceps tendon disorders include traumatic rupture and superior labral tears (SLAP lesions) [25].
• Traumatic rupture of the long head of the biceps tendon is classified into Type I (partial) and Type II (complete) [25].
• Superior labral tears (SLAP lesions) are classified into Type I (significant fraying), Type II (complete detachment of biceps tendon and superior labrum from glenoid), Type III (“bucket-handle” tear of superior labrum), and Type IV (central superior labrum tear with extension into the biceps) [25].
• Type II SLAP tears are the most common subtype of SLAP lesions initially described by the Snyder classification [56].
• Type II SLAP lesions are thought to result from a peelback mechanism during maximum external rotation of the arm during the throwing motion involving eccentric biceps contraction and high tensile forces on the biceps anchor [56].
• The Yamaguchi and Bindra classification organizes the pathogenesis of biceps tendon disorders to help formulate protocols for appropriate management [25].

Clinical Presentation

History and Symptoms

• A history of acute trauma, consisting of sudden traction or compression to the affected extremity, may be present in patients with SLAP tears [48].
• SLAP tears can be associated with a previous subluxation or dislocation event [48].
• Insidious onset of symptoms associated with SLAP tears is most common in overhead throwing athletes [48].
• Pain caused by a SLAP tear is often localized deep within the glenohumeral joint [48].
• SLAP tear pain can be associated with mechanical symptoms, fatigue, or a “dead arm” sensation of the extremity during overhead activities [48].
• SLAP tear pain can be associated with frank weakness of the rotator cuff in the presence of a concomitant paralabral cyst [48].
• Patients with tenosynovitis of the long head of the biceps tendon (LHBT) often report pain in the anterior aspect of the shoulder that radiates down the arm into the anterior biceps [34].
• Symptoms of LHBT tenosynovitis may be exacerbated with overhead activity and activity that requires elbow flexion [34].
• Pain caused by LHBT tendinitis is usually localized more distally than pain typically caused by rotator cuff impingement [34].
• Patients with LHBT pathology may report mechanical symptoms as a result of the tendon snapping or catching in the anterior shoulder [34].
• In patients with an LHBT rupture, ecchymosis in the proximal aspect of the arm and a Popeye deformity are frequently observed [34].
• Muscle belly cramping may be reported in patients with an LHBT rupture [34].
• With LHB tendon instability, the patient describes a clicking or snapping with overhead motions [33].
• The proximal LHB tendon is a source of substantial anterior shoulder pain that can be difficult to diagnose because it occurs with other pathologies including SLAP lesions, rotator cuff disorders, impingement, bursitis, and acromioclavicular joint disorders [33].
• Biceps tendon pain in the absence of tears is associated with microscopic changes consistent with tendinopathy, which are often missed by MRI [63].
• 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 [21].
• Macroscopic changes in the long head of the biceps tendon do not always correlate with symptoms, and a normal arthroscopy does not exclude important symptomatic pathology [64].

Physical Examination

• Clinical diagnosis of a SLAP tear or symptomatic LHB tendinopathy through physical examination is often challenging because examination findings are similar to other pathologies within the glenohumeral joint [96].
• No single physical examination finding produces a consistently accurate SLAP tear diagnosis [96].
• Various provocative tests have been described for SLAP tears and biceps pathology, but none have sufficient accuracy to confirm the diagnosis [48].
• Clinical examination alone has been shown to be unreliable in diagnosing SLAP tears when multiple physical examination tests have been compared with intraoperative findings [96].
• The O’Brien active compression test is the most commonly used maneuver to evaluate for a possible SLAP tear [96].
• The O’Brien active compression test is positive if pain occurs deep within the shoulder in maximum internal rotation and improves with maximum external rotation [48].
• 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 [48].
• The Biceps load I and II tests are positive if pain or apprehension worsens with resisted elbow flexion in a position of 90° to 120° abduction, maximal external rotation, and maximal forearm supination [48].
• 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 with the hand on the hip and thumb posterior [48].
• The Speed test is positive if pain is experienced in the anterior shoulder or glenohumeral joint when the patient resists downward pressure on an extremity elevated to 90° in full supination with the elbow extended [48].
• The dynamic labral shear test is characterized by a reproducible painful click deep in the shoulder in the mid-arc of abduction when the affected arm is externally rotated and progressively abducted while horizontally extended [48].
• The Yergason test is positive if pain is experienced in the bicipital groove or glenohumeral joint when the patient supinates against resistance with the elbow flexed to 90° [48].
• Speed and Yergason tests demonstrate poor sensitivity, moderate specificity, and poor accuracy for diagnosing SLAP tears and biceps pathology [48].
• Including two sensitive tests (active compression and crank tests) and a specific test (Speed test) increases the overall accuracy of the diagnosis [48].
• The Speed test has a sensitivity of 0.54, specificity of 0.81, positive predictive value of 0.56, and negative predictive value of 0.79 for long head biceps pathologic conditions [87].
• The Yergason test has a sensitivity of 0.41, specificity of 0.79, positive predictive value of 0.48, and negative predictive value of 0.74 for long head biceps pathologic conditions [87].
• The O’Brien test has a sensitivity of 0.38, specificity of 0.61, positive predictive value of 0.31, and negative predictive value of 0.67 for long head biceps pathologic conditions [87].
• Both the Yergason and Speed tests are specific but not sensitive in detecting LHB tendinitis, rupture, and SLAP lesions [96].
• The most common physical examination finding for LHB pathology is tenderness caused by palpating the tendon within the bicipital groove [96].
• A positive subpectoral biceps test was associated with gross pathologic changes of the biceps in 93% of patients [9].
• A deformity of the LHB tendon such as a Popeye sign indicates tendon rupture [96].
• A painful click or tenderness to palpation at full abduction and external rotation indicates medial LHB instability [96].
• If the LHB tendon is dislocated, it can be rolled under the examiner’s fingers [96].
• 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 [96].
• Range of motion and rotator cuff strength are usually preserved in patients with SLAP tears [96].
• Overt instability in the setting of an isolated SLAP tear is rare [96].
• Glenohumeral internal rotation deficit greater than 25° to 30° can predispose patients to internal impingement and SLAP tears [96].
• The 3-pack examination consists of the active compression test, the throwing test, and bicipital tunnel palpation [96].
• 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 [96].
• 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 [96].
• The area of the intertubercular groove, located 7 cm below the acromion with the arm internally rotated 10°, is the most common site of pain in LHBT pathology [34].
• Pain in LHBT pathology can be elicited via direct palpation of the intertubercular groove, especially with gentle internal and external rotation of the shoulder during palpation [34].
• In the subpectoral LHB tendon test, the examiner palpates the tendon just medial to the pectoralis major tendon insertion while the patient internally rotates the arm against resistance [50].
• A greater amount of pain on the affected side during the subpectoral LHB tendon test suggests that synovitis is localized to the bicipital groove [50].
• The unaffected, contralateral side should be tested for comparison when evaluating LHB tendinopathy [50].
• Physical examination should include assessment of rotator cuff strength and infraspinatus atrophy to identify patients who may have suprascapular nerve compression from a paralabral ganglion cyst [48].
• An instability examination should be performed when evaluating for SLAP tears [48].
• Assessment of throwing athletes includes the total arc of rotation to identify those with a glenohumeral internal rotation deficit [48].

Imaging and Diagnostic Confirmation

• MRI is the imaging modality of choice for diagnosing SLAP tears and LHB pathology [48].
• Diagnostic accuracy of MRI may be improved by positioning the arm in abduction and external rotation [48].
• Magnetic resonance (MR) arthrography improves the diagnostic performance of an MRI for the detection of a SLAP tear [48].
• MRA helps diagnose LHB pathology and SLAP tears because it is more specific and more sensitive than MRI alone [24].
• Diagnostic accuracy of MRI ranges widely in the literature [48].
• Overdiagnosis of SLAP tears is common as normal anatomy can be misconstrued as pathologic [48].
• Accurate diagnosis of SLAP tears is predicated on clinical examination and concordant MRI findings and cannot be confirmed until the time of surgery [48].
• Ultrasonography can be useful in the dynamic assessment of the biceps tendon [48].
• Diagnostic injection of local anesthetic with or without corticosteroid into the glenohumeral joint or bicipital groove may aid in confirming the diagnosis of SLAP tears and biceps pathology [48].
• A subacromial injection may relieve pain caused by impingement, and if biceps pain persists, an injection into the bicipital groove may be given to help differentiate LHB tendinitis from other common causes of anterior shoulder pain [50].
• An intraarticular injection is diagnostically and therapeutically useful, especially when a SLAP tear is suspected [50].
• 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 [8].
• 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 [52].
• Arthroscopic examination is limited to the intra-articular LHBT as well as the proximal groove, missing less common distal biceps groove lesions [97].
• In approximately 80% of the intra-articular biceps tears evaluated in a study of subpectoral biceps tenodesis, a 'hidden lesion' was observed going beyond the bicipital groove and extending to the distal extra-articular portion [66].

Investigations

Clinical Examination

• A combined physical examination approach aids in the diagnosis of SLAP or long head of biceps (LHB) pathology [24].
• Provocative tests for symptomatic patients with LHB pathology include direct palpation over the bicipital groove and specific examination maneuvers [34].
• The area of the intertubercular groove, located 7 cm below the acromion with the arm internally rotated 10 degrees, is the most common site of pain in LHB pathology [34].
• Pain in LHB pathology can be elicited via direct palpation of the intertubercular groove, especially with gentle internal and external rotation of the shoulder during palpation [34].
• The Speed test and Yergason test are sensitive for the diagnosis of LHB pathology but are associated with poor specificity [34].
• The "3-pack" examination consists of the active compression test, throwing test, and bicipital tunnel palpation [30].

Imaging

• Plain radiographs (scapular Y, AP, and axillary lateral views) should be obtained to assess the glenohumeral joint for abnormalities [93].
• MRI may be used to assess the LHB tendon, associated fluid, possible synovitis, bicipital groove morphology, and the presence of bony osteophytes [93].
• MRI can help identify concomitant shoulder and acromioclavicular joint pathologies [93].
• Studies have demonstrated poor correlation between MRI and arthroscopic findings regarding LHB pathology [93].
• MRI has poor to moderate sensitivity for inflammation, partial-thickness tendon tears, and tendon ruptures of the LHB [93].
• Magnetic resonance arthrography (MRA) is more specific and sensitive for LHB pathology and SLAP tears than MRI [24, 93].
• In patients with no pathology, MRA shows the LHB tendon surrounded by contrast fluid, resembling a kidney bean [93].
• 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 [93].
• Ultrasonography is accurate and cost-effective in the diagnosis of LHB dislocation, subluxation, and rupture [93].
• Ultrasonography is not as accurate as other modalities in diagnosing partial-thickness LHB tendon tears [93].
• The exact role of ultrasonography for the diagnosis of tendon inflammation has not been fully defined [93].
• Proton density–weighted sequences with fat suppression have the greatest sensitivity for detecting biceps tendon degeneration [45].
• Tendon caliber change is more specific than signal intensity for detecting biceps tendon degeneration [45].
• Biceps tendon partial tears at the entrance to the bicipital groove show abnormal signal intensity, but half have an associated caliber change [45].
• Evaluation in all imaging planes aids in the identification of a biceps groove entrance lesion [45].
• MRA has a sensitivity of 82% to 89% and a specificity of 87% to 98% in the evaluation of the biceps pulley [45].
• Diagnostic criteria for biceps pulley evaluation 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 [45].
• The rotator cuff interval is best assessed with MRA because joint distension can separate the components of the rotator cuff interval [45].
• Bicipital groove morphology measured by MRI has no value as a predictor of biceps tendon or rotator cuff pathology at the time of surgery [126].
• Biceps-radial MR images excellently agreed with arthroscopic findings regarding LHB instability and pulley lesions [146].
• Conventional MR images poorly or moderately agreed with arthroscopic findings regarding LHB instability and pulley lesions [146].
• Preoperative MRI scans of the shoulder interpreted by orthopaedic surgeons using a systematic approach resulted in improved accuracy in diagnosing subscapularis tendon tears compared with previous studies [135].
• The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits, and suspected cuff tendinopathy other than full-thickness tears provides negative value in management [147].

Arthroscopic Assessment

• 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 [51].
• The concomitant presence of SLAP and pulley lesions is significantly rare, occurring in only about 10% of all patients with SLAP and pulley lesions [37].
• In approximately 80% of intra-articular biceps tears evaluated, a "hidden lesion" was observed extending beyond the bicipital groove to the distal extra-articular portion [66].
• Surgeons should maintain a high level of suspicion and utilize specific techniques to prevent missing long head biceps tendon and subscapularis pathology [52].

Treatment

Non-Operative Management

• Nonoperative treatment of SLAP tears is the mainstay of treatment, particularly in throwers, and has achieved good success [55].
• A second course of physical therapy specifically designed to improve glenohumeral internal rotation deficit, scapular dyskinesia, posterior capsular contracture, and concomitant injuries has demonstrated reasonable success after initial failure of nonoperative treatment [55].
• Surgical management of SLAP tears should be considered in patients with persistent symptoms following a 3-month period of nonsurgical treatment [51].
• Injection of local anesthetic with corticosteroid into the glenohumeral joint or bicipital groove is diagnostic and potentially therapeutic for SLAP tears and biceps pathology [115].
• Aspiration of the spinoglenoid notch cyst can be performed to treat suprascapular nerve compression associated with SLAP tears [115].
• Physical therapy for superior labral tears consists of rotator cuff strengthening, periscapular muscular strengthening, and posteroinferior capsular stretching [115].
• In the general population, predictive factors for failure of nonsurgical management of SLAP tears include history of trauma, positive compression-rotation test, and participation in overhead sports [115].
• In baseball players, advanced age, prolonged symptoms, pitching, presence of exostosis of the posterior band of the inferior glenohumeral ligament (Bennett lesion), and presence of partial articular rotator cuff tear have been associated with failure of conservative management [115].
• Initial management of biceps tendinitis includes strengthening exercises and local corticosteroid injection into the biceps sheath [112].
• Surgical release for biceps tendinitis is usually reserved for refractory cases [112].
• Diagnosis and nonoperative management of long head of biceps tendon disorders are categorized as inflammation, instability, and rupture, requiring specific protocols [61].

Operative Management: SLAP Repair

• SLAP repairs are generally favored in younger, active patients [4].
• SLAP repairs have proved more beneficial than tenodesis in patients younger than 40 years [24].
• SLAP repairs may be even more successful if not associated with rotator cuff repair [24].
• Type I SLAP tears are usually managed with a débridement back to a stable base [51].
• Type II SLAP lesions should be repaired when the history and examination suggest a SLAP tear and the arthroscopic examination confirms existence of a type II tear [51].
• 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 [51].
• 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 [51].
• Type I degenerative tears typically demonstrate fraying with an intact biceps anchor, and débridement alone is sufficient [115].
• 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 [115].
• 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 [115].
• Type III tears are managed by débriding the unstable bucket-handle labral tear [115].
• Type IV tears with less than 25% to 50% of the biceps tendon involved are managed by débriding the tear and its extension into the tendon [115].
• Type IV tears with 25% to 50% or more of the biceps tendon involved are managed with biceps tenodesis or tenotomy with labral débridement or repair [115].
• Management of type IV tears depends on the patient age and the extent of LHB tendon involvement [51].
• If less than 30% of the tendon is involved in a type IV tear, these tears are usually managed with débridement [51].
• Tears of more than 30% of the LHB tendon are usually managed with LHB tenodesis [51].
• Bioabsorbable tacks are no longer used for SLAP repair because of concerns about synovitis and cartilage damage caused by the degradation and release of loose bodies [51].
• A revision surgery rate of 6.3%, with a 4.3% rate of revision SLAP repair, has been reported [51].
• Revision surgery and failure after index SLAP repair correlated with the use of absorbable poly-l/d-lactic acid suture anchors [51].
• Bulky suture knots should be avoided during SLAP repair to prevent shoulder pain, impingement, and chondral injury [51].
• 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 [51].
• Knotless horizontal mattress suture fixation resulted in significantly better range of motion compared with vertical knot fixation, although no significant difference in functional outcomes scores was noted [51].
• Paralabral ganglion cysts associated with SLAP tears can successfully be treated arthroscopically [51].
• Concomitant repair of rotator cuff tears and SLAP tears have shown good clinical outcomes with high patient satisfaction [51].
• 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 [51].
• Subacromial procedures performed in conjunction with a superior labral repair should be done with caution because they may increase the risk of postoperative stiffness [115].
• It is generally preferable to perform a biceps procedure, rather than a SLAP repair, when a concomitant rotator cuff repair is performed [115].
• Overconstraining of the biceps anchor should be avoided during superior labral repair [115].
• Knotless implants eliminate the need for arthroscopic knot tying and, with a horizontal mattress suture configuration, decrease the potential adverse effects of bulky intra-articular suture material [115].
• Attempting repair of degenerative lesions of the labrum can lead to unwanted shoulder tightness [36].
• Placement of suture anchors for labral repairs is critical to avoid problems with “anchor arthropathy” [36].

Operative Management: Biceps Tenodesis and Tenotomy

• Biceps tenodesis has consistent and reliable results for operative treatment in overhead athletes [1].
• Return to play after SLAP repair can be unpredictable in overhead athletes [1].
• Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions [3].
• Treating the biceps is preferred in lower-demand patients aged >30 years [4].
• 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 [5].
• SLAP repair and biceps tenodesis both present viable treatment options but come with specific advantages and disadvantages [6].
• 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 [18].
• 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 [19].
• Biceps tenodesis remains a reliable treatment for pathologic abnormality of the long head of the biceps [22].
• 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 [27].
• High-quality randomized controlled trials comparing biceps tenotomy versus tenodesis during shoulder arthroscopy have largely demonstrated statistical noninferiority of clinical outcomes [111].
• The choice between biceps tenotomy and tenodesis for pathology of the proximal biceps tendon can continue to be based on surgeon and patient preference in active patients younger than 55 years [73].
• Revision to subpectoral biceps tenodesis may be an effective strategy to address failed prior biceps surgery, but the potential complication of persistent pain must be emphasized [74].
• Subpectoral biceps tenodesis utilizing a dual suture anchor technique is a treatment option for SLAP lesions, partial thickness tears, subluxation, and tenosynovitis of the long head of the biceps with high rates of postoperative patient satisfaction, a low failure rate, and improved outcome scores [102].
• Biceps tenotomy has been recommended by some authors as it is simpler to perform and requires no postoperative rehabilitation or restrictions [106].
• Biceps tenodesis can help minimize complications such as cosmetic deformity, biceps cramping, and fatigue pain while also improving anterior shoulder pain [106].
• Tenodesis has become more popular for treating biceps pathology in younger patients, athletes, and laborers [106].
• 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 [59].
• 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 [59].
• Recent literature suggests no difference in the outcome from biceps tenodesis and tenotomy procedures [59].
• 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 in the literature [59].
• Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis [132].
• High-quality randomized controlled trials are necessary to understand how different biceps management techniques truly perform [140].
• Tenodesis is favored over tenotomy in active patients for cosmesis and prevention of biceps cramping [58].
• The method of fixation for biceps tenodesis seems to be less important than the quality of the tissue fixed [58].
• Subpectoral tenodesis has been recommended to prevent the groove pain reported in some series [58].
• The potential for plexus and musculocutaneous nerve injury or humeral diaphyseal stress fractures has been reported with subpectoral tenodesis techniques [58].
• Biceps tenodesis to treat type 2 SLAP tears has been reported to be successful in approximately two thirds of athletes, comparable to primary SLAP repair [58].
• Pitchers treated with tenodesis tend to have persistence of some anterior shoulder pain [58].
• Tenotomy without tenodesis is associated with subjective cramping and potential for cosmetic deformity (“Popeye deformity”), but weakness is not associated with tenotomy [112].
• Tenodesis may result in “groove pain” if the technique of the tenodesis retains a portion of the tendon in the intertubercular groove; a subpectoral tenodesis technique reduces the risk of groove pain [112].
• 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 of the biceps muscle [115].
• Biceps tenodesis involves removal of the intra-articular portion of the tendon (a pain generator) with more distal reinsertion of the tendon to maintain the length-tension relationship of the biceps muscle [115].
• 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 [115].
• 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 [115].
• In biceps tendon instability, acceptable outcomes have not been achieved with pulley repair or reconstruction [115].
• 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 [115].
• 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 [57].
• Outcomes for both SLAP repair and biceps tenodesis exhibit massive variability when treating SLAP tears in overhead throwers [70].
• 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 [40].
• Surgical results for SLAP tears are far less favorable in overhead athletes compared to the general population [55].
• Success of surgical intervention for SLAP tears in throwers may be largely influenced by factors independent of the quality of surgical repair, such as age, associated pathology, position in sport, and the competitive level [55].
• Higher level pitchers return to play and at a higher level than lower level pitchers regardless of whether they undergo nonoperative or operative treatment [55].
• Biceps tenodesis or tenotomy should be performed at the time of repair of a subscapularis tendon tear, regardless of any identified biceps tendon or pulley pathology, according to Edwards et al. [59].
• In certain subsets of patients such as younger patients with simple rupture of the pulley sling or those with acute injuries, comparable results have been reported with isolated repair of the biceps pulley [59].
• There is a general consensus that if there is evidence of biceps pathology or if the tendon is subluxated or dislocated, a tenodesis or tenotomy is the preferred treatment [59].
• There is no clear consensus regarding the decision between tenodesis and tenotomy, and evidence of superiority of one procedure over the other with respect to pain relief, functional outcomes, or strength is largely inconsistent [59].
• In patients who have chronic impingement and persistent biceps tendinitis with more than 50% of the biceps tendon disrupted, or with biceps tendon subluxation, an arthroscopic or mini-open tenodesis can be used [58].
• Boileau et al. described an hourglass-shaped biceps deformity that is associated with inflammation and triggering through the proximal pulley, and the treatment is arthroscopic tendon debulking or tenodesis [58].
• Biceps tenodesis offers reliable improvements in pain and function while maintaining biceps contour [54].
• The longitudinal anatomy of the long head of the biceps tendon has implications on tenodesis that will potentially result in the most efficient biceps muscle–tendon function and improve the results of biceps surgery [118].
• Tenodesis can be done with a PEEK tenodesis screw, with two suture anchors, or with the use of a FiberSnare [119].
• The resistance to cyclic loading is comparable between PEEK tenodesis screw and suture anchor techniques, whereas the ultimate pull-out strength of the biotenodesis screw is stronger than the suture anchors [119].
• Whether done arthroscopically or through a mini-open approach with a small anterior incision or a small subpectoral incision, long-term results for biceps tenodesis are comparable [119].
• The technique for biceps tenodesis should be chosen based on the skills and experience of the operating surgeon [119].
• Postoperative management after biceps tenodes

Complications

Postoperative Stiffness and Range of Motion

• Arthroscopic biceps tenodesis is associated with an increased incidence of postoperative stiffness compared with open biceps tenodesis [78].

Revision and Reoperation Rates

• After type II SLAP repair, roughly 1 in 10 patients may undergo reoperation [80].
• The number of isolated SLAP repairs performed has decreased over time, and management of failed SLAP repair has shifted toward biceps tenodesis or tenotomy over revision SLAP repair in more recent years [12].
• Although revision to subpectoral biceps tenodesis may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized [74].

Risk Factors for Revision

• 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 [20].

Return to Sport and Outcomes

• For operative treatment, biceps tenodesis has consistent and reliable results, whereas return to play after SLAP repair can be unpredictable [1].
• 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 with low risk for complications [19].

Fixation and Technical Complications

Recovery

• Return to play after SLAP repair can be unpredictable for overhead athletes [1].
• Biceps tenodesis has been increasingly used for the management of SLAP lesions [5].
• Recent studies report high rates of return to sport for biceps tenodesis in carefully selected athletes [5].
• Recent studies report high satisfaction for biceps tenodesis in carefully selected athletes [5].
• Recent studies report good to excellent patient-reported outcomes for biceps tenodesis in carefully selected athletes [5].
• SLAP repair and biceps tenodesis both present viable treatment options with specific advantages and disadvantages [6].
• The decision between SLAP repair and biceps tenodesis is ultimately made individually with the patient [6].
• Short-term follow-up of 20 subpectoral biceps tenodesis procedures using an all-suture anchor fixation has not shown any failure of fixation [13].
• Short-term follow-up of 20 subpectoral biceps tenodesis procedures using an all-suture anchor fixation has not shown any residual biceps discomfort [13].
• Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the long head of the biceps tendon provides significant improvement in shoulder outcomes [19].
• Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the long head of the biceps tendon provides a reliable return to activity level [19].
• Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the long head of the biceps tendon carries a low risk for complications [19].
• Risk factors for revision surgery after SLAP repair include age >40 years [20].
• Risk factors for revision surgery after SLAP repair include female sex [20].
• Risk factors for revision surgery after SLAP repair include obesity [20].
• Risk factors for revision surgery after SLAP repair include smoking [20].
• Risk factors for revision surgery after SLAP repair include diagnosis of biceps tendinitis or long head of the biceps tearing [20].
• Patients undergoing treatment for long head of biceps tendon or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes [27].
• Return to sport for throwers after SLAP repair or biceps tenodesis remains completely unpredictable due to massive variability in outcomes [40].
• Return to sport for throwers after SLAP repair or biceps tenodesis remains completely unpredictable due to a lack of robust comparative literature [40].
• The musculotendinous junction of the biceps begins further proximal than may be appreciated intraoperatively [42].
• The decision to perform tenotomy or tenodesis should be made preoperatively based on patient symptoms and concomitant pathologies [64].
• Macroscopic changes in the long head of the biceps tendon do not always correlate with symptoms [64].
• A normal arthroscopy does not exclude important symptomatic pathology [64].
• After biceps tenotomy, SLAP repair does not affect glenohumeral translation [75].
• Scapular muscle detachment appears to be a clinically identifiable syndrome with a homogeneous set of history and physical findings [79].
• Biceps tenodesis has no significant difference in rates of return to play in athletes compared to SLAP repair in younger patients [138].
• Biceps tenodesis has no significant difference in functional outcome scores compared to SLAP repair in younger patients [138].
• Biceps tenodesis has no significant difference in rates of revision surgery compared to SLAP repair in younger patients [138].
• Superior clinical outcomes are seen in nonsmokers undergoing revision rotator cuff repairs [148].
• Superior clinical outcomes are seen in patients with only 1 tendon affected undergoing revision rotator cuff repairs [148].
• Superior clinical outcomes are seen in patients who undergo tenotomy instead of tenodesis for a damaged long head of biceps tendon during revision rotator cuff repair [148].

Key Evidence

• [L5] For operative treatment, biceps tenodesis has consistent and reliable results, whereas return to play after SLAP repair can be unpredictable. [1] (10.1016/j.csm.2015.08.009)
• [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. [2] (10.1177/0363546514540273)
• [L1] Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions. [3] (10.1186/s13018-019-1096-y)
• [L5] SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years. [4] (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. [5] (10.5435/jaaos-d-21-01199)
• [L5] SLAP repair and biceps tenodesis both present viable treatment options but come with specific advantages and disadvantages, with the decision ultimately made individually with the patient. [6] (10.1016/j.arthro.2019.02.026)
• [L4] Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up. [7] (10.1177/0363546513520122)
• [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. [8] (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. [9] (10.1016/j.arthro.2019.02.017)
• [Paper] The article outlines that appropriate treatment for biceps pathology, whether conservative or surgical, should be based on established pathology. [10] (10.1016/j.csm.2009.12.003)
• [L3] Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair. [11] (10.1177/0363546514534939)
• [L3] In addition, the number of isolated SLAP repairs performed has decreased over time, and management of failed SLAP repair has shifted toward biceps tenodesis or tenotomy over revision SLAP repair in more recent years. [12] (10.1016/j.arthro.2016.01.053)
• [L5] Short-term follow-up of 20 procedures has not shown any failure of fixation or residual biceps discomfort. [13] (10.1007/s00167-014-3348-z)
• [L3] In a young active population, primary arthroscopic biceps tenodesis is a viable surgical alternative to labral repair for type II SLAP lesions. [14] (10.1007/s00167-020-05971-0)
• [L5] Biceps tenodesis may be considered a valid primary or revision surgery for patients suffering from symptomatic type II SLAP tears due to no detrimental effect on glenohumeral stability. [15] (10.1016/j.jse.2013.07.036)
• [L4] In the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity. [17] (10.1016/j.jse.2008.05.044)
• [L3] Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair. [18] (10.1016/j.arthro.2018.01.029)
• [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. [19] (10.1016/j.arthro.2019.06.035)
• [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. [20] (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. [21] (10.1016/j.arthro.2018.01.021)
• [L3] Biceps tenodesis remains a reliable treatment for pathologic abnormality of the long head of the biceps. [22] (10.1177/0363546515570024)
• [L5] There is no single pattern of pain that distinguishes biceps conditions from other shoulder abnormalities. [23] (10.1016/j.csm.2015.08.004)
• [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. [27] (10.1016/j.jse.2020.11.012)
• [L5] Treatment of proximal biceps pathology is largely based on expert opinion and patient preferences rather than robust randomized evidence. [28] (10.1097/corr.0000000000002448)
• [L3] Adjuvant biceps procedures are not required when repairing isolated supraspinatus tears, unless biceps pathology is observed intraoperatively, for which tenodesis grants better function and strength than tenotomy. [29] (10.1016/j.jse.2018.03.030)
• [L5] [34] (10.5435/jaaos-d-17-00085)
• [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. [35] (10.1016/j.arthro.2010.10.014)
• [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. [37] (10.1016/j.arthro.2011.01.005)
• [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. [40] (10.1016/j.arthro.2025.03.022)
• [L3] Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. [41] (10.1016/j.jse.2019.04.001)
• [L5] The MTJ of the biceps begins further proximal than may be appreciated intraoperatively. [42] (10.1177/0363546513482297)
• [L5] [50] (10.5435/00124635-201011000-00002)
• [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. [52] (10.1016/j.arthro.2017.09.005)
• [L5] [56] (10.1016/j.arthro.2025.05.022)
• [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. [57] (10.1016/j.arthro.2018.01.001)
• [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. [60] (10.1007/s00167-015-3774-6)
• [L5] Diagnosis and nonoperative management of long head of biceps tendon disorders are categorized as inflammation, instability, and rupture, requiring specific protocols. [61] (10.1016/j.csm.2015.08.006)
• [L5] The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. [62] (10.1186/s12891-023-06346-5)
• [L5] Biceps tendon pain in the absence of tears is associated with microscopic changes consistent with tendinopathy, which are often missed by MRI. [63] (10.1016/j.csm.2015.08.002)
• [Letter] The decision to perform tenotomy or tenodesis should be made preoperatively based on patient symptoms and concomitant pathologies, as macroscopic changes in the long head of the biceps tendon do not always correlate with symptoms and a normal arthroscopy does not exclude important symptomatic pathology. [64] (10.1016/j.arthro.2018.08.014)
• [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. [66] (10.1177/0363546514554193)
• [L1] Outcomes for both SLAP repair and BT exhibit massive variability when treating SLAP tears in overhead throwers. [70] (10.1016/j.arthro.2025.01.061)
• [L4] Biceps tenotomy is well accepted by most patients with good overall results. [71] (10.1016/j.jse.2011.01.014)
• [L3] The choice between biceps tenotomy and tenodesis for pathology of the proximal biceps tendon can continue to be based on surgeon and patient preference. [73] (10.1177/2325967115570848)
• [L4] Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. [74] (10.1177/0363546519892922)
• [L5] After biceps tenotomy, SLAP repair does not affect glenohumeral translation. [75] (10.1016/j.jse.2011.11.005)
• [L3] [78] (10.1016/j.arthro.2014.03.024)
• [L4] Scapular muscle detachment appears to be a clinically identifiable syndrome with a homogeneous set of history and physical findings. [79] (10.1016/j.jse.2013.05.008)
• [L3] After type II SLAP repair, roughly 1 in 10 patients may undergo reoperation. [80] (10.1007/s00167-020-06397-4)
• [L5] [87] (10.1016/j.csm.2015.08.008)
• [L4] Subpectoral biceps tenodesis utilizing a dual suture anchor technique is a treatment option for SLAP lesions, partial thickness tears, subluxation, and tenosynovitis of the long head of the biceps with high rates of postoperative patient satisfaction, a low failure rate, and improved outcome scores. [102] (10.1007/s00402-017-2810-z)
• [L3] [106] (10.1016/j.arthro.2016.07.007)
• [L1] High-quality randomized controlled trials comparing biceps tenotomy versus tenodesis during shoulder arthroscopy have largely demonstrated statistical noninferiority of clinical outcomes. [111] (10.1177/03635465261440392)
• [L4] This benefit will potentially result in the most efficient biceps muscle–tendon function and improve the results of biceps surgery. [118] (10.1007/s00167-014-2909-5)
• [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. [126] (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. [127] (10.1007/s00167-011-1423-2)
• [L4] Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis. [132] (10.1016/j.arthro.2016.04.022)
• [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. [135] (10.1016/j.arthro.2012.04.142)
• [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. [138] (10.1016/j.jisako.2023.09.007)
• [L5] High-quality randomized controlled trials are necessary to understand how different biceps management techniques truly perform. [140] (10.1016/j.arthro.2025.01.001)
• [L3] The biceps-radial MR images excellently agreed with the arthroscopic findings regarding LHBT instability and pulley lesions, whereas the conventional MR images poorly or moderately agreed. [146] (10.1016/j.jse.2023.06.037)
• [L4] The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in the management of these patients, at both the individual and population level. [147] (10.1016/j.jse.2019.04.003)
• [L4] Superior clinical outcomes are seen in nonsmokers, those with only 1 tendon affected, and those who undergo tenotomy instead of tenodesis for a damaged long head of biceps tendon. [148] (10.1016/j.jse.2019.12.011)

References

[1] Proximal Biceps in Overhead Athletes. Clinics in Sports Medicine. 2016. DOI: 10.1016/j.csm.2015.08.009

[2] 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

[3] 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

[4] Principles of the superior labrum and biceps complex: an expert consensus from the NEER Circle. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.09.040

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[21] Radiologic and Histologic Evaluation of Proximal Bicep Pathology in Patients With Chronic Biceps Tendinopathy Undergoing Open Subpectoral Biceps Tenodesis. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.01.021

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[71] Patient acceptance of long head of biceps brachii tenotomy. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.01.014

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[127] 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

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[148] Medium-term outcomes of a cohort of revision rotator cuff repairs. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.12.011