Patologia SLAP e do Bíceps Folheto

O que você está sentindo

Você pode notar uma dor profunda na parte frontal do ombro. Essa dor geralmente ocorre exatamente onde o tendão da cabeça longa do bíceps se insere na parte superior da cavidade glenoide do ombro. Como esses sintomas podem imitar outras condições, como impingement ou problemas do manguito rotador, a fonte exata pode parecer pouco clara inicialmente. Você também pode sentir uma sensação de instabilidade, como se o ombro estivesse travando ou escorregando.

A dor tipicamente piora com atividades acima da cabeça. Alcançar uma prateleira alta ou levantar objetos acima da cabeça pode desencadear desconforto agudo. Você pode ter dificuldade em realizar tarefas diárias que exigem que o braço fique atrás das costas, como fechar um sutiã ou guardar uma camisa dentro da calça. Movimentos simples, como girar uma maçaneta ou levantar uma sacola de compras pesada, também podem agravar a área.

Muitos pacientes relatam que a dor se intensifica à noite. Deitar-se do lado afetado frequentemente torna-se impossível, perturbando o sono. Você pode acordar com o ombro rígido e dolorido pela manhã. Embora o repouso possa proporcionar algum alívio, o desconforto frequentemente retorna quando você retoma suas atividades habituais.

É importante notar que esses sintomas podem variar. Em alguns casos, você pode ter uma lesão SLAP associada a uma lesão da polia, embora essa combinação seja rara, ocorrendo em apenas cerca de 10% dos pacientes com ambas as condições. Ocasionalmente, a dor pode estar ligada à tendinite calcificante, na qual depósitos de cálcio se acumulam na origem do tendão. Se você suspeitar disso, seu cirurgião avaliará se há uma lesão SLAP concomitante.

Como o diagnóstico pode variar, seu cirurgião avaliará cuidadosamente seus sintomas específicos. Independentemente de você ter menos de 30 ou mais de 50 anos, o objetivo é identificar o tratamento adequado para você. As opções podem incluir reparo ou tenodese do bíceps, um procedimento no qual o tendão é reanexado em um local mais inferior. Seu cirurgião discutirá qual abordagem oferece os melhores resultados funcionais para sua idade e nível de atividade.

O que está realmente acontecendo

A sua articulação do ombro é revestida por um anel de cartilagem chamado lábio glenoidal. Pense neste anel como uma junta ou amortecedor que aprofunda a cavidade. Ele mantém o osso do seu braço no lugar e fornece uma âncora firme para o tendão da cabeça longa do bíceps. Este tendão passa pela articulação como uma corda, ajudando a levantar e rodar o seu braço.

Uma lesão SLAP ocorre quando este ponto de fixação é danificado. A lesão pode alterar a forma como o seu ombro se move, potencialmente causando instabilidade ou tensão adicional na articulação. Frequentemente, sente-se como uma dor aguda ao alcançar acima da cabeça. Por vezes, esta lesão imita outros problemas do ombro, tornando difícil identificar a fonte exata do seu desconforto sem um exame cuidadoso.

À medida que envelhecemos, as alterações nesta cartilagem são comuns e nem sempre estão ligadas a uma lesão específica. Na verdade, pessoas com mais de 50 anos frequentemente apresentam estas alterações mesmo sem dor significativa. No entanto, se tiver menos de 30 anos e for ativo, é mais provável que uma lesão afete a sua capacidade de regressar aos desportos ou a trabalhos pesados.

Compreendemos que lidar com a dor no ombro é frustrante. O seu cirurgião irá analisar os seus sintomas específicos e a idade para decidir o melhor caminho a seguir. Para muitos pacientes, especialmente adultos mais velhos, o tratamento não cirúrgico, como repouso e fisioterapia, é uma primeira etapa segura e eficaz. Esta abordagem ajuda a reduzir a dor e melhorar a função sem cirurgia.

Para pacientes mais jovens e ativos, podemos discutir opções cirúrgicas. Estas incluem a reparação do tecido lesado ou a reanexação do tendão do bíceps a um local diferente (tenodese). Ambos os métodos visam aliviar a dor e restaurar a estabilidade. Escolhemos a opção que melhor se adapta ao seu estilo de vida e objetivos de recuperação, garantindo que volte às atividades que ama de forma segura.

O que podemos fazer a respeito

Esta orientação reflete a abordagem do Dr. Kieran Hirpara, cirurgião de membro superior do Mater Private Hospital Rockhampton, para este assunto em nossa clínica. Os pacientes chegam à nossa prática por meio de encaminhamento do clínico geral ou fisioterapeuta. Uma avaliação clínica, incluindo anamnese, exame físico e exames de imagem quando necessário, estabelece o diagnóstico. Para problemas degenerativos ou de longa data, geralmente tentamos primeiro o tratamento não operatório. Isso inclui modificação da atividade, fisioterapia ou terapia manual, uso de órteses e injeções. Consideramos a cirurgia quando isso não proporcionou melhora suficiente. Para problemas estruturais ou agudos, a cirurgia pode ser recomendada imediatamente, sem uma tentativa prévia de tratamento não operatório.

O tratamento não operatório com um regime adequado proporcionou resultados clínicos satisfatórios em pacientes de meia-idade com lesões de SLAP sintomáticas e deve ser considerado antes de recomendar o tratamento operatório. As decisões de tratamento para lesões de SLAP são orientadas principalmente pela presença de dor, nível de atividade acima da cabeça e manejo não operatório prévio. Um modelo de previsão clínica composto por variáveis que descrevem características do paciente, sintomas específicos e o tipo de modalidades de tratamento não operatório utilizadas foi encontrado para prever a falha do manejo não operatório de lesões de SLAP com precisão moderada. Nosso objetivo é reduzir a dor e restaurar a função por meio de exercícios direcionados. Você deve dar uma chance justa a essa abordagem antes de considerar outras opções.

O manejo médico concentra-se no controle da dor e da inflamação. Seu cirurgião pode recomendar medicamentos para dor ou anti-inflamatórios para ajudá-lo a gerenciar as atividades diárias. Injeções, como cortisona, ácido hialurônico ou PRP, podem ser oferecidas para reduzir o inchaço e a dor na articulação. Esses tratamentos proporcionam alívio temporário para permitir que você participe da fisioterapia. O efeito dessas injeções geralmente dura de várias semanas a meses, dependendo da sua resposta individual e da gravidade da lesão. Elas não curam a lesão, mas podem tornar o manejo conservador mais eficaz.

A cirurgia é considerada quando o tratamento conservador atingiu seu limite e a dor ou instabilidade persistem. Em nossa clínica, discutimos a melhor opção cirúrgica com base na sua idade, nível de atividade e no tipo específico de lesão. Para pacientes ativos com menos de 30 anos, a tenodese do bíceps primária proporciona melhores resultados funcionais em pacientes ativos com menos de 30 anos quando comparada à reparação de SLAP no seguimento mínimo de 2 anos. Em uma população jovem e ativa, a tenodese do bíceps pode ser uma alternativa cirúrgica viável para lesões de SLAP tipo II e pode facilitar o retorno mais precoce à atividade em comparação com a reparação. A tenodese subpectoral do bíceps pode ser uma alternativa confiável à reparação artroscópica para lesões de SLAP em pacientes com menos de 30 anos de idade. A tenodese do bíceps primária oferece maior eficácia quando comparada tanto à reparação primária de SLAP quanto ao tratamento não operatório, e custos mais baixos do que a reparação primária de SLAP. Tanto a reparação artroscópica quanto as intervenções de tenotomia e tenodese do bíceps apresentaram benefícios em lesões de SLAP tipo II. A tenodese artroscópica do bíceps pode ser considerada uma alternativa eficaz à reinserção no tratamento de lesões isoladas de SLAP tipo II. A tenodese do bíceps é uma alternativa segura, eficaz e tecnicamente simples à reparação primária de SLAP em pacientes com lesões de SLAP tipo II e IV. A tenodese subpectoral do bíceps proporciona resultados satisfatórios para o tratamento de lesões de SLAP tipo II e tipo IV em pacientes de meia-idade. A reparação de SLAP e a tenodese do bíceps apresentam opções de tratamento viáveis, mas vêm com vantagens e desvantagens específicas, sendo a decisão tomada individualmente com o paciente. A tenodese do bíceps tem sido cada vez mais utilizada para o manejo de lesões de SLAP, com estudos recentes relatando altas taxas de retorno ao esporte, alta satisfação e bons a excelentes resultados relatados pelos pacientes em atletas cuidadosamente selecionados.

O que esperar

O seu prognóstico depende do tipo de lesão e da sua idade. Para pacientes ativos com menos de 30 anos, a tenodese do bíceps (movimento da inserção do tendão do bíceps) frequentemente proporciona melhor função do que o reparo SLAP (reatamento do labrum rompido). Essa abordagem ajuda você a retornar às atividades mais rapidamente. Para pacientes de meia-idade, esse procedimento também reduz a dor e melhora significativamente a função do ombro.

Se você é do sexo feminino, seus resultados com qualquer um dos tratamentos são comparáveis em relação à dor e à capacidade esportiva. No entanto, certos fatores aumentam o risco de necessidade de cirurgia de revisão após um reparo SLAP. Esses fatores incluem ter mais de 40 anos, sexo feminino, obesidade, tabagismo, ou ter tendinite do bíceps ou uma lesão da cabeça longa do bíceps.

Para reparos falhos, a tenodese do bíceps é uma opção de salvamento segura e eficaz. Ela melhora os resultados de forma confiável mesmo após cirurgias anteriores não terem tido sucesso. Em atletas competitivos que realizam movimentos acima da cabeça, 81% retornam ao seu nível anterior de atuação em média 4,1 meses após a cirurgia, após tenodese subpectoral do bíceps para lesão SLAP sintomática.

Os resultados variam com base na sua patologia e características específicas. Embora muitos pacientes relatem alta satisfação e bons resultados, a decisão entre reparo e tenodese é individualizada. O seu cirurgião avaliará os benefícios e as desvantagens de cada método para escolher o melhor caminho para você.

Quando procurar atendimento

Procure seu médico de família se tiver dor persistente no ombro que não melhora com o repouso. Solicite uma avaliação especializada se apresentar fraqueza, instabilidade ou sensação de bloqueio ou cedência. Esses sintomas podem interferir no seu sono ou no trabalho. O agravamento súbito da dor também é motivo para buscar atendimento. Observe que as lesões SLAP podem simular outras condições, como impingement ou problemas no manguito rotador. Como o diagnóstico pode variar, é importante uma avaliação profissional. Seu cirurgião ajudará a determinar se a dor decorre de um rasgo SLAP ou de outra causa. A avaliação precoce ajuda a esclarecer seus sintomas e orienta o caminho adequado para sua recuperação.

Evidence & references

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

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

Anatomy & Pathophysiology

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

Classification

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

Clinical Presentation

A positive subpectoral biceps test was associated with gross pathologic changes of the biceps in 93% of patients [3].
Diagnosis of long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology can be challenging due to limitations in MRI and arthroscopic visualization [22].
Surgeons should maintain a high level of suspicion and utilize specific techniques to prevent missing pathology when diagnosing long head biceps tendon and subscapularis pathology in association with shoulder rotator cuff pathology [22].
The concomitant presence of SLAP and pulley lesions is significantly rare, occurring in only about 10% of all patients with SLAP and pulley lesions [25].
If calcific tendinitis of the long head of the biceps brachii at its origin is suspected, it may be helpful to consider the presence of a concurrent SLAP lesion and its management [2].
A 10.1% incidence of subsequent surgery after isolated SLAP repair was identified, often related to an additional diagnosis [14].
Clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions [14].

Investigations

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

Treatment

Operative Management: SLAP Repair vs. Biceps Tenodesis/Tenotomy

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

Biceps Tenodesis vs. Tenotomy

Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes [23].
Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis [49].

Subpectoral Biceps Tenodesis Outcomes

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

Nonoperative Management

Diagnosis and nonoperative management of long head of biceps tendon disorders are categorized as inflammation, instability, and rupture, requiring specific protocols [41].

Associated Pathology

Complications

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

Recovery

Biceps tenodesis is increasingly used for SLAP lesions, with recent studies reporting high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes in carefully selected athletes [7].
Primary subpectoral open biceps tenodesis for SLAP tears or long head of the biceps pathology provides significant improvement in shoulder outcomes, reliable return to activity level, and low risk for complications [9].
There is a 10.1% incidence of subsequent surgery after isolated SLAP repair, often related to an additional diagnosis [14].
Short-term follow-up of 20 procedures using an all-suture anchor fixation for subpectoral biceps tenodesis showed no failure of fixation or residual biceps discomfort [15].
Risk factors for revision surgery after SLAP repair include age >40 years, female sex, obesity, smoking, and diagnosis of biceps tendinitis or long head of the biceps tearing [18].
Superior clinical outcomes are seen in nonsmokers, those with only 1 tendon affected, and those who undergo tenotomy instead of tenodesis for a damaged long head of biceps tendon [58].

Key Evidence

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

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