The Diagnosis and Management of Superior Labral (SLAP) Tears of the Shoulder: A Review Article

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 15-21| Bijayendra Singh, N Bakti

Authors: Bijayendra Singh [1], N Bakti [1]

[1]Medway NHS Foundation Trust, Visiting Professor Canterbury Christchurch University.

Address of Correspondence
Prof. Bijayendra Singh,
Consultant Orthopaedic Surgeon,
Medway NHS Foundation Trust, Visiting Professor Canterbury Christchurch University, Medway, KENT


The labrum helps deepen the glenoid and serves as an attachment of the long head of biceps. Superior Labrum antero posterior (SLAP) tears are common in the overhead throwing athlete and is a common cause of shoulder pain in the younger population. Often its due to repetitive throwing action or may present after a single acute injury. The diagnosis can be challenging and hence a careful history and examination followed by investigation is key to clinch the diagnosis. The normal variants of the capsulo – labral complex can make the diagnosis difficult. A thorough understanding of the condition is hence essential. This article reviews the relevant anatomy, clinical diagnosis, investigations and management of the condition.
Keywords: Superior Labrum Antero Posterior, SLAP, Arthroscopy, Stabilization, Tenodesis.


Andrews et al first described superior labral anterior-posterior lesions (SLAP) of the shoulder in 1985 amongst overhead-throwing athletes [1]. Recent published studies have reported an incidence between 6% and 20% and are not exclusive to these athletes [2]. Pathogenesis can be related to trauma or part of a degenerative process. For the treating Orthopaedic surgeon, SLAP pathologies can be a challenging problem to manage due to ambiguity in clinical diagnosis, variation in normal labral anatomy and controversies in treatment.

Role and function
The labrum helps deepen the anatomically shallow glenoid, which in turn helps confer additional passive stability to the glenohumeral joint [3]. The superior aspect of the labrum also serves as points of attachment of the tendon for the long head of biceps, the superior and middle glenohumeral ligament (MGHL) and the posterior-superior aspect of the capsule, they have an important role in stabilizing the shoulder especially in the first half of shoulder elevation [4, 5].

Histologically, the superior labrum is a triangular structure and is composed of fibrous and fibrocartilaginous tissue [3, 6]. Vascular supply to this region of the labrum is from joint capsule via the branches of the suprascapular artery, the circumflex scapular branch of the subscapular artery and the posterior humeral circumflex artery [6].
Literature describes significant variability in the anatomy of the superior aspect of the glenoid labrum and the attachment of the long head of biceps, which can cloud the management of a SLAP pathology [3]. Williams et al retrospectively reviewed 200 consecutive shoulder arthroscopies to find a 12% incidence of a sublabral foramen [7]. When this variation was present, 75% of the patients had a ‘cord-like’ appearance of the MGHL that attaches directly to the labrum. The group also noted a rare variation, known as the Buford complex, which occurred in 1.5% of the arthroscopies they reviewed. This is described as a cord like MGHL with an anterior superior glenoid that is devoid of a labrum. Subsequent published studies have further confirmed the incidence rates of these normal anatomical variations [ 8, 9].
In addition, the labrum can appear meniscoid as it drapes over the superior glenoid articular cartilage, which may give an appearance of labral detachment [10]. The surgeon must be aware of these, as reattachment or repair of these normal variations can lead to a significant loss of range of motion of the shoulder [11].

SLAP lesions were first noted as a repetitive injury in overhead-throwing athletes [1]. Increased external rotation of the shoulder at the cocking phase of a throw displaces the labrum and biceps tendon medially and is thought to increase torsional force at the biceps anchor. This results in a phenomenon known as ‘peel-back’ injury to the labrum [12]. These athletes also increase the forces at the superior labrum by adopting a reduced internal rotation motion while in the abducted position of a throw [12, 13]
SLAP tears can also occur due to forceful traction to the shoulder, direct compression injuries or fall on an abducted and externally rotated arm. The position of the shoulder at the point of impact loading is thought to be key and studies have shown SLAP tears are more likely to occur when the shoulder is forward flexed rather than extended [14]

In 1990, Snyder et al described four types of SLAP lesions based retrospective review of 700 shoulder arthroscopies [15]. Over the last 30 years, this classification has been expanded to include six more types but Synder’s original classification is still the most recognized and widely used.
In Snyder’s paper, he described Type I SLAP lesions as a superior labral fraying with localized degeneration. The superior labrum and the biceps anchor remain intact and patients are commonly middle-aged and clinically asymptomatic.
Type II lesions occur when there is detachment of the labrum and the biceps anchor from its attachment to the glenoid. This type of SLAP pathology is the most clinically significant variant.
Type III lesion is a bucket handle tear superior labrum with the biceps anchor still intact. This phenomenon is very similar to a bucket handle injury of the meniscus in the knee joint and if significantly unstable, it can displace into the glenohumeral joint to cause mechanical symptoms.
Type IV lesions differ form Type III lesions by having split in the biceps tendon itself and this split is included in the bucket handle component of the SLAP tear.

Clinical diagnosis
Making a clinical diagnosis of a SLAP lesion can be challenging for a myriad of reasons. Patients’ history of preceding events can be variable and examination is often ambiguous and frequently reveals a variety of other co-existing pathologies.

Depending of the specific pathogenesis of the SLAP tear, symptoms can arise insidiously or acutely. Overhead throwing athletes are more likely to present with an insidious history due to the progressive nature of the tear and may complain of reduced throwing velocity and overhead movement. Acute trauma causing a SLAP lesion can be due to a traction injury can be due to unexpected weight shift of a heavy object or a compression injury from a fall on an outstretched limb.
The most common presenting complain in patients with a SLAP pathology is pain [16]. The location of pain can either be felt deep in the shoulder joint or a discomfort radiating to the anterior aspect of the shoulder. The nature of the pain can either be sharp or a dull ache that is often exacerbated by activities of pushing, heavy lifting or overhead actions. For patients with a Type III or IV SLAP pathology, they may complain of mechanical symptoms including sensation of giving way especially when performing overhead activities.
Patient may also complain of weakness to the affected limb. Ganglion cyst formation secondary to a chronic SLAP lesion can cause compression of the suprascapular nerve to result in this symptom.

Clinical examination of patients with suspected SLAP pathology can be unequivocal and confusing as the numerous provocative tests to elicit SLAP lesions lack sensitivity or specificity. Patients also often present with co-existing shoulder pathology to further cloud the clinical picture. One study found 88% of patients with SLAP lesions found at arthroscopy had co-existing shoulder pathology ranging from subacromial impingement, rotator cuff pathology acromioclavicular joint arthritis [8].

When examining a patient with a possible SLAP lesion, pay particular attention to the symmetry of muscle around the shoulder girdle. Wasting of the supraspinatus and infraspinatus muscle may indicate the presence of a glenoid cyst impinging on the suprascapular nerve. In these patients, the active range of motions of the glenohumeral joints often remains normal but pain may be elicited in the position of internal impingement (external rotation of the abducted and externally rotated shoulder) [11]. Stability and apprehension tests of the joint should be tested but significant instability of the joint is rare in SLAP pathologies [16].
Table 1 shows the various tests used to clinically elicit a SLAP lesion. Of these, the O’Brien test is probably the most commonly utilized [17]. To perform this test, the shoulder is position at 90° of flexion, 15° of adduction, full internal rotation and pronation of the forearm. At this point, the patient is asked to flex against resistance. A positive test is declared if patient experiences a deep or anterior shoulder pain. Symptoms should not be reproduced with the shoulder in similar position but in external rotation. Due to the poor reproducibility, sensitivity and specificity the various special tests available, Arnander & Tennant suggested the combination of Kim’s biceps load test II and the O’Brien’s test gave the best likelihood of a positive result in identifying an isolated SLAP lesion [18].

As a baseline, standard plain radiographs (anteroposterior view of shoulder, axillary and scapular ‘Y’ view) of the affected shoulder should be attained. Although this will not help with the diagnosis of SLAP pathology, this practice might highlight any co-existing pathology that will help in formulating a surgical management plan.
Magnetic resonance imaging (MRI) is the gold standard for imaging labral pathologies. When compared to arthroscopy, MRI is thought to have a sensitivity of 90%, specificity of 89.5% and accuracy of 98% [25]. Although there have been debates in the past, several studies have shown that introducing intra-articular contrast into the shoulder can help increase diagnostic sensitivity [26-28]. Despite this, and taking into consideration anatomical variations, interpretation of the MRI images can remain difficult. Identifying SLAP lesions on MRI scan is best done from the coronal oblique sequences and positioning the shoulder in abduction and external rotation is thought to further help with diagnosis.11 Applying axial traction to the arm has also been suggested as a possible technique to increase contrast dissipation into the intra-articular space and hence improve sensitivity [29].

Arthroscopy remains the gold standard in diagnosing SLAP lesions [26, 28, 30]. Direct visualization and gentle probing of the labral-biceps complex often helps identify the lesion. Despite this, arthroscopic findings can be difficult to interpret and knowledge of patients’ presenting history, examination findings, imaging results can help the clinician determine if the visualized labrum represents a pathological process. Awareness of the possible anatomical variations to the superior labrum will also prevent inadvertent repair of an otherwise normal biceps-labral complex.
Several authors have suggested dynamic testing the biceps attachment to the labrum can assist diagnosis by making subtle pathologies more obvious. This is achieved by placing the arm in abduction and external rotation which applies tension to the biceps and can cause the labrum to “peel-away” from the glenoid [12, 31]. Other signs of a pathological labrum-biceps complex include signs of reactive synovitis under the labrum, excessive sublabral recess beyond the edge of the glenoid cartilage and hypermobility of more than 5mm on biceps manipulation [32].

Treatment options
Non operative
Conservative treatment of SLAP pathology revolves mainly around physiotherapy, non-steroidal medications and steroid injections into the shoulder. Although there are no published studies on conservative management of SLAP lesions, authors have experienced poor long-term outcomes following conservative management. Patients are rarely satisfied with their function and ends up requiring surgical intervention an average of one or two years following initial presentation [33].

Surgical Treatment
The role of surgical treatment of SLAP tears is shrouded in controversy. The lack of clear guidelines and randomized control studies further compounds this issue. It is critical to note that not all SLAP lesions identified intra-operatively require repair. Meticulous patient selection taking into consideration patient age, levels of activity and co-existing shoulder pathology should guide the treating surgeon which is the best way to surgically treat a SLAP lesion.

Isolated SLAP Lesions
Type I
This subtype of SLAP lesions is often an incidental finding at arthroscopy as it is usually subclinical in terms of its symptoms. Thought to be secondary to degeneration, it is not usually picked up during MRI imaging and when encountered intraoperatively, it can be left alone. If significantly frayed, it is recommended that the lesion is debrided back to healthy labral tissue [30, 34-36]. Care should be taken to find other co-existing pathology such as subacromial impingement or rotator cuff pathology as a cause of symptoms.

Type II
This is the most common and clinically important subtype of SLAP lesions. It should be treated if patients’ symptoms, clinical examination is suggestive of SLAP pathology and arthroscopic examination of the rest of the shoulder does not reveal any other co-existing shoulder pathology. Managing these isolated lesions can be achieved via various techniques and is again a source of much controversy.
Suture anchors are the most common method of repairing SLAP lesions with more predictable and favorable outcomes when compared to biodegradable tacks [31, 35, 36]. Patients from this treatment group report at least 94% good to excellent results post-operatively and about 74% of patients returned to their pre-injury sporting activities [8, 37] The ideal configuration in terms of the number of anchors and suturing technique; simple, dual simple or horizontal mattress, is again a subject of heated debate. Various studies have been published to support the use of each argument with good outcomes [35, 36, 38]. A prospective study by Bedi et al found similar clinical outcomes in patients independent of the number of suture anchors used for repairing of the SLAP lesion [39].
Despite several of these studies showing good outcomes with primary repair, Denard, in his study, noticed a trend of poor outcomes with increasing age [40]. Provencher et al carried out a large prospective study and agreed with Denard’s findings and highlighted an increased rate of failure of SLAP repairs in patients above the age of 36 [41]. Boileau and his team were first to study the differences in outcome between primary repairs versus biceps tenodesis for SLAP injuries. His team found that 60% of patients who had a repair were dissatisfied or disappointed with their outcomes while 87% of patients in the tenodesis group were satisfied with their outcome with higher rates of return to sports [42]. He also went on to report 40% of patients from the repair cohort required revision surgery due to persistent pain and inability to participate in sports.
Findings of this study were replicated in several other studies and based on these recent evidence, a significant shift has taken place in the management of this subtype of SLAP lesions [10, 43]. It is now recommended that in patients with a isolated type II SLAP lesion, aged above 36 years old, low sporting demand and poor tissue repair quality, a biceps tenodesis is a viable surgical option. This can be performed either arthroscopically or via a mini-open technique. The biceps tendon tenotomised, doubled on a suture and pulled into a humeral socket drilled at the proximal aspect of the bicipital groove. It is fixed in placed using a biodegradable interference screw. These patients had functional outcomes comparable to younger patients with primary repair of their lesions [10].
However, if the patient is under 36 years-old, active athlete with good tissue quality, the recommendation is to still perform a repair of the lesion using suture anchors [42, 44]. This option aims to restore normal anatomy and is most likely influenced by several studies suggesting a key role of the labral-biceps complex in maintaining glenohumeral stabilization [45, 46]. In the event of non-resolution of symptoms or poor overhead performance, biceps tenodesis can still be performed as a salvage procedure with good and predictable outcomes.

Type III
Management of this subtype requires resection of the unstable bucket-handle lesion. It is of upmost importance that the MGHL is not destabilized during the resection process as damage can cause significant anterior instability of the joint [34, 38, 39, 47]

Type IV
Management of Type IV lesions is determined by the extent of biceps tendon involvement and patients’ age. When less than 30% of the biceps tendon is involved, both the labrum and the pathological biceps tendon is debrided and resected. If more than 30% of the biceps is involved, in a young patient, a biceps tenodesis and labral repair is carried out. However, in an older patient or if the labral tissue quality is poor, then a labral debridement is performed with either biceps tenotomy or tenodesis [16].

Type V to X
These subtypes of SLAP injuries often represent a more significant labral injury and are often associated with shoulder instability [11]. Treatment should not only address the labral-biceps complex but also the other parts of the labrum and the MGHL injury.
Slap with co-existing pathologies
Eighty-eight percent of patients with SLAP lesions diagnosed during arthroscopy have co-existing pathology [8]. In view of this, it is recommended to have a clear idea on how to manage these patients based on latest evidence.
SLAP tear with rotator cuff pathology
In patients with these pathologies, it is important to clinically determine which pathology is causing the clinical picture. If both structures are thought to be the generator of symptoms, surgical repair of both can be done at the same sitting with good outcomes [48, 49]. This treatment option is thought to help improve range of motion and patient satisfaction. However, another study looked at patients above the age of 50 with similar dual pathology and found that in this subgroup of patients, managing their pathology with a rotator cuff repair and a biceps tenotomy yielded a significantly better outcome compared to a SLAP and rotator cuff repair [50].

Subacromial Impingement
It is recommended that patients with symptoms of clinical signs of impingement in the shoulder have arthroscopic subacromial decompression during surgery for a SLAP repair. Coleman et al looked at this particular co-existing pathology in his study and concluded that although functional outcome measures were similar in both groups, patients who had an acromioplasty in the same sitting were more satisfied with their surgery [51].

Ganglion cysts
Ganglion cysts may develop secondary to chronic SLAP tears and if anatomically favorable, can cause suprascapular nerve palsy via impingement. Literature have described arthroscopic decompression with a probe, shaver and ever a spinal needle [52, 53]. However, if it occurs due to an isolated SLAP pathology, these cysts have been shows to resolve spontaneously following a SLAP repair. In Youm at al case series, even patients with clinical weakness due to compressive neuropathy of the suprascapular nerves have been shown to make a full recovery following SLAP repair [54].


1. Andrews, J.R., W.G. Carson, Jr., and W.D. McLeod, Glenoid labrum tears related to the long head of the biceps. Am J Sports Med, 1985. 13(5): p. 337-41.
2. Maffet, M.W., G.M. Gartsman, and B. Moseley, Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med, 1995. 23(1): p. 93-8.
3. Vangsness, C.T., Jr., et al., The origin of the long head of the biceps from the scapula and glenoid labrum. An anatomical study of 100 shoulders. J Bone Joint Surg Br, 1994. 76(6): p. 951-4.
4. DePalma AF, G.G., Bennett GA, Variational anatomy and degenerative lesions of the shoulder joint. J Am Acad Orthop Surg, 1949: p. 225-81.
5. O’Connell, P.W., et al., The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint. Am J Sports Med, 1990. 18(6): p. 579-84.
6. Cooper, D.E., et al., Anatomy, histology, and vascularity of the glenoid labrum. An anatomical study. J Bone Joint Surg Am, 1992. 74(1): p. 46-52.
7. Williams, M.M., S.J. Snyder, and D. Buford, Jr., The Buford complex–the “cord-like” middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant. Arthroscopy, 1994. 10(3): p. 241-7.
8. Kim, T.K., et al., Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. J Bone Joint Surg Am, 2003. 85-A(1): p. 66-71.
9. Rao, A.G., et al., Anatomical variants in the anterosuperior aspect of the glenoid labrum: a statistical analysis of seventy-three cases. J Bone Joint Surg Am, 2003. 85-A(4): p. 653-9.
10. Burns, J.P., M. Bahk, and S.J. Snyder, Superior labral tears: repair versus biceps tenodesis. J Shoulder Elbow Surg, 2011. 20(2 Suppl): p. S2-8.
11. Bedi, A. and A.A. Allen, Superior labral lesions anterior to posterior-evaluation and arthroscopic management. Clin Sports Med, 2008. 27(4): p. 607-30.
12. Burkhart, S.S. and C.D. Morgan, The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy, 1998. 14(6): p. 637-40.
13. Burkhart, S.S., C.D. Morgan, and W.B. Kibler, The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy, 2003. 19(4): p. 404-20.
14. Clavert, P., et al., Contribution to the study of the pathogenesis of type II superior labrum anterior-posterior lesions: a cadaveric model of a fall on the outstretched hand. J Shoulder Elbow Surg, 2004. 13(1): p. 45-50.
15. Snyder, S.J., et al., SLAP lesions of the shoulder. Arthroscopy, 1990. 6(4): p. 274-9.
16. Keener, J.D. and R.H. Brophy, Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg, 2009. 17(10): p. 627-37.
17. Parentis, M.A., et al., An evaluation of the provocative tests for superior labral anterior posterior lesions. Am J Sports Med, 2006. 34(2): p. 265-8.
18. Arnander, M. and D. Tennent, Clinical assessment of the glenoid labrum. Shoulder Elbow, 2014. 6(4): p. 291-9.
19. O’Brien, S.J., et al., The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med, 1998. 26(5): p. 610-3.
20. Hegedus, E.J., et al., Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med, 2012. 46(14): p. 964-78.
21. Liu, S.H., M.H. Henry, and S.L. Nuccion, A prospective evaluation of a new physical examination in predicting glenoid labral tears. Am J Sports Med, 1996. 24(6): p. 721-5.
22. Kim, S.H., K.I. Ha, and K.Y. Han, Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations. Am J Sports Med, 1999. 27(3): p. 300-3.
23. Mimori, K., et al., A new pain provocation test for superior labral tears of the shoulder. Am J Sports Med, 1999. 27(2): p. 137-42.
24. Kibler, W.B., Specificity and sensitivity of the anterior slide test in throwing athletes with superior glenoid labral tears. Arthroscopy, 1995. 11(3): p. 296-300.
25. Connell, D.A., et al., Noncontrast magnetic resonance imaging of superior labral lesions. 102 cases confirmed at arthroscopic surgery. Am J Sports Med, 1999. 27(2): p. 208-13.
26. Jee, W.H., et al., Superior labral anterior posterior (SLAP) lesions of the glenoid labrum: reliability and accuracy of MR arthrography for diagnosis. Radiology, 2001. 218(1): p. 127-32.
27. Major, N.M., et al., Evaluation of the glenoid labrum with 3-T MRI: is intraarticular contrast necessary? AJR Am J Roentgenol, 2011. 196(5): p. 1139-44.
28. Waldt, S., et al., Diagnostic performance of MR arthrography in the assessment of superior labral anteroposterior lesions of the shoulder. AJR Am J Roentgenol, 2004. 182(5): p. 1271-8.
29. Becce, F., et al., Direct MR arthrography of the shoulder under axial traction: feasibility study to evaluate the superior labrum-biceps tendon complex and articular cartilage. J Magn Reson Imaging, 2013. 37(5): p. 1228-33.
30. Johnson, L.L., The shoulder joint. An arthroscopist’s perspective of anatomy and pathology. Clin Orthop Relat Res, 1987(223): p. 113-25.
31. Morgan, C.D., et al., Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy, 1998. 14(6): p. 553-65.
32. Nam, E.K. and S.J. Snyder, The diagnosis and treatment of superior labrum, anterior and posterior (SLAP) lesions. Am J Sports Med, 2003. 31(5): p. 798-810.
33. Wilk, K.E., et al., Current concepts in the recognition and treatment of superior labral (SLAP) lesions. J Orthop Sports Phys Ther, 2005. 35(5): p. 273-91.
34. Cordasco, F.A., et al., Arthroscopic treatment of glenoid labral tears. Am J Sports Med, 1993. 21(3): p. 425-30; discussion 430-1.
35. Funk, L. and M. Snow, SLAP tears of the glenoid labrum in contact athletes. Clin J Sport Med, 2007. 17(1): p. 1-4.
36. Kartus, J. and M. Perko, Arthroscopic repair of a type II SLAP lesion using a single corkscrew anchor. Arthroscopy, 2002. 18(3): p. E10.
37. Samani, J.E., S.B. Marston, and D.D. Buss, Arthroscopic stabilization of type II SLAP lesions using an absorbable tack. Arthroscopy, 2001. 17(1): p. 19-24.
38. O’Brien, S.J., et al., The trans-rotator cuff approach to SLAP lesions: technical aspects for repair and a clinical follow-up of 31 patients at a minimum of 2 years. Arthroscopy, 2002. 18(4): p. 372-7.
39. Field, L.D. and F.H. Savoie, 3rd, Arthroscopic suture repair of superior labral detachment lesions of the shoulder. Am J Sports Med, 1993. 21(6): p. 783-90; discussion 790.
40. Denard, P.J., A. Ladermann, and S.S. Burkhart, Long-term outcome after arthroscopic repair of type II SLAP lesions: results according to age and workers’ compensation status. Arthroscopy, 2012. 28(4): p. 451-7.
41. Provencher, M.T., et al., A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med, 2013. 41(4): p. 880-6.
42. Boileau, P., et al., Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med, 2009. 37(5): p. 929-36.
43. Ek, E.T., et al., Surgical treatment of isolated type II superior labrum anterior-posterior (SLAP) lesions: repair versus biceps tenodesis. J Shoulder Elbow Surg, 2014. 23(7): p. 1059-65.
44. Brockmeier, S.F., et al., Outcomes after arthroscopic repair of type-II SLAP lesions. J Bone Joint Surg Am, 2009. 91(7): p. 1595-603.
45. Pagnani, M.J., et al., Role of the long head of the biceps brachii in glenohumeral stability: a biomechanical study in cadavera. J Shoulder Elbow Surg, 1996. 5(4): p. 255-62.
46. Patzer, T., et al., Increased glenohumeral translation and biceps load after SLAP lesions with potential influence on glenohumeral chondral lesions: a biomechanical study on human cadavers. Knee Surg Sports Traumatol Arthrosc, 2011. 19(10): p. 1780-7.
47. Mileski, R.A. and S.J. Snyder, Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg, 1998. 6(2): p. 121-31.
48. Gartsman, G.M. and E. Taverna, The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears. Arthroscopy, 1997. 13(4): p. 450-5.
49. Voos, J.E., et al., Outcomes of combined arthroscopic rotator cuff and labral repair. Am J Sports Med, 2007. 35(7): p. 1174-9.
50. Franceschi, F., et al., No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50: a randomized controlled trial. Am J Sports Med, 2008. 36(2): p. 247-53.
51. Coleman, S.H., et al., Arthroscopic repair of type II superior labral anterior posterior lesions with and without acromioplasty: a clinical analysis of 50 patients. Am J Sports Med, 2007. 35(5): p. 749-53.
52. Abboud, J.A., et al., Arthroscopy effectively treats ganglion cysts of the shoulder. Clin Orthop Relat Res, 2006. 444: p. 129-33.
53. Westerheide, K.J., et al., Suprascapular nerve palsy secondary to spinoglenoid cysts: results of arthroscopic treatment. Arthroscopy, 2006. 22(7): p. 721-7.
54. Youm, T., P.V. Matthews, and N.S. El Attrache, Treatment of patients with spinoglenoid cysts associated with superior labral tears without cyst aspiration, debridement, or excision. Arthroscopy, 2006. 22(5): p. 548-52.

How to Cite this article:Singh B, Bakti N. The Diagnosis and Management of Superior Labral (SLAP) Tears of the Shoulder: A Review Article. Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):15-21.

Prof. Bijayendra Singh

(Abstract Full Text HTML) (Download PDF)

Arthroscopic Long Head Biceps Tenodesis in Coracoid associated with its Transfer to the Conjoined Tendon

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 7-10| José Carlos Garcia Jr, Alvaro Motta Cardoso Jr, Marcelo Boulos D. Mello

Authors: José Carlos Garcia Jr [1], Alvaro Motta Cardoso Jr [1]., Marcelo Boulos D. Mello [1]

[1]NAEON-Santa Catarina Hospital
[2]IFOR Hospital

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil


Introduction: The knowledge of the long head of biceps tendon as a potential source of pain in the shoulder has been longstanding. However LHBT’s pathology and its treatment remains controversial. Current surgical options include tenotomy, tenodesis, or transfer. The author has presented a surgical technique of LHBT tenodesis in coracoid associated to its transfer to the conjoined tendon.
Methods: Patients were assessed before the surgeries using UCLA score. After surgery UCLA, SF-36 and raw scale for function, physical limitation and pain were evaluated 2 years after surgeries.
Results: The average UCLA changed from 22.00±0.69 to 33.14±0.52, p=0,0001. The average SF-36 6-month-after-surgery was 140.40±1.44. The minimal follow up was 2 years. There was no surgery failures.
Conclusion: The surgical procedure has achieved satisfactory results and it can be one more surgical option in order to treat the biceps pathologies. The author do not belive LHBT transfer isolated may be superior to its association with tenodesis in the coracoid.
Level of evidence: This is study has a level of evidence 4.
Key words: Arthroscopy, biceps, tenodesis, transfer.


The knowledge of the long head of biceps tendon (LHBT) as a potential source of pain in the shoulder has been longstanding [1-4].
When conservative management fails treatment options are either tenotomy or tenodesis. Tenotomy provides reliable pain relief, however its complications include muscle spasm in younger patients and cosmetic deformity in all ages [5-8].
In 1936 Gilcreest wrote about many different types of biceps tenodesis such as suture of the tendon to the short head of biceps, suggested by Bazy; suture to the coracoid process, suggested by Perthes, suture to the insertion of the pectoralis major, suggested by Hoffman and suture in the sulcus intertubecularis, suggested by Roloff9. The Gilcreest’s personal option was by combining the Bazy and Perthes techniques [9].
Many other LHBT surgical techniques have also been reported since them, however LHBT’s treatment remains controversial [2, 3] .
O`Brien suggested that the suture of the tendon to the short head of biceps could present superior healing when compared with the bony tenodesis. Other advantage is that it could also preserve the natural biceps axis [10].
When Gilcreest combined Bazy and Perthes techniques [5] he preserved the natural biceps axis [10] with the advantages of soft tissue healing and also added the advantages related to the bony tenodesis in a stronger and safer system [9].
All the ancient techniques mentioned above, unless the Gilcreest’s one, currently can be done by using minimally invasive procedures, with its related benefits [10].
The author developed an arthroscopic technique of LHBT transfer to conjoined tendon associated with its tenodesis on the coracoid`s tip and presents its results in this study.

From June 2008 to January 2009 15 patients underwent to the arthroscopic Gilcreest procedure in this service.
Inclusion Criteria:
Patients older than 18 years.
At least two years follow up
Patients with biceps pathology associated or not with rotator cuff lesions or acromioclavicular osteoarthritis.
Exclusion Criteria:
Patients with other shoulder pathologies
Patients that underwent to other surgical procedures after the tenodesis
Patients that refused to take part of this trial

Surgical Technique
The patient is placed on the beach-chair position on the operating room table. A standard posterior viewing portal is established and the arthroscope is introduced. Diagnostic arthroscopy is performed and an accessory portal in the anterior triangle is established.
At this point, the biceps tendon is inspected, including the anchor to the superior labrum. A probe is used to low the tendon allowing better visualization of its entire intra-articular portion.
The scope is located in the subacromial space and a decompression is performed by using a combination of shaver and radiofrequency. Visualization of the subacromial space and of the bicipital groove laterally is them possible. Other procedures such as rotator cuff reconstructions or suprascapular nerve release can also be performed at this time, if necessary.
A spinal needle is then used to localize a superior, anterolateral portal just anterior to the bicipital groove allowing introduction of devices to work in this space.
The coracoacromial ligament completely removed, allowing better access and visualization to the lateral aspect of the coracoid and conjoint tendon by using the arthroscope in the lateral portal. The subdeltoid space needs to be carefully cleared to better expose the conjoint tendon(figure 1). The scope direction changes to dowonwards until it faces the insertion of the pectoralis major insertion. At this moment the LHBT is cleaned just superiorly to the pectoralis major tendon using the probe and the shaver (figure 2). Bleeding is a frequent problem in this space and radiofrequency devices are used to stop local bleeding.

The biceps tendon is tagged in this space using a Caspary`s(Conmed/Linvatec®) device through a nylon 0 for making landmarks. The scope returns to the posterior portal through the intraarticular space and the biceps tendon is tenotomized from its origin on the superior labrum. The scope returns to the lateral portal and the LHBT is pulled out of the body using a grasper through the anterolateral portal (figure 3). Sometimes all the intertubecularis sulcus need to be released to allow biceps extrusion.
A 3mm anchor is inserted at the superolateral portion of the coracoid(figure 4). The anchor wires are pulled out through the same anterolateral portal where the tendon is. Cannulas are not recommended on this surgical step.
Using a Caspary`s (Conmed/Linvatec®-Largo-FL-USA) (figure 5), 2 fiber wire® (Arthrex®-Naples-Fl-USA) wires passes through the short head of biceps tendon just under the coracoid tip to the posterior portal.
Out of the body the LHBT is sutured using Krakov suture by using one wire from the suture anchor. The simple knot pushes the sutured tendon into the subdeltoid space to find the coracoid and the tenodesis is done.
Using a 18 gauge needle 2 nylon 0 wires are passed through the LHBT in its new location at the same level the fiberwires® have been passed in the short head.
The nylon wires guides the fiberwires® through the LHBT and the suture between both biceps heads are made using regular arthroscopic knots (figures 6 and 7).
II) Patients evaluation:
Patients were evaluated before the surgeries using UCLA score and six monts after surgery using the UCLA score, SF-36, raw scale for function, physical limitation and pain.
Patients were interviewed by phone 1 year and 2 years after surgeries using the raw scale evaluation for function, physical limitation pain and the presence of popey sign.
Data from UCLA were also checked at these times, patients with changes in UCLA were assessed again and just the last result was recorded.
Our minimal follow up was 2 years.
Statistic tests followed the characteristics of the curves.

Fifteen patients were enrolled in this study were 15 with tendinopathy of the long head of biceps tendon (LHBT) were chosen to be submitted to surgical treatment.
One patient was withdrawn because he did not approved his data for publication.
In 12 patients supraspinal tendon lesions were associated.
In 5 patients subscapular tendon lesions were associated.
No patients presented Popey sign after surgery.
UCLA two-year post surgery changed from 22.00±0.69 to 33.14±0.52, p=0,0001. The statistical test used was Wilcoxon matched-pairs signed rank test.
SF-36 two-year post surgery was 140.40±1.44. The raw scale of function two-year post surgery was 93.43%±1.33%. The raw scale for physical limitation two-year post surgery was 96.43%±2.04%. The raw scale for pain two-year post surgery was 94.64%±1.61.
The 1 year and 2 years after surgeries interview by phone used the raw scale evaluation for function, physical limitation pain, the presence of popey sign and patients were also questioned about possible changes in UCLA.
The interviews 2-yer-after-surgery revealed no changes for UCLA scores.
No overtensioning happened.
There was an anterior discomfort for extremes of adduction

The long head biceps tendon continues to play a controversial role in shoulder surgery. In fact, its exact role in shoulder kinematics has not yet been elucidated. Some authors believe that the tendon may play an important role in shoulder stability [11-13]. Others believe that the tendon is clinically insignificant, serving only as a vestigial structure [14-16]. Despite this controversy, it is commonly accepted that the biceps tendon can play an important role in shoulder pathology and serve as a pain generator in the shoulder. The surgical management of biceps tendon pathology remains equally controversial. Current surgical options include tenotomy, tenodesis, or transfer [2, 3, 17, 18]. Tenotomy provides reliable pain relief with the shoulder at rest 5-7. However, in younger patients, complications including cosmetic Popeye deformity and spasm of the biceps muscle belly were not uncommon.
Multiple techniques of LHBT fixation can be used to avoid these problems. Bone tunnels, bone anchors, staples, or interference screws are available options 3, [18-22]. Earlier techniques of transposition of the long head biceps to the conjoint tendon have involved direct tenodesis to the coracoid process [4, 17, 23, 24] reviving the description of Gilcreest in 1936.
O`Brien reported the LHBT transference as being a reliable option when focusing a closer reproduction of the native axis of pull of the biceps muscle and allow the long head and short head to share load. The transfer allows a soft-tissue healing, which may be more favorable than soft tissue to bone healing as it recreates the normal bungee effect of the superior labrum/biceps anchor complex. Finally, this technique provides the surgeon with direct visualization during tensioning and suturing helps prevent overtensioning of the tendon [2].
Our technique has associated the LHBT tenodesis into the coracoid to the O`Brien`s transfer technique in order to avoid loss of the surgeries. We added the tenodesis protection to the soft tissue healing purposed by O´Brien.
The coracoid tenodesis associated to transfer has presented higher difficulty than in the traditional humeral biceps tenodesis.
Some authors belive that if the LHBT natural location`s is the biceps groove in the humerus, moving the tendon can raise unknown biomechanical consequences [11, 12, 16, 17, 21, 23, 24].
However for others the transfer to the coracoid can be more favorable to the biceps natural axes and can be the best choice for the tendon healing [2].
Our experience suggests that in terms of healing and activities, the coracoid axis do not cause clinical problems, however this transference demands proper training and increases time to the surgical procedure.

Indeed our long term results are favorable, however the author do not believe this technique is better than other types of tenodesis.
The surgery increased time to the surgery and demanded very specific training.
This technique is a possible option for biceps pathology.


1. Neviaser RJ. Lesions of the biceps and tendonitis of the shoulder. Orthop Clin North Am 1980;11:343-348.
2. Verma NN, Drakos M, O’Brien SJ. Arthroscopic transfer of the long head biceps to the conjoint tendon. Arthroscopy 2005;21(6):764.
3. Guelich DR, Lintner D. Arthroscopic Intraosseous Biceps Tenodesis. Oper Tech Sports Med 2007;15(1): 16-19 .
4. Abrams JS. Arthroscopic Biceps Tenodesis: Direct Suturing and Results. Oper Tech Sports Med 2007;15(1);10-15.
5. Gill TJ, McIrvin E, Mair SD, Hawkins RJ. Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii. J Shoulder Elbow Surg 2001;10:247-249.
6. Huffman GR, Wolf EM. Arthroscopic biceps tenotomy: Results in patients with symptomatic degeneration of the long head of the biceps brachii tendon. Arthroscopy 2003;19:5(suppl 2).
7. Kelly AM, Drakos MC, Fealy S, Taylor SA, O’Brien SJ. Arthroscopic release of the long head of the biceps tendon: Functional outcome and clinical results. Am J Sports Med 2005; 33:208-213.
8. Paulos LE, Mendez KT, Berg T. A Novel Approach to Arthroscopic Biceps Tenodesis. Oper Tech Sports Med 2007;15(1): 27-34.
9. Gilcreest EL, Dislocations and elongations of the long head of the biceps brachii. Ann. Surg 1936;104:118-138.
10. O’Brien SJ , Miller AN, Drakos MC. Arthroscopic Subdeltoid Approach to the Biceps Transfer . Oper Tech Sports Med 2007;15(1): 20-26.
11. Kumar VP, Satku K, Balasubramaniam P. The role of the long head of biceps brachii in the stabilization of the head of the humerus. Clinic Orthop Rel Res 1989;244:172-175.
12. Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:120-121.
13. Bhatia DN, van Rooyen KS, de Beer JF. Direct arthroscopy of the bicipital groove: a new approach to evaluation and treatment of bicipital groove and biceps tendon pathology. Arthroscopy 2008;24(3):368.e1-6.
14. Lippmann RK. Bicipital tenosynovitis. N Y State J Med 1944; Oct:2235-2241.
15. Levy AS, Kelly B, Lintner S, Speer KP. The function of the long head of the biceps at the shoulder: An EMG analysis. J Shoulder Elbow Surg 2001;10:250-255.
16. Yamaguchi K, Riew KD, Galatz LM, Syme JA, Neviaser RJ. Biceps activity during shoulder motion: An electromyographic analysis. Clin Orthop 1997;336:122-129.
17. Dines D, Warren RF, Inglis AE. Surgical treatment of the long head of the biceps. Clin Orthop Rel Res 1982;164:165-171.
18. Lo IKY, Burkhart SS. Arthroscopic biceps tenodesis: Indications and technique. Oper Tech Sports Med 2002;10(2):105-112.
19. Nord KD, Smith GB, Mauck BM. Arthroscopic biceps tenodesis using suture anchors through the subclavian portal. Arthroscopy 2005;21(2):248-52.
20. Kim SH, Yoo JC. Arthroscopic biceps tenodesis using interference screw: end-tunnel technique. Arthroscopy 2005;21(11):1405.
21. Boileau P, Krishnan SG, Coste JS, Walch G. Arthroscopic biceps tenodesis: a new technique using bioabsorbable interference screw fixation. Arthroscopy 2002;18(9):1002-12
22. Richards DP, Burkhart SS, Lo IKY. Arthroscopic biceps tenodesis with interference screw fixation: The lateral decubitus position. Oper Tech Sports Med 2003;11(1):15-23.
23. Drakos MC, Verma NN, Gulotta LV, Potucek F, Taylor S, Fealy S, Selby RM, O’Brien SJ. Arthroscopic transfer of the long head of the biceps tendon: functional outcome and clinical results. Arthroscopy 2008;24(2):217-23.
24. Ozalay M, Akpinar S, Karaeminogullari O, Balcik C, Tasci A, Tandogan RN, Gecit R. Mechanical strength of four different biceps tenodesis techniques. Arthroscopy 2005;21(8):992-8.

How to Cite this article:JC Garcia Jr, AM Cardoso Jr, MB D. Mello. Arthroscopic Long Head Biceps Tenodesis in Coracoid associated with its Transfer to the Conjoined Tendon. Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):7-10.
Dr. Jose Carlos Garcia Jr Dr. Alvaro Motta Cardoso Jr Dr. Marcelo Boulos D. Mello

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