1. Introduction

SLAP (superior labrum anterior-posterior) tears are a source of shoulder pain most frequently seen in young, overhead throwing athletes, as well as older patients, often seen as degenerative tears. These injuries are initially managed conservatively with rest, symptomatic treatment, and physical therapy. However, when conservative measures fail, operative treatment may be indicated. This chapter will focus on the failure of SLAP repairs as well as discuss the role of biceps tenotomy and tenodesis in the management of SLAP tears and long head of the biceps tendon pathology. Biceps tenotomy or tenodesis can be utilized either as the primary procedure or as an adjunct to SLAP repair.

2. SLAP (superior labrum anterior-posterior) tears

SLAP tears of the glenohumeral labrum are uncommon injuries most often seen in overhead throwing athletes. In the initial description by Andrews, it was found that most tears occur at the anterior-superior portion of the labrum in close proximity to the biceps insertion, and the long head of the biceps tendon is under increased stress in the throwing motion [1]. SLAP pathology is also associated with glenohumeral internal rotation deficit (GIRD), internal impingement, scapular dyskinesis and articular sided rotator cuff tears. Patient presentation is often delayed, with complaints of vague, nonspecific, deep shoulder pain. Throwing athletes will complain of decreased effectiveness and early fatigue [2, 3]. SLAP tears were initially classified by Snyder, which is the most commonly used classification system. The most common tear type, as defined by Snyder, was Type II, defined as fraying of the labrum with associated detachment of the biceps anchor [3]. The superior glenoid serves as the attachment point for the long head of the biceps, with insertion commonly occurring on the glenoid labrum. The biceps tendon anchor is the weakest point, leading to SLAP pathology [1]. The anatomy of this attachment is important in consideration of both the surgical treatment of SLAP lesions, and the post operative complications, including SLAP repair failure.

The diagnosis of a SLAP tear can be made with a combination of provocative physical examination maneuvers and imaging modalities. One option for advanced imaging is the magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA). Studies have shown that MRA is better utilized for diagnosis of SLAP tear, as it can also be diagnostic for associated injuries including rotator cuff tear [4]. However, it is important to correlate imaging findings with patient history and clinical examination, as not all SLAP tears are symptomatic, or even require operative treatment. There are multiple studies that have evaluated the correlation of SLAP tear on MRI and impact on athletes, when they were asymptomatic. One such study found that there was no relationship between findings on imaging and likelihood of future symptoms in Major League Baseball players. However, this study did demonstrate that MRI findings were more common in players who pitched more innings, suggesting that these injuries are attributable to overuse and overhead throwing motion [5]. Additional studies suggest that there is a significant number of overhead athletes who have SLAP tears found on MRI but remain asymptomatic. For example, Stetson et al. published their MRI review of U.S. Olympic volleyball athletes, 46% of asymptomatic elite volleyball players had MRI evidence of SLAP tears or fraying but no history or complaints of shoulder problems. This suggests that non operative management can be a successful mainstay in these patients [6, 7]. This is extremely important to note due to the significantly poor outcomes with competitive overhead throwers who undergo surgical fixation of SLAP tears. Return to play in baseball players ranges from 7 to 62% [8, 9, 10, 11, 12].

Treatment of SLAP lesions initially consists of conservative measures including throwing rest and physical therapy. However increased level of overhead throwing may predispose athletes to failure of conservative treatment and physical therapy [13, 14]. A physical therapy regimen focuses to address underlying associated pathology including glenohumeral internal rotation deficit (GIRD) and internal impingement by addressing rotator cuff strengthening, posterior capsular stretching, and scapular stability. Operative treatment interventions include arthroscopic debridement alone, arthroscopic debridement with bicep anchor/labral repair, or arthroscopic debridement with biceps tenotomy or tenodesis.

The treatment algorithm for operative management of SLAP tears involves the patient’s age, activity level, body habitus, and cosmetic expectations. Patients over age 40 are best treated with tenotomy of the long head of the biceps versus biceps tenodesis alone [6]. Younger patients, especially overhead-throwing athletes, are typically treated with SLAP repair and do not tolerate non operative treatment well [13, 15]. Surgical technique involves the use of suture anchors placed in the glenoid rim and configured optimally based on arthroscopic observation of labral tear [11, 16]. The most common adverse outcomes associated with SLAP repair are decreased rate of return to competitive sport and shoulder stiffness [2, 3, 4, 11, 13, 14, 15, 16]. Shoulder stiffness is the most common complication following SLAP repair. Therefore, differentiating a type II SLAP tear from a meniscoid type of labrum, a normal sublabral foramen or variant is also critical to the success of the operation. Gobezie et al. showed that even among expert shoulder surgeons, interobserver and intraobserver reliability is poor (48%) in differentiating type II SLAP tears from normal variants or degenerative type I SLAP lesions. Arthroscopic repair of a normal variant can lead to loss of external rotation and alter normal throwing mechanics [17, 18]. SLAP repair failure is an additional complication seen.

3. SLAP tears repair failure

SLAP repair failure is defined as persistent shoulder pain with or without mechanical symptoms requiring additional treatment. SLAP repair failure is seen following arthroscopic repair with multiple potential etiologies. Common etiologies for SLAP repair failure include failure of the repair (which can be secondary to hardware failure of the suture anchors) or articular cartilage damage. SLAP repair is more often utilized and has shown to have greater effectiveness in patients who are younger than thirty-six years old [19]. Research shows that there are less complications and reported failures in patients who undergo tenodesis of the long head of the biceps and arthroscopic debridement, instead of repair [20, 21, 22]. Patients undergoing primary tenotomy or tenodesis of the long head of the biceps are typically older patients, however more recent studies suggest this as a viable treatment method in younger patients [15].

Complications and failure of SLAP repair are not infrequent and can cause significant exacerbation of symptoms in patients. SLAP repair failure is managed with either nonoperative management, revision SLAP repair, or repair revision to long head of the biceps tenodesis. Literature suggests that revision repair is well tolerated, however biceps tenodesis is better tolerated. Biceps tenodesis also demonstrates higher return to functional activity level [22]. The most prevalent complication following SLAP repair is post operative stiffness. In review of cases from the American Board of Orthopedic Surgery (ABOS) part II cases, it was noted that only 26.3% of patients reported absence of pain and only 13.1% of patients reported function as normal [23]. These findings help illustrate the impact of SLAP repair failure and the importance of preventing this complication. Numerous biomechanical studies have been performed with the goal of evaluating methods of SLAP repair. These studies address topics such as the number and location of suture anchors on the glenoid. A cadaveric study by Lehtinen found the optimal anchor position was found to be approximately a thirty-degree angle in relation to the articular surface, the anchor in this position provides the greatest glenoid bone stock to complete the repair [24]. In another cadaveric study focused on the configuration of suture anchors, they found that there is no biomechanical advantage to the placement of suture anchor anterior to the biceps anchor [25]. Prior studies have suggested that suture anchor placement anterior to the biceps anchor can lead to increased stiffness post operatively in SLAP repair [26].

The reason for SLAP repair failure is poorly understood, however there are multiple reasons hypothesized in the literature. One theory is that concomitant injuries lead to poor outcomes and the inability to return to sport, including rotator cuff tears. Ability to return to sport is also dependent upon position played, as there is significant evidence suggesting worse outcomes in baseball pitchers [9, 27, 28]. Additionally, SLAP repair has been shown to change pitching mechanics and yield diminished throwing performance highlighted by decreased velocity and inability to maintain command of their pitches. These altered mechanics were highlighted in a study by McLaughlin who found that pitchers who had undergone SLAP repair had decreased abduction, decreased external rotation, and forward trunk tilt [29]. In addition to patient factors, technical factors from surgery may also play a role in SLAP repair failure and poor patient outcomes. Review of the literature suggests that use of the trans-rotator cuff portal may lead to damage of the musculotendinous portion of the supraspinatus, which predisposes patients to decreased return to play and poor outcomes [17]. Using the trans rotator cuff portal, O’Brien et al. [30] reported a 44% return-to-sport rate and Cohen et al. [12] reported a 38% rate whereas Neri et al. [9] reported a 13% rate. Therefore, using a single anchor placed via a cannula through the rotator interval is recommended.

Studies also indicate that anchor location in SLAP repair can impact patient outcomes and may explain some of the biomechanical alterations seen including decreased external rotation. If the SLAP repair anchor is placed anteriorly, this can lead to loss of external rotation [27, 31] due to entrapment of the superior glenohumeral ligament and middle glenohumeral ligament causing an inadvertent small but statistically significant loss of external rotation [11, 32]. Furthermore, a biomechanical study of the peel-back mechanism of failure has shown no advantage to the placement of an anterior anchor [25].

Associated shoulder pathology may be another reason SLAP repairs fare so poorly. For example, baseball pitchers with partial rotator cuff tears at the time of SLAP repair have shown a lower rate of return to baseball. Neri et al. [9] reported that only 13% were able to return to base- ball, whereas Brockmeier et al. reported that 64% were able to return [11]. Partial articular-sided rotator cuff tears present a challenge to the surgeon. These need to be addressed with either debridement (<50% of the tendon involved) or repair (>50% of the tendon involved) either using a PASTA (partial articular supraspinatus tendon avulsion) repair technique, which is preferred in younger overhead athletes, or completing the tear and repairing it in older athletes [17].

The final technical point that may impact patient outcomes is the type of suture used to repair. Studies have demonstrated that mattress suture is able to better recreate the native labrum/glenoid interface, as well as provide a more robust fixation method when compared to a simple suture [33, 34]. Because of the prevalence of SLAP repair failure, additional research has been performed to evaluate the use of biceps tenodesis or tenotomy as primary treatment of SLAP repair.

4. Biceps tenodesis vs. biceps tenotomy

In addition to SLAP repair, SLAP pathology can be managed with long head of the biceps tenotomy or tenodesis. The clinical indications of long head of biceps tenotomy compared to biceps tenodesis are not universally agreed upon. Multiple techniques have been described for biceps tenodesis, and multiple studies have been performed to determine the clinical indications and utilization of tenodesis or tenotomy. Biceps tenodesis can be performed through an open or an arthroscopic approach, and the tendon may be anchored in a proximal suprapectoral (above the groove), suprapectoral (below the groove), or distal subpectoral position [1, 23, 24].

One popular method of all arthroscopic tenodesis is the “loop ‘N’ tack biceps tenodesis”. This technique is a knotless, intra-articular, arthroscopy only technique [35]. The loop and tack technique involves standard arthroscopy positioning in either the lateral decubitus or beach chair position. A diagnostic arthroscopy is performed utilizing a standard posterior viewing portal and a standard anterior working portal is then made under direct visualization. Then, the surgeon passes a looped suture around the proximal portion of the long head of the biceps tendon and retrieves the loop through the anterior canula. The free end of the suture is placed through the loop to complete a luggage tag stitch (Figure 1). Utilizing a sharp arthroscopic tool, like the Bird Beak (Arthrex), the surgeon passes the free end of the suture through the biceps tendon to anchor to the humeral head. Then the proximal portion of the long head of the biceps is cut using either arthroscopic scissors, shaver, or radiofrequency device near the attachment point of the superior labrum. The free end of the suture is then anchored to the humerus at the superior border of the subscapularis and the most distal portion of the bicipital groove visualized (Figure 2). This can be done with the surgical anchor of the surgeon’s preference [35].

Figure 1.
Arthroscopic image of long head of the biceps tendon. Patient positioned in beach chair position, viewing from standard posterior shoulder portal. Loop suture has been secured around the biceps tendon. Suture is anchored to the humerus at the superior border of the subscapularis and the most distal portion of the bicipital groove.

Figure 2.
Arthroscopic image of long head of the biceps tendon after completion of biceps tenodesis with tenotomy utilizing arthroscopic scissor. Patient positioned in beach chair position, viewing from standard posterior shoulder portal.

Another option for repair is a mini-open subpectoral technique for biceps tenodesis utilizing all suture technique [36]. This subpectoral technique can utilize different fixation methods including a tenodesis screw, an all-suture anchor, or a cortical button for fixation of the biceps. The surgeon begins this technique by starting the patient in the beach chair position, utilizing a mechanical arm holder of the surgeon’s choice for positioning of the operative extremity. Standard diagnostic arthroscopy is performed with a standard posterior viewing portal and a standard anterior working portal, made under direct visualization. Tenotomy of the pathologic long head of the biceps is performed using either arthroscopic scissors, radiofrequency device, or shaver. Attention is then turned distally to the subpectoral bicipital groove. The arm is abducted and externally rotated to expose the pectoralis major tendon; a longitudinal skin incision is made distal to this. The coracobrachialis, biceps and pectoralis are identified. The long head of the biceps is palpated after retraction of the pectoralis major tendon. A clamp is then placed around the long head of the biceps tendon and the free end of the tendon is then delivered through the skin incision [36]. At this point multiple different fixation devices have been described including the all-suture anchor technique, tenodesis interference screw, and cortical button [36, 37]. There is no generalized consensus as to which of these techniques yields the best results.

Research on this topic comparing the use of the interference screw versus all suture anchor showed that the two options were equivalent in both ultimate failure load and stiffness [38]. There is no general consensus regarding which tenodesis technique leads to the best outcomes; both all-arthroscopic biceps tenodesis and open subpectoral biceps tenodesis are viable treatment methods for management of pathology of the long head of the biceps [9].

Conversely, biceps tenotomy is also an option in management of long head of the biceps pathology. The patient is positioned in either the beach chair or lateral decubitus position, based on surgeon comfort and preference. Pathologic long head of the biceps tendon is visualized through the standard posterior portal (Figure 3). Tenotomy is best achieved using arthroscopic scissors, shaver, or radiofrequency device near the attachment point of the superior labrum, depending on surgeon preference (Figure 4). Meeks reported high patient satisfaction with reported 13% rate of cosmetic deformity in patients who underwent biceps tenotomy. These results suggest that tenotomy alone is a viable alternative surgical management [39]. Other concerns with biceps tenotomy include decreased supination function and muscle cramping. This study demonstrates similar results regarding biceps cramping, 20%, when compared to other tenotomy evaluations [39]. With this alternative in treatment, multiple studies exist comparing biceps tenotomy and tenodesis.

Figure 3.
Arthroscopic image of diseased long head of the biceps tendon with probe placed around tendon. Patient positioned in lateral decubitus position, viewing from standard posterior shoulder portal.

Figure 4.
Arthroscopic image of long head of the superior glenoid labrum and biceps anchor after completion of biceps tenotomy with arthroscopic shave. Patient positioned in lateral decubitus position, viewing from standard posterior shoulder portal.

Biceps tenotomy compared to tenodesis has been a frequently studied topic. According to multiple review articles and meta-analysis, tenotomy is more likely to result in cosmetic deformity, Popeye deformity, and muscle cramping (although cramping is not obviated by performing tenodesis). Additionally, tenotomy has also shown decreased functional scores and diminished supination strength [40, 41]. Additional meta-analysis demonstrates there is increased incidence of cosmetic deformity and post operative cramping with tenotomy, however there are no functional differences noted between tenotomy and tenodesis of the long head of the biceps [42]. Tenotomy is best utilized in older, overweight patients, with less functional demand, and less concern for cosmesis [41]. Tenodesis is often reserved for younger, higher functional demand, and less likely to tolerate Popeye deformity [41]. Tenodesis can be performed in patients best suited for tenotomy, however there may be no clinical benefit in this patient population.

As discussed above, tenodesis can be performed all arthroscopically, using the loop and tack technique, or using a mini open technique using a tenodesis interference screw, tightrope with cortical button, or suture/suture anchor utilizing an onlay technique. These techniques have been studied, with no general consensus. Studies demonstrate favorable results with use of these tenodesis techniques, especially in management of SLAP repairs, however there is no general consensus.

Newer research advocates for the use of tenodesis in the treatment of SLAP repairs in younger patients, especially those who participate in overhead throwing activities. The study by Pogorzelski evaluated the use of biceps tenodesis utilizing biceps tenotomy with radiofrequency device followed by mini open subpectoral biceps tenodesis with utilization of tenodesis screw. Results demonstrated patients had significant improvement in American Shoulder Elbow Society Scores (ASES) and a 90% rate of return to preoperative level of function, including return to sports and overhead activities [15]. Additional review demonstrates comparable return to sport in patients undergoing SLAP repair compared to biceps tenodesis, although these results do not account for activity, including overhead throwing versus non overhead throwing athletes [43]. Other attempted treatment modalities in this population includes repair of the SLAP tear with concomitant biceps tenodesis, however these results show that these patients experience worse outcomes in comparison to patients undergoing primary repair or biceps tenodesis in isolation [44]. This may demonstrate the role of biceps tenodesis in younger, overhead throwing athletes. Given the complication rates and failures noted in SLAP repair, more studies are necessary to evaluate the role of biceps tenodesis compared to SLAP repair.

5. Conclusions

SLAP (superior labrum anterior-posterior) tears are a source of shoulder pain most frequently seen in young, overhead throwing, patients, as well as older patients, degenerative tears. SLAP lesions and concomitant shoulder pathology is best diagnosed using advanced imaging including magnetic resonance imaging (MRI) and magnetic resonance arthrogram (MRA). Treatment of SLAP lesions initially consists of conservative measures including throwing rest, in younger, overhead throwing athletes and physical therapy. Operative treatment interventions include arthroscopic debridement alone, arthroscopic debridement with bicep anchor/labral repair, or arthroscopic debridement with biceps tenotomy or tenodesis. Patients over 40 are best treated with biceps tenotomy vs. tenodesis alone. Younger patients, especially overhead athletes less than 40 are typically treated with SLAP repair. There is a high incidence of SLAP repair failure in competitive overhead athletes that is multifactorial in nature, secondary to patient characteristics and surgical technique. There remains debate between the use of long head of biceps tenotomy compared to biceps tenodesis, either mini open (subpectoral) or arthroscopic tenodesis. Tenotomy is best utilized in older, overweight patients, with less functional demand, and less concern for cosmesis. Tenodesis is often reserved for younger, higher functional demand, and less likely to tolerate Popeye deformity.

Conflict of interest

The authors declare no conflict of interest.

BSN Prasad

Chapters authored

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