Long Head of Biceps Tendon Pathology

Snyder described the SLAP lesion in 1990 with four types, and the system has since been expanded to ten:

Type II is the one that matters. It is true detachment of the biceps-labral anchor, which makes the biceps origin unstable, and it is the most clinically significant type because the surgical decision hangs on it: repair or tenodesis, depending heavily on patient age and activity level. Morgan (1998) subdivided it by the direction of extension:

Types V-X. Rare, and primarily of academic interest:

• Type V - Bankart lesion extending to SLAP
• Type VI - unstable labral flap
• Type VII - extension into the middle glenohumeral ligament
• Type VIII - extension into the posterior labrum
• Type IX - circumferential labral tear
• Type X - extension into the rotator interval

Tendinitis is graded by severity on its arthroscopic appearance:

Location. The tendinitis may sit in the intra-articular segment, in the bicipital groove, which is the most common symptomatic location, or at the musculotendinous junction, the distal symptomatic zone. Correlating the clinical picture with the location helps guide the treatment approach.

Habermeyer's classification grades biceps instability by which parts of the pulley have failed and whether the subscapularis is involved:

Direction. Medial subluxation is the most common pattern and goes with a subscapularis tear; lateral subluxation is rare and goes with a massive cuff tear; frank dislocation means complete disruption of the pulley.

Partial tears are classified by the percentage of the tendon involved, and that percentage is the key surgical decision factor:

Location. Articular-sided tears come from synovitis and impingement, bursal-sided tears from external impingement, and intrasubstance tears are degenerative and age-related.

Who. Biceps tendinitis without instability, partial tears under 25%, SLAP I lesions (degenerative fraying), and elderly patients with low functional demands. Conservative management remains the foundation of treatment for patients over 40.

Corticosteroid injection. An injection can be used for bicipital groove tendinitis, but avoid injecting into the tendon substance, and keep to a maximum of 2-3 injections at 3-month intervals.

How often it works. Conservative treatment resolves symptoms in 40-50%, with higher success in older, low-demand patients. SLAP lesions in young athletes rarely resolve without surgery.

Clear indications for surgery

• SLAP Type II in a young overhead athlete who has failed 3-6 months of conservative treatment
• Partial biceps tear over 50%
• Biceps instability with a pulley lesion
• Painful SLAP with mechanical symptoms (catching, locking)
• Complete biceps rupture, acute, in a young patient

Under 40 and an overhead athlete. Consider SLAP repair for a Type II lesion: arthroscopic repair with suture anchors, with a 70-80% return to sport.

Age 40-50. An individualised decision, weighing activity level and tissue quality. Tenodesis is often preferred over SLAP repair, because SLAP repair outcomes decline with age.

Over 50. Tenodesis or tenotomy is preferred; SLAP repair has poor outcomes in this age group. Choose between the two on functional demands and cosmesis.

Associated pathology. With a rotator cuff tear, address the cuff and consider biceps tenotomy or tenodesis. With instability and a SLAP lesion, repair the instability and consider SLAP repair in a young patient. With a subscapularis tear, repair the subscapularis and perform a biceps tenodesis. The decision must account for all the shoulder's pathology in combination.

The three operations

1. SLAP repair - anchor the biceps-labrum complex back to the glenoid
2. Biceps tenodesis - secure the biceps to the humerus, suprapectoral or subpectoral
3. Biceps tenotomy - release the biceps intra-articularly and let it retract

Where to put a tenodesis. A suprapectoral (proximal) tenodesis is an arthroscopic technique with a shorter recovery and a higher risk of groove pain, and it suits younger patients. A subpectoral (distal) tenodesis, open or arthroscopic, has a lower rate of groove pain, is biomechanically superior, and is preferred for most patients over 40. Treatment is individualised on patient factors and surgeon expertise.

Who. A SLAP Type II in a patient under 40, an overhead athlete (throwing, swimming), healthy labral and biceps tissue, and 3-6 months of failed conservative management.

Step 1 - diagnostic arthroscopy. View from the standard posterior portal. Probe the biceps anchor for stability (the peel-back sign), confirm the SLAP type and extent, and evaluate the associated pathology: cuff, labrum, cartilage.

Step 2 - preparation. Debride frayed labral tissue back to a stable base and prepare the superior glenoid neck with a gentle burr to bleeding bone, creating a healthy tissue bed for healing while preserving the biceps tendon insertion.

Step 3 - anchor placement. Place 1-2 suture anchors in the superior glenoid, just posterior to the biceps root and off the articular surface, 5.5 mm or 3.0 mm depending on bone quality, angled toward the centre of the glenoid to maximise pull-out strength.

Step 4 - suture passage and tying. Pass sutures through the labrum and the biceps-labral junction with penetrating devices or suture shuttles, in a simple or mattress configuration, and tie with arthroscopic knots (SMC, Duncan loop). Confirm stable fixation with the probe.

Rehabilitation is set out under Postoperative Care. In carefully selected young overhead athletes the outcomes are good.

Who. Biceps pathology in an active patient aged 40-60, a SLAP lesion in an older patient (instead of repair), a partial biceps tear over 50%, and biceps instability.

Step 1 - prepare the biceps. Evaluate arthroscopically through the standard portals, release the biceps from the superior labrum if a SLAP lesion is present, pull the tendon into the joint to assess tissue quality, and mark the appropriate tension point.

Step 2 - fix the tendon. Two options:

• Interference screw - create an anterolateral portal and position the scope to view the proximal humerus. Drill an 8-10 mm socket in the bicipital groove to a depth of 25-30 mm, whipstitch the biceps, insert it into the socket under tension and advance the interference screw (bioabsorbable or PEEK)
• Suture anchor - place a suture anchor in the supratubercular groove, shuttle the sutures through the tendon, tie to secure the biceps to bone, and excise the redundant proximal stump

Step 3 - confirm fixation. Test the stability of the tenodesis, excise the remaining intra-articular stump and assess for impingement.

Trade-offs. All arthroscopic, with a shorter surgical time and a faster recovery, which is why it is popular with younger, active patients who want a faster return to activity. Against that: the potential for groove pain, a technical challenge, and a risk of fracture through the bone socket.

Who. Biceps pathology at any age, tenodesis combined with a rotator cuff repair, and a previous failed suprapectoral tenodesis. The reasons it is preferred over the suprapectoral option are under Management.

Step 1 - position and incise. Beach chair or lateral decubitus. Make a 3-4 cm incision in the axilla along the inferior border of pectoralis major, and identify that border.

Step 2 - find and release the biceps. Palpate the tendon in the groove and release it with the arm in external rotation; an arthroscopic release from the superior labrum may be needed first. Pull the biceps distally through the incision and excise the diseased portion.

Step 3 - prepare the bone. Identify cortical bone of the humeral shaft distal to the groove and create a socket 8 mm in diameter and 25-30 mm deep, angled parallel to the shaft.

Step 4 - prepare and fix the tendon. Whipstitch the biceps with non-absorbable suture, set the tension with the elbow at 90 degrees and slight tension on the tendon, insert it into the socket and advance an interference screw (7 mm x 23 mm typical). Suture anchor fixation to cortical bone is the alternative.

Step 5 - close. Excise the redundant biceps stump, then close the deep fascia and the skin.

This technique has excellent outcomes with low complication rates.

Who. Age over 60-65, low functional demands, tissue too poor for tenodesis, a patient unconcerned about cosmesis, or a tenotomy combined with an extensive rotator cuff repair, where it simplifies the surgery.

Step 1 - diagnostic arthroscopy. View from the posterior portal, assess the quality of the tendon, identify its origin at the superior labrum and evaluate the associated pathology.

Step 2 - release. Divide the biceps at its origin, just distal to the labral attachment, with arthroscopic scissors or electrocautery. Release it cleanly so that no stump is retained, and watch the tendon retract out of the joint.

Step 3 - debride. Remove any retained stump fragments, smooth the labral edges if frayed, and address the other pathology (cuff, labrum).

Trade-offs. It is the simplest technique, with the shortest surgical time, the lowest complication rate, no risk of fixation failure and immediate unrestricted motion, which makes it excellent for older, low-demand patients who accept the cosmetic risk. Against that: the Popeye deformity, slight fatigue discomfort, and a potential loss of elbow flexion and supination strength (the figures are under Outcomes).

The sling stays on for 4-6 weeks and comes off for exercises only. Motion is passive only at first, with active motion from 6 weeks. There is no active biceps contraction in the first 4 weeks, no overhead lifting in the first 8 weeks, and no throwing before 6 months at the minimum.

A sling for comfort for 2 weeks, passive motion immediately and active motion from 2-3 weeks, but no resisted elbow flexion or supination for 6 weeks to protect the healing tenodesis. Strengthening begins at 6-8 weeks and return to sport at 3-4 months.

A sling for comfort only, for 1-2 weeks. Motion is as tolerated from day one with no restriction on activity, strengthening as able, and return to activities at 6-8 weeks, the fastest recovery of the biceps procedures and the reason it suits patients who want a quick return to function.