LONG HEAD OF BICEPS TENDON PATHOLOGY
SLAP Lesions | Biceps Tendinitis | Pulley Lesions | Tenotomy vs Tenodesis
SLAP LESION TYPES (SNYDER)
Critical Must-Knows
- Anatomy: Intra-articular portion 3-4cm, passes through rotator interval (biceps pulley system)
- SLAP Type II most clinically significant - detachment of biceps anchor from superior labrum
- Clinical triad: Speed test (flexion resistance), Yergason (supination resistance), O'Brien (active compression)
- Age-based treatment: Under 40 = repair SLAP, over 40-50 = consider tenodesis/tenotomy
- Pulley lesions (medial sling damage) cause instability - require repair or tenodesis
Examiner's Pearls
- "SLAP = Superior Labrum Anterior to Posterior
- "Type II SLAP is biceps anchor detachment - most common surgical lesion
- "MRA gold standard for SLAP diagnosis (sensitivity 90%)
- "Tenotomy vs tenodesis: age, activity level, cosmesis are key factors
- "Associated RTC tears in 30% - always evaluate cuff in biceps pathology
Clinical Imaging
Imaging Gallery
Critical Biceps Pathology Exam Points
SLAP Type II Most Important
Type II SLAP lesion is detachment of the biceps anchor from the superior labrum. This is the most clinically significant type requiring surgical decision-making. Younger athletes may benefit from repair, older patients from tenodesis.
Age Influences Treatment
Age over 40-50 years shifts treatment toward tenodesis or tenotomy rather than SLAP repair. Outcomes of SLAP repair in older patients are inferior. Consider activity level and cosmetic concerns.
Pulley System Critical
The biceps pulley (SGHL, CHL, subscapularis) stabilizes the biceps in the groove. Medial subluxation occurs with pulley lesions. Look for associated subscapularis tears - these create combined instability.
Always Assess Rotator Cuff
30% of biceps pathology occurs with rotator cuff tears. The biceps acts as a secondary humeral head depressor. Isolated biceps symptoms may be from underlying cuff pathology - always evaluate the cuff.
Quick Decision Guide - Biceps Treatment Algorithm
| Pathology | Age/Activity | First-Line Treatment | Backup Options |
|---|---|---|---|
| SLAP Type II | Under 40, athlete | Arthroscopic SLAP repair | Tenodesis if repair fails |
| SLAP Type II | Over 40-50, recreational | Biceps tenodesis | Tenotomy if low demand |
| Biceps tendinitis (isolated) | Any age | Conservative (NSAIDs, physio, injection) | Tenodesis if failed conservative |
| Biceps instability (pulley lesion) | Any age, active | Subpectoral tenodesis | Suprapectoral if young athlete |
| Partial biceps tear (greater than 50%) | Any age | Tenotomy or tenodesis | Debridement if under 25% |
SLAP - Superior Labrum Tear Classification
Memory Hook:SLAP describes the location and direction of the labral tear involving the biceps anchor
SPEED Test - Clinical Examination
Memory Hook:SPEED test evaluates the long head of biceps - most sensitive clinical test for biceps tendinitis
PULLEY - Biceps Stabilizing Structures
Memory Hook:The PULLEY system prevents medial subluxation of the biceps tendon
TENODESIS vs TENOTOMY Decision Factors
Memory Hook:ACTIVE decision-making balances age, cosmesis, activity level, and tissue quality
Overview and Epidemiology
Long head of biceps (LHB) pathology encompasses a spectrum of conditions affecting the intra-articular and proximal extra-articular portions of the biceps tendon. These include SLAP lesions, tendinitis, instability, and partial or complete tears.
Clinical significance:
- Common cause of anterior shoulder pain
- Often associated with rotator cuff pathology
- Can be primary or secondary to other shoulder conditions
- Treatment has evolved significantly with age-based algorithms
Primary vs Secondary Pathology
Biceps pathology can be primary (isolated tendinitis, SLAP tear) or secondary to rotator cuff disease, glenohumeral instability, or impingement. Secondary pathology is more common in patients over 40. Always evaluate for underlying shoulder conditions.
Mechanism of injury:
- SLAP lesions: Traction injury (fall on outstretched hand), repetitive overhead activity (throwing, swimming)
- Biceps tendinitis: Overuse, impingement, instability
- Pulley lesions: Trauma, subscapularis tears, chronic instability
Risk factors:
- Overhead athletes (baseball pitchers, swimmers, tennis players)
- Repetitive lifting activities
- Age over 40 (degenerative changes)
- Shoulder instability
- Rotator cuff disease
Pathophysiology and Mechanisms
Long head of biceps anatomy:
The LHB has four distinct anatomical zones:
- Intra-articular portion (3-4 cm) - from superior labrum to bicipital groove entrance
- Extra-articular proximal - within the bicipital groove
- Musculotendinous junction - distal to groove
- Muscle belly - continues to radial tuberosity
Intra-articular Nature
The intra-articular portion of the LHB is unique - it is the only tendon coursing through a synovial joint without a synovial sheath in its intra-articular segment. This makes it vulnerable to inflammatory processes affecting the glenohumeral joint.
Biceps anchor and superior labrum:
- LHB originates from superior glenoid labrum (50-60% posterior, 40-50% anterior)
- Also attaches to supraglenoid tubercle of scapula
- Type of attachment varies (entirely posterior, entirely labral, or mixed)
- Normal anatomical variants can mimic SLAP lesions
The biceps pulley system:
Critical stabilizing structure preventing medial subluxation:
- Superior glenohumeral ligament (SGHL) - forms superior roof
- Coracohumeral ligament (CHL) - reinforces laterally
- Superior subscapularis fibers - forms medial sling
- Supraspinatus fibers - contributes laterally
Pulley Lesion Recognition
Damage to the medial sling (superior subscapularis and SGHL) allows medial subluxation of the biceps tendon. This creates a "pseudolaxity" pattern. Look for associated subscapularis tears - these are combined pulley lesions requiring different management than isolated biceps pathology.
Bicipital groove anatomy:
- Bounded by lesser tuberosity (medial) and greater tuberosity (lateral)
- Intertubercular ridge height varies (shallow groove = instability prone)
- Transverse humeral ligament - spans the groove, holds biceps
- Average depth 4-6 mm, width 9-10 mm
Biomechanical functions:
- Elbow flexion - primary function with short head
- Forearm supination - works with supinator
- Secondary humeral head depressor - particularly with rotator cuff deficiency
- Anterior shoulder stabilizer - controversial role in glenohumeral stability
Blood supply:
- Anterior humeral circumflex artery - primary supply
- Tendon relatively avascular in intra-articular zone - predisposes to degeneration
- Watershed area at bicipital groove entrance - common tear location
Classification Systems
Snyder Classification of SLAP Lesions (1990, expanded to 10 types)
Original Four Types:
| Type | Description | Treatment |
|---|---|---|
| I | Degenerative fraying, stable anchor | Debridement |
| II | Biceps anchor detachment from labrum | Repair (young) or tenodesis (older) |
| III | Bucket-handle tear, stable biceps anchor | Excise unstable portion, preserve anchor |
| IV | Bucket-handle tear extending into biceps tendon | Repair or tenodesis based on extent |
Type II Subtypes (Morgan 1998):
| Subtype | Pattern | Clinical Significance |
|---|---|---|
| Anterior | Anterior extension | May be associated with instability |
| Posterior | Posterior extension | Most common throwing athlete pattern |
| Combined | Anterior and posterior | Complex tear, surgical challenge |
Type II Most Important
SLAP Type II represents true detachment of the biceps-labral anchor. This is the most clinically significant type because it creates instability of the biceps origin. Decision between repair and tenodesis depends heavily on patient age and activity level.
Extended Types V-X (less common):
- Type V: Bankart lesion extending to SLAP
- Type VI: Unstable labral flap
- Type VII: Extension into middle glenohumeral ligament
- Type VIII: Extension into posterior labrum
- Type IX: Circumferential labral tear
- Type X: Extension into rotator interval
These extended types are rare and primarily of academic interest.
Clinical Presentation and Examination
History:
- Pain location: Anterior shoulder, bicipital groove tenderness
- Mechanism: Acute (fall on hand, sudden load) vs chronic (overuse)
- Occupation/sport: Overhead athletes, manual laborers
- Symptoms: Night pain, catching, popping sensation (SLAP), weakness
- Previous treatments: Injections, physiotherapy
Physical examination:
Clinical Examination Tests for Biceps Pathology
| Test | Technique | Positive Finding | Sensitivity/Notes |
|---|---|---|---|
| Speed Test | Shoulder flexion 90deg, elbow extended, forearm supinated. Resist forward flexion. | Pain in bicipital groove | Sensitivity 90%, most sensitive test |
| Yergason Test | Elbow 90deg flexed, forearm pronated. Resist supination and elbow flexion. | Pain in bicipital groove or biceps subluxation | Sensitivity 43%, tests stability |
| O'Brien Test (Active Compression) | Arm forward flexed 90deg, adducted 10deg, internally rotated (thumb down). Resist forward flexion. Repeat with forearm supinated. | Pain with thumb down, relief with palm up | For SLAP lesions, specificity 90% |
| Biceps Load Test I | Supine, shoulder abducted 90deg, elbow flexed 90deg, forearm supinated. Resist elbow flexion while externally rotating shoulder. | Increased apprehension or pain | For SLAP in patients with instability |
| Upper Cut Test | Elbow 90deg, forearm supinated. Patient performs uppercut motion against resistance. | Pain in bicipital groove | Good for proximal biceps pathology |
| Bicipital Groove Tenderness | Direct palpation of groove with arm in 10deg internal rotation. | Point tenderness over groove | Simple, low specificity but useful |
Test Combinations
No single test is definitive. Combine tests for better accuracy. A positive Speed test + O'Brien test is highly suggestive of biceps-labral pathology. Add imaging (MRA) for definitive diagnosis.
Associated examination findings:
- Rotator cuff testing - Jobe, external rotation lag, hornblower
- Impingement signs - Neer, Hawkins-Kennedy
- Instability testing - Apprehension, relocation, load-shift
- AC joint - cross-arm adduction
Specific findings:
- Popeye deformity - complete LHB rupture, distal muscle belly retraction
- Audible snap/pop - biceps instability with arm movement
- Tenderness - bicipital groove, anterior shoulder
Investigations and Imaging
Plain radiographs:
Standard shoulder series (AP, scapular Y, axillary):
- Usually normal in isolated biceps pathology
- May show calcific tendinitis in groove
- Assess for other pathology (arthritis, AC joint, fracture)
Ultrasound:
Advantages:
- Dynamic assessment - can visualize subluxation with arm movement
- Cost-effective, readily available
- Good for bicipital groove pathology
Findings:
- Tendinopathy (thickening, hypoechoic changes)
- Fluid in tendon sheath
- Partial or complete tears
- Subluxation with dynamic imaging
Ultrasound Utility
Ultrasound is excellent for bicipital groove pathology (tendinitis, partial tears, instability) but poor for SLAP lesions. The intra-articular biceps origin cannot be adequately assessed with ultrasound. Use MRA for suspected SLAP tears.
MRI/MRA (Magnetic Resonance Arthrography):
Gold standard for SLAP lesions and intra-articular pathology.
Standard MRI findings:
- T2 hyperintensity around biceps (tendinitis)
- Partial or complete tendon tears
- Associated rotator cuff tears
- Labral pathology
MRA (with gadolinium injection):
- Sensitivity 90% for SLAP lesions
- Specificity 95%
- Better delineation of labral detachment
- Identifies extent and type of SLAP
MRA vs Standard MRI
For suspected SLAP lesions, MRA is superior to standard MRI. The intra-articular contrast outlines the biceps anchor and labral detachment. Standard MRI has lower sensitivity (60-70%) and may miss SLAP II lesions.
MRI/MRA findings by pathology:
| Pathology | MRI Finding |
|---|---|
| SLAP Type II | Fluid signal extending under biceps anchor on coronal images |
| Biceps tendinitis | T2 hyperintensity, tendon thickening |
| Partial tear | Partial discontinuity, increased signal |
| Complete tear | Empty groove, retracted tendon |
| Subluxation/dislocation | Tendon medial to lesser tuberosity |
| Pulley lesion | SGHL/CHL tear, subscapularis partial tear |
Diagnostic arthroscopy:
Remains the gold standard for definitive diagnosis and treatment.
Advantages:
- Direct visualization of biceps, labrum, cuff
- Dynamic assessment of stability
- Therapeutic (can debride, repair at same setting)
Findings:
- SLAP lesion type and extent
- Biceps quality (degenerative vs healthy)
- Associated cuff tears, labral tears
- Pulley integrity assessment
Management Algorithm
Indications:
- Biceps tendinitis without instability
- Partial tears under 25%
- SLAP I lesions (degenerative fraying)
- Elderly patients with low functional demands
Conservative treatment protocol:
- Rest from aggravating activities (overhead, lifting)
- NSAIDs for pain and inflammation
- Ice therapy
- Activity modification
- Gentle pendulum exercises
- Progressive ROM exercises
- Rotator cuff strengthening
- Scapular stabilization
- Posterior capsule stretching
- Eccentric biceps exercises
- Sport-specific rehabilitation
- Return to overhead activities gradually
- Maintenance strengthening program
- Ergonomic modifications for work
Corticosteroid injection:
- Can be used for bicipital groove tendinitis
- Risk of tendon rupture if repeated injections
- Avoid injection into tendon substance
- Maximum 2-3 injections with 3-month intervals
Injection Caution
Avoid repeated steroid injections into the bicipital groove. Multiple injections increase risk of complete tendon rupture. If symptoms recur after 2 injections, consider surgical options.
Success rates:
- 40-50% resolution with conservative treatment
- Higher success in older, low-demand patients
- SLAP lesions in young athletes rarely resolve without surgery
Conservative management remains the foundation of treatment for patients over 40 years of age.
Surgical Technique
Indications:
- SLAP Type II in patients under 40
- Overhead athletes (throwing, swimming)
- Healthy labral and biceps tissue
- Failed conservative management 3-6 months
Arthroscopic technique:
Step 1: Diagnostic arthroscopy
- Standard posterior viewing portal
- Assess biceps anchor stability (probe test - peel-back sign)
- Confirm SLAP type and extent
- Evaluate associated pathology (cuff, labrum, cartilage)
Step 2: Preparation
- Debride frayed labral tissue to stable base
- Prepare superior glenoid neck (gentle burr to bleeding bone)
- Preserve biceps tendon insertion
- Create healthy tissue bed for healing
Step 3: Anchor placement
- Place 1-2 suture anchors in superior glenoid
- Position just posterior to biceps root (avoid articular surface)
- 5.5mm or 3.0mm anchors depending on bone quality
- Angle toward glenoid center to maximize pullout strength
Step 4: Suture passage and tying
- Pass sutures through labrum and biceps-labral junction
- Use penetrating devices or suture shuttles
- Simple or mattress suture configuration
- Tie with arthroscopic knots (SMC, Duncan loop)
- Confirm stable fixation with probe
Peel-Back Sign
The peel-back sign is pathognomonic for SLAP Type II. With the arm in abduction and external rotation (throwing position), the biceps tightens and peels the posterior-superior labrum off the glenoid. This is visible arthroscopically and confirms unstable biceps anchor.
Postoperative protocol:
- Sling immobilization 4-6 weeks
- Passive ROM only initially
- Active ROM at 6 weeks
- Strengthening at 12 weeks
- Return to throwing 6-9 months
This technique has good outcomes in carefully selected young overhead athletes.
Complications
Complications by Procedure Type
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Stiffness (SLAP repair) | 20-30% | Early passive ROM, aggressive physiotherapy |
| Failed SLAP repair | 10-25% in athletes over 40 | Age-appropriate patient selection, avoid repair over 45 |
| Groove pain (suprapectoral tenodesis) | 10-15% | Consider subpectoral approach, avoid hardware prominence |
| Popeye deformity (tenotomy) | 10-30% | Counsel preoperatively, use tenodesis if cosmesis important |
| Humeral fracture (tenodesis) | Under 1% | Limit bone socket size to 8mm, avoid excessive depth |
| Fixation failure (tenodesis) | 2-5% | Adequate bone socket depth, interference screw sized appropriately |
| Muscle cramping/fatigue | 5-10% | More common with tenotomy, usually resolves with time |
| Persistent pain | 10-15% | Address associated pathology (cuff, labrum, impingement) |
SLAP repair specific complications:
- Stiffness (most common) - prolonged immobilization, capsular reaction
- Failure to return to sport - 20-40% in overhead athletes
- Revision surgery - May need conversion to tenodesis
Tenodesis complications:
- Groove pain (suprapectoral) - hardware prominence, irritation
- Residual tendinitis - If diseased portion not fully excised
- Cosmetic concerns - Though less than tenotomy
Tenotomy complications:
- Popeye deformity - Higher in young, muscular patients
- Cramping - Transient in 5-10%
- Strength loss - Usually under 10%, not functionally significant
Managing Failed SLAP Repair
Failed SLAP repair in patients over 40 is common. Do not attempt revision SLAP repair - outcomes are poor. Instead, perform biceps tenodesis as a salvage procedure. Counsel patient about realistic expectations for return to overhead sport.
Postoperative Care and Rehabilitation
Rehabilitation protocols by procedure:
- Sling immobilization (remove for exercises only)
- Passive ROM only (no active ROM)
- Pendulum exercises
- Gentle scapular activation
- Elbow/wrist/hand ROM
- No lifting, pushing, pulling
- Begin active-assisted ROM
- Continue passive stretching
- Gentle isometric rotator cuff
- Progress to full passive ROM
- Light scapular strengthening
- Active ROM all planes
- Progressive resistive exercises
- Rotator cuff strengthening
- Scapular stabilization program
- Begin light functional activities
- Sport-specific training
- Plyometric exercises for overhead athletes
- Interval throwing program (pitchers)
- Progressive loading
- Full unrestricted activity
- Return to competitive throwing (if applicable)
- Maintenance strengthening program
Key restrictions:
- No active biceps contraction first 4 weeks
- No overhead lifting first 8 weeks
- No throwing until 6 months minimum
SLAP repair has the most restrictive and prolonged rehabilitation of biceps procedures.
Outcomes and Prognosis
Outcomes by procedure:
SLAP Repair:
- Young overhead athletes (under 35): 70-85% return to sport at same level
- Age 35-40: 60-70% return to sport
- Age over 40: 40-50% return to overhead sport, 20-30% revision rate
- Overall satisfaction: 70-80% in appropriate candidates
Prognostic factors for SLAP repair:
- Age (younger better)
- Sport type (throwers worse than swimmers)
- Tissue quality (degenerative labrum worse)
- Associated pathology (worse with cuff tears)
SLAP Repair Age Threshold
The key message for exams: SLAP repair outcomes decline significantly after age 40. This is due to degenerative labral changes and poor healing capacity. For patients over 40-45, tenodesis or tenotomy is preferred over SLAP repair in most cases.
Biceps Tenodesis:
- Overall satisfaction: 85-95%
- Pain relief: 90%
- Return to activity: 90% at 3-4 months
- Cosmetic outcome: Excellent (maintains muscle contour)
- Strength: Preserved (equivalent to normal)
Tenodesis complications:
- Persistent groove pain: 10-15% (suprapectoral)
- Fixation failure: 2-5%
- Reoperation rate: under 5%
Subpectoral vs suprapectoral outcomes:
- Subpectoral: Lower groove pain (5% vs 15%)
- Suprapectoral: Faster recovery, all arthroscopic
- Both: Equivalent strength and function at 1 year
Biceps Tenotomy:
- Overall satisfaction: 90-95% (in appropriate patients over 60)
- Pain relief: 95%
- Popeye deformity: 10-30% (cosmetic only)
- Strength loss: 8-10% elbow flexion, 5-10% supination (not functionally significant)
- Cramping: 10% initially, resolves in most
Return to work:
- Desk work: 2-4 weeks (all procedures)
- Manual labor: 3-6 months (SLAP repair), 2-3 months (tenodesis), 6-8 weeks (tenotomy)
- Overhead work: 4-6 months (SLAP), 3-4 months (tenodesis)
Long-term outcomes:
- SLAP repair has highest failure rate at 5-10 years (especially over 40)
- Tenodesis has excellent durability
- Tenotomy outcomes remain stable long-term
Evidence Base
- Original description of SLAP lesion classification (Types I-IV). Type II identified as biceps anchor detachment - most clinically significant pattern requiring surgical treatment in symptomatic patients.
- Compared SLAP repair vs biceps tenodesis in patients over 35. Tenodesis had 87% satisfaction vs 20% for SLAP repair. Age emerged as critical factor - outcomes of SLAP repair decline significantly after age 35-40.
- Long-term follow-up of SLAP repairs showed 63% good/excellent results overall. Only 45% of overhead athletes returned to preinjury level. Age over 36 and worker's compensation status were negative prognostic factors.
- Subpectoral tenodesis for failed SLAP repairs or Type II SLAP in patients over 35 showed 93% satisfaction, 8% persistent pain, no Popeye deformity. Recommended as primary treatment for biceps-labral pathology in patients over 40.
- Meta-analysis comparing tenotomy vs tenodesis showed no difference in functional outcomes or patient satisfaction. Tenotomy had higher Popeye deformity rate (18% vs 8%) but equivalent strength. Tenotomy faster recovery and lower cost.
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Young Overhead Athlete with SLAP Tear
"A 28-year-old competitive baseball pitcher presents with 8 months of posterior shoulder pain, particularly during the late cocking phase of throwing. Clinical examination shows positive O'Brien test and Speed test. MRA shows a Type II SLAP lesion. He has failed 4 months of physiotherapy. How do you manage this patient?"
Scenario 2: Middle-Aged Patient with Biceps Pathology and Rotator Cuff Tear
"A 52-year-old recreational golfer presents with anterior shoulder pain for 6 months. Examination shows positive Speed test, Yergason test, and a positive Jobe test. MRI shows biceps tendinosis with 60% partial tearing of the biceps tendon, and a full-thickness supraspinatus tear (2cm retraction). What is your treatment plan?"
Combined Pathology Strategy
Scenario 3: Failed SLAP Repair in Older Patient
"A 43-year-old patient had an arthroscopic Type II SLAP repair 18 months ago for shoulder pain. He has persistent anterior shoulder pain despite extensive physiotherapy. He cannot return to overhead work as a carpenter. Examination shows positive Speed test and bicipital groove tenderness. Repeat MRI shows intact SLAP repair but biceps tendinosis. What is your management?"
MCQ Practice Points
SLAP Classification Question
Q: Which SLAP type represents detachment of the biceps anchor from the superior labrum? A: Type II. This is the most clinically significant SLAP type requiring surgical decision-making (repair vs tenodesis based on age). Type I is degenerative fraying, Type III is bucket-handle with stable anchor, Type IV extends into biceps.
Clinical Test Question
Q: What is the most sensitive clinical test for long head of biceps tendinitis? A: Speed test (sensitivity 90%). Performed with shoulder flexion 90 degrees, elbow extended, forearm supinated, resisting forward flexion. Pain in bicipital groove is positive. Yergason tests biceps stability (supination resistance).
Age Threshold Question
Q: At what age do outcomes of SLAP repair decline significantly, favoring tenodesis instead? A: Age 40-45 years. SLAP repair success rates decline dramatically over 40 due to degenerative labral changes. Tenodesis has superior outcomes in this age group and should be considered as primary treatment.
Anatomy Question
Q: What structures comprise the biceps pulley system that prevents medial subluxation? A: The pulley consists of SGHL (superior glenohumeral ligament), CHL (coracohumeral ligament), and superior subscapularis fibers. Damage to the medial sling (subscapularis and SGHL) causes medial biceps instability.
Treatment Decision Question
Q: A 55-year-old with biceps tendinosis and 70% partial tear needs surgical treatment. What is the most appropriate option? A: Biceps tenotomy or tenodesis. Over 50% partial thickness tears are not salvageable. At age 55, either tenotomy (simpler, faster recovery) or tenodesis (preserves strength, avoids Popeye) are appropriate. Decision based on activity level and cosmetic concerns.
Australian Context
Epidemiology:
- Overhead sports common in Australia (cricket, swimming, tennis)
- Manual labor workforce (construction, mining) at risk for biceps pathology
- Aging population with degenerative biceps conditions
Imaging availability:
- MRA available at major centers and private radiology
- Ultrasound widely available, cost-effective for bicipital groove pathology
- Medicare rebates for MRI with appropriate clinical indication
Surgical practice:
- Arthroscopic expertise widely available
- Trend toward age-appropriate surgery (tenodesis over SLAP repair in over 40s)
- Subpectoral tenodesis gaining popularity over suprapectoral
Rehabilitation:
- Physiotherapy essential component of conservative and postoperative management
- Private health insurance often covers extended physiotherapy
- Return to work programs for injured workers
Workers compensation:
- Overhead workers (electricians, painters) commonly affected
- Documentation of work capacity critical
- Realistic return-to-work timelines important for compensation cases
Exam Context
Be prepared to discuss age-based treatment algorithms for biceps pathology. Know SLAP classification, clinical tests (Speed, Yergason, O'Brien), and the decision between SLAP repair (young athlete) vs tenodesis (over 40) vs tenotomy (over 60, low demand). Understand pulley lesions and their association with subscapularis tears.
LONG HEAD OF BICEPS TENDON PATHOLOGY
High-Yield Exam Summary
KEY ANATOMY
- •Intra-articular portion 3-4cm (unique - no synovial sheath in joint)
- •Origin: Superior labrum (50-60% posterior, 40-50% anterior)
- •Pulley system: SGHL, CHL, superior subscapularis (prevents medial subluxation)
- •Bicipital groove: lesser tuberosity (medial), greater tuberosity (lateral)
- •Functions: Elbow flexion, supination, secondary humeral head depressor
SLAP CLASSIFICATION (SNYDER)
- •Type I: Degenerative fraying (debridement)
- •Type II: Biceps anchor detachment (MOST IMPORTANT - repair vs tenodesis)
- •Type III: Bucket-handle, stable anchor (debride unstable portion)
- •Type IV: Bucket-handle into biceps (repair or tenodesis)
- •Types V-X: Rare variants with labral extensions
CLINICAL TESTS
- •Speed test: Flexion 90deg, elbow extended, supinated - resist flexion (90% sensitive)
- •Yergason: Elbow 90deg, pronated - resist supination (tests stability)
- •O'Brien (Active compression): Forward flex 90deg, adduct 10deg, IR - thumb down pain (SLAP specific)
- •Bicipital groove tenderness: Direct palpation with arm in 10deg IR
- •Combine tests for better accuracy
AGE-BASED TREATMENT
- •Under 40, athlete: SLAP repair for Type II (70-80% RTS)
- •Age 40-50: Tenodesis preferred over SLAP repair (better outcomes)
- •Over 50-60: Tenodesis or tenotomy based on activity/cosmesis
- •Over 65, low demand: Tenotomy (simplest, fastest recovery)
- •Key principle: Outcomes of SLAP repair decline significantly over 40
SURGICAL OPTIONS
- •SLAP repair: Young athlete, healthy tissue, 6-9 month recovery
- •Suprapectoral tenodesis: All arthroscopic, faster recovery, 10-15% groove pain
- •Subpectoral tenodesis: Avoids groove, lower pain rate, preferred over 40
- •Tenotomy: Simplest, no restrictions, 10-30% Popeye deformity
- •Partial tear over 50%: Not salvageable, needs tenotomy or tenodesis
CRITICAL EXAM POINTS
- •Type II SLAP is biceps anchor detachment - most clinically significant
- •Age 40 is threshold - tenodesis over SLAP repair after this age
- •MRA gold standard for SLAP (sensitivity 90%), ultrasound good for groove pathology
- •30% biceps pathology occurs with RTC tears - always assess cuff
- •Pulley lesion (subscapularis tear) causes medial instability - needs tenodesis
- •Failed SLAP repair: salvage with tenodesis, NOT revision SLAP repair