Long Head of Biceps Tendon Pathology

Snyder Classification of SLAP Lesions (1990, expanded to 10 types)

Original Four Types:

Type II Subtypes (Morgan 1998):

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.

Classification by Severity:

Location:

• Intra-articular - within glenohumeral joint
• Bicipital groove - most common symptomatic location
• Musculotendinous junction - distal symptomatic zone

Clinical correlation with location helps guide treatment approach.

Biceps Instability Classification:

Habermeyer Classification:

Direction of instability:

• Medial subluxation - most common, subscapularis tear
• Lateral subluxation - rare, massive cuff tear
• Frank dislocation - complete pulley disruption

Partial Biceps Tear Classification:

Based on percentage of tendon involvement:

Location of partial tears:

• Articular-sided - from synovitis, impingement
• Bursal-sided - from external impingement
• Intrasubstance - degenerative, age-related

Percentage of involvement is the key surgical decision factor.

Indications:

• Biceps tendinitis without instability
• Partial tears under 25%
• SLAP I lesions (degenerative fraying)
• Elderly patients with low functional demands

Conservative treatment protocol:

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

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.

Clear indications for surgery:

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

Age-based algorithm:

Under 40 years, overhead athlete:

• Consider SLAP repair for Type II lesions
• Arthroscopic repair with suture anchors
• Success rate 70-80% return to sport

Age 40-50 years:

• Individualized decision
• Consider activity level, tissue quality
• Tenodesis often preferred over SLAP repair
• SLAP repair outcomes decline with age

Over 50 years:

• Tenodesis or tenotomy preferred
• SLAP repair has poor outcomes in this age group
• Consider functional demands and cosmesis

Associated pathology considerations:

• RTC tear + biceps pathology: Address cuff, consider biceps tenotomy/tenodesis
• Instability + SLAP: Repair instability, consider SLAP repair in young patients
• Subscapularis tear + biceps: Repair subscapularis, perform biceps tenodesis

Surgical decision-making must account for all shoulder pathology in combination.

Surgical options:

1. SLAP repair - anchor biceps-labrum to glenoid
2. Biceps tenodesis - secure biceps to humerus (suprapectoral or subpectoral)
3. Biceps tenotomy - release biceps intra-articularly, allow retraction

Decision factors:

Tenodesis location decision:

Suprapectoral (proximal) tenodesis:

• Arthroscopic technique
• Shorter recovery
• Higher risk of groove pain
• Good for younger patients

Subpectoral (distal) tenodesis:

• Open or arthroscopic
• Lower groove pain rate
• Biomechanically superior
• Preferred for most patients over 40

Treatment should be individualized based on patient factors and surgeon expertise.

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

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.

Indications:

• Biceps pathology age 40-60, active
• SLAP in older patient (instead of repair)
• Partial biceps tear over 50%
• Biceps instability

Arthroscopic suprapectoral tenodesis:

Step 1: Prepare biceps

• Arthroscopic evaluation via standard portals
• Release biceps from superior labrum (if SLAP present)
• Pull biceps into joint, assess tissue quality
• Mark appropriate tension point

Step 2: Create bone tunnel or use interference screw

Option A: Interference screw technique

• Create anterior lateral portal
• Position scope to view proximal humerus
• Drill 8-10mm socket in bicipital groove
• Depth 25-30mm
• Prepare biceps (whipstitch with suture)
• Insert biceps into socket with tension
• Advance interference screw (bioabsorbable or PEEK)

Option B: Suture anchor technique

• Place suture anchor in supratubercular groove
• Shuttle sutures through biceps tendon
• Tie to secure biceps to bone
• Excise redundant proximal stump

Step 3: Confirm fixation

• Test stability of tenodesis
• Excise remaining intra-articular stump
• Assess for impingement

Advantages:

• All arthroscopic
• Shorter surgical time
• Faster recovery

Disadvantages:

• Potential groove pain (10-15%)
• Technical challenge
• Risk of fracture with bone socket

This approach is popular for younger, active patients who want faster return to activity.

Indications:

• Biceps pathology any age
• Preferred technique for patients over 50
• Combined with rotator cuff repair
• Previous failed suprapectoral tenodesis

Open subpectoral tenodesis:

Step 1: Positioning and incision

• Beach chair or lateral decubitus
• 3-4 cm incision in axilla along inferior pec major border
• Identify pectoralis major inferior border

Step 2: Biceps identification

• Palpate biceps tendon in groove
• Release with arm in external rotation
• May need arthroscopic release from superior labrum first
• Pull biceps distally through incision
• Excise diseased portion

Step 3: Bone preparation

• Identify cortical bone of humeral shaft distal to groove
• Create bone socket 8mm diameter, 25-30mm depth
• Angle parallel to humeral shaft

Step 4: Tendon preparation and fixation

• Whipstitch biceps with non-absorbable suture
• Determine appropriate tension (elbow 90deg, slight tension)
• Insert into bone socket
• Advance interference screw (7mm x 23mm typical)
• Alternative: suture anchor fixation to cortical bone

Step 5: Closure

• Excise redundant biceps stump
• Close deep fascia
• Skin closure

Postoperative protocol:

• Sling for comfort 2 weeks
• Immediate passive ROM allowed
• Active ROM at 2-3 weeks
• No resisted elbow flexion or forearm supination for 6 weeks
• Strengthening begins at 6-8 weeks
• Return to sport 3-4 months

This technique has excellent outcomes with low complication rates.

Indications:

• Age over 60-65
• Low functional demands
• Poor tissue quality (not amenable to tenodesis)
• Patient unconcerned about cosmesis
• Combined with extensive rotator cuff repair (simplifies surgery)

Arthroscopic tenotomy technique:

Step 1: Diagnostic arthroscopy

• Standard posterior portal viewing
• Assess biceps tendon quality
• Identify biceps origin at superior labrum
• Evaluate associated pathology

Step 2: Biceps release

• Use arthroscopic scissors or electrocautery
• Divide biceps at origin (just distal to labral attachment)
• Release cleanly to prevent retained stump
• Observe tendon retract out of joint

Step 3: Debridement

• Remove any retained biceps stump fragments
• Smooth labral edges if frayed
• Address other pathology (cuff, labrum)

Advantages:

• Simplest technique
• Shortest surgical time
• Lowest complication rate
• No risk of fixation failure
• Immediate unrestricted ROM

Disadvantages:

• Popeye deformity (cosmetic)
• Slight fatigue discomfort (10% of patients)
• Potential 10% loss of elbow flexion/supination strength

Postoperative protocol:

• Sling for comfort only (1-2 weeks)
• Immediate ROM as tolerated
• No restrictions on activity
• Strengthening as able
• Return to activities 6-8 weeks

This simple technique is excellent for older, low-demand patients who accept cosmetic risk.

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.

Key restriction:

• No resisted biceps contraction for 6 weeks (protect tenodesis healing)
• Otherwise, ROM unrestricted immediately

Tenodesis rehabilitation is faster than SLAP repair but requires biceps protection.

Key advantage:

• No restrictions on ROM or activity from day 1
• Fastest recovery of all biceps procedures
• Ideal for patients wanting quick return to function

Tenotomy has the most liberal and fastest rehabilitation protocol.