Authors’ Disclosure Statement: Dr. Romeo reports that he receives royalties from Arthrex and Elsevier; is a consultant for Arthrex; receives research support from Arthrex, Smith & Nephew, Össur, MioMed Orthopaedics, DJO Global, ConMed Linvatec, and Athletico; is on the editorial board of Orthopedics Today, Journal of Shoulder and Elbow Surgery, Techniques in Shoulder and Elbow Surgery, Operative Techniques in Sports Medicine, Sports Health, and Orthopedics; and receives publisher support from Elsevier and Orthopedics Today. The other authors report no actual or potential conflict of interest in relation to this article.
Overhead throwing is a common causative factor in disorders of the proximal biceps in athletes. In recent years, arthroscopic repair of unstable superior labral tears or biceps tendonitis involving the long head of the biceps tendon anchor has become the standard of care. However, in some cases, superior labrum anterior-posterior (SLAP) repair requires additional evaluation and even revision surgery, which contributes to patient dissatisfaction. Differentiating overall biceps tendonitis from superior labral tears alone can be a challenge. More recently, biceps tenodesis has been suggested as a potential option for the treatment of SLAP lesions in overhead athletes. This option is controversial, and data on return to play in overhead athletes are scant.
In recent decades, the long head of the biceps (LHB) tendon has been recognized as a pain generator in the shoulder of throwing athletes. The LHB muscle and its role in glenohumeral kinematics remains largely in question. The LHB tendon varies in size but most commonly is 5 mm to 6mm in diameter and about 9 cm in length, inserting on the superior labrum and supraglenoid tubercle after traveling through the bicipital groove.1 The many conditions that can develop along the course of the biceps tendon include overall biceps tendonitis, biceps tendon subluxation or instability, and injuries to the superior anterior to posterior area of the labrum.
These injuries can occur in young overhead athletes as well as manual laborers and older overhead recreational athletes. Pitching is the most common activity that leads to proximal biceps tendon disorders. The 6 phases of the pitch are linked in a kinetic chain that generates energy that is then translated to high velocity. The amount of force that is exerted on the shoulder during pitching and especially after ball release is impressive, and the athlete’s shoulder changes in many ways as it adapts to the motion.2-5 The late-cocking and deceleration phases are most commonly associated with proximal biceps pathology and the “peel-back” phenomenon. Other common activities that lead to biceps tendon issues in a young population are volleyball, baseball, tennis, softball, swimming, and cricket. Shoulder arthroscopies performed in older patients show degenerative biceps and labrum tears, which should be treated appropriately but perhaps different from how they are treated in overhead athletes.6-8 Further, many professional athletes have asymptomatic superior labrum anterior-posterior (SLAP) tears.9
Mechanism of Injury
Overhead throwing is commonly thought to be the mechanism by which lesions are created in the biceps–labrum complex (BLC). Pitching in particular generates incredible force and torque within the shoulder. In professional pitchers, the resulting throwing speed creates forces regularly in excess of 1000 N.3 These forces effect internal compensatory changes and internal derangement of the BLC. These changes often involve internal rotation deficits and alterations in the rotator cuff, which may contribute to glenohumeral instability and altered joint kinematics.10
Repetitive overhead activity is largely considered the mechanism of injury in this population, though more specific mechanisms have been described, including the peel-back mechanism11 and the posterior superior glenoid impingement. There is little evidence that preventive programs have any effect on decreasing the incidence of SLAP tears in overhead athletes.
Preoperative Evaluation
Preoperative evaluation is arguably the most important step in treating a patient with persistent or recurrent symptoms consistent with a SLAP tear. Evaluation includes thorough history, physical examination, and review of any prior injuries or surgical procedures. The physical examination should focus on maneuvers that define where the problem is occurring. Although SLAP tears are most common in this population, disorders of the biceps tendon within the groove, including inflammation and instability, should be ruled out with physical examination and advanced imaging. Palpation for groove tenderness, impingement-type complaints, internal rotation loss, and SLAP provocative testing are crucial in the diagnosis.12,13 The cause of symptoms may be multifactorial and include the often encountered concomitant pathology of rotator cuff tears, internal impingement, and instability.
Standard radiographs (Grashey anteroposterior, scapular/lateral, axillary lateral) and magnetic resonance imaging (MRI) with or without arthrography can be helpful in identifying and characterizing most SLAP tears as well as failed SLAP tear repairs. However, MRI is often positive for SLAP tears in asymptomatic patients, and diagnosing SLAP tears with MRI is often a challenge.14 MRI can help in determining concomitant pathology, including rotator cuff injury and cysts causing nerve compression. Correlation with clinical examination and patient history is most crucial. Conservative treatment (rest, activity modification, use of oral anti-inflammatory medications) typically is attempted and coordinated with respect to the athlete’s season of play.15,16
Classification
In overhead throwing athletes, SLAP tears typically are associated with anterior shoulder pain. Associated shoulder instability and significant glenohumeral dysfunction are not uncommon in athletes with lesions of the BLC. In 1985, Andrews and colleagues17 were the first to describe SLAP tears in overhead athletes (73 patients). Later, Snyder and colleagues18,19 further classified these lesions into 4 types based on tear stability and location, and they coined the acronym SLAP (Figure 1).
Morgan and colleagues20 subclassified type II lesions into 3 groups based on location (anterior SLAP, posterior SLAP, and combined SLAP tear).
