Biceps & SLAP
Superior Labrum and Proximal Biceps Injuries
The Superior labrum anterior to posterior (SLAP) tears and injury to the long head of the biceps (LHB) are common issues that may occur together, resulting in shoulder pain, dysfunction and loss of function.
The glenoid (shoulder socket) labrum is composed of fibrocartilaginous tissue, with the LHB attached to the superior aspect of the labrum. The biceps muscle is located on the front of the upper arm, with tendons attaching to the bone proximally (at the shoulder) and distally (at the elbow). Irritation and inflammation the biceps tendon may result in pain. Tendinopathy (or chronic tendonitis) occurs from overuse of the arm and shoulder, or from direct injury to the area. In more severe cases, the tendon may become torn either partially or fully at their attachment.
Pathophysiology of the Overhead Athlete
Certain anatomic and biomechanical factors can predispose overhead athletes to SLAP tears. Excessive external rotation of the shoulder in the late cocking phase may result in increased forces displaced at the LHB attachment (root), resulting in a peel-back injury to the labrum.
Physical Examination and Work-Up
Examination includes assessment of your range of motion, function and strength. The clinical diagnosis of a SLAP tear or a symptomatic LHB tendiopathy is difficult as they present similarly. In the setting of a complete tendon rupture, usually there is a palpable defect where the tendon should be. A proximal biceps tendon rupture results in a “Popeye” deformity of the upper arm, with a large muscle bulge and bruising. X-rays are included to assess for any joint abnormalities, while MRI will help discern the extent of injury as well as any concomitant pathology.
Nonsurgical management of SLAP tears focuses on addressing tightness of the posterior capsule of the shoulder, while concurrently strengthening the rotator cuff and peri-scapular musculature. On occasion, steroid injections may assist in treatment of SLAP tears.
In the case of biceps tendinopathy, treatment begins with a course of physical therapy focusing on correction of scapular dyskinesia, and may also include an injection. The goal of rehabilitations is to return to your desired sport or activity as soon as is safely possible.
Surgical management for SLAP tears is considered in patients with persistent symptoms despite a course of nonsurgical treatment for at least 3 months. Arthroscopipc intervention includes SLAP repairs versus open biceps tenodesis, with treatment details determined by multiple factors such as patient age and activity level.
Partial long head biceps tendon tears may require surgery, while acute, full thickness tear are primarily fixed surgically. There is no definitive consensus on treatment technique, biceps tenodesis versus tenotomy, and the ultimate decision is based on the discussion between you and your surgeon.