Long Head Biceps

Arthroscopic SLAP Repair

Shoulder Scope SLAP 2




1. Establish portals


A.  Posterior portal for viewing


B.  Anterior portal

- need to keep low and away from biceps, otherwise difficult to get around biceps

- for suture passage, if in combination with bankart repair often use AI portal instead of AS


SLAP repair anterior portal


C.  Anterosuperolateral portal / Wilminton for insertion of anchors

- insert spinal needle first

- anterolateral border acromion

- needs to be close to acromion to get angle over humeral head

- check with needle

- need best angle to insert anchors to anterior and posterior aspect of biceps

- passes through supraspinatous

- use knife to cut in line with fibres

- insert portal


SLAP Repair Port WilmingtonShoulder Portal WilmingtonShoulder SLAP Repair Portals


2.  Prepare insertion

- shaver via anterior portal

- debride frayed labrum

- mobilise biceps tendon

- debride bony base to create ledge and bleeding bone


Shoulder SLAP Preparation Base


3.  Anchors


Drill and insert via Wilminton portal

Usually 3 anchors is a minimum



- insert anchor

- suture through each cannula

- limb through W portal will be the suture limb that is passed

- suture passer through anterior portal (right angled for left shoulder)


SLAP Anchor InsertionShoulder SLAP Repair Suture Management


Anterior anchor

- best to pass the suture passer above the biceps to get good bite

- retrieve sutures and tie from port of Wilmington


SLAP Repair Suture PasserSLAP repair Anterior AnchorSLAP Repair anterior anchor 2


SLAP Anchor 1SLAP Tie anterior anchor


Posterior 2 anchors

- pass suture passer under biceps


SLAP Vertical MattressSLAP Second Anchor


SLAP third anchorSLAP 3 anchor repair


Can suture Portal of Wilminton if desired


Portal WilmingtonWilminton Repair 1Wilminton Repair 3


4.  Dfficult posterior anchors


Camera through anterior / anterosuperiorlateral portal


A.  Place anchor through posterior portal

- does not always give good angle


SLAP repair posterior portal


B.  Trans infraspinatous Portal


SLAP Insertion Posterior AnchorsSLAP Posterior SuturesSLAP Posterior Repair


Biceps Tenodesis




- intra-articular

- suprapectoral



- suprapectoral

- subpectoral


A.  Arthroscopic Intra-articular


Biceps Tenodesis Intra articular



- suture biceps to superior capsule using figure 8 no 2 non absorbable



- anterior portal + portal of Wilmington

- debride capsule and biceps with shaver so will heal

- use curved suture passer with no 1 PDS

- suture shuttle no 2 fibre wire

- divide 90% biceps insertion so will rupture in time

- allows healing of biceps to capsule


Biceps Tenodesis First PassBiceps Tenodesis PDSBiceps Tenodesis First Suture


Biceps Tenodesis Second PassBiceps Tenodesis CompletedBiceps Tendon Insertion Cut


Attempt Figure 8 Suture Configuration


Biceps Tenodesis Step 1Biceps Tenodesis Step 2


B.  Arthroscopic Suprapectoral Technique


1.  Secure Biceps Tendon - allows tensioning and prevents losing tendon


A.  Birds Beak Passer with 2 ethibond loop

- pass loop through intact tendon at entry through RC interval

- retrieve loop out through portal and lock

- this gives strong hold on tendon


B.  Pass 18 G spinal needle through biceps tendon

- thread 1 PDS or nylon

- retrieve both suture ends via portal in rotator interval

- secure with half hitches

- pass 1 loop of PDS about entire tendon and tie again


Arthroscopy Tagging Biceps TendonArthroscopy Secured Biceps Tendon


2.  Resect tendon with electrocautery at insertion


Arthroscopy Biceps Tenotomy


3.  Make portal over biceps interval into subacromial space

- release biceps tendon with electrocautery or arthroscopic scissors


4.  Secure tendon

- make drill hole

- insert tendon

- secure with biotenodesis screw

- multiple techniques with specifically designed equipment


C.  Open Technique for Intact Biceps


1.  Divide biceps arthroscopically

- may wish to place stay suture first to avoid retraction

- biceps normally has vinculae preventing complete retraction into arm


2.  Suprapectoral

- deltoid split

- between anterior and middle parts

- find biceps in groove

- pull out of wound and whip stitch with heavy suture

- drill appropriate size tunnel for fixation screw

- multiple biceps tenodesis devices

- push the tendon into the hole, then fixate with screw


3.  Subpectoral

- medial incision in arm

- below inferior edge of pectoralis major

- find biceps tendon

- whip stitch

- pass through drill holes / secure with screw / secure with anchor


Biceps Subpectoral TenodesisSubpectoral Biceps Tenodesis


D.  Open Technique for Ruptured LHB / Popeye in young patient


1.  Locate biceps




A.  Suprapectoral

- best to make deltopectoral approach

- biceps may be futher retracted


B.  Subpectoral approach


2.  Fixation

SLAP lesion

DefinitionMRI SLAP Tear


Superior labrum anterior & posterior


Injury to superior part of glenoid labrum involving region of biceps tendon insertion




2 groups


1.  Young patients

- most common in young males

- fall / trauma

- also associated with glenohumeral instability


2.  Older patients 

- have rotator cuff tear or other pathology

- don't repair in this group

- tenotomy / tenodesis




Three mechanisms


1.  Compression force applied to GHJ


- commonest

- arm in abduction & forward flexion

- head subluxes superiorly over glenoid edge & detaches labrum by shear & compression


2.  Traction on Arm

- sudden pull on arm

- grab while falling


3.  Overhead motion

- throwing thlete

- repetitive microtrauma due to eccentric loading




Pain with overhead activities


Catching or popping with overhead activities


Acute trauma


Mimics impingement




Speed's Test 

Yergason's Test


O'Brien's test


Causes impingement of biceps on anterosuperior labrum


1.  Shoulder flexed 90o in plane of scapula

- adducted 30-45o / max IR

- i.e. thumb down

- resisted elevation produces pain


2.  Relieved when same again but with ER

- i.e. no pain with thumbs up


McMurray's Shoulder test


Compression-Rotation test

- patient supine 

- shoulder abducted 90°, elbow flexed 90°

- compression force to humerus and humerus rotated

- attempt to trap torn labrum

- positive if pain & click




See fluid up under biceps insertion

- note: difficult to distinguish pathological v normal variant


MRI Slap with SS tearMRI Anterior Bankart


Supralabral ganglion cyst

- associated with posterior SLAP tears


Normal Arthroscopy


Normal Biceps Insertion


Arthroscopic Classification Snyder


Type 1 (10%)

- fraying & degeneration of the edge of superior labrum

- firmly attached labrum and biceps anchor 


Arthroscopy Meniscoid Biceps Insertion


Type 2 (40%)

- Superior labrum + Biceps tendon stripped off glenoid   



- anterior

- posterior

- anterior and posterior


SLAP arthroscopyShoulder Scope SLAP Type 2


Type 3 (30%)

- bucket handle tear of superior labrum

- displacement of labrum into joint

- biceps tendon attached to glenoid


Shoulder Scope Type 3 SLAP


Type 4

- bucket handle tear of superior labrum with part of biceps

- extension into biceps tendon which remains attached but with partial tear


Type 4 SLAP Tear extends partially into bicepsSLAP Type 4


Type 5 - 7 added by Gartsman


Type 5
- SLAP 2 with anterior bankart extension


Type 6

- SLAP 2 with free flap of meniscal tissue


Type 7

- Slap 2 with anterior bankart extension and into MGHL


Normal Variations of the Superior Labrum


The superior labrum can be mobile

- normal cartilage extending over the tubercle

- no evidence of trauma

- the labrum and biceps is firmly attached to the tubercle

- this is not pathological

- do not repair


Arthroscopy Normal Cartilage under Biceps LabrumArthroscopy Stable Biceps Insertion


Davidson et al Am J Sports Medicine 2004

- described normal variations


1.  Triangular


2.  Bumper

- lump of fibrous tissue


3.  Meniscoid

- labrum extends down over glenoid face




Non Operative



- physio





Arthroscopic diagnosis

- high level of pre-operative suspicion

- must establish is pathological

- treated at time of arthroscopy




1. Debridement of frayed labrum / Type 1 & 3

2. Repair superior labrum and biceps / Type 2

3. Biceps tenodesis

4. Tenotomy




1.  Older patient with RC tear and SLAP


Francheschi Am J Sports Med April 2008

- RCT patients with SLAP and RC > 50

- tenotomy v SLAP repair in setting RC tear

- improved ROM and functional scores in tenotomy group


2.  Repair v Tenodesis Type II SLAP


Boileau et al Am J Sports Med May 2009

- compared cohort arthroscopic repair v arthroscopic tenodesis in overhead athletes (Level 3 evidence)

- repair group 40% satisified, 20% returned to previous level of sport

- tenodesis patients 93% satisified, 87% return to previous level of sport


Altcheck et al JBJS Am 2009

- case series of 37 athletes with SLAP 2 repair

- 87% rated outcome as good or excellent

- 75% able to return to previous level of sport

- this was higher (92%) if athlete described a discrete traumatic event


3.  SLAP and instability in young patient

- SLAP lesions can cause instability

- a SLAP lesion can contribute to inferior instability

- a SLAP and a Bankart can co-exist


MRI SLAPMRI Anterior Bankart


Management Algorithm


Type 1


Debride labrum


Type 2


A.  Arthroscopic repair


B.  Tenotomy / tenodesis


Type 3


Debride bucket handle labrum


Type 4


Remove labral flap


Repair / debride / tenodesis biceps

- may be evidence that do better with tenodesis


Types 5 - 7

- associated with instability

- repair as per treatment of instability

Tendinosis / Rupture / Subluxation / Hypertrophy

FunctionNormal Biceps


LHB primary function is humeral head depressor


Also accelerate / decelerate arm in overhead sports




Biceps problems usually occur with other pathology 

- rotator cuff / instability


3 main problems


1.  Degeneration

- "Tendinosis"

- usually associated with impingement

- can lead to rupture



- rarely associated with weakness

- 80% flexion strength from brachialis and short head biceps


2.  Instability


Stability contributed by

- transverse humeral ligament

- coracohumeral ligament

- superior GH ligament


Almost always associated with cuff tears

- SS tears

- medial subluxation with SSC tear


Lafosse et al Arthroscopy 2007

- biceps can be unstable anteriorly or posteriorly

- anterior with SSC tears

- posterior with SS tears


3.  Disorders of the origin (SLAP)


4.  Hourglass Biceps


Wiley etal J Shoulder Hand Surg 2004

- thickened intra-articular portion biceps

- unable to travel in groove

- with forward flexion of arm, arthroscopically see bunching of biceps

- requires double release  / tenotomy / tenodesis





- from postero-superior labrum and supraglenoid tubercule


Tendon is intra-articular

- passes deep to CH ligament, through rotator interval

- enters bicipital groove, beneath transverse humeral ligament




Tenderness over biceps tendon crucial



- Popeye appearance


Popeye Sign BicepsPopeye Biceps



- forward flexed shoulder against resistance

- elbow kept extended and supinated

- feel pain or palpate tenderness



- elbow flexed and pronated

- resist supination

- pain over LHB


O'Brien's / SLAP

- arm forward flexed and adducted in plane of scapula

- point thumb down and resist downwards force

- this generates pain

- no / less pain with thumb up






MRI Enlocated Biceps Tendon




Biceps Tendonitis MRI


Tendonosis / thickening


Biceps Tendinosis MRI


Medial Subluxation


Biceps Tendon Medially DislocatedMedially Dislocated Biceps Tendon with Torn SubscapularisBiceps Medially Dislocated and Torn SSC






Arthroscopy Normal Biceps Tendon Arthroscopy Normal Biceps Exit


Mild Tendonopathy


Biceps Tendonopathy Grade 2 Arthroscopy


Moderate Tendonopathy


Shoulder Biceps Moderate Tendonopathy


Severe Tendonopathy


Biceps Tendonopathy ArhroscopyBiceps Tear near complete


Dislocated Biceps in Presence of complete SSC Rupture


Shoulder Scope Dislocated Biceps TendonMedially Subluxed Biceps Tendon




1.  Tendonitis


Non Operative


As per rotator cuff / impingement


- physio


Surgical Options


1.  SAD

2.  Manage rotator cuff pathology

3.  Consider for inflamed but intact LHB

- release THL

- spare CH ligament


2.  Tendon Fraying / Tendinosis / Rupture


Grade tendon integrity


I     Minor fraying <25%

II    Fraying 25-50%

III   Fraying >50%

IV   Complete rupture


Management Strategy


I & II

- SAD & debride tendon 



- SAD & biceps tenodesis / tenotomy


Tenotomy v Tenodesis


Frost et al Am J Sports Medicine April 2009

- reviewed all articles on tenotomy / tenodesis

- concluded that there is no evidence for superiority of one over another


Koh et al Am J Sports Med 2010

- tenotomy v tenodesis in setting RC tears

- 9% popeye in tenodesis (suture anchor) and 27% in tenotomy

- no other difference in terms elbow flexion power / shoulder scores




Popeye deformity


Lim et al Am J Sports Med 2011

- incidence of pop-eye of 45% post tenotomy

- more common in men


Cosmetic deformity acceptable in elderly

- not in young

- avoided by tenodesis




Shank et al Arthroscopy 2011

- no evidence of decreased elbow flexion or supination strength





- young patient grade II, III, IV

- slim arm (where popeye would cause significant cosmetic problem)



- screw prominence / pain

- failure of fixation



- arthroscopic

- open

- see techniques




Soft tissue or bony fixation

- in inter-tubercular groove

- suprapectoral


Sheibel Am J Sports Med 2011

- soft tissue v bony anchor fixation

- superior cosmetic and functional outcome with bony




Suprapectoral or subpectoral


Nho et al J Should Elbow Surgery 2010

- 353 patients treated with subpectoral bioabsorbable tenodesis screw

- 2% complication rate

- 2 patients with popeye

- 2 with tenderness over screw

- 1 deep infection

- 1 MCN injury


3.  Subluxation




Usually medial from SSC tear

- must manage LHB or SSC repair will fail




1.  Tenodesis / Tenotomy + SSC repair


2.  Stabilisation + SSC repair



- can get stenosed painful tendon  


Maler et al JBJS Am 2007

- 21 patients with traumatic tear of SSC treated within 6 weeks

- open SSC repair and LHB stabilisation

- 7 had symptoms of mild tenodinopathy

- 2 recurrent instability and 1 rupture on US