Long Head of Biceps Tendinopathy and SLAP Tears: Peeling-Back Mechanism and Rehab
In short
Anterior shoulder pain in overhead athletes is frequently rooted in the long head of the biceps and superior labrum. Learn SLAP tears, peeling-back biomechanics, and rehab.
In this guide (5 sections)
Anatomy of the Biceps-Labral Complex
The long head of the biceps tendon (LHBT) originates from the supraglenoid tubercle of the scapula and the superior labrum, exiting the glenohumeral joint cavity through the bicipital groove of the humerus under the transverse humeral ligament.
The LHBT acts as an active anterior and superior stabilizer of the humeral head, particularly during abduction and external rotation.
Overuse, friction within the fibro-osseous bicipital tunnel, or repetitive overhead traction leads to primary or secondary bicipital tendinopathy, frequently coexisting with subacromial impingement and rotator cuff tears.
SLAP Tears and the Peeling-Back Mechanism in Throwers
Superior Labrum Anterior to Posterior (SLAP) tears occur where the long head of the biceps anchors into the superior labrum, classified by Snyder into Types I through IV.
In throwing athletes (cricketers, tennis players), SLAP Type II lesions develop via the 'Peeling-Back Mechanism' described by Stephen Burkhart: during the late cocking phase of throwing (arm maximally abducted and externally rotated), the biceps tendon vector shifts posteriorly.
This exerts a torsional twisting force that peels the superior labral anchor medially off the glenoid rim, causing deep, painful clicking, loss of throwing velocity, and 'dead arm syndrome'.
Clinical Examination: Speed's, Yergason's and O'Brien's Tests
Accurate diagnosis requires differentiating isolated groove tendinopathy from an unstable superior labral detachment.
| Clinical Special Test | Patient Positioning & Resistance | Positive Test Finding | Target Anatomical Structure | |
|---|---|---|---|---|
| 1. Speed's Test | Arm in 90 degrees shoulder flexion, supinated; resist downward push | Sharp pain localized directly in the anterior bicipital groove | Long head of biceps tendon tenosynovitis. | |
| 2. Yergason's Test | Elbow flexed to 90 degrees; resist active forearm supination and external rotation | Pain in bicipital groove or tendon 'pop' out of groove | Transverse humeral ligament tear / biceps subluxation. | |
| 3. O'Brien Active Compression | Arm in 90 deg flexion, 10 deg adduction; test internal vs external rotation | Pain deep inside joint with thumb down; relieved with thumb up | SLAP lesion (superior labral tear). | |
| 4. Biceps Load II Test | Supine; arm at 120 deg abduction, maximal ER; resist elbow flexion | Deep shoulder pain or familiar clicking reproduced | Type II SLAP lesion in throwing athletes. |
Conservative Rehabilitation Protocol
Non-surgical rehabilitation focuses on resolving kinetic chain deficits, restoring scapular control, and strengthening the dynamic rotators to offload the biceps.
Direct heavy isolated biceps curls are strictly prohibited during early rehab.
- Phase 1: Biceps Offloading & Isometrics: Rest from overhead throwing; perform submaximal isometric rotator cuff and scapular stabilization drills with the elbow supported in 90 degrees flexion.
- Phase 2: Posterior Capsular Stretching: Perform sleeper stretches and cross-body adduction stretches to correct GIRD, which shifts the humeral head forward and strains the biceps anchor.
- Phase 3: Scapular Retraining (Serratus & Lower Trap): Wall slides, prone Ts, and serratus punches to ensure smooth upward scapular rotation during elevation.
- Phase 4: Eccentric Biceps and Deceleration: Gradual reintroduction of light eccentric biceps lengthening (lowering light weights with arm at side) to prepare the tendon for rapid elbow deceleration in throwing.
Frequently Asked Questions
What is the difference between a biceps tenotomy and biceps tenodesis?
In severe degenerative LHBT disease or failed SLAP repair, surgeons perform either a tenotomy (cutting the damaged tendon and releasing it, which can cause a harmless 'Popeye' muscle bulge) or a tenodesis (cutting the tendon and re-anchoring it to the upper humerus bone outside the joint). Both relieve deep shoulder pain effectively.
Can a SLAP tear heal without surgery?
Many Type I and Type II SLAP tears respond successfully to 3 to 6 months of specialized physiotherapy focusing on rotator cuff strengthening and correcting GIRD, particularly in recreational non-overhead athletes.
Why do athletes get a 'dead arm' feeling with a SLAP tear?
Superior labral detachment permits subtle anterior subluxation of the humeral head during late cocking, stretching the anterior joint capsule and transiently tractioning the brachial plexus, producing acute weakness and numbness.
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