Injuries of the Biceps and Superior Labral Complex in Overhead Athletes

The treatment of biceps and superior labral complex injuries in overhead athletes, incorporating findings from prospective randomized controlled studies and meta-analyses


Overhead athletes, such as baseball players, are prone to injuries of the biceps and superior labral complex, which can be challenging to diagnose and treat. Understanding current evidence from high-quality studies can help guide management.

Anatomy and Biomechanics

The biceps-labral complex has distinct anatomical zones: inside, junction, and bicipital tunnel. The long head biceps tendon contributes to glenohumeral stability and experiences significant loads during the throwing motion.


Physical exam maneuvers like the active compression test have moderate diagnostic accuracy. MRI misses many extra-articular lesions. Arthroscopy cannot fully visualize the bicipital tunnel.


Initial management is non-operative with rest, activity modification, physiotherapy. Refractory cases may require surgery.

Non-Operative Treatment

A RCT by Fedoriw et al. showed relative success of non-operative rehabilitation in baseball players, with a 40% return to play rate for pitchers.

Operative Treatment

SLAP Repair: A Cochrane review found sparse evidence to support SLAP repair, with most studies being case series. An RCT by Provencher et al. found 36.8% failure rate after SLAP repair. Older age predicts worse outcomes.

Biceps Tenodesis: A systematic review by Erickson et al. recommended tenodesis or tenotomy over SLAP repair in patients over 40 years old. Biomechanics studies show tenodesis does not fully restore shoulder kinematics.

Tenotomy: Provides reliable pain relief but has high risk of Popeye deformity and weakness. Not ideal for overhead athletes.

Outcomes in Overhead Athletes

Return to sport rates around 50-60% after SLAP repair or biceps tenodesis have been reported in case series of elite overhead athletes. A meta-analysis found bicipital tunnel decompression may improve outcomes.


Injuries to the biceps and labrum continue to pose management challenges. High quality evidence, particularly from RCTs, is lacking to firmly guide treatment. Individualized treatment plans accounting for patient factors are needed. More research is required on optimal surgical techniques.

In summary, while some low quality evidence exists, there is a need for properly designed comparative trials to better determine the most effective treatments for biceps-labral injuries in overhead athletes. Outcomes are unpredictable, and a multimodal approach accounting for patient characteristics appears best. Continued research in this area can help establish stronger guidelines for managing these athletes.

For Full Research Paper:


© 2023 Dr. Robert Afra – San Diego Orthopedic Surgery Shoulder – Knee – Elbow