SLAP Lesion and Injury of the Proximal Portion of Long Head of Biceps Tendon in Elite Amateur Wrestlers

Abstract

Background

Injuries to the proximal portion of the tendon of the long head of the biceps are challenging, and often only diagnosed at arthroscopy. However, it is important to be able to formulate a preoperative plan based on physical examination and imaging studies, so as to inform patients correctly, plan the likely procedure, and give indication to length and modalities of rehabilitation.

Materials and Methods

Eleven elite wrestlers who suffered their injury between 2008 and 2018 were investigated retrospectively. We aimed to identify an association between the mechanism and the symptoms of the biceps-labral complex injury.

Results

The injury was sustained at a mean age of 20.63 years, and most wrestlers were middle or light weight. All injuries occurred during shoulder movements in closed kinetic chain with the elbow extended, the forearm pronated and the shoulder slightly elevated. The surgical procedures performed were tenodesis in three wrestlers, reinsertion in seven wrestlers, and one tenotomy of the tendon of the long head of the biceps. The postoperative rehabilitation was shorter (1–3 month) in case of tenodesis or tenotomy, and markedly longer after reinsertion (6–9 months).

Conclusions

Injuries to the proximal part of long head of biceps tendon are relatively frequent in elite wrestlers, reflecting the high functional demands imposed on the upper limb. Though necessitating surgery, in these athletes, such injuries are not career ending, and most of our elite athletes returned to high performance levels after surgery.

Introduction

The tendon of the long head of the biceps brachii (LHBT) is often involved in shoulder pathologies [1], and can present clinically relevant ailments along its entire course, from the musculotendinous junction to its origin on the glenoid labrum [2]. The LHBT and the glenoid labrum form the biceps-labral complex [3], and disruption of the kinetic chain, incorrect throwing motion and techniques can produce downstream effects as other joints compensate for increased forces [4]. There is no univocal consensus regarding the best surgical management of pathology of the LHBT resistant to conservative management [5, 6].

Superior labrum anterior to posterior (SLAP) tears cause pain and disability in young active populations and overhead athletes [7–9]. SLAP lesions commonly arise from either direct trauma to the shoulder or degeneration from chronic overuse [10–12], as a result of the forces imposed on the biceps-labral complex from acceleration and deceleration of the arm during the follow-through phase of throwing or the “peel-back mechanism” seen in the cocking phase of baseball throwing in abduction and external rotation [13, 14]. Conservative management may prove effective, but, if it fails, arthroscopic SLAP repair using suture anchor fixation is effective, with good results in young athletic patients [9–14].

Amateur wrestling is a highly physically demanding sport, and the upper limb is put under enormous stresses [15, 16]. Classically, the upper limb can become weight bearing and can be subjected to high impact loads, for example when a wrestler lands on the hand after a throw from a standing position with the elbow fully extended, the forearm pronated and the shoulder elevated (Fig. 1).

Fig. 1.

Common situation in wrestling: landing after a throw from standing position with defense—provided by Gábor Martin (United World Wrestling)

Another complicating factor in wrestling is that well trained and conditioned athletes become more prone to injuries following making weight practices [17–19].

There is limited information about SLAP lesions, biceps-labral complex and LHBT injuries suffered by wrestlers [19–22], and most studies are retrospective [23, 24]. SLAP lesions are uncommon and difficult to diagnose clinically, and therefore, athletes with chronic shoulder pain are referred to orthopaedic surgeons late [7, 25–27].

We report the results of a retrospective analysis of longitudinally collected data on the outcome of surgical management of LHBT injuries or SLAP lesions occurring in elite amateur wrestlers competing at international to Olympic level, focussing on their outcome and return to sport.

Materials and Methods

The present study involves a retrospective analysis of prospectively collected data on 11 elite wrestlers who had competed at European, World and up to Olympic level between 2008 and 2018. To be included in the present study, the athletes had to be members of the national Hungary team and be registered in the United World Wrestling database. All these wrestlers trained at least eight times a week if adults, and five to seven times a week during school term and at least eight times a week during school break if they were students. The surgical procedures were performed in five different institutions by seven different orthopaedic surgeons, all fellowship trained in shoulder surgery or sports traumatology. All the surgeons were consultants for the National Hungarian Wrestling team. All the procedures described in the present study were approved by our local ethics committee.

We investigated the following (Table 1):

• Basic data: style of wrestling, year of injury, weight category and age at the time of injury.

• Data related to the injury: side, dominant arm, place of injury, the mechanism of injury and the time from injury to surgery, pre-injury symptoms, source of diagnosis, and diagnosis.

• Data related to the surgery and rehabilitation: type of operation, length of rehabilitation; participation in sports-related rehabilitation; time to first competition after treatment; the best result before and after surgery.

Table 1.

Basic data, injury, surgery and rehabilitation

Style—no wrestlers	WW—6	GR—4	FS—1
Year of injury, respectively	2009, 2011, 2012, 2014, 2016, 2017	2008, 2013, 2015, 2018	2011
Weight category (kg)	55, 59, 49, 65, 53, 48	66, 74, 63, 55	96
age	20, 21, 16, 17, 22, 18	22, 30, 17, 19	25
Side/dominancy	L/R, R/R, L/L, R/R, R/R, R/R	R/R, L/R, L/R, L/R	L/R
Place of injury	C, T, C, T, C, C	C, T, C, T	T
Mechanism of injury	Defence of a throw in standing position	Defending in par terre position	Standing position, searching for throw
	Single leg attack, upperly slipped arm	Standing position, trying to throw
	Single leg attack	Defence of a throw in standing position
	Defence of gut wrench	Defence of gut wrench
	Single leg attack, body load by the opponent of the arm
	Defence of a throw in standing position
Time from injury to surgery	9 M, 4 M, 48 M, 4 M, 5 M, 4 M	4 D, 1 D, 3.5 M, 6 M	12 M
Pre-injury symptoms	No evident instability, only discomfort in the first 3 and last 2 female cases	Yes—Popeye sign in the first 2 cases	No evident instability, only discomfort
	Instability in the 4th case	No evident instability, only discomfort in the last 2 cases
Source of diagnosis	MRA, MRA, MRA, MRA, MRI, MRI	physical exam in the first 2 cases, MRA, MRI	MRI + US
Diagnosis	SLAP V in the first 2 cases	LHBT tear in the first 2 cases	AC arthrosis, biceps tendinosis
	SLAP II int he last 4 cases	SLAP II
		SLAP V
Type of operation	Reinsertion in all female wrestler	Open tenodesis in the first 3 cases	BT, ASD and AC resection
		Reinsertion
Length of rehabilitation	6 M, 6 M, 6 M, 10 M, 5 M, 6 M	3 M, 3 M, 6 M, 6 M	3 months
Sport related rehabilitation	Yes, Yes, Yes, Yes, Yes, No	No, Yes, Yes, Yes	Yes
First competition after treatment, respectively	9 M, 9 M, finish sport, 12 M, 6 M, 7 M	6, 6, 9 M, finish sport	5 M
Best results before/after surgery	ECh3, junior WCh2/ECh3, WCh3, EG1	ECh1, OG2/ECh1, WCh1	Junior ECh2, junior WCh 5/BW WCh3
	ECh5/university WCh2 and 3, ECh5	ECh1, OG5/WCh1, ECh1, OG5
	Cadet ECh 3, junior WCh11/finish sport—low back pain	Cadet ECh 16/U23 ECh 15
	Cadet ECh2 and 7/junior ECh10	Cadet ECh10/finish sport—chose civil life
	Junior WCh2 and 3, U23
	Cadet ECh3, WCh 11/no results yet

GR Greco-Roman style, WW woman wrestling, FS freestyle, L left, R right, C competition, T training, M month, D day, MRA magnetic resonance arthrography, MRI magnetic resonance imaging, US ultrasonography, LHBT long head of biceps, SLAP superior labrum anterior to posterior, AC acromioclavicular, BT biceps tenotomy, ASD arthroscopic subacromial decompression, ECh European Championship, OG Olympic Games, WCh World championship, EG European games, U23 under 23 years, BW beach wrestling

To diagnose the pathology at hand, we devised clinical tests mutated from wrestling-specific moves. We remark that these tests aim to reproduce some of the wrestling moves, and the examiner has to have some experience in wrestling for this purpose. The reproduction of a basic wrestling manouver, the ‘gut wrench’, under medical conditions in a standing position is demonstrated in Fig. 2. During defense from gut wrench, wrestlers are in a position which may predispose them to an SLAP injury: the elbow is extended, the forearm pronated, and the shoulder is elevated. In practice, this is a closed kinetic chain mechanism regarding the biceps, since it is elongated and fixed distally (as the elbow is in extension and the forearm in pronation). During this manouver, when the shoulder is elevated, only the proximal portion of the biceps can contract, as its distal portion is already tensioned.

Fig. 2.

Examination of wrestler’s SLAP lesion in closed kinetic chain in a consultation room. Red arrow: rotation in the longitudinal axis of the trunk. Blue arrow: push

Another test performed during clinical examination reproduces a leg attack. We are aware that its execution can be limited by the space available in the consulting room (Fig. 3). If the right shoulder is affected, the patient steps forward with the right lower limb and puts forward the right arm aiming to grab the examiner’s left upper thigh. The examiner pulls up the patient’s right arm with his left arm. The elbow is blocked at the waist of the examiner. A closed kinetic chain is thus produced, with the patient’s elbow in extension, the forearm in pronation, and the shoulder in elevation. Shoulder pain is produced in this position.

Fig. 3.

Leg attack provocation test

Results

Our 11 athletes were elite wrestlers who participated in continental or global championships and won high level competitions after having been operated on their affected shoulder (except for one female athlete who gave up her sporting carrier because of low back pain and one male who chose to retire). Given the organisation of sports practice in Hungary, the analysis and follow-up of all sport related injuries is centralised, and this ensures that all injuries are recorded in real time, and no athlete is lost to follow-up.

The present study includes six women and five men. All women wrestle in free style (there is no other style for women), three of them are adults, with European Championships’ (EC) and/or World Championships’ (WC) medals. The three junior age female wrestlers are medalists at their respective age-level ECh. Of the male athletes, two are greco-roman (GR) style top wrestlers with an Olympic Games 2nd place plus 1st place from ECh and WCh. One male is a free style (FS) wrestler (ECh 2nd place and WCh 5th place) and two are junior GR wrestlers (with previous Cadet ECh participation).

The mean age was 20.63 years at the time of injury, with one of the GR wrestlers who suffered from an LHBT tear at the age of 30.

Most of the wrestlers are middle or light weight (49–74 kg), except for one FS man wrestling at 96 kg and one woman wrestling at 65 kg. Six wrestlers suffered the injury during competition and five during training. Five injuries were sustained on the non-dominant side. All but one female athlete suffered the injury on the dominant side. On the contrary, in male wrestlers the non-dominant side was affected in all but one subject.

All injuries occurred under the previously detailed conditions: namely movements in closed kinetic chain with the elbow extended, the forearm pronated and the shoulder slightly elevated.

Two elite wrestlers had been operated a couple of days after the injury, as they presented obvious clinical signs of LHBT tears. Six athletes received their treatment 3–6 months after the injury, two wrestlers 9–12 months after the injury, and a junior athlete was operated 48 months after the index injury. The long delay in treatment at least partially reflects the difficulties in formulating the correct diagnosis, but also reflects the resilience of such athletes, who seem to be able to compensate their symptoms remarkably well.

The diagnosis of SLAP lesion was formulated following Magnetic Resonance Arthrography in five patients, and plain Magnetic Resonance Imaging in four athletes. The two tears of the LHBT were identified by physical examination.

Table 2 shows the diagnoses: SLAP II in five wrestlers, SLAP V in three wrestlers, LHBT tear in two wrestlers and tendinopathy of the long head of the biceps in the remaining wrestler. Four wrestlers who suffered a SLAP II injury were juniors.

Table 2.

Number of the different injuries

Diagnosis	SLAP II	SLAP V	LHBT tear	Biceps tendinosis (+ AC arthrosis)
Number	5	3	2	1

LHBT long head of biceps, SLAP superior labrum anterior to posterior, AC acromioclavicular

In the present cohort, the two LHBT tears were treated with tenodesis, the three SLAP V lesions and four of SLAP II lesions were treated with reinsertion, and one SLAP II injury underwent tenodesis. The patient with tendinopathy of the LHBT biceps underwent a simple tenotomy.

The postoperative rehabilitation was shorter (1–3 month) in case of LHBT problems treated by tenodesis or tenotomy, but took longer after SLAP II and V lesions: none of these athletes competed earlier than 6–9 month after the index surgery.

The postoperative results of our elite wrestlers’ are remarkably promising: two adult GR wrestlers (both of them with an LHBT injury) gained gold medals in WCh, ECh and silver medals in Olympic Games after the index surgery. Equally, adult women wrestlers won medals in global competitions; European Games 1st place, WCh and EhC 3rd places, University WCh 2nd and 3rd place). One of our adult FS wrestlers won 3rd place on Beach Wrestling WCh, and one of the junior women achieved 10th place on Junior ECh after the operation. One of our junior wrestlers had a successful rehabilitation but retired to concentrate on his non-sporting life.

Discussion

The superior labral biceps complex presents several anatomic variants and different types of injury, which may account for the difficulty to formulate a prompt diagnosis and plan appropriate management [28].

The biceps works in a closed kinetic chain fashion if the elbow is extended, the forearm is pronated and the glenohumeral joint is elevated, as highlighted when describing the biceps function and SLAP pathomechanism.

Several examination methods can be found for proximal biceps pathology in the scientific literature, but none exhibits sufficient sensitivity and specificity. Of the above-mentioned tests, the Speed test shows 67–90% sensitivity and 13.5–50% specificity [29, 30]. The O’Brien test has a low sensitivity (38–68%) and specificity (46–61%), also [30, 31]. The upper cut test has a 77% sensitivity and 80% specificity [31]. However, these tests are likely not specific for wrestling. We have not formally evaluated the sensitivity and specificity of the proposed tests, but the two simple tests described in the present work do reproduce real wrestling situations, and can, therefore, be adopted as being more specific to the sport.

In our athletes, the injury affected the non-dominant side in five athletes. This draws attention to the importance of functional preventive training to prevent or lower the chances for this particular injury. Functional Movement Screen should be built in the training process to identify and correct the abnormalities in kinetic chain potentially leading to an injury. This is in progress within the Hungarian Amateur Wrestling Federation.

The most useful imaging techniques to diagnose a SLAP lesion are plain Magnetic Resonance Imaging and Magnetic Resonance Arthrography [32–34], but the final management plan is based on the intra-articular abnormalities identified at arthroscopy [35]. In the 11 wrestlers who form the cohort studied in the present investigation, we identified the same injury pattern in all of them: glenohumeral elevation, full elbow flexion and forearm pronation when the biceps tendon is working in closed kinetic chain. Female wrestlers were more likely to be injured on the dominant side while male wrestlers on the non-dominant side. We cannot explain this finding at the present time.

A relative limitation of the present study is the fact that we did not use validated scores to assess the outcome of the procedures performed. However, we point out that the commonly used outcome measures have not been cross-culturally validated in Hungarian. In addition, the aim of surgery in these elite athletes was to return to the high performance level in their chosen specialty. To be able to recover from the index injury and return to sport at continental and world championship, and Olympic level is an exacting threshold, which would be hard to achieve without an excellent function of the operated shoulder.

Another potential issue is the fact that the elite wrestlers in the present study were operated by different surgeons in different centres. However, all the surgeons were consultants for the Hungarian National Wrestling Federation, were fellowship trained, and used similar surgical techniques and rehabilitation protocols. In this respect, therefore, we are sure that our athletes uniformly received optimal care.

The LHBT recovered perfect function after surgical treatment. Both the wrestlers with LHBT tear and tenodesis went on to win global competitions after the operation. Both female wrestlers who sustained a SLAP V lesion were treated with reinsertion, and won international competitions. Regarding our junior wrestlers, SLAP II injuries reinsertion was the preferred method. In the present investigation, a SLAP II injury was typical of junior wrestlers, while tendinopathy of the long head of the biceps was frequent in older athletes. Indeed, the wrestler who underwent tenotomy of the long head of the biceps regained optimal performance in FS beach wrestling after such procedure.

In conclusion, lesions of the whole course of the long head of the biceps tendon are relatively frequent in elite wrestlers, reflecting the high functional demands imposed on the upper limb. Though necessitating surgery, in these athletes, such injuries are not necessarily career ending: most of our elite athletes returned to a high performance wrestling after surgery.

Abbreviations

ECh

European championship

FS

Freestyle

GR

Greco-Roman style

LHBT

Long head biceps tendon

SLAP

Superior labrum anterior to posterior

WCh

World championship

Compliance with Ethical Standards

Conflict of Interest

No conflict of interest.

Ethical Approval

All the procedures described in the present study were approved by our local ethics committee.

Informed Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given his/her consent for his/her images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.