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Surgical management of internal impingement in overhead athletes: a systematic review

Article information

Clin Shoulder Elb. 2026;29(1):115-133
Publication date (electronic) : 2026 February 13
doi : https://doi.org/10.5397/cise.2025.01123
Dimitris Challoumas,1,2orcid_icon, Cheryl Loh1orcid_icon, Nachika Ibekwe1orcid_icon, Tze Ching Christy Leung2orcid_icon, Neal Millar1orcid_icon
1School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
2Department of Trauma and Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, UK
Corresponding author: Dimitris Challoumas School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Sir Graeme Davies Building, 126 University Pl, Glasgow G12 8TA, UK Tel: +44-756-405-3234 Email: dchalloumas@hotmail.co.uk
Received 2025 September 27; Revised 2025 December 15; Accepted 2025 December 26.

Abstract

Background

We aimed to review all published evidence on the surgical management of internal impingement and associated conditions in athletes of overhead sports.

Methods

Our search included studies reporting outcomes of any surgical intervention on shoulder internal impingement and its sequelae in overhead athletes. The primary outcome was return to sport at pre-injury level or higher in the main text (RTS+). Secondary outcomes included return to sport at any level (RTS), shoulder function, and complications. No quantitative analyses were possible due to the nature of the evidence included.

Results

Forty-two observational studies were eligible. They included 1,420 overhead athletes with a mean age of 27.3 years. RTS+ across all surgical procedures ranged from 25% to 94%. In patients treated with debridement of articular-sided partial-thickness rotator cuff tears, the RTS+ ranged from 50% to 85%, and in those who underwent posterior glenoidplasty for glenoid spurs, it ranged from 55% to 63.6%. Comparative studies for superior labrum anterior to posterior (SLAP) tears demonstrated similar RTS+ after open subpectoral tenodesis and arthroscopic SLAP repair. RTS+ after the two procedures in all observational studies ranged from 35% to 100% and 54.2% to 100%, respectively. RTS+ after capsulorrhaphy, when performed concomitantly with other procedures, ranged from 25% to 93%.

Conclusions

Outcomes associated with the surgical management of internal impingement are variable. Surgical decision-making should prioritize patient-specific factors following unsuccessful conservative management. We provide surgical recommendations and considerations.

Keywords: Throwing; Baseball; Labral tear; Rotator cuff; Superior labrum anterior to posterior

INTRODUCTION

Internal impingement of the shoulder is a condition that results from repetitive external rotation and abduction during the throwing motion. Its precise etiology and predisposing factors remain unclear. Leading theories include impingement of the rotator cuff tendons beneath the acromial arch due to anterior subluxation of the humeral head (anterior micro-instability), or impingement of the posterior rotator cuff undersurface (supraspinatus and infraspinatus) on the posterosuperior glenoid labrum during extreme abduction and external rotation. Although typically physiological and without consequences during everyday use, this contact can become pathological with repetitive overhead activity, as described by Walch et al. [1].

Internal impingement encompasses a spectrum of pathology: undersurface rotator cuff fraying or tears; posterior/superior labral tears (detached or non-detached), including superior labrum anterior to posterior (SLAP) tears; long head of biceps (LHB) tendinopathy or detachment; and posterior glenoid spurs (Bennett lesions), the latter being pathognomonic for this condition [2,3]. These sequelae cause posterior shoulder pain, loss of function, reduced performance, and career-impacting disability.

The overhead throwing motion consists of five phases: windup, cocking, acceleration, deceleration, and follow-through [4,5]. The repetitive and extreme demands of these phases produce structural and biomechanical adaptations, including excessive humeral retroversion (developing before epiphyseal closure), anterior capsular laxity, and posterior capsular tightness, resulting in a gain in external rotation but loss of internal rotation, known as glenohumeral internal rotation deficit (GIRD) [4,6]. Altered scapulohumeral rhythm, or scapular dyskinesis, contributes further via scapular protraction, increased glenoid anteversion, and posterior humeral head translation [5]. These adaptations collectively predispose the shoulder to internal impingement, encapsulating the “thrower’s paradox”: the need for a shoulder loose enough to throw yet stable enough to prevent subluxation [7].

The late cocking and early acceleration phases are particularly associated with overuse injuries such as SLAP tears, which may also be a consequence of internal impingement. During late cocking, tension in the LHB applies repetitive shear to the superior labrum, causing a “peel-back” mechanism [8]. During acceleration, eccentric LHB contraction against shoulder distraction may cause tensile SLAP injury [9]. Snyder et al. [10,11] classified SLAP lesions into four types (I–IV) based on labral and biceps involvement.

Initial management of internal impingement is conservative, emphasizing posterior capsular stretching and internal rotation strengthening. Surgical intervention is reserved for refractory cases after 6–12 months [12] of physiotherapy, or longer if GIRD correction is ongoing. Procedures vary with pathology and athletic demands, including debridement, labral repair, biceps tenodesis, or capsulorrhaphy.

This review presents and evaluates the efficacy and safety profile of the surgical interventions described for overhead athletes with internal impingement of the shoulder and associated conditions. It aims to inform both implicated healthcare professionals and overhead athletes. We hypothesize that surgery is effective and safe for overhead athletes with internal impingement of the shoulder after failed conservative management and is associated with high rates of return to sports at the pre-injury level or higher.

METHODS

The present systematic review was conducted and authored according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [13]. A protocol was written and registered on the PROSPERO website (CRD42023432315).

Eligibility

Studies were eligible if they described any type of surgical intervention for internal impingement and its sequelae in overhead athletes. Both comparative and non-comparative studies were included. No criteria were applied for publication year, patient’s age, severity of internal impingement, length of follow-up, and type of overhead sport. Case reports and reviews were excluded. No language or publication date criteria were used.

Search Strategy

A thorough literature search was conducted via Ovid (Medline and Embase) from inception to October 1, 2024 (Supplementary Fig. 1). The following search terms were used in “all fields”: (internal impingement OR glenoid impingement OR posterior impingement OR posterosuperior impingement OR micro-instability OR labral tear OR SLAP tear OR SLAP lesion OR Bennett lesion) AND (overhead OR throwing) AND (management OR treatment OR surgery OR arthroscopy). Relevant review articles were screened to identify eligible articles that may have been missed at the initial search. Additionally, reference list screening and citation tracking in Google Scholar were performed for each eligible article. The grey literature was searched via Open Grey for unpublished studies to minimize the risk of publication bias.

Screening

After duplicates were removed from the initial search, title and abstract screening were performed, followed by full-text screening to confirm article eligibility. No additional articles were identified from reviews, reference list screening, citation tracking, or the grey literature. Supplementary Fig. 2 (PRISMA flowchart) illustrates the article screening process. Two reviewers (CL and DC) performed screening independently, and disagreements were resolved through discussion.

Data extraction—handling

The key methodological characteristics and results of each study included were tabulated in Microsoft Word to facilitate analysis and presentation. Two reviewers (CL and DC) performed data extraction independently, and disagreements were resolved through discussion. The primary outcome was return to sport at pre-injury level or higher (RTS+). Secondary outcomes included shoulder function tests, return to sport at any level (RTS), and complications. The results of all studies were presented narratively. Pooling of results, pairwise meta-analyses, or other quantitative syntheses were not conducted due to the non-randomized nature of all included studies and the substantial clinical heterogeneity owing to diverse populations and sports, concomitant procedures, study designs and characteristics, and follow-up time frames. For the primary outcome, results of studies published after 2010 were reported separately to provide insights into potential temporal differences. Risk of bias for the included studies was assessed with the use of the Newcastle-Ottawa tool for comparative studies and the Joanna Briggs Institute quality assessment tool for case series. Two reviewers (DC and CL) performed risk of bias assessments independently, and disagreements were resolved through discussion.

RESULTS

Our review included 42 studies (overall n=1,420 overhead athletes, mean age 27.3 years) published between 1985 and 2023 investigating outcomes of surgical management of internal impingement and associated conditions. Most studies were retrospective case series (n=32, 76%), and the remaining were comparative retrospective cohort studies (n=5, 12%), comparative prospective cohort studies (n=2, 5%), and non-comparative prospective case series (n=3, 7%). The range of the reported mean follow-up across all studies was 13.1 months to 10.4 years. Table 1 [14-55] summarizes the included population and surgical management characteristics, and Table 2 details the main methodological characteristics. Among the seven cohort studies included, the quality of two was poor overall, one was fair, and four were good. All 35 case series were of adequate quality for inclusion (Supplementary Tables 1 and 2). The RTS+ and functional results of the included studies are summarized in the following text based on the primary pathology treated. More detailed data on primary (RTS+) and secondary outcomes (RTS, function, complications) can be seen in Table 3.

Main population and surgical management characteristics of included studies

Methodological characteristics of included studies

Main results of the included studies

Internal Impingement––All Sequelae

Outcomes of surgical management of internal impingement and its sequelae in overhead athletes were presented in 16 studies (overall n=663; mean age, 24.8 years) [14-29]. In a large retrospective multi-center series of 135 overhead athletes with sequelae of internal impingement, Peduzzi et al. [23] reported an overall 52% RTS+ at a mean follow-up of 7.9 years. Interventions in this study included simple labral debridement, anterior capsulorrhaphy, glenoidplasty, rotator cuff debridement, and posterior capsular release. On arthroscopic exploration, it was common for the athletes treated to have an overlap of two or more sequelae. Predictors that affected RTS+ negatively were female sex and a greater tuberosity cyst on preoperative imaging, while the presence of a cuff lesion intra-operatively affected RTS+ positively. Anterior capsulorrhaphy did not influence RTS+, but was associated with higher postoperative pain (odds ratio, 2.9) [23]. There was a significant improvement in shoulder function scores (mean Kerlan and Jobe Orthopedic Clinic Shoulder and Elbow Score [KJOC], from 44 to 82; mean Constant score, from 67 to 81).

Glenoid Spurs

In four studies (n=73; mean follow-up; 25.7–76 months), surgical management focused on posterior glenoid spurs (Bennett lesions) [19,21,22,29]. Two studies included baseball players only (n=38), and the other two studies included overhead athletes of mixed sports (n=35). All subjects in the four studies underwent arthroscopic posterior glenoidplasty. In all four studies, there were concomitant diagnoses consistent with internal impingement (articular-sided rotator cuff tears, posterior labral pathology, and biceps-labrum complex pathology), which were treated concomitantly, mainly with debridement. RTS+ ranged from 55% to 69.2%. In the single study [22] that reported shoulder function tests, the mean postoperative KJOC and Simple Shoulder Test (SST) were 75 and 11.2, respectively. When studies published before 2010 were excluded, RTS+ were 63.6%–69.2%.

Articular-Sided Rotator Cuff Tears

Five studies (n=177; mean follow-up, 13.1–66.6 months) focused on the management of articular-sided rotator cuff pathology. The subjects in three studies [14,25,27] (n=146, baseball and tennis) underwent debridement of the partial-thickness articular-sided rotator cuff tears. The RTS+ ranged from 50% to 85%. In all three studies, most patients underwent concomitant labral debridement (mostly) or labral repair. Only one study [23] reported functional outcomes with a mean American Shoulder and Elbow Surgeons (ASES) score of 27/30. In the other two studies (n=33, both baseball), the primary treatment was rotator cuff repair: arthroscopic in one study, involving either full-thickness or >50% partial-thickness tears of the infraspinatus with no supraspinatus pathology; and mini-open in the other, in which all participants had full-thickness supraspinatus tears [20,28]. RTS+ was 35% in one study and 25% in the other. In the study by Mazoué and Andrews [20], subgroup analyses showed an RTS+ of 8% in baseball pitchers, compared to 80% in position players. Concomitant procedures in the two studies varied. In the study by van Kleunen et al. [28], all patients underwent SLAP repairs, and posteroinferior capsule release occurred in 65% of subjects. In the study by Mazoué and Andrews [20], less than half of the subjects underwent capsulorrhaphy with labral repair or debridement. Functional outcomes were only reported in the study by van Kleunen et al. [28], who found a mean postoperative KJOC score of 57.

Glenohumeral Laxity

Five studies (n=266) attempted to address the anteroinferior glenohumeral laxity as the root cause for the internal impingement, in addition to the other intra-articular pathology [15-18,24]. Two of them included baseball players only (n=94). The treatment of choice in three studies was thermal capsulorrhaphy. In one study, capsulorrhaphy was performed with sutures or suture anchors, and in the other study, anterior glenohumeral capsular ligament reconstruction with a hamstring autograft was the surgical procedure of choice.

A retrospective cohort study of baseball players compared traditional arthroscopic treatment (labral debridement/repair and articular-sided rotator cuff debridement/repair) with traditional treatment plus thermal capsulorrhaphy [18]. The RTS+ in those who had additional capsulorrhaphy was higher both at initial follow-up (93% vs. 80%) and at 30 months follow-up (87% vs. 61%). No functional scores were reported. An early large case series of 130 overhead athletes (mostly baseball players) reported an RTS+ of 87% and a mean Modified Athletic Shoulder test score of 79 following thermal capsulorrhaphy [17]. A similar smaller study of 20 overhead athletes reported an RTS+ of 85% after capsulorrhaphy using sutures or suture anchors, with high mean KJOC and Single Assessment Numeric Evaluation (SANE) scores (82 and 86, respectively) [24]. Most patients in both studies underwent concomitant procedures, predominantly debridement of labral and rotator cuff tears. In the final study that added thermal capsulorrhaphy in “those with glenohumeral laxity” (percentage not stated), along with traditional treatment (articular-sided rotator cuff and labral debridement), an RTS+ of 25% at 7 years follow-up was reported [16]. Shoulder function, assessed with the Rowe score, had improved substantially up to 2 years (from a mean of 46 to 90) but then dropped to 70 at 7 years follow up.

In a small prospective series of baseball players, Funakoshi et al. [15] reported an RTS+ of 83.3% with the use of anterior glenohumeral capsular ligament reconstruction with a hamstring autograft. Mean shoulder function scores had improved significantly compared to preoperative values (Disabilities of Arm, Shoulder and Hand [DASH] score, 80–22; KJOC, 28–81). All the patients in the study underwent concomitant articular-sided rotator cuff debridement, and 92% of them underwent debridement or repair of SLAP tears. An early prospective study by Riand et al. [26] assessed the outcomes of humeral derotational osteotomy with subscapularis myorrhaphy in 20 overhead athletes from mixed sports who had failed rotator cuff and labral debridement. The RTS+ was 55% at a mean follow-up of 46 months.

SLAP Lesions

Twenty-six studies (overall n=757; mean age, 28.4 years) described surgical management of SLAP lesions in overhead athletes (n=767) [30-55]. The participants in 11 studies (42.3%) had isolated SLAP tears. The remaining 15 studies (57.7%) included athletes with other articular sequelae of internal impingement (labral and rotator cuff fraying/tears), which were managed concomitantly. The included studies managed SLAP lesions either by arthroscopic labral repair (n=16), open subpectoral biceps tenodesis (n=13), or arthroscopic labral repair or debridement (n=1).

Comparative studies

Three retrospective and one prospective cohort studies (total n=158) compared outcomes of SLAP repair and biceps tenodesis [21,34,56]. Lacheta et al. [41] and Rothermich et al. [50] conducted very similar studies comparing arthroscopic SLAP repairs vs open subpectoral biceps tenodesis in overhead athletes of various sports, and softball athletes, respectively [41,50]. In both studies, no significant differences in RTS+ rates were observed between the two interventions (79.2% vs. 85.7% and 94% vs. 93%, respectively). In the study by Lacheta et al. [41], significantly more patients in the biceps tenodesis group had to modify their activities due to weakness compared to the SLAP repair group (80% vs. 12%). Lacheta et al. [41] performed biceps tenodesis in those with fraying of the superior labrum and SLAP repair in those with a bucket-handle SLAP tear. Similarly, in the study by Rothermich et al. [50], those with primarily a SLAP tear underwent SLAP repair, and those with primarily biceps tendinopathy underwent a biceps tenodesis. When the two techniques were compared in another large retrospective study of 103 athletes (56 overhead), RTS rates and shoulder function tests were also similar in the two groups [40]. RTS+ was not included as an outcome measure. Finally, a small prospective cohort study of 11 baseball players with type II SLAP tears reported RTS+ rates of 100% in both groups [33].

In a group of athletes of mixed overhead sports who underwent SLAP repair for isolated type II SLAP tears, Maier et al. [43] compared suture anchor vs transglenoid suture repair and found statistically similar RTS+ (66.7% vs. 50%, respectively) at a mean follow-up of 3.9 years.

Non-comparative studies

Nine retrospective series (n=146; mean follow-up, 24 months to 4.5 years) reported outcomes in athletes of various overhead sports with SLAP tears treated with open subpectoral biceps tenodesis [32,37,38,42,48,49,51,53,54]. RTS+ ranged from 35% to 100%. A mixture of SLAP tear types was included. SLAP tears were an isolated pathology in only two studies (22.2%); in the remaining seven studies (77.8%), other features of internal impingement were identified and treated concomitantly.

Ten retrospective series (n=361; mean follow-up, 27.6–52 months) managed overhead athletes with SLAP tears with labral repair [30,31,35,36,40,44-46,52,54]. Two of them used RTS but not RTS+ as an outcome [45,47]. RTS+ ranged from 54.2% to 92%. SLAP tears were an isolated diagnosis in four studies (40%); features of internal impingement were seen and treated concomitantly in the remaining six studies (60%). Among the seven studies that described SLAP tear types, all were type II in six studies (86%) and mainly type II (93% of patients) in the seventh study.

Across all comparative and non-comparative studies, significant functional improvements were reported after both procedures. After open subpectoral tenodesis, the mean postoperative ASES and KJOC score ranged between 89 and 98 (n=8 studies), and 73 and 74 (n=2 studies), respectively, and after arthroscopic SLAP repair, they ranged between 83 and 94 (n=9 studies), and 75 and 81 (n=3 studies), respectively. Quick DASH, DASH, SST, and SANE scores were used by single studies and also exhibited significant improvements (Table 3).

When only the studies that included isolated surgical management of the SLAP tears without concomitant pathology or procedures were reviewed, RTS+ ranged from 59.1% to 100% after open subpectoral tenodesis (n=3 studies) and 73% to 94% after arthroscopic SLAP repair (n=2 studies). For RTS+, when studies published before 2010 were excluded, the range after open subpectoral tenodesis and arthroscopic SLAP repair was 35%–100% and 59%–100%, respectively.

In another study, the authors performed revision labral repair for SLAP lesions and found an RTS+ rate of 41.3% and a postoperative mean ASES of 73 [47]. Neri et al. [44] found that the presence of a partial articular-sided tear was an important negative predictor for RTS+. In a retrospective series of 68 baseball players, Fedoriw et al. [34] demonstrated that pitchers had worse outcomes compared to position players after surgical management of a SLAP tear either with labral debridement or repair (RTS+ 7% vs. 54%, respectively). Concomitant rotator cuff tears were associated with worse outcomes regardless of whether debridement or repair was performed. Separate data for labral repair vs debridement are not presented. Fig. 1 summarizes the RTS+ ranges for each main procedure assessed.

Fig. 1.

Ranges of return to sport at pre-injury level or higher (RTS+) after each main procedure. These procedures were performed to address the main pathologies/sequelae of internal impingement, but in most studies, additional procedures were performed concomitantly for associated pathologies.

DISCUSSION

This study represents the most comprehensive review to date of the surgical management of shoulder internal impingement in overhead athletes. The majority of evidence is low-level, derived from non-comparative retrospective series. The most definitive conclusion that can be made from our findings is that considerable variability can be found in RTS+ after surgical management of internal impingement and its sequelae; wide ranges of RTS+ were reported in the studies included. Full-thickness rotator cuff tears and being a baseball pitcher have a particularly bad prognosis for RTS+. Treatment of glenohumeral laxity, which is thought to be the root cause of the pathology, by capsulorrhaphy has demonstrated high RTS+ rates, but the limitations of the existing evidence cannot provide definitive conclusions. For SLAP lesions, RTS+ ranges were similar after biceps tenodesis (range, 35%–100%) and SLAP repair (range, 54.2%–100%). The populations in the studies included were heterogeneous in terms of their sports, competition level, and concomitant pathologies. Importantly, some of the comparative studies performed biceps tenodesis and SLAP repairs for different types of SLAP tears. Therefore, the outcomes may not necessarily be related to the type of surgical treatment alone but also to the pathology itself. Concomitant rotator cuff pathology that requires simultaneous surgical treatment may represent a negative predictor of RTS+. Most procedures were shown to be safe with no or minimal complications. No significant temporal associations were observed when older studies were excluded.

Early recognition of internal impingement is crucial to achieving a successful return to sport. During physical examination, tenderness to palpation along the biceps groove, acromioclavicular joint, and posteroinferior aspect of the glenohumeral joint may be observed. The traditional anterior apprehension test and Jobe relocation test are negative in these athletes as they do not suffer from true anterior instability [15,16,23]. Pain when the arm is placed in the late cocking phase of throwing is characteristic, with subsequent relief with a posteriorly applied force [56,57]. Several physical tests have been described for the detection of SLAP tears with varying sensitivity and specificity. These include the compression (Crank) test, the O’Brien test, the Yergason test, the Speed test, and the Biceps Load test, which can also be used to detect biceps tendinopathy [58,59]. The most sensitive imaging modality is high-resolution magnetic resonance imaging (MRI), with a subsequent MR arthrogram, which can demonstrate all sequelae of internal impingement [29,44]. Associated findings include paralabral and greater tuberosity cysts. Bennett lesions are best appreciated on computed tomography (CT). Diagnostic arthroscopy is indicated with persistent pain when no abnormality is detected on MRI and before surgical management of any of the sequelae to confirm the diagnosis and quantify the severity of the lesions. Upon arthroscopy, in addition to the labral and articular-sided rotator cuff pathology, the “drive-through” sign is characteristic, which is due to plastic deformation of the capsule, mostly the inferior glenohumeral ligament [60].

Most overhead athletes with internal impingement and SLAP tears can be successfully managed conservatively. Some authors speculate that the SLAP tears themselves may in fact be asymptomatic in some overhead athletes who may experience pain from the posterior capsule tightness and scapular dyskinesia, which are often seen with internal impingement [36,61,62]. Rehabilitation focuses on correcting GIRD, scapular dyskinesia, posterior capsule contracture, and any concomitant injuries, and its high efficacy is well documented in the literature [63-65].

Traditionally, arthroscopic SLAP repair has been considered the intervention of choice in symptomatic SLAP tears in overhead athletes after unsuccessful conservative management, with biceps tenodesis being favored for the less athletic non-overhead population. Compared to biceps tenodesis, the disadvantages of SLAP repair include the failure to address the concomitant biceps tendinopathy and/or instability, which is usually present with SLAP tears, as well as potential reductions in external rotation range of motion or mechanical problems related to the suture knot, which can induce pain and internal impingement itself. A recent meta-analysis by Shin et al. [66] also compared biceps tenodesis with labral repair for isolated SLAP lesions in overhead athletes. They found a mean RTS+ of 78.2% with biceps tenodesis vs 69.0% with SLAP repair, with the difference being statistically insignificant. Postoperative ASES was slightly higher with biceps tenodesis (94.7%) compared to SLAP repair (84.3%), and the complication rate was also lower in the biceps tenodesis group at 4.5% compared to 10% in the SLAP repair group; neither of these differences was statistically significant. Frantz et al. also reported favorable results of biceps tenodesis in overhead athletes in their systematic review; the mean overall RTS (athletes of all levels) was 70%, for recreational athletes it was 69%, for collegiate/competitive athletes 80%, and for professionals 60% [67]. No RTS+ rates were presented. Finally, an early systematic review by Sayde et al. [68] reported an RTS+ rate of 63% in overhead athletes with SLAP tears who underwent labral repair. Non-randomized study designs limit direct equivalence claims, warranting further prospective studies.

Decisions about the need and nature of surgical management of the overhead athlete’s shoulder can be challenging, as some changes seen on MRI and diagnostic arthroscopy can be adaptive and non-pathological. Studies previously reported that asymptomatic overhead athletes can have significant findings on an MRI, even full-thickness rotator cuff tears [69,70]. Kibler et al. [71] provide some practical guidance for decision-making and for successful surgical management of shoulder internal impingement. Pathological changes typically result in pain and compromised performance, usually starting with trouble warming up. A subacromial steroid injection relieving pain temporarily also suggests pathological changes. Non-pathological adaptations include the labrum rolling back instead of peeling back in the abducted externally rotated position, absence of articular-sided rotator cuff tears, and a non-painful biceps tunnel. Knowledge of normal anatomical variants of the superior labrum is very important in avoiding unnecessary repair, as a degree of superior labral detachment may be a beneficial adaptation optimizing performance, as long as the inferior labrum is intact, allowing the superior labrum to act as a tension band. The “good” superior labral tears usually appear smooth and more chronic, are of type I or IIb, and do not have concomitant rotator cuff tears. When a SLAP repair is indicated for a “bad” tear, knotless repair with care not to cause overconstraint (by incorporating the capsule in the repair) is advised. Kibler et al. recommend against biceps tenodesis as a primary procedure for SLAP tears. They argue that the LHB has important functions, including providing proprioception and secondary stabilization for rotation and translation at extremes of range of motion, aiding concavity/compression of the glenohumeral joint, and acting as a humeral head depressor [71]. These theoretical functions may not be clinically relevant according to our results, as the RTS+ rates between labral repairs and primary tenodesis were similar. However, this may become relevant with a longer-term follow-up. The topic remains controversial.

We recommend that all athletes with shoulder internal impingement and its sequelae be treated conservatively for at least 6 months before considering surgical management. This excludes those with full-thickness rotator cuff tears. Where conservative management fails, we recommend that SLAP tears without concomitant LHB tendinopathy in the young overhead athlete (<35 years) are managed with SLAP repairs and not biceps tenodesis. This takes into consideration potential long-term adverse effects relating to the anatomical and biomechanical role of the LHB in the glenohumeral joint, as well as possible loss of power, which may be noticeable in some sports. Biceps tenodesis should be reserved for older, recreational athletes and those with a failed SLAP repair or with concomitant LHB tendinopathy. Capsulorrhaphy should be performed where there is clear evidence of glenohumeral laxity with a positive “drive-through” sign. This can be thermal or suture-based (capsular plication); even though there is no published evidence comparing the two in internal impingement specifically, the lower durability of the former, shown in shoulder instability, should be considered [72]. Overall, based on the presented evidence, we could not provide an answer to our research hypothesis with confidence due to the wide range of RTS+ reported for the assessed procedures. This is most likely a consequence of heterogeneity; outcomes vary by sport, performance level, extent of pathology, concomitant procedures, and follow-up duration.

The limitations of our review predominantly relate to the inherent weaknesses of the included evidence, which is mostly of an observational, non-comparative nature and highly heterogeneous. The few comparative studies presented are non-randomized, and their indications in terms of pathology were not always the same. Therefore, the procedures may have been considered because they were more appropriate for specific pathologies or types of athletes, and their outcomes may be influenced by these variables. Unfortunately, no relevant randomized study was found, which is why all our included studies are non-randomized. We do recognize their weaknesses, which are inherent to their study design. Consequently, we decided not to pool the data for the same procedures across studies and only present them narratively. Additionally, RTS+, which we used as our primary outcome measure, is highly subjective as it may be perceived differently by different athletes and researchers, but we believe it represents the most clinically useful outcome. Less subjective patient-reported outcome measures, such as shoulder function tests or pain, were inconsistent across studies and may also have different relevance and impact in different sports. In addition to the primary procedures analyzed in each section of our results, the athletes in most studies underwent concomitant procedures, which were necessary for other manifestations of internal impingement (usually rotator cuff and labral repair/debridement). Therefore, the reported results may not be solely attributed to a single surgical technique. Finally, other factors may have contributed to athletes not performing at the same level postoperatively or discontinuing their participation, especially in studies that included long follow-ups, including new injuries in the shoulder or other injuries elsewhere, increasing age, and changes in life circumstances.

CONCLUSIONS

Internal impingement of the shoulder in overhead athletes is a challenging condition to treat. A return to the previous level of performance is variable in the existing literature and is somewhat unpredictable with surgical management, even under the best circumstances. For SLAP tears, despite the similar rates of RTS+ after open biceps tenodesis compared to arthroscopic labral repair, the existing data are highly heterogeneous for definitive conclusions. Future prospective comparative trials are needed to refine treatment algorithms. The possible impact on glenohumeral kinematics and proprioception post-tenodesis needs to be considered, as well as age, level of competition, previous surgery, and concomitant pathology. A capsule tightening procedure should be considered where there is clear evidence of glenohumeral laxity.

Notes

Author contributions

Conceptualization: DC. Data curation: DC, CL, NI, TCCL. Formal Analysis: DC, CL, NI, TCCL. Funding acquisition: NM. Investigation: CL. Methodology: DC. Project administration: DC. Supervision: DC, NI. Validation: DC. Writing – original draft: DC, CL. Writing – review & editing: DC, NM. All authors read and agreed to the published version of the manuscript.

Conflict of interest

None.

Funding

This research was supported by the grant No. MRC MR/X036766/1.

Data availability

Contact the corresponding author for data availability.

Acknowledgments

None.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.5397/cise.2025.01123.

Supplementary Table 1.

Quality assessment of the included cohort studies using the Newcastle-Ottawa scale

cise-2025-01123-Supplementary-Table-1.pdf
Supplementary Table 2.

Quality assessment of the included case series using the Joanna Briggs Institute tool

cise-2025-01123-Supplementary-Table-2.pdf
Supplementary Fig. 1.

Search strategy in Medline and Embase (via Ovid).

cise-2025-01123-Supplementary-Fig-1.pdf
Supplementary Fig. 2.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

cise-2025-01123-Supplementary-Fig-2.pdf

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Fig. 1.

Fig. 1.

Ranges of return to sport at pre-injury level or higher (RTS+) after each main procedure. These procedures were performed to address the main pathologies/sequelae of internal impingement, but in most studies, additional procedures were performed concomitantly for associated pathologies.

Table 1.

Main population and surgical management characteristics of included studies

Study Study type Main pathology Concomitant pathology (% of study population) Mean follow-up Population, type, mean age, % female) Primary surgical procedure (% of study population) Concomitant procedures (% of study population) Notes
Peduzzi et al. (2019) [23] Retrospective case series Internal impingement–all sequelae (partial articular-sided cuff tears, posterior labral tears, Bennett lesions) - 7.9 yr n=135; handball, tennis, volleyball, swimming, other; 29 yr; 24% Anterior capsulorrhaphy (15%) -
Postero-superior labral debridement (71%)
Posterior glenoidplasty with posterior capsule release (61%)
Posterior capsule release without glenoidplasty (18%)
Rotator cuff tear debridement (58%) or repair (16%) (all arthroscopic)
Nourissat et al. (2020) [22] Retrospective case series Partial articular-sided cuff tears and posterior labral tears (all patients) Posterior glenoid spurs (33%) 53 mo n=9; volleyball, badminton, tennis, handball; 29 yr, 0% Arthroscopic posterior glenoidplasty with posterior labral re-attachment (all arthroscopic) Rotator cuff debridement (89%), rotator cuff repair (11%)
Lévigne et al. (2012) [19] Retrospective case series Posterior labral pathology and articular-sided cuff tears (all patients) Posterior glenoid spur (63%) 27 mo n=26; handball, volleyball, tennis, javelin throw, swimming, baseball; 27 yr; NR Arthroscopic posterior glenoidplasty, posterior labral and rotator cuff debridement (all arthroscopic) -
Meister et al. (1999) [21] Retrospective case series Posterior glenoid spur (all patients) Partial articular-sided cuff tears 95%, posterior labral tears 68%, anterior labral tears 18%, superior labral tears 5%) 6.3 yr n=22; Baseball; 24 yr onset of symptoms; 0% Arthroscopic posterior glenoidplasty Debridement of articular-sided partial rotator cuff tear (95%)
Debridement of labral tears (68% posterior, 18% anterior, 5% superior) (all arthroscopic)
Yoneda et al. (2002) [29] Prospective cohort study Posterior glenoid spur (all patients) Partial articular-sided cuff tears 38%, posteroinferior labral injury 25%, biceps-labral complex injury 25%, Bankart lesion 6%, anterosuperior labral lesion 6%, subacromial lesions 56% 25.7 mo n=16; baseball; 25.7 yr; 0% Arthroscopic posterior glenoidplasty only (13%) Biceps and labral debridement (13%), biceps and labral repair (13%), debridement of articular-sided partial rotator cuff tear (38%), anterosuperior labral repair (6%), Bankart repair (6%), subacromial decompression (13%), bursectomy (44%) (all arthroscopic)
Arthroscopic posterior glenoidplasty with posterior capsule repair (63%)
Arthroscopic posterior glenoidplasty with posterior labral re-attachment (25%)
Reynolds et al. (2008) [25] Retrospective case series Partial articular-sided cuff tears (all patients) Labral tears (85%, unstable 70%) 39.2 mo n=82; baseball; 25.6 yr; NR Arthroscopic rotator cuff debridement Labral repair (unstable tears, overall (60%) athletes; of which (84%) superior labrum, (14%) posterior), labral debridement (26%), subacromial decompression (30%), thermal shrinkage (33%), other subacromial space procedures (40%), other (15%)
Sonnery-Cottet et al. (2002) [27] Retrospective case series Partial articular-sided cuff tears (all patients) labral tear 89% 45.7 mo n=28; tennis; 26.9 yr; 17.9% Arthroscopic supraspinatus tendon debridement Labral tear debridement (89%)
Andrews et al. (1985) [14] Retrospective case series Partial articular-sided cuff tears and labral tears (all patients) LHB tendinopathy 8%, partial tears 17% 13.1 mo n=36; baseball, football, tennis; 22 yr; 8.3% Supraspinatus tendon debridement and labral debridement (all arthroscopic) -
Van Kleunen et al. (2012) [28] Retrospective case series Infraspinatus tears (>50% partial infraspinatus tear 65%, full-thickness infraspinatus tear 35%), SLAP tear (all patients) - 37.1 mo n=17; baseball; 19.2 yr; 0% SLAP repair (suture anchor) and infraspinatus repair (polydioxanone suture or suture anchor) (all arthroscopic) Posteroinferior capsule release (65%)
Mazoué and Andrews [20] Retrospective case series Full-thickness rotator cuff tear (all patients) SLAP tears 13%, posterior labral tears 13% 66.6 mo n=16; baseball; 29.6 yr; NR Mini-open rotator cuff repair SLAP repair and thermal capsulorrhaphy of anteroinferior capsule (13%), capsulorrhaphy and posterior labral tear debridement (13%), capsulorrhaphy of anteroinferior capsule (6%) or posterior capsule (6%)
Levitz et al. (2001) [18] Retrospective cohort study Glenohumeral micro-instability (all patients) SLAP tears, posterior labral tears, partial articular-sided rotator cuff tears 30 mo n=82; baseball; 23 yr; 0% Group 1: traditional treatment (Arthroscopic), n=51 vs. Group 2: traditional treatment plus thermal capsulorrhaphy (Arthroscopic), n=31
Traditional treatment
Group 1: labral debridement 73%, rotator cuff debridement 86%, labral repair 25%
Group 2: labral debridement 39%, rotator cuff debridement 87%, labral repair 42%
Funakoshi et al. (2022) [15] Prospective case series Glenohumeral micro-instability (all patients) SLAP tears (overall 92%, type I 17%, type II 50%, type IV 8%, type V 8%, type VII 17%), LHB detachment (8%) 25.3 mo n=12; baseball; 20.5 yr; 0% Anterior glenohumeral capsular ligament reconstruction with hamstring autograft (open) Labral repair (8%, type V SLAP), labral debridement (all other SLAP types), rotator cuff debridement (100%) (all arthroscopic)
Jansen et al. (2012) [16] Prospective case series Glenohumeral micro-instability (all patients) Partial articular-sided supraspinatus tears (50%), posterosuperior labral fraying (58%), anterior labral fraying (8%), posterosuperior cartilage lesion (8%) 1, 2, and 7 yr n=12; volleyball, baseball, tennis, swimming; 27 yr; 16.7% Thermal capsulorrhaphy (% NR) Partial articular rotator cuff tear debridement (50%), labral debridement (66%) (all arthroscopic)
Reinold et al. (2003) [24] Retrospective case series Glenohumeral micro-instability (all patients) 29.3 mo n=130; baseball, softball, tennis, football, swimming; 24 yr; 13% Thermal capsulorrhaphy Labral debridement (69%), rotator cuff debridement (65%), SLAP repairs (35%), subacromial decompression (17%), anterior Bankart repair (8%), rotator cuff repair (3%)
Jones et al. (2012) [17] Retrospective case series Glenohumeral micro-instability (all patients) Articular-sided rotator cuff fraying 20% or partial-thickness tears 20%, anterior or posterior labral fraying 25% 3.6 yr n=20; baseball, swimming, softball, volleyball, tennis, water polo; 19.1 yr; 65% Capsular plication (with suture or anchor) Labral debridement (25%), rotator cuff debridement (%NR)
Riand et al. (1998) [26] Prospective case series Previous failed rotator cuff and labral debridement (all patients) - 46 mo n=20; volleyball and handball, tennis, javelin throw, badminton; 24.9 yr; 45% Derotational humeral osteotomy and subscapularis myorrhaphy
Lacheta et al. (2022) [41] Retrospective cohort study Isolated SLAP tear (all type II) - 39.3 mo n=44; acrobatics, baseball, basketball, climbing, crossfit, football, kayaking/rafting, lacrosse, mixed martial arts, softball, tennis, volleyball, weightlifting, wrestling; 28.6 yr; 21.1% Arthroscopic SLAP repair, n=16 (bucket-handle SLAP tear) vs. open subpectoral biceps tenodesis, n=28 (fraying of superior labrum) -
Rothermich et al. (2023) [50] Retrospective cohort study SLAP tear (types NR) and biceps tendinopathy - 2 yr n=47; softball; 17.4 yr; 100% Arthroscopic SLAP repair, n=18 (for SLAP tear) vs. open subpectoral biceps tenodesis, n=29 (for biceps tendinopathy) -
Chalmers et al. (2014) [33] Prospective cohort SLAP tear (all type II) NR 5.9 yr n=11; baseball; 28.0 yr; NR Arthroscopic SLAP repair, n=6 vs. open subpectoral biceps tenodesis, n=5 Subacromial decompression and repair of partial rotator cuff tears (18%)
Hurley et al. (2022) [39] Retrospective cohort study Isolated SLAP tear (types II 89%, type III 7%, type IV 5%) NR 60 mo n=56; baseball, softball, volleyball, rock climbing, tennis, boxing, handball, swimming, crossfit, golf; 24.8 yr; 21.6% Open subpectoral biceps tenodesis, n=18 vs. arthroscopic SLAP repair, n=38 Debridement, synovectomy, subacromial decompression and acromioplasty “where necessary” (% NR) Percentages of SLAP tear types are for overall study population, including non-overhead athletes (n=107)
Maier et al. (2013) [43] Retrospective cohort study Isolated SLAP tear (all type II) - 3.9 yr n=24; volleyball, soccer, boxing, tennis, badminton, weightlifting, basketball, swimming; 36.5 yr; 16.7% Arthroscopic SLAP repair by suture anchor technique (Arthroscopic), n=12 vs. arthroscopic SLAP repair by transglenoid suture technique (Arthroscopic), n=12 -
Chalmers et al. (2018) [32] Retrospective case series SLAP tear (type NR) NR 24 mo n=17; baseball; 28 yr Open subpectoral biceps tenodesis Labral repair superior (41%), anteroinferior (6%), rotator cuff repair (6%), capsulorrhaphy (6%), rotator cuff debridement/labral debridement/subacromial decompression/acromioplasty/articular debridement (53%)
Gottschalk et al. (2014) [37] Retrospective case series SLAP tear (type II 73%, type IV 39%) Impingement-type disorder 100%, ACJ arthritis 54%, partial rotator cuff tears 38%, adhesive capsulitis 12%, recurrent tears of previous SLAP repair 12% 40.2 mo n=16; weightlifting, tennis, racquetball, baseball/softball, swimming, cricket, gymnastics; 46.7 yr; 38.5% Open subpectoral biceps tenodesis Subacromial decompression (100%), distal clavicle excision (54%), rotator cuff debridement (38%), manipulation under anesthesia (12%), labral debridement (12%) Percentages of SLAP tear types, concomitant diagnoses, and concomitant procedures are for the overall study population, including non-overhead athletes (n=28)
Gupta et al. (2015) [38] Retrospective case series SLAP tear (type I 54%, type II 36%, type III 4%, type V 7%) NR 2.0 yr n=7; baseball/softball, volleyball, basketball, swimming; 43.7 yr; NR Open subpectoral biceps tenodesis Intra-articular debridement (100%), acromioplasty (50%), suprascapular nerve release (7%), distal clavicle excision (11%), chondroplasty of humeral head, release of rotator interval, and release of coracoacromial ligament (14%), rotator cuff repair (4%) Percentages of SLAP tear types, concomitant diagnoses, and concomitant procedures are for the overall study population, including non-overhead athletes (n=28)
Lorentz et al. (2022) [42] Retrospective case series Isolated SLAP tear (all involving biceps-labral complex) - 49 mo n=44; baseball, basketball, climbing, softball, tennis, volleyball; 34.9 yr; 20.5% Open subpectoral biceps tenodesis -
Patriota et al. (2019) [48] Retrospective case series SLAP tear (all type IV) LHB tendinopathy 50% 24 mo n=4; gymnastics, climbing; 25.5 yr; 50% Open subpectoral biceps tenodesis NR
Pogorzelski et al. (2018) [49] Retrospective case series SLAP tear (all type II) NR 3.4 y yr n=20; baseball, basketball, weightlifting, golf, volleyball; 38 yr; 50% Open subpectoral biceps tenodesis Debridement, synovectomy, subacromial decompression, acromioplasty where necessary (% NR) Overall study population included non-overhead athletes (n=20), but only data for overhead athletes is presented here
Schöffl et al. (2011) [51] Retrospective case series SLAP tear (type I 33%, type II 33%, type III 17%, type IV 17%) Pulley lesion 17%, partial subscapularis tear 17%, impingement syndrome 17% 2 yr n=6; rock climbing; 36.2 yr; 16.7% Open subpectoral biceps tenodesis NR
Ulrich et al. (2023) [53] Retrospective case series SLAP tear (type II 77%, type IV 23%) LHB tendinopathy 62%, paralabral cysts 15%, articular-sided rotator cuff tears 38% 4.3 yr n=16; gymnasts; 21.8 yr; 8% Open subpectoral biceps tenodesis Debridement articular-sided rotator cuff lesions (15%), labral repair (15%), and rotator cuff repair (23%)
Waterman et al. (2023) [54] Retrospective case series Isolated SLAP tear (all type II) - 4.5 yr n=16; baseball, softball, gymnastics, swimming, others; 21 yr; 31.3% Open subpectoral biceps tenodesis -
Beyzadeoglu et al. (2015) [31] Retrospective case series SLAP tear (types NR), Partial articular-sided rotator cuff tears 26%, Bankart lesion 37%, full-thickness rotator cuff tear 9%, Bankart and posterior labral lesion 9%, Bankart and full-thickness rotator cuff tear 3% 52 mo n=34; volleyball, American soccer, basketball, tennis, handball, weightlifting, swimming; 25 yr; 11.8% Arthroscopic SLAP repair Repair/debridement of all other pathologies as per concomitant diagnoses
Friel et al. (2010) [35] Retrospective case series SLAP tear (all type II) NR 3.4 yr n=22; baseball, racquetball, softball, volleyball, basketball, tennis; 33.1 yr; NR Arthroscopic SLAP repair Bankart repair (21%), subacromial decompression (10%), distal clavicle excision (4%), cystic decompression (4%), microfracture of humeral head (2%), capsular release (2%), acromioplasty (2%) Percentages of concomitant diagnoses and concomitant procedures are for the overall study population, including non-overhead athletes (n=48)
Ide et al. (2005) [30] Retrospective case series SLAP tear (type II 93%, type II and III 5%, type III and IV 2%) Partial rotator cuff tear 75% 41 mo n=40; baseball, handball, volleyball, basketball, softball, racquetball, goalkeeping, swimming; 24 yr; 17.5% Arthroscopic SLAP repair Debridement of rotator cuff tears (75%)
Kim et al. (2002) [40] Retrospective case series Isolated SLAP tear (all type II) - 33 mo n=18; “overhead”; 26 yr; 11.8% Arthroscopic SLAP repair -
Neri et al. (2011) [44] Retrospective case series SLAP tear (all type II) Partial articular-sided rotator cuff tears (35%) 38 mo n=23; baseball, water polo, tennis, volleyball; 25 yr; 0% Arthroscopic SLAP repair Arthroscopic debridement of rotator cuff tears (35%)
Neuman et al. (2011) [45] Retrospective case series Isolated SLAP tear (all type II) - 3.5 yr n=30; baseball/softball, “other”; 24.2 yr; 73.3% Arthroscopic SLAP repair -
Park et al. (2013) [46] Retrospective case series Isolated SLAP tear (all type II) - 45.8 mo n=24; baseball, javelin, volleyball, badminton; 22.7 yr; 25% Arthroscopic SLAP repair -
Smith et al. (2016) [52] Retrospective case series SLAP tear (type NR) NR NR n=24; baseball; 28.3 yr; NR Arthroscopic SLAP repair NR
Yung et al. (2008) [55] Retrospective case series Isolated SLAP tear (all type II) - 27.6 mo n=13; tennis, handball, badminton; 24.2 yr; NR Arthroscopic SLAP repair -
Gilliam et al. (2018) [36] Retrospective case series SLAP tear (types NR), Partial articular-sided rotator cuff tear (%NR) 78 mo n=133; baseball players; 19.5 yr; 0% Arthroscopic SLAP repair Debridement of partial-thickness articular-sided rotator cuff tear (% NR)
Park and Glousman (2011) [47] Retrospective case series Recurrent SLAP tear after repair (all type II) NR 50.5 mo n=12; volleyball, baseball, softball; 32.6 yr; NR Revision arthroscopic SLAP repair Debridement of partial rotator cuff tear (58%), subacromial decompression/bursectomy (33%), humeral head chondroplasty (8%)
Fedoriw et al. (2014) [34] Retrospective case series SLAP tear (types NR) Rotator cuff tear at least 30% thickness 18% NR n=68; baseball players; 23.8 yr Arthroscopic SLAP repair or debridement Rotator cuff repair (12%), rotator cuff debridement (% NR)

NR: not reported, LHB: long head of biceps, SLAP: superior labrum anterior to posterior, ACJ: acromioclavicular joint.

Table 2.

Methodological characteristics of included studies

Study Study design Randomized? Prospective/retrospective Comparative? Adjustment for confounding?
Peduzzi et al. (2019) [23] Case series No Retrospective No No
Nourissat et al. (2020) [22] Case series No Retrospective No No
Lévigne et al. (2012) [19] Case series No Retrospective No No
Meister et al. (1999) [21] Case series No Retrospective No No
Yoneda et al. (2002) [29] Cohort study No Prospective No No
Reynolds et al. (2008) [25] Case series No Retrospective No No
Sonnery-Cottet et al. (2002) [27] Case series No Retrospective No No
Andrews et al. (1985) [14] Case series No Retrospective No No
Van Kleunen et al. (2012) [28] Case series No Retrospective No No
Mazoué and Andrews [20] Case series No Retrospective No No
Levitz et al. (2001) [18] Cohort study No Retrospective Yes No
Funakoshi et al. (2022) [15] Case series No Prospective No No
Jansen et al. (2012) [16] Case series No Prospective No No
Reinold et al. (2003) [24] Case series No Retrospective No No
Jones et al. (2012) [17] Case series No Retrospective No No
Riand et al. (1998) [26] Case series No Retrospective No No
Lacheta et al. (2022) [41] Cohort study No Retrospective Yes No
Rothermich et al. (2023) [50] Cohort study No Retrospective Yes No
Chalmers et al. (2014) [33] Cohort study No Prospective Yes No
Hurley et al. (2022) [39] Cohort study No Retrospective Yes No
Maier et al. (2013) [43] Cohort study No Retrospective Yes No
Chalmers et al. (2018) [32] Case series No Retrospective No No
Gottschalk et al. (2014) [37] Case series No Retrospective No No
Gupta et al. (2015) [38] Case series No Retrospective No No
Lorentz et al. (2022) [42] Case series No Retrospective No No
Patriota et al. (2019) [48] Case series No Retrospective No No
Pogorzelski et al. (2018) [49] Case series No Retrospective No No
Schöffl et al. (2011) [51] Case series No Retrospective No No
Ulrich et al. (2023) [53] Case series No Retrospective No No
Waterman et al. (2023) [54] Case series No Retrospective No No
Beyzadeoglu et al. (2015) [31] Case series No Retrospective No No
Friel et al. (2010) [35] Case series No Retrospective No No
Ide et al. (2005) [30] Case series No Retrospective No No
Kim et al. (2002) [40] Case series No Retrospective No No
Neri et al. (2011) [44] Case series No Retrospective No No
Neuman et al. (2011) [45] Case series No Retrospective No No
Park et al. (2013) [46] Case series No Retrospective No No
Smith et al. (2016) [52] Case series No Retrospective No No
Yung et al. (2008) [55] Case series No Retrospective No No
Gilliam et al. (2018) [36] Case series No Retrospective No No
Park and Glousman (2011) [47] Case series No Retrospective No No
Fedoriw et al. (2014) [34] Case series No Retrospective No No

Table 3.

Main results of the included studies

Study RTS+/RTS Shoulder function (mean±SD) Complication
Peduzzi et al. (2019) [23] RTS+: 52%, RTS: 90% KJOC score: 44±17 to 82±19 NR
Constant score: 67±18 to 81±12
Nourissat et al. (2020) [22] RTS+: 63.6%, RTS: 72.7% KJOC score: 75 n=1 adhesive capsulitis (patient who had rotator cuff repair)
SST score: 11.2
Lévigne et al. (2012) [19] RTS+: 69.2%, RTS: 92.3% - NA
Meister et al. (1999) [21] RTS+ 55% - Recurrence of glenoid spur n=1 (6%)
Yoneda et al. (2002) [29] RTS+: 68.8% - NA
Reynolds et al. (2008) [25] RTS+ 55%, RTS: 91% - NR
Mean time: RTS 5.6 mo (2.6 mo), return to competition 10.7 mo (4.3 mo)
Sonnery-Cottet et al. (2002) [27] RTS+: 50%, RTS: 78.6% ASES score: 26.9/30 n=1 adhesive capsulitis (resolved non-surgically)
Andrews et al. (1985) [14] RTS+: 85% - NA
Van Kleunen et al. (2012) [28] RTS+: 35%, RTS: 64.7% KJOC score: 59 NA
Mazoué and Andrews [20] RTS+ 25% overall, RTS+ 8% pitchers - NR
Levitz et al. (2001) [18] At initial RTS: - NA
RTS+ traditional only 80%, traditional plus capsulorrhaphy 93%
Mean time to RTS: traditional only 7.2 mo, traditional plus capsulorrhaphy 8.4 mo
At 30 mo:
RTS+ traditional only 61%, traditional plus capsulorrhaphy 87%,
RTS traditional only 80%, traditional plus capsulorrhaphy 97%
Funakoshi et al. (2022) [15] RTS+: 83.3% KJOC score: 28.4±8.3 to 80.8±7.7 NA
DASH score: 80.2±11.1 to 22.4±18.7
Jansen et al. (2012) [16] RTS+: 25%, RTS: 50% Rowe score: preop 45.8, 1 yr 89.5, 2 yr 90.4, 7 yr 70.4 NA
Reinold et al. (2003) [24] RTS+ 87%, mean time to RTS 8.4 mo (4.6) Modified Athletic Shoulder Outcome scale score: 79±14.5 NA
RTS+ not influenced by concomitant procedures
Jones et al. (2012) [17] RTS+: 85%, RTS: 90% SANE score: 86±17.5 NA
KJOC score: 82±18.2
Riand et al. (1998) [26] RTS+: 55%, RTS: 80% - n=4 postop stiffness (n=3 resolved)
n=2 re-operation (one for hematoma drainage, one for non-union)
n=16 needed metalwork removal
n=9 hypertrophic scars
Lacheta et al. (2022) [41] RTS+: 79.2% SLAP repair, 85.7% biceps tenodesis (P>0.05) ASES score: 70.6±16.5 (preop) to 89.1±16.7 SLAP repair, 72.1±14.2 (preop) to 92.7±10.4 biceps tenodesis (P>0.05) n=1 in each group had postoperative stiffness that required arthroscopic arthrolysis
QuickDASH score: 28.9±10.2 (preop) to 9±14.3 SLAP repair, 26.9±18.4 (preop) to 10±12.7 biceps tenodesis (P>0.05) n=1 in the tenodesis group had a humeral shaft fracture
Activity modification due to weakness 80% biceps tenodesis, 15% SLAP repair (P<0.05)
Rothermich et al. (2023) [50] RTS+: 94% SLAP repair, 93% biceps tenodesis (P>0.05) KJOC score: 75.4±14.8 SLAP repair, 73.2±18.9 biceps tenodesis (P>0.05) NR
RTS+: pitchers 87%, position players 97% (P>0.05) ASES score: 93.6 ±6.6 SLAP repair, 90.4±10.7 biceps tenodesis (P>0.05)
Mean time to RTS: 7.9 mo (3.3) SLAP repair, 7.1 mo (4.3) biceps tenodesis (P>0.05)
Chalmers et al. (2014) [33] RTS+: 100% both groups (P>0.05), RTS: 100% both groups (P>0.05) ASES score: 95±4 biceps tenodesis, 88±7 SLAP repair (P>0.05) NR
Hurley et al. (2022) [39] RTS SLAP repair 84.2% vs. biceps tenodesis 83.3% (P>0.05) ASES score: SLAP repair 92±20.6, biceps tenodesis 91.2±13.7 (P>0.05) Reoperations SLAP repair 21.9% (8/38) vs. biceps tenodesis 0%
Maier et al. (2013) [43] RTS+: 66.7% suture anchor, 50% transglenoid suture (P>0.05), Overall RTS+: 58% Constant score: 91.6 suture anchor, 81.3 transglenoid suture (P>0.05) Suture anchor n=2 revisions due to hardware failure
Transglenoid suture n=1 adhesive capsulitis that required manipulation under anesthesia
n=6 local tenderness from the polydioxanone suture knot, n=1 suture granuloma had to be excised
Chalmers et al. (2018) [32] RTS+: overall 35%, RTS+: pitchers 17% - NR
RTS+: position players 80%
Gottschalk et al. (2014) [37] RTS+: 81% (13/16), RTS: 81% - n=1 traumatic biceps tendon rupture (3%)
Gupta et al. (2015) [38] RTS+: 43%, RTS: 57% - NA
Lorentz et al. (2022) [42] RTS+: 59.1%, RTS: 81.8% ASES score: 92 NA
Mean time to RTS: 8.7 mo
Patriota et al. (2019) [48] RTS+: 100%, RTS :100% ASES score: 96±4.6 NA
Pogorzelski et al. (2018) [49] RTS+: 80% in overhead athletes ASES score: 98 (range, 80–100) n=1 adhesive capsulitis (9.1%)
QuickDASH score: 31 (preop) to 8
SANE score: 60 (preop) to 92
Schöffl et al. (2011) [51] RTS+: 100%, RTS: 100% - NR
Ulrich et al. (2023) [53] RTS+: 62%, RTS: 62% ASES score: 89.1±9.1 NA
DASH score: 2.4±3.2
Waterman et al. (2023) [54] RTS+: 81.3%, RTS: 94% KJOC score: 74 NR
Mean time: RTS 4.1 mo SANE score: 55.4 (preop) to 76.7
Beyzadeoglu et al. (2015) [31] RTS+: 88.2%, mean time RTS: 6.4±1.5 mo ASES score: 64±7.2 (preop) to 89.6±4.6 n=1 revision due to re-tear (hardware failure)
KJOC score: 50.5±10.3 (preop) to 80.9±6.8 n=1 re-injury after shoulder dislocation
Friel et al. (2010) [35] RTS+: 59% ASES score: 83.4 n=2 re-operations (revision SLAP repair n=1, revision anteroinferior stabilization n=1)
SST score: 10.2
Ide et al. (2005) [30] RTS+: 75%, RTS: 95% - NA
Kim et al. (2002) [40] RTS+: 83%, RTS: 100% - NR
Neri et al. (2011) [44] RTS+: 57%, RTS: 83% ASES score: 93.7 (range, 90–100) NR
KJOC score: 76.9
Neuman et al. (2011) [45] RTS: 73% ASES score: 87.9±15.4 n=4 reoperations (revision labral repair n=3, rotator interval closure n=1) (9%)
Park et al. (2013) [46] RTS: 50% ASES score: 55.8 (preop) to 87.1 n=2 re-tears
n=2 osteolysis
Smith et al. (2016) [52] RTS+: 54.2%, RTS: 62.5% - NR
Yung et al. (2008) [55] RTS+: 92%, RTS: 92% - NA
Gilliam et al. (2018) [36] RTS+: 64% - Overall failure 7.5% (10/133) (need for revision repairs or biceps tenodesis)
Park and Glousman (2011) [47] RTS+: 41.3% ASES score: 72.5 n=2 reoperations (for additional surgical procedures)
Fedoriw et al. (2014) [34] Pitchers (n=21): conservative management, RTS+: 22% - NR
Pitchers (n=27): SLAP repair or debridement, RTS+: 7%
Position players (n=10): conservative management, RTS+: 26%
Position players (n=13): repair or debridement, RTS+: 54%

RTS+: return to sport at pre-injury level or higher, RTS: return to sport any level, SD: standard deviation, KJOC: Kerlan-Jobe Orthopedic Clinic, SST: Simple Shoulder Test, NA: not applicable, NR: not reported, ASES: American Shoulder and Elbow Surgeons, DASH: Disabilities of the Arm, Shoulder and Hand, preop: preoperative, SANE: Single Assessment Numeric Evaluation, SLAP: superior labrum anterior to posterior.