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Superior labrum, anterior and posterior (SLAP) lesions are common and identified in up to 26% of shoulder arthroscopies, with the greatest risk factor appearing to be overhead sporting activities. Symptomatic patients are treated with physical therapy and activity modification. However, after the failure of non-operative measures or when activity modification is precluded by athletic demands, SLAP tears have been managed with debridement, repair, biceps tenodesis or biceps tenotomy. Recently, there have been noticeable trends in the operative management of SLAP lesions with older patients receiving biceps tenodesis and younger patients undergoing SLAP repair, largely with suture anchors. For overhead athletes, particularly baseball players, SLAP lesions remain a difficult pathology to manage secondary to concomitant pathologies and unpredictable rates of return to play. As a consequence, the most appropriate surgical option in elite throwers is controversial. The objective of this current concepts review is to discuss the anatomy, mechanism of injury, presentation, diagnosis and treatment options of SLAP lesions and to present current literature on outcomes affecting return to sport and work.
Superior labrum, anterior and posterior (SLAP) lesions are common in overhead throwing athletes.
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Clinical trend in increasing numbers of biceps tenodeses being performed, particularly in older patients (greater than 40 years old).
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Overall successful outcomes are seen in both SLAP repair and biceps tenodesis, with results favouring tenodesis in terms of return to play in athletes. However, there is a paucity of Level I studies comparing biceps tenodesis to SLAP repair.
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Return to sport rates in overhead athletes after SLAP repair reported as 63%, with lower rates of return in baseball players. Pitchers remain the most difficult subset.
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Limited knowledge on return to work performance in middle-aged patients.
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Limited insight on the clinical outcomes that biceps tenodesis would have on young throwing athletes. Most practitioners choose SLAP repair in this setting.
Future perspectives
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Increased numbers of Level I studies comparing biceps tenodesis versus SLAP repair, particularly focusing on young throwing athletes.
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Long-term studies investigating the consequences of biceps tenodesis in throwing athletes and whether this non-anatomic treatment option has a higher propensity for future shoulder injuries compared to SLAP repair.
Introduction
The optimal treatment of superior labrum, anterior and posterior (SLAP) lesions in overhead throwing athletes is controversial. Furthermore, accurate diagnosis is difficult secondary to non-specific provocative examination manoeuvres and the presence of concomitant shoulder pathologies. SLAP tears have been identified in 6%−26% of all-cause shoulder arthroscopies.
In 1985, Andrews et al were the first to describe labral injuries in throwing or overhead athletes, with 83% of glenoid labral tears involving some portion of the anterosuperior region, at the confluence of the biceps tendon and labral complex.
In 1990, Snyder et al coined the term ‘SLAP’ lesion to describe pathology of the superior labrum that began posteriorly and extended anteriorly into the region of the biceps ‘anchor’.
Treatment options for SLAP lesions include observation/conservative measures, debridement, repair, biceps tenodesis and biceps tenotomy. More recently, there has been a shift towards the selection of biceps tenodesis, but SLAP repair remains the most common procedure in young, throwing athletes.
Surgical trends in the treatment of superior labrum anterior and posterior lesions of the shoulder: analysis of data from the American Board of orthopaedic surgery certification examination database.
The purpose of this study is to discuss the anatomy, mechanism of injury, presentation, diagnosis and treatment options of SLAP lesions and to present current literature on outcomes affecting return to sport and work.
Anatomy
The glenoid labrum enhances glenohumeral joint stability by adding depth to the glenoid fossa, resisting translational forces and augmenting the concavity-compression mechanism.
In relation to the healing potential of labral tears, the superior and anterosuperior portions of the labrum have less vascularity compared with other regions.
Furthermore, feeding vessels arise from the capsule and periosteum rather than the underlying bone, which confines vascularity to the labral periphery. Moreover, the vascularity decreases with age,
which has unknown implications on operative repair in older populations.
Anatomic variations of the superior labrum exist. This knowledge is necessary to make an accurate diagnosis and to avoid unnecessary surgery, the latter of which could lead to postoperative stiffness that limits motion, particularly with external rotation and forward elevation.
Rao et al described three predominant labral variations: (i) sublabral recess, (ii) sublabral foramen and (iii) the Buford complex, the presence of a thick, cord-like middle glenohumeral ligament (MGHL) and the absence of anterosuperior labral tissue.
Multiple mechanisms have been described for SLAP lesions. Snyder et al described two primary mechanisms of injury: (1) compressive force, generally via a fall onto an outstretched arm with the shoulder in abduction and slight flexion and (2) traction on the arm.
During the throwing motion, it is believed that the biceps functions as a means of ‘stress protection’ by assisting with deceleration after ball release, glenohumeral joint compressive forces, and reversing torques on the humerus that were created during cocking and early acceleration phases.
With the arm in abduction and external rotation, as in the cocking phase of throwing, LHBT contraction results in a torsional force on the posterior labrum.
Furthermore, posterior-inferior capsular contracture and glenohumeral internal rotation deficit (GIRD) can result in altered glenohumeral contact position and increased shear forces to the posterior-superior labrum, generating a ‘peel back’ effect and inciting labral injury in throwing athletes.
Symptomatic SLAP tears tend to occur in two patient populations: overhead athletes and middle-aged workers (generally men). Injuries can be provoked by a single, acute traumatic event, such as a traction injury while falling from a ladder, or in a more chronic manner, secondary to repetitive overhead motion.
The most common complaint is shoulder pain, particularly with overhead activities. There may be feelings of instability, secondary to interposition of the labrum between the glenoid and humeral head, preventing congruent fit.
In labourers, symptoms do not typically lead to significant disability, with a gradual waning of symptoms and possible recurrence.
Concomitant shoulder injuries are common, including rotator cuff tears, glenohumeral instability and internal impingement, which may present with night pain, weakness or instability, making the diagnosis more difficult.
There is not a definitive test for SLAP lesions. Furthermore, the high prevalence of concomitant injuries in those with SLAP lesions makes it difficult for the examiner to discern symptoms from each pathology. As such, complete bilateral shoulder and cervical spine examinations are mandatory. In the throwing athlete, the examiner must investigate for signs of scapular dyskinesis and GIRD.
Various tests have been proposed for SLAP tears, including the O’Brien active compression test, anterior slide test, biceps load test, crank test, resisted supination external rotation test, rotation compression test and forced abduction test.
Snyder et al stated that the most useful tests were the biceps tension test and the joint compression-rotation test, the latter of which is analogous to the McMurray test for evaluating meniscal tears of the knee.
In a prospective case-control study comparing five tests (O’Brien active compression test, Speed’s test, biceps load II test, O’Driscoll/dynamic labral shear test and labral tension test), Cook et al concluded that these tests provided no to minimal diagnostic value for SLAP lesions.
In a meta-analysis by Meserve et al, the O’Brien active compression test was identified to be the most sensitive for SLAP tears, with reported sensitivity ranging from 47% to 78% and specificity from 11% to 73%.
Crank test sensitivity ranged from 13% to 58% and specificity from 56% to 83%. Speed’s test sensitivity was poor, ranging from 4% to 48%, but had the highest specificity of 67% to 99%.
In our practice, we use the O’Brien active compression test and the subpectoral biceps test (figure 2). Repeatable positive O’Brien tests on multiple clinical visits, which improve with glenohumeral lidocaine injection, strengthens the clinical diagnosis. As SLAP lesions can cause tenderness to palpation of the rotator interval and anterior shoulder,
the subpectoral biceps test can be used to identify pathology at the proximal biceps tendon and identify patients who may benefit from tenodesis/tenotomy.
Figure 2(A,B) The O’Brien active compression test. The patient’s arms are positioned at 90° of forward flexion in full extension at the elbows, with the arm internally rotated and forearm pronated (thumb down). The examiner applies downward distal pressure, which recreates the patient’s pain. Improvement in pain or clicking with forearm supination (thumb up) is a positive test for a SLAP tear. (C) The subpectoral biceps tests. The patient forcefully internally rotates and adducts the arm to allow the examiner to locate the pectoralis tendon. Then, the examiner places a finger in the axilla underneath the pectoralis tendon to palpate the biceps tendon. Positive tenderness of the proximal biceps that resolves with intra-articular injection is a positive test.
Furthermore, it is important to differentiate a SLAP tear from an anatomic variant, such as a sublabral foramen or recess. Sheridan et al described a tendency to overcall SLAP tears on MRI, with a positive predictive value of only 24%.
Figure 3T1 fat-supressed MRI of a right shoulder suggestive of a superior labral tear with increased signal and oedema at the glenoid rim and superior to the glenoid neck.
Figure 4Arthroscopic view of the superior glenoid labrum and long head of the biceps tendon from the posterior portal revealing a Type II SLAP tear (top) with a positive “peel back” sign (bottom) during abduction and external rotation of the operative upper extremity.
Secondary to limitations on specific physical examination manoeuvres, unreliability of advanced imaging and obscurity by concomitant pathologies, it is imperative to consider the patient’s symptomology and aggravating factors during diagnosis. To aid in the diagnosis, we use an intra-articular injection to confirm intra-articular pathology. In young individuals, lidocaine without corticosteroids, due to its potential chondrotoxic effects, is injected into the glenohumeral joint. The patient is monitored for improvement or resolution of aggravating activities, particularly overhead motions or the cocking phase of throwing. For older individuals, a mixture of lidocaine, Marcaine and Depo-Medrol is used, which can be both diagnostic and therapeutic. Symptom improvement with this differential injection is not confirmative but strengthens the clinical diagnosis.
Classification
Snyder et al originally created a four-part classification system to describe the pathology of the superior labrum: Type I, fraying; Type II (most common), detachment of the biceps tendon with or without fraying; Type III, bucket-handle tear and Type IV, similar to Type III but the tear extends into the biceps tendon (figure 5).
This classification system was revised by Maffet et al for further inclusiveness, adding three other common variations: Type V, anterior–inferior Bankart lesion that propagates superiorly to the biceps tendon; Type VI, unstable flap tear with separation of the biceps anchor; and Type VII, superior biceps-labral detachment that extends anteriorly beneath the MGHL.
These subclassifications were associated with the position of the biceps anchor on the superior labrum; namely, a posterior-dominant biceps attachment would cause posterior or combined anterior and posterior labral avulsions with a tensile load. Further modifications were added by Nord and Ryu: Type VIII, extension along the posterior glenoid labrum as far as 6 o’clock; Type IX, pan-labral injury; and Type X, superior labral tear associated with a posterior-inferior labral tear (reverse Bankart lesion).
Figure 5The original four-part classification of SLAP tears. Type I involves fraying of the superior labrum. Type II, the most common, involves detachment of the biceps tendon, with or without fraying of the superior labrum. Type III involves a bucket-handle tear of the superior labrum. Type IV involves a bucket-handle tear as well, but the tear extends into the biceps tendon. SLAP, superior labrum, anterior and posterior.
Initial treatment of SLAP lesions is non-operative. In particular, Type II lesions, which are the most common form, are not considered an indication for acute operative management.
Non-operative measures for SLAP lesions largely involve rest, avoidance of aggravating factors and physical therapy. Therapy should focus on correcting scapular dyskinesis and posterior capsular contracture.
When these conservative therapies fail, and level of performance drops, surgical treatment of SLAP lesions and potentially other concomitant pathologies are offered to the patient. Surgical options include debridement, repair, biceps tenotomy and biceps tenodesis. Jang et al identified failure of non-operative treatment is strongly linked to a history of trauma, mechanical symptoms and demand for overhead activities.
Due to limited higher-level evidence studies, significant controversy remains regarding the optimal treatment of SLAP tears with regard to age and activity level, particularly for Type II lesions. Furthermore, the natural history of isolated SLAP tears is unknown, with limited studies investigating the outcomes of non-operatively treated SLAP lesions.
Moreover, a recent study comparing sham surgery, repair and biceps tenodesis identified no differences in functional outcomes, suggesting that current indications for the operative management of SLAP lesions need to be narrowed and that patients may do well with non-operative management.
However, over the past two decades, large database studies have identified significant trends in the operative management of SLAP lesions with rising rates of biceps tenodesis and decreasing rates of labral repairs, with repairs generally reserved for younger patients.
Surgical trends in the treatment of superior labrum anterior and posterior lesions of the shoulder: analysis of data from the American Board of orthopaedic surgery certification examination database.
From 2007 to 2016, there was a 69% decrease in isolated SLAP repairs and a 370% increase in biceps tenodesis, with trends favouring conservative management of isolated lesions,
In the throwing athlete, despite these trends, limitations on high-level evidence and uncertainties regarding the function of the LHBT in throwing mechanics continue to make treatment decisions difficult, and consequently, labral repair remains the most common. This uncertainty has provoked hesitancy to perform biceps tenodesis in throwing athletes due to concerns for either loss of control or velocity, or perhaps a predisposition to future injury.
Postoperative restoration of upper extremity motion and neuromuscular control during the overhand pitch: evaluation of tenodesis and repair for superior labral anterior-posterior tears.
In a recent online survey of Major League Baseball team physicians, 93.3% would recommend Type II SLAP repair, only 1 (3.3%) would recommend debridement and none recommended biceps tenodesis.
As such, the decision for repair versus tenodesis is multifactorial based on lesion type, chronicity, tissue quality, patient age, occupation and/or activity level.
There is an abundance of literature suggesting positive results of surgical management of SLAP lesions. However, the appropriate treatment in younger patients, particularly high-level throwing athletes, is controversial with unpredictable rates of return to play.
Postoperative restoration of upper extremity motion and neuromuscular control during the overhand pitch: evaluation of tenodesis and repair for superior labral anterior-posterior tears.
However, despite these positive results, there is a paucity of Level I and II evidence for SLAP repair outcomes, and not all studies focus on the overhead athlete, potentially falsely elevating success rates.
In a systematic review by Gorantla et al, good and excellent results ranged from 40% to 94% and return to the previous level of play ranged from 20% to 94%, but only 5 of 12 studies evaluated outcome measures in overhead athletes, which they described as the most challenging group to return to the previous level of performance.
Figure 7Arthroscopic SLAP repairs using knotted (top) and knotless (bottom) suture anchors. Knotless anchors are favourable for their lower profile and decreased risk of suture or knot abrasion to the articular surface. SLAP, superior labrum, anterior and posterior.
Park et al identified a 38% return to play rate in baseball players compared with 75% in other overhead athletes following isolated Type II SLAP repair. Similarly, Ide et al showed a return rate of 63% for baseball players compared with 86% for other overhead athletes.
In a series of 27 professional baseball pitchers, Fedoriw et al identified a 48% rate of return to play after SLAP repair or debridement, but only a 7% rate of return to prior performance, based on their professional level and performance statistics. However, reliable outcomes are limited to concomitant pathology, particularly associated rotator cuff tears, which is a negative prognostic indicator for return to play.
Interestingly, Laughlin et al identified altered pitching mechanics in those who underwent SLAP repair compared with healthy controls, with significantly less shoulder horizontal abduction and external rotation and a more upright trunk position.
However, it is unclear if these differences are secondary to the repair itself or the pitcher’s pre-injury form.
Similar to throwing athletes, active military personnel are an elite group, and successful outcomes are prudent. Provencher et al evaluated 179 active military patients who underwent Type II SLAP tear repair and identified a 37% failure rate and 28% revision rate, with younger patients (those under 36 years old) having higher outcome scores and greater levels of function in the follow-up period.
however, older populations may experience a slower return to activity and the presence of osteoarthritis is a negative indicator for a return to prior level of activity.
Recent trends favor biceps tenodesis in those older than 30 years old and repair in those less than 30 years old, based on overall poor results with repair and successful results with tenodesis in older populations.
Boileau et al described increased satisfaction (93% vs 40%) and increased return to the previous level of sports participation (87% vs 20%) following biceps tenodesis compared with arthroscopic repair for Type II lesions, although older patients were preferentially chosen for biceps tenodesis.
Recent systematic reviews have identified improved patient satisfaction (95.6% vs 76.2%, p=0.01) and rate of return to sport (81.3% vs 64.3%, p=0.02) with similar functional outcomes.
De Sa et al reported similar American Shoulder and Elbow Surgeons (ASES) and visual analog scale (VAS) scores; however, the rate of return to sports ranged from 20% to 95% and 73% to 100% for SLAP repair and biceps tenodesis, respectively, with lower reoperation rates in those with tenodesis.
However, systematic reviews can be limited by the heterogeneity of their populations, particularly with respect to athletic level, sport and age. Thus, despite biceps tenodesis becoming popular in older patients, it remains unclear if this is an appropriate option in younger athletes, particularly throwers.
In professional baseball players, Chalmers et al reported a poor rate of return to prior level of play (35%) following all-cause indications for biceps tenodesis, with a 17% rate for pitchers compared with 80% for positional players.
Despite these poor results, others have identified a more reliable return of upper extremity thoracic rotation in the throwing motion compared with SLAP repairs.
Postoperative restoration of upper extremity motion and neuromuscular control during the overhand pitch: evaluation of tenodesis and repair for superior labral anterior-posterior tears.
As such, the selection of biceps tenodesis in this patient population is controversial. We preferentially perform biceps tenodesis in older patients and those with concomitant shoulder pathologies, in accordance with current trends.
Surgical trends in the treatment of superior labrum anterior and posterior lesions of the shoulder: analysis of data from the American Board of orthopaedic surgery certification examination database.
No advantages in repairing a type II superior Labrum anterior and posterior (slap) lesion when associated with rotator cuff repair in patients over age 50.
Franceschi et al performed a randomised controlled trial comparing repair versus tenotomy in the setting of arthroscopic rotator cuff repair (RCR) in patients greater than 50 years of age, finding improved outcome scores in the tenotomy group.
No advantages in repairing a type II superior Labrum anterior and posterior (slap) lesion when associated with rotator cuff repair in patients over age 50.
For the middle-aged worker, there are limited studies investigating rates of return to work. One study showed significantly lower functional outcome scores with worker’s compensation cases.
Recently, in a randomised sham-controlled trial comparing sham surgery, repair and biceps tenodesis for isolated Type II SLAP lesions, Brox et al identified on average 148 days of sick leave in the 2 years following surgery. There were no differences in rates of return to work, but preoperative sick leave, anxiety/depression and manual labour were associated with decreased rates of return to work. However, this study was completed in Norway, and employed citizens receive 1 year of compensated pay postoperatively.
As such, extrapolation of these data to other countries may not be possible, particularly in the USA with self-employed manual labourers or those with private-pay insurance plans.
Complications
The most common postoperative complication following SLAP repair is stiffness.
Yoneda et al advised using caution when placing anchors anterior to the biceps tendon to avoid inadvertent tightening of the MGHL or closure of a sublabral foramen, which would result in limited external rotation,
particularly restrictive for throwers. Despite commonly associating stiffness with SLAP repairs, Cvetanovich et al identified no statistical difference between the incidence of stiffness between repair and tenodesis, with an overall rate of 4.7%.
Chondral injuries, and in rare instances suprascapular nerve injury, can occur during anchor drilling. Furthermore, others express that bulky knots may be a source of pain in the throwing shoulder or can cause cartilage erosion.
For these reasons, the senior author has shifted to using knotless anchors for SLAP repairs to decrease the risk of abrasion of the soft tissues as well as impingement of the suture in the glenohumeral joint.
Rehabilitation is geared towards balancing repair integrity and hastening the return to sport. Patients begin with a brief period of immobilisation in a sling and begin gentle pendulum and isometric deltoid exercises as the pain subsides.
It is important to prevent ‘peel back’ and avoid premature torsional stresses on the repair, limiting active shoulder external rotation, abduction, extension, forward flexion and biceps contractions.
At 3 weeks, active and passive glenohumeral range of motion is begun. At 6 weeks, strengthening of the rotator cuff and scapular stabilisers is initiated. At 3 months, sports-specific exercise programs begin, and throwing can be initiated 4–6 months postoperatively. Full return to unrestricted throwing can be expected from 8 to 9 months post-operatively.
SLAP lesions are common injuries, and treatment is controversial in young overhead athletes. Return to sport in overhead athletes following SLAP repair is 63%,
Over the past two decades, surgeons have stratified surgical treatment based on the age of the patient, with biceps tenodesis favoured in older patients and SLAP repair in younger patients. However, the uncertain role of the LHBT in the throwing motion and its role in glenohumeral stability has made surgeons tentative to perform tenodesis in elite throwers. Future studies will be needed to identify the role of biceps tenodesis in these high demand populations.
Ethics statements
Patient consent for publication
Not required.
Ethics approval
The Institutional Review Board approval at the University of Connecticut was not required for this review, as no protected health information was used.
References
Kim TK
Queale WS
Cosgarea AJ
et al.
Clinical features of the different types of slap lesions: an analysis of one hundred and Thirty-Nine cases.
Surgical trends in the treatment of superior labrum anterior and posterior lesions of the shoulder: analysis of data from the American Board of orthopaedic surgery certification examination database.
Postoperative restoration of upper extremity motion and neuromuscular control during the overhand pitch: evaluation of tenodesis and repair for superior labral anterior-posterior tears.
No advantages in repairing a type II superior Labrum anterior and posterior (slap) lesion when associated with rotator cuff repair in patients over age 50.
Contributors MRL contributed to the conception, drafting, revising and final approval of the manuscript. MRM and BCH contributed to the revising of the manuscript and final approval of the manuscript. AAR, EC and ADM contributed to the conception, revising and final approval of the manuscript. All authors attest to the accuracy and integrity of the complete manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests AAR provides research support for Arthrex, Inc. and Northwell Health. AAR is a paid consultant for Arthrex, Inc. and Paragen Technologies. AAR receives royalties from Saunders/Mosby-Elsevier. N.N.V. and Arthrex, Inc. AAR is a stockholder in Healthpoint Capital, DuPage Medical Group and Paragen Technologies. AAR provides publisher support for Slack, Inc., Orthopedics Today and Saunders/Mosby-Elsevier. N.N.V. and is on the editorial boards of Techniques in Shoulder and Elbow, Techniques in Sports Medicine, Sports Health and Orthopedics and is the chief medical editor of Orthopedics Today. EC is a paid presenter or speaker for DePuy, Smith & Nephew and Stryker as well as a paid consultant for Johnson & Johnson and research support for Smith & Nephew. EC is a board or committee member for the European Society for Surgery of the Shoulder and Elbow as well as the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine. EC is also a member of the editorial or governing board of the Journal of Shoulder and Elbow Surgery. ADM is a research support and consultant for Arthrex, Inc.
Provenance and peer review Commissioned; externally peer reviewed.
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