17 SLAP Repair
Abstract
Superior labrum tears, SLAP lesions, and biceps tendon-superior labral complex injuries are among the most common injuries associated with shoulder pain and dysfunction. Numerous theories have been proposed for both overhead athletes as well as the general population. In throwing athletes, the treatment and pathogenesis remains controversial, and the structural changes encountered may be purposeful and adaptive. In the general population, pathogenesis has been related typically to degenerative processes with associated arthritis, rotator cuff disease and age. This chapter addresses the senior author (JEC)’s treatment approach and surgical indications in addressing SLAP tears as well as the preferred technique in performing surgical repair.
17.1 Introduction
Superior labrum tears, SLAP (superior labral tear from anterior to posterior) lesions, and biceps tendon–superior labral complex injuries are among the most common structural derangements, correctly and incorrectly associated with shoulder pain and dysfunction, especially in the thrower’s shoulder. Numerous theories regarding the etiology of these superior labral lesions have been proposed, and they vary for the general population, non-overhead athletes, and overhead athletes. For the thrower, the pathogenesis of biceps tendon–superior labral complex pathology remains both controversial and multifactorial, but in many cases, mobilization of the superior labrum may be either purposeful and adaptive, or pathologic and destabilizing. In the general population, pathogenesis is typically degenerative and has been related to rotator cuff disease, arthritis, and increased age.
The nonoperative treatment of SLAP lesions is now, or should now be, the mainstay of treatment, particularly in throwers, and has shown some success. 1 Even with initial failure of nonoperative treatment, Fedoriw et al demonstrated reasonable success with a second course of physical therapy specifically designed to address concomitant pathology such as kinetic chain disorders, glenohumeral motion deficits, scapular dyskinesia, and posterior capsular contracture. 2 The surgical treatment of SLAP lesions, whether by debridement, repair, or biceps tenotomy/tenodesis, has overall been successful in selected general population patients, but results of surgery are far less favorable in overhead athletes. Traumatic SLAP tears represent a subset in which surgery may be indicated when symptomatic. In the older degenerative population, surgical SLAP repairs have yielded worse results with increased revision rates. 3
Initial emphasis for the majority of SLAP tears should be placed on conservative treatment, namely rest and physical therapy for this condition. Subacromial and biceps tunnel injections of anesthetic/steroid serve both therapeutic and diagnostic roles and may be of significant help in determining if the SLAP tear is indeed a pain generator. Failed nonoperative treatment may warrant surgical intervention; however, success may be largely influenced by factors independent of the quality of surgical repair, such as age, associated pathology, competitive level, and position in sport. For instance, Fedoriw et al showed that higher level pitchers return to play and at a higher level than lower level pitchers, regardless of whether they undergo nonoperative or operative treatment. 2
Prior to the recognition of superior labral lesions as potential contributors to shoulder dysfunction in a thrower, these lesions were treated either nonoperatively or with debridement alone. After this lesion was further defined and classified, numerous repair methods were described. Unfortunately, the overall success with surgical treatment of SLAP lesion has been less than satisfactory in throwers. In the nonthrowing general population, the surgical treatment of degenerative SLAP lesions has also gained considerable attention and repair is no longer recommended in patients older than 40 years. In that setting, debridement or biceps tenotomy/tenodesis provides a more predictable and successful outcome.
17.2 Goals
The goal of treatment is to improve pain and function in all subsets of patients. In nonthrowers, in the event of a symptomatic traumatic SLAP tear, restoration of anatomy is the surgical goal. In throwers, SLAP tears may contribute to decreasing velocity and performance in conjunction with other shoulder pathology. The goal of treatment in throwers is to first restore the overhead athlete’s shoulder function and return the athlete to play at his or her previous level without the need for surgery. When that fails, the surgical goal is to do as little as is needed to accomplish that aforementioned goal, understanding that undoing adaptive changes in the shoulder, whether this involves mobilizing the posterosuperior labrum or peeling away a portion of the posterosuperior rotator cuff within the rotator cable, will likely result in loss of shoulder motion, alteration in throwing mechanics, and a decrease in performance.
A better understanding of the potential purposeful and adaptive etiology of SLAP lesions as well as which SLAP lesions are potentially “good” and “bad” has left a more selective treatment algorithm in the management of SLAP lesions. The SLAP lesion should be classified as “good” or “bad” based on a number of factors, which will be discussed later in this chapter. In addition, we now understand that intra-articular long head biceps disease and biceps tunnel disease are separate entities that need to be considered independently and included in the treatment algorithm regarding superior labral tears.
Nonoperative treatment of superior labral tears in the overhead athlete is recommended as initial treatment and there are reported improved outcomes treating SLAP lesions nonoperatively when compared to treating these lesions operatively. Physical therapy should be directed toward treating concomitant pathology and kinetic chain problems. This would include quadriceps weakness, motion loss in the leg and hip, lumbo–pelvic–hip malalignment, core strength deficiencies, scapular malposition/dyskinesia, shoulder motion recovery (now based on humeral torsion measurements), shoulder stabilization including entities such as dynamic posterior instability in a thrower, and correction of known throwing mechanic factors that contribute to injury. The majority of the SLAP lesions in the thrower probably occur gradually with attrition over time and many are not symptomatic.
17.3 Indications
As part of the clinical assessment, many special shoulder tests have been described for SLAP lesions. None have been shown individually or collectively to have reliably high sensitivity and specificity. It is the opinion of the senior author that none of the tests can be expected to confirm pain caused by an intra-articular structural change until after the subacromial spaces have been injected. If there is pain on a test that is completely relieved by subacromial injection, then the pain is caused by subacromial outlet impingement. Whether that intra-articular structural change contributes to the cause of subacromial impingement is unclear. Nevertheless, it is not possible to say that a documented SLAP lesion is causing pain during a specialized test if the pain on that test is relieved by subacromial injection. Some authors advocate for intra-articular injections, but in the senior author’s opinion, that is rarely indicated. More commonly, a biceps tunnel injection may be valuable in helping to sort out whether or not the pain is caused by the biceps tunnel disease. This is because many overhead athletes with shoulder pain will have some glenohumeral synovitis and the injection itself may relieve the pain caused by that synovitis and this superior labral tear may still be an asymptomatic lesion.
17.3.1 Indications for Primary Repair in a Thrower
The management of type II SLAP tears in patients without obvious intra- or extra-articular long head of the biceps tendon disease is still controversial. The biceps tendon–superior labral complex contributes to the translational and rotational stability in the shoulder. As such, preserving the biceps tendon–superior labral complex even in the presence of a superior labral tear is preferred over biceps tenodesis given its contribution to stability. Furthermore, repairing clearly degenerative and disrupted superior labral tissue or employing methods that overconstrain the biceps tendon at its base or along the posterosuperior labrum is known to cause loss of external rotation. For example, placing anchors anterior to the biceps tendon in the absence of superior glenohumeral ligament (SGHL) avulsion would not be appropriate. The overhead athlete, especially a thrower, was previously always considered for SLAP lesion repair. However, outcomes of repair in this population are concerning, as 22 to 64% of throwing athletes return to the same level of play. This rate of return for throwers was worse than for other overhead athletes. 4 It has been argued that in overhead athletes, the chronic attritional loads placed on the superior labrum in the late cocking stage of throwing may be too high even for a repaired labrum to withstand. While this may be true, some experts would argue that the method with which the superior labrum was repaired and the selection process of which lesions to repair may have contributed to the poor outcomes.
Careful assessment of SLAP tear patterns with consideration of associated intra- and extra-articular pathology allows for subclassification of an overhead athlete’s lesion into “good” and “bad” SLAP tears. The “good” SLAP lesions are purposeful, beneficial adaptations in throwers that allow greater labral mobility, horizontal abduction, and external rotation with possible improvements in pitch velocity and performance. While these good SLAP lesions may become frayed and may benefit from debridement, repair would likely undo adaptive benefits conferred by the extra mobility, resulting in loss of motion and decreased performance. Laughlin et al reported an alteration in throwing mechanics in athletes undergoing SLAP repair. 5
The “bad” SLAP lesions are pathologic changes causing translational and rotational microinstability, pain, and worsening performance. These tears have more complicated lesions of the complex with disrupted labral tear patterns and are often associated with more significant posterosuperior rotator cuff disease such as the PASTA lesion (partial-thickness articular surface rotator cuff tear occurring at the junction of the posterior supraspinatus and anterior infraspinatus). When history and the arthroscopic findings suggest that these “bad” SLAP lesions are traumatic, then repair is reasonable as these tears did not occur slowly over time as purposeful adaptations. When degenerative disruptive pathologic tears are debrided and leave behind poor-quality tissue for repair or the tear pattern extends into the biceps tendon itself, then biceps tenodesis becomes a more reasonable option. In addition, since many “bad” SLAP lesions are associated with rotator cuff disease, the surgeon needs to be confident that the anterior and posterior rotator cables are intact and that rotator cuff pathology is appropriately addressed. In most cases, a footprint repair should not be considered, and rotator cuff repair would only be added to the management of the superior labral treatment if the anterior or posterior rotator cables are detached. Additionally, the surgeon must also address the subacromial bursa. The best candidate for repair has history, physical examination, MRI, and arthroscopic findings consistent with a symptomatic “bad” SLAP lesion but no evidence of intra- or extra-articular biceps tendon pathology. 6
The surgeon must be able to differentiate from multiple pain generators and treat pathology where it exists. By recognizing certain salient features of pain associated with SLAP tears, the surgeon is capable of treating superior labral disease and biceps tunnel disease with the appropriate operation. It is important to recognize that biceps tunnel disease does occur in throwers who have concomitant biceps tendon–superior labral complex pathology. When unrecognized, superior labral debridement and repair will fail to relieve anterior shoulder pain, resulting in continued functional limitation and loss of performance. You cannot treat biceps tunnel disease with superior labral surgery. Given our current understanding of biceps–superior labral pathology in the upper extremity athlete, debridement alone and management of other shoulder pathology, such as dynamic posterior instability with posteroinferior labral repair, subacromial outlet impingement with subacromial bursectomy, or biceps tunnel disease with suprapectoral biceps tenodesis, would be a more reasonable surgical option that superior labral repair.
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