Management of the Throwing Shoulder With a SLAP Tear


Chapter 54

Management of the Throwing Shoulder With a SLAP Tear



John M. Tokish, Michael J. Kissenberth, and Jared C. Bentley

Introduction


Pathology involving the superior labrum presents a diagnostic and therapeutic challenge for the arthroscopic surgeon. First described by Andrews and colleagues in 1985, Snyder later classified lesions of the superior labrum into four types and coined the term SLAP tear (superior labral tear anterior–posterior). Since that time, other authors have expanded this classification to the current inclusion of ten different types. Concomitantly, the incidence of surgically treated tears has increased up to 5.5-fold. An area that is anatomically variable, biomechanically controversial, and increasingly recognized has become a source of much controversy in terms of management. With extremely variable rates of return to preinjury function, ranging from 22% to 64%, this is particularly true in the throwing shoulder. Proper treatment of overhead athletes requires a thorough understanding of the adaptive and pathologic biomechanics and goals of rehabilitative treatment strategies.

Procedure


The disabled throwing shoulder, with a suspected pathologic SLAP lesion, is initially subjected to appropriate rehabilitation. Isolated lesions refractory to nonoperative measures are offered surgical treatment after extensive counseling regarding natural history and expectations. Arthroscopic anatomic SLAP repair is the mainstay of surgical treatment in the young competitive thrower and remains the gold standard. Controversies remain, including the role of tenodesis, anterior repair, and simultaneously addressing concomitant pathology.

Patient History



Patient Examination





  1. • Inspection


    1. • Scapular rhythm and kinematic abnormalities
    2. • Shoulder asymmetry, muscle atrophy

  3. • Range of motion


    1. • Internal and external rotation with shoulder abducted to 90 degrees
    2. • Throwers commonly exhibit a shift in total arc with increased external and decreased internal rotation.
    3. • Total arc of motion of each shoulder should be symmetric as arcs with deficits of 5 degrees or greater arc predictive of increased injury.
    4. • Glenohumeral internal rotation deficit (GIRD) is present if the internal rotation side-to-side difference is greater than 20 degrees, predisposing the athlete to SLAP tears and internal impingement (Fig. 54.1).

  5. • Strength


    1. • Rotator cuff muscle strength should be carefully tested.
    2. • Weakness with examination is indicative of rotator cuff pathology potentially from internal or subacromial impingement.

  7. • Specialized tests


    1. • A multitude of specific tests have been described to improved detection of SLAP lesions.
    2. • Active compression test (O’Brien Test)
    3. • Internal rotation resistance strength test (Zaslav Test)
    4. • Crank
    5. • Biceps load I and II (Kim Test)
    6. • Dynamic Labral Sheer Test (O’Driscoll Test)
    7. • Whipple test


    9. image
      FIG. 54.1 Modified Sleeper Stretch. (A) The athlete is slightly rotated posteriorly (20 degrees to 30 degrees posterior to the coronal plane of the body) to place the shoulder in the scapular plane as passive internal rotation is performed. (B) This position stabilizes the scapula without causing subacromial impingement complaints. 
      From: Wilk KE, Hooks TR, Macrina LC. The Modified Sleeper Stretch and modified cross-body stretch to increase shoulder internal range of motion in the overhead throwing athlete. J Orthop Sports PhysTher. 2013;43(12):891-894.       Figure 1 Page 892.

    10. • Anterior slide test
    11. • Labral tension Test

  9. • Despite reported good to excellent diagnostic results, independent research comparing examination with intraoperative findings have concluded clinical findings in isolation are of limited value to the clinician.
  10. • Multiple positive tests with the appropriate clinical history are likely the most indicative of a symptomatic SLAP lesion.

Imaging



Treatment Options: Nonoperative and Operative





  1. • Nonoperative


    1. • Recent reports note nonoperative management of type II SLAP lesions in the throwing athlete is associated with not only greater return to competition but also greater return to the same level of competition.
    2. • Relative rest, nonsteroidal antiinflammatory drugs (NSAIDS)
    3. • Stretching focused on the posterior capsule
    4. • Throwers with clinical findings of a tight posterior capsule are disposed to SLAP lesions and should undergo a regimented effort at posterior capsular stretching. This is coupled with a strengthening program focused on improving scapular weakness and dyskinesis.

  3. • Operative


    1. • Diagnostic arthroscopy is perhaps the most important tool in confirming diagnosis of a SLAP lesion.
    2. • Once confirmed, management of the disabled thrower with a pathologic SLAP lesion is a controversial topic. Despite satisfactory pain relief approaching 90%, return to overhead throwing has been less tangible, reported between 22% and 64% with operative treatment
    3. • The throwing shoulder with SLAP pathology must be thought of separately with more specific outcomes, measures, and understanding of associated pathology.



    5. TABLE 54.1





















































































      Return To Throwing Following Slap Repair.
      1 Morgan et al. Arthroscopy 1998 Repair of SLAP 37 pitchers in 102 throwers 87% returned to previous level of play
      2 Bradley et al. AJSM 2008 Posterior capsulolabral repair throwers vs. nonthrowers 27 throwers 89% good and excellent, but 55% returned to previous level
      3 Kim et al. JBJS 2002 SLAP Repair 18 overhead athletes only 22% overheads returned to same level
      4 Andrews et al. JOSPT 2003 Repair +/- Thermal in throwers 130 athletes (105 pitchers) 87% returned to play Better results with thermal and repair than repair alone
      5 Ide et al. AJSM 2005 SLAP repair 19 pitchers 63% returned to previous level Results worse in baseball than other overhead athletes
      6 Neuman et al. AJSM 2011 SLAP Repair 30 overhead athletes ASES: 88, KJOC: 74 3.5-yr retro review survey
      7 Brockmeier et al. JBJS(Am) 2009 SLAP Repair 28 overhead athletes in larger series 71% return to throw Traumatic return to play higher (92%) than insidious (64%)
      8 Cohen et al. Sports Health 2011 SLAP repairs from larger group of pitchers 22 pro pitchers 32% return to play
      9 Neri et al. AJSM 2011 SLAP repair 23 elite throwers 57% returned to preinjury level, worse with RC tear KJOC score better than ASES in predicting outcome
      10 Park et al. AJSM 2013 SLAP repair 24 elite overhead athletes 78% return to preinjury level Only 38% return in baseball players


      image


    6. 1. Repair
    7. 2. Isolated biceps tenodesis

  5. • Given the important role in stabilizing the shoulder during pitch, concern remains regarding the effect this has on the throwing shoulder, despite becoming accepted treatment in many nonthrowers.


Surgical Anatomy



Surgical Indications



Surgical Technique Setup


Positioning





  1. • General anesthetic is administered with or without preoperative interscalene nerve block.
  2. • Examination under anesthesia is performed on both shoulders. Range of motion is recorded. Particularly close attention is paid to document objective signs of translation with anterior load and shift and posterior push-pull, as SLAP lesions may result in increased translation. Further attempt is made to detect and reproduce catching or clicking suggestive of mechanical block.

  3. image
    FIG. 54.2 (A) MRI diagnostic imaging with gadolinium enhances the identification of the superior labral anatomy (arrow) coronal view with a fat-suppressed T1-weighted image, intraarticular gadolinium. (B) A sublabral cyst (arrow) is often associated with a SLAP tear and sometimes with suprascapular nerve compression. It can be identified using a gadolinium-enhanced MRI study; axial view with a fat-suppressed T1-weighted image; intraarticular gadolinium. 
    From: Rapley JH, Barber AB. The shoulder: superior labrum anterior and posterior (SLAP) tears. Angelo RL, ed. AANA :177-187.

    Related posts:

    Patient Positioning and Anesthesia for Rotator Cuff Surgery Arthroscopic Trillat Procedure for Recurrent Anterior Shoulder Instability With Associated Irreparable Rotator Cuff Tear Nonoperative Care of Rotator Cuff Disorders: Physical Therapy, Modalities, and Injectables What Type of Rotator Cuff Tear Is This? Tear Pattern Recognition and Soft-Tissue Releases Subscapularis Tendon Tears: Arthroscopic Management Arthroscopic Rotator Cuff Repair: Double Row

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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Management of the Throwing Shoulder With a SLAP Tear

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