SLAP Lesions and the Biceps

INTRODUCTION

There is considerable controversy over the management of SLAP lesions and the biceps tendon. In recent years, the trend has been toward tenodesis as opposed to repair of Type II SLAP lesions based on more predictable outcomes and quicker recovery in most patients.¹ However, indications for repair of SLAP lesions remain, and the advent of knotless technology has facilitated lower profile, anatomic repair of these lesions.

In most cases, biceps tenodesis is preferable to tenotomy in order to preserve cosmesis and function. In our experience, a tenodesis at the articular margin of the humeral head is predictable with a low rate of complications and also provides the versatility of an anchor, which can also be used for rotator cuff repair.² For the most part, we limit subpectoral tenodesis to cases of acute rupture or the rare case (<1%) of persistent pain following a tenodesis at the top of the groove.

TYPE II SLAP LESIONS

Despite being described over 30 years ago, the definition of Type II SLAP lesions remains controversial. In Snyder’s initial classification of SLAP lesions, he stated that in Type II lesions: “The superior labrum and attached biceps tendon were stripped off the underlying glenoid, with the result that the labral-biceps anchor was unstable and arched away from the glenoid.” However, subsequent studies have demonstrated a poor intra- and interrater reliability for the classification of Type II SLAP lesions. This leads to the first conundrum of Type II SLAP lesions: the diagnosis.

Diagnosing Type II SLAP lesions involves a combination of history, physical exam, imaging, and arthroscopy. Unfortunately, no one tool stands on its own when it comes to diagnosing Type II SLAP lesions. While in rare cases a SLAP lesion will result from a trauma, the majority of cases are either attritional or degenerative. The former classically occur in the young overhead athlete who has no pain at rest but who has difficulty with overhead activities. Specifically, these patients frequently report pain in the abducted and maximally externally rotated position (e.g., late cocking phase of throwing). Degenerative lesions, on the other hand, typically occur in older patients. Many are associated with rotator cuff lesions and are noted at the time of arthroscopy. On physical exam, the most reliable test is the O’Driscoll or dynamic labral shear test. Additionally, younger patients with an attritional etiology often have posterior shoulder pain in the apprehension position, which is reduced with a relocation maneuver. We find MRI or MR arthrogram useful for diagnosing isolated lesions, particularly in younger patients. However, in older patients (i.e., >50 years old), the MRI cannot be depended upon since the majority of people of this age in the normal population have some degree of degenerative signal in the superior labrum. While all of these factors must be considered, the most important tool for the diagnosis of Type II SLAP lesions remains arthroscopy. We base the diagnosis of a Type II SLAP lesion on arthroscopy and use five specific findings:

1. Drive-through sign

2. Superior sublabral sulcus >5 mm

3. Bare sublabral footprint

4. Displaceable biceps root

5. Positive peel-back sign (in overhead athletes)

The next major conundrum for Type II SLAP lesion is whether to repair the lesion or perform a primary biceps tenodesis. Our treatment algorithm is based on patient age, patient activity, and associated lesions. We previously reported that age ≥40 years and workers’ compensation status are risk factors for long-term failure following repair of Type II SLAP lesions.³ In another study, we found that biceps tenodesis led to a more predictable functional outcome and quicker recovery compared to repair of a Type II SLAP lesion in patients >35 years of age.¹ Based on these studies, as a general rule, we perform a primary biceps tenodesis for Type II SLAP lesions in patients over the age of 35. This age cutoff also tends to correspond with the different etiologies with younger patients more typically being overhead athletes with attritional lesions that warrant repair, whereas older patients typically have degenerative lesions with lower activity demands and decreased healing potential. Exceptions to these rules include patients with concomitant instability and associated spinoglenoid cysts. For instance, since the superior labrum contributes to glenohumeral stability, we typically repair a Type II SLAP lesion in a patient with anterior instability and a Bankart tear. Additionally, in the setting of a spinoglenoid cyst that requires decompression, we believe the superior labrum should always be repaired. In this setting, the labral tear allows the creation of a one-way valve that can lead to a large cyst and compression of the suprascapular nerve. Therefore, in addition to decompressing the cyst (done arthroscopically by elevating the labrum), the labrum should be repaired to seal the one-way valve.

FIGURE 4-1 Schematic diagram of anchor placement for SLAP repair. A: Anchors placed posterior to the biceps tendon via an anterosuperolateral (ASL) portal risk injury to the suprascapular nerve (SSN). B: The same anchor placed via a Port of Wilmington (PW) portal directs the anchor toward the coracoid base and avoids the suprascapular nerve.

The next conundrum with regard to Type II SLAP lesions is whether or not to repair the superior labrum following biceps tenodesis. In the vast majority of cases, we do not repair the superior labrum following biceps tenodesis since the evidence does not support the need for concomitant repair. Uncommon exceptions include patients with instability or a spinoglenoid cyst and extensive labral tearing. In these circumstances, both pathologies need to be addressed separately.

When the decision is made to repair the superior labrum, either a knotted or a knotless technique may be used. While historically we used a knotted technique, we now prefer a knotless technique in most cases because it provides a low-profile repair and avoids the potential for knot impingement or migration. Anchor placement and the number of anchors used are based on the extent of the tear. We most frequently place anchors only posterior to the biceps tendon, but will also repair the superior labrum anterior to the biceps if it is torn as well. Anchor placement may be performed via an anterosuperolateral portal or a Port of Wilmington portal. For anchors placed posterior to the biceps tendon, particularly those placed posterior to the 11 o’clock position on a right shoulder, we prefer a percutaneous approach (percutaneous insertion kit) via a Port of Wilmington portal. For these anchors, this portal directs the anchor toward the base of the coracoid and avoids the potential for iatrogenic suprascapular nerve injury (Fig. 4-1).

History:

A 29-year-old man has pain after a fall on an outstretched arm.

Physical Exam:

Normal range of motion and strength
Positive O’Driscoll maneuver (Mayo shear sign)

Imaging:

Plain radiographs are normal.
MRI demonstrates a possible SLAP tear.

Arthroscopy Findings:

A Type II SLAP tear is noted and repaired with a single knotless 2.9-mm BioComposite PushLock anchor and LabralTape (Fig. 4-2).

Pearls, Pitfalls, and Decision-Making:

This tear is an indication for repair based on the traumatic origin and the patient age of 29 (<35 years of age).
In most cases, anchor placement posterior to the biceps is most safely performed with a percutaneous approach using a Port of Wilmington portal.
LabralTape and a PushLock (Arthrex, Inc.; Naples, FL) anchor provide a low-profile, knotless repair.

FIGURE 4-2 Right shoulder, posterior viewing portal demonstrates (A) a posterior Type II SLAP tear followed by (B) a completed repair. G, glenoid; BT, biceps tendon.

History:

A 32-year-old man has persistent posterior shoulder pain 2 years after an arthroscopic acromioplasty performed elsewhere.

Physical Exam:

Mild atrophy of the infraspinatus fossa
Normal range of motion
Weakness in external rotation with the arm at the side

Imaging:

Plain radiographs are normal.
MRI demonstrates a large spinoglenoid cyst with mild infraspinatus atrophy (Fig. 4-3).
The presence of the cyst was confirmed on the MRI prior to the initial surgery as well.

Arthroscopy Findings:

Fissuring of the posterosuperior labrum is noted.
The labrum was elevated and a large bloody spinoglenoid cyst was evacuated.
The labral tear was repaired with a knotless technique using LabralTape and two 2.9-mm BioComposite PushLock anchors placed through a percutaneous Port of Wilmington portal (Fig. 4-4).

FIGURE 4-3 Preoperative MRI of a left shoulder. Axial (A) and sagittal (B) T2 images demonstrate a large spinoglenoid cyst. (C) Sagittal T1 image located medial to the spinoglenoid cyst demonstrates slight atrophy of the infraspinatus consistent with entrapment of the suprascapular nerve by the spinoglenoid cyst.

Pearls, Pitfalls, and Decision-Making:

The failure to decompress the spinoglenoid cyst at the initial surgery led to persistent pain and weakness for this individual.
Posterior SLAP tears associated with a spinoglenoid cyst are often subtle, but the cyst cannot occur without a labral tear.
Identification of the cyst requires close arthroscopic assessment and correlation with location on MRI.
For placement of anchors posterior to the biceps tendon, a Port of Wilmington portal provides the safest angle of approach.
A knotless technique for SLAP repair in this location is facilitated by a percutaneous kit.

History:

A 39-year-old man has 9 months of shoulder pain while throwing.

Physical Exam:

Normal range of motion and strength
Positive O’Driscoll maneuver (Mayo shear sign)

FIGURE 4-4 Left shoulder posterior glenohumeral viewing portal demonstrates a knotless labral repair after a spinoglenoid cyst decompression. H, humeral head; G, glenoid; BT, biceps tendon.

Imaging:

Plain radiographs are normal.
MRI demonstrates bursitis and a possible SLAP tear.

Arthroscopy Findings:

A degenerative SLAP tear was noted and treated with an arthroscopic tenodesis adjacent to the articular margin (Fig. 4-5).
The rotator cuff was intact.
There was substantial bursitis and a subacromial decompression was performed.

FIGURE 4-5 Right shoulder, posterior viewing portal demonstrates (A) a degenerative SLAP tear with a displaceable biceps root, followed by (B) a completed biceps tenodesis (asterisk at tenodesed biceps). G, glenoid; BT, biceps tendon.

Pearls, Pitfalls, and Decision-Making:

SLAP tears in patients over the age of 35 are most predictably managed with biceps tenodesis as opposed to SLAP repair.
When performing tenodesis with an interference screw, it is important to prepare the biceps tendon toward the beginning of the procedure in order to maximize the ability to exteriorize the tendon.
Visualization of the bicipital groove during the procedure is maximized with a 70° arthroscope.

History:

A 44-year-old male with persistent pain and mild weakness in his right dominant shoulder for 9 months
The patient is very active with weight lifting, ice hockey, and golf.
The patient stated he is limiting his activities due to the pain.
Physical therapy for 2 months and two cortisone injections failed to relieve his symptoms.

Physical Exam:

Range of Motion:
- Full active and passive right shoulder motion except slight restriction in internal rotation compared to the other shoulder
Strength:
- 4/5 strength with resisted elevation and external rotation
- 4+/5 internal rotation strength
Special Tests:
- Pain with palpation anterior shoulder
- Pain with Neer impingement test
- Pain and weakness with supraspinatus test
- Mild pain with bear hug test (however no weakness)
- Pain with Speed and O’Brien tests

FIGURE 4-6 Right shoulder, posterior viewing portal a probe is being used to demonstrate a Type II SLAP tear. G, glenoid.

Imaging:

Plain radiographs were unremarkable.
MR arthrogram revealed a Type II SLAP tear and a suspected supraspinatus PASTA.

FIGURE 4-7 Right shoulder, posterior viewing portal. A Penetrator (Arthrex, Inc., Naples, FL) suture passer is creating a half-racking stitch around the biceps tendon (BT) with a No. 2 TigerWire (Arthrex, Inc., Naples, FL) suture. H, humeral head; SSc, subscapularis tendon.

FIGURE 4-8 Right shoulder, outside view of the same patient after the biceps tendon (BT) was exteriorized and a whipstitch with No. 2 FiberWire was passed four to five times down each side of the tendon.

Arthroscopy Findings:

Arthroscopic evaluation revealed a PASTA of the anterior supraspinatus tendon and a Type II SLAP tear (Fig. 4-6).
A half-racking stitch with a No. 2 FiberWire (Arthrex, Inc., Naples, FL) suture was placed around the biceps tendon to gain control of the biceps tendon prior to a tenotomy (Fig. 4-7).
After the biceps tenotomy, the biceps tendon was exteriorized, and a whipstitch with No. 2 FiberWire was passed four to five times down each side of the tendon (Fig. 4-8).
A reamer was used to create a pilot hole at the top of the biceps groove slightly over to the anteromedial location of the greater tuberosity (Fig. 4-9).
The No. 2 FiberWire whipstitch sutures were placed through the eyelet of the BioComposite SwiveLock Tenodesis (Arthrex, Inc., Naples, FL) anchor, and the tendon and anchor were secured into place (Fig. 4-10).
After completion of the biceps tenodesis, the FiberWire sutures from the anchor were passed through the anterior supraspinatus and the tendon was repaired (Fig. 4-11).

FIGURE 4-9 Right shoulder, posterior viewing portal demonstrating a pilot head reamer inside a clear 8.25-mm Twist-In Cannula (Arthrex, Inc., Naples, FL). Notice the biceps tendon (BT) is behind and protected by the hard cannula. H, humeral head.

FIGURE 4-10 Right shoulder, posterior viewing portal the No. 2 FiberWire whipstitch sutures were placed through the eyelet of the BioComposite SwiveLock Tenodesis (Arthrex, Inc., Naples, FL) anchor and the biceps tendon (BT) and anchor were secured into place.

FIGURE 4-11 Right shoulder, posterior viewing portal after the biceps tenodesis (BT) was completed. The No. 2 FiberWire (Arthrex, Inc., Naples, FL) sutures from the biceps tenodesis anchor were then passed through the overlying tendon and the supraspinatus repair was completed. H, humeral head.

Pearls, Pitfalls, and Decision-Making:

Patients over the age of 40 with a Type II SLAP and a concomitant rotator cuff tear will often benefit more from a biceps tenodesis than an in situ superior labral repair.
We will combine a biceps tenodesis with a superior labral repair if the patient has a Type II SLAP tear with an associated paralabral cyst that is pressing on the suprascapular nerve.
The sutures from a proximal biceps tenodesis anchor can often be incorporated into a subscapularis or supraspinatus repair if necessary.

History:

A 44-year-old man who slipped on a boat dock and jammed his left shoulder
Persistent left shoulder pain, unresponsive to nonoperative management

Physical Exam:

Positive O’Driscoll test (Mayo Shear)
Positive O’Brien test

Imaging:

X-rays were normal.
MRI showed a degenerative Type 2 SLAP lesion.

Arthroscopic Findings:

Degenerative SLAP lesion was observed.
Arthroscopic biceps tenodesis was done at the top of the bicipital groove with a BioComposite SwiveLock Tenodesis Screw (Arthrex, Inc.; Naples, FL) (Fig. 4-12).

Pearls, Pitfalls, and Decision-Making:

The SwiveLock Tenodesis Screw is a versatile implant that can be used either for isolated biceps tenodesis or for biceps tenodesis combined with rotator cuff tear. In using this implant, the sutures from the biceps whipstitch are passed through the eyelet of the SwiveLock and tensioned as the eyelet is brought to the cut edge of the tendon to lead it into the bone socket (Fig. 4-13).

FIGURE 4-12 Left shoulder, posterior viewing portal with 70° arthroscope. BioComposite Tenodesis Screw is being inserted alongside biceps tendon.

History:

A 32-year-old left hand-dominant woman had the insidious onset of posterior shoulder pain over 4 months.
A guided intra-articular injection and physical therapy did not provide any relief.
She was unable to carry her children, play tennis, or sleep because of the pain.

FIGURE 4-13 Left shoulder, posterior viewing portal. Whipstitch sutures are tensioned in order to keep the biceps tendon against the eyelet of the anchor as the anchor eyelet and inserter pull the tendon into the bone socket.

FIGURE 4-14 Axial (A) and coronal (B) T2 MRI show the paralabral cyst and SLAP tear.

Physical Exam:

Left shoulder had full active range of motion (forward elevation 170°, ER 60°, IR T7).
Strength was 5/5 in abduction, internal and external rotation.
Dynamic labral shear test and O’Brien tests were positive.

Imaging:

X-rays of the shoulder were unremarkable. MRI arthrogram demonstrated a SLAP tear from 11 to 2 o’clock with a contrast-filled anterior paralabral cyst (Fig. 4-14).

FIGURE 4-15 Type 2 SLAP tear demonstrates discontinuity of the biceps insertion into the supraglenoid tubercle (displaceable biceps root).

Arthroscopy Findings:

An anterosuperior Type 2 SLAP tear was present (Fig. 4-15).
A paralabral hemorrhagic cyst was found superior to the biceps root (Fig. 4-16).

Pearls, Pitfalls, and Decision-Making:

For most patients over 30 to 35 years of age who are not throwing athletes, biceps tenodesis would be our treatment of choice for a SLAP tear such as in this case.
When a paralabral cyst is present, we consider cyst decompression and labral repair (Fig. 4-17) to be necessary to fully address the pathology.
In this case, we chose BioComposite 3.0-mm Knotless SutureTak anchors (Arthrex, Naples, FL) to avoid any potential complications from knots in this area (Fig. 4-18).

FIGURE 4-16 An uncommon hemorrhagic paralabral cyst (A) was found adjacent to the SLAP tear. A spinal needle was used to puncture the cyst (B) prior to decompression with a shaver.