SLAP Repairs

W. Ben Kibler, MD

Dr. Kibler or an immediate family member serves as an unpaid consultant to Alignmed; has stock or stock options held in Alignmed; and serves as a board member, owner, officer, or committee member of the Arthroscopy Association of North America and the British Journal of Sports Medicine.

Introduction

Rehabilitation following superior labral anterior posterior (SLAP) repair is a key component to returning the patient to functional status. Since SLAP injuries are most frequently associated with multiple functional deficits in many areas of the kinetic chain, a comprehensive approach to evaluation and functional rehabilitation is needed. Although much of the focus of this chapter is directed to the treatment of the overhead throwing athlete, many of the principles of surgical repair and postoperative rehabilitation can be applied to other patients who undergo SLAP repair.

Relevant Anatomy and Patient Evaluation

The clinically significant SLAP injury is one in which the anatomic alteration in the labrum results in elements of the clinical history of the dysfunction that can be attributed to the loss of labral roles; the injury can be highlighted by specific physical examination tests that are clinically useful for detection of the injured labrum. It is a positive diagnosis, not a catch-all term in the presence of shoulder pain of unknown etiology in which the diagnosis is uncertain.

The history findings suggestive of loss of labral roles include pain upon external rotation/cocking, weakness in clinical or functional arm strength, symptoms of internal derangement (clicking, popping, catching, sliding), or decreased capsular tension, and a feeling of a “dead arm.” These are not exclusively seen in a labral injury, but point toward the loss of labral roles.

Kinetic chain deficits are discovered on examination in a majority of patients with SLAP injuries. Deficits in hip abductor or extensor strength, hip rotation flexibility, or core strength weakness have been identified in 50% of SLAP injuries, while scapular dyskinesis is seen in around 90% of patients with labral injuries. These alterations can be identified by specific screening examinations.

Labral examination tests can provide intra-articular clues to the presence of a labral injury. Of the labral examination tests, the modified dynamic labral shear (M-DLS) test has been shown to be of high clinical utility in the evaluation of labral injuries when the test is performed in the manner described. Other labral examination tests advocated include O’Brien’s active compression test; the relocation test, with pain as the indicator; and an anterior levering maneuver to place a posterior load and shear.

The labral injury can be confirmed by MRI, MRI arthrography, or CT arthrogram, but should not be defined by imaging. Specific criteria have been developed to distinguish a labral alteration, but MRI is best viewed as a static estimation of labral status with inconsistent relation to the dynamic roles. A percentage of patients will demonstrate “labral tears” without symptoms relating to loss of the labral roles. There is some evidence that rehabilitation can decrease symptoms and provide functional control in 40% to 50% of patients with SLAP injuries.

Surgical Procedures

Indications and Contraindications

There is continuing debate regarding which characteristics of the lesion and the patient should be considered as helpful criteria for surgical indications. Most papers suggest that SLAP tears classified as type I should not be repaired, and that types 2, 3, and 4 should be surgically addressed. However, there is a wide variability in the accuracy, reliability, and consistency of making the determination of the specific lesion type. Also, many papers recommend an upper age limitation, usually 40 years, for surgical repair, based on rates of stiffness and less successful outcomes, although no anatomic evidence supports this recommendation. Finally, most papers recommend that anticipated physical demands be considered since the importance of an intact labral complex to maximize joint concavity-compression is greater in patients with higher-demand activities such as overhead athletes or overhead workers. All of these factors should be considered in the
evaluation of the patient with a suspected clinically significant labral injury, but they should be evaluated with the rest of the clinical presentation.

Given these parameters, the indications for surgical repair of SLAP injuries include the proper history, a positive clinical examination for findings associated with a labral injury, and failure to respond to a rehabilitation program that addresses the deficits found on the examination. The findings of arthroscopic examination have a critically important role in the management of superior labral tears. The arthroscopic findings most frequently associated with a clinically significant labral injury include (1) a type II or higher lesion; (2) a peel-back phenomenon indicating labral detachment and increased compliance; (3) glenoid articular cartilage damage or chondromalacia; (4) loss of capsular tension indicated by a drive-through sign or loss of tension in the posterior band of the inferior glenohumeral ligament (PIGHL); (5) increased posterior labral thickness, indicating increased translation and shear with compression on the labrum; and/or (6) excessive posterior inferior capsular thickness and scar indicating end-stage capsular damage that helps create glenohumeral internal rotation deficit.

Figure 7.1 Arthroscopic view of left shoulder posterior superior labral injury.

Figure 7.2 Arthroscopic view of example of peel-back lesion with external rotation.

Contraindications for a SLAP repair include (1) lack of demonstrated clinical significance, by history and physical exam, in a patient with an MRI finding of labral injury; (2) repair at the same time as a capsular release for adhesive capsulitis; and (3) repair in the face of advanced arthrosis. In these cases, the symptoms and dysfunction are not due to the loss of labral roles and may lead to more dysfunction. Relative contraindications to SLAP repair are those that are associated with rotator cuff injury. SLAP injuries can be frequently seen in patients undergoing rotator cuff repair—the majority of these do not need to be treated, as they are usually degenerative. However, if the patients exhibit a positive M-DLS on preoperative examination, the SLAP injury probably does play a role in the clinical picture, and needs to be treated in conjunction with the rotator cuff injury.

Figure 7.3 Arthroscopic visualization of lack of PIGHL tension.

Procedure

The arthroscopic evaluation of the suspected labral injury must be specific in order to understand and treat the labral injury properly. Arthroscopic treatment guidelines for labral injury include (1) evaluation of the labral injury and mobility (Figure 7.1), peel-back (Figure 7.2), glenoid surface, and capsular tension (Figure 7.3) by direct visualization;
(2) preparation of the glenoid to maximize bone to labrum healing (Figure 7.4); (3) multiple anchor placement to secure at least 2-point fixation of the labrum on the posterior superior glenoid (12:30 and 1:30 on the left shoulder, a double-loaded single anchor is still only one point fixation; Figure 7.5); (4) placement of enough posterior superior anchors to eliminate the peel-back (Figure 7.6); (5) evaluation of biceps mobility after anchor and suture placement to make sure that there is adequate motion of the biceps in shoulder external rotation; (6) rare placement of anchors and sutures in the anterior superior glenoid (12:00–10:30 on the left shoulder) to reduce the chance of biceps tethering; (7) evaluating the effect of the labral repair on capsular tension by evaluation in the PIGHL tautness and elimination of the drive-through (Figure 7.7); (8) assessing total glenohumeral rotation to ensure that no external rotation has been lost; and (9) treatment of the associated pathology in the glenohumeral joint.

Figure 7.4 Arthroscopic view of bone preparation prior to labral repair.

Figure 7.5 Labral mobilization and suture passage

Figure 7.6 Arthroscopic view of completed superior labral repair. Note that anterior repair was also performed.

Figure 7.7 Establishment of tension in the PIGHL as a result of the labral repair

Postoperative Rehabilitation

The goals of postoperative therapy are to facilitate healing of the SLAP repair, while restoring shoulder and upper
extremity function through optimizing glenohumeral rotation, scapular stability and motion, local muscle strength and balance, and kinetic chain strength and flexibility (Table 7.1). Functional restoration may be initiated even while the repair is protected, starting with kinetic chain activation, progressing to scapular control, and then involving the glenohumeral rotation and strength.

Table 7.1 FUNCTIONAL REHABILITATION PARAMETERS

Kinetic Chain
1. Leg drive and lower extremity strength
2. Hip mobility
3. Proximal core stability
4. Dynamic core strength/power
5. Scapular stabilization
Shoulder Mobility
1. Restoring internal and external rotation deficits to achieve safe total ROM
2. Addressing joint restrictions in the spine and shoulder complex
3. Addressing muscular flexibility imbalances in the spine and scapula
Arm Strength and Endurance
1. Restoring scapular motor control for functional and pain-free motion
2. Facilitating inhibited or weak scapular musculature
3. Integrating scapular exercises with functional tasks
4. Facilitating endurance and eccentric control by advanced shoulder and scapular exercises
5. Strengthening forearm, wrist, and hand