Rationale

The clinical presentation and evaluation of SLAP tears in overhead athletes can be highly variable. Physical examination and imaging studies may be inconsistent and unreliable for predictably diagnosing these injuries.

Clinical comment

Shoulder pain in the overhead throwing athlete may be difficult to isolate. Physical examination is important;¹,² however, it has questionable utility in reliably diagnosing SLAP tears.³–⁵ The role of advanced imaging may be limited by high false‐positive rates reported in asymptomatic overhead athletes⁶ and concomitant pathology frequently associated with SLAP tears.⁷ Accurate diagnosis is paramount prior to directing any surgical or nonsurgical treatment.

Available literature and quality of the evidence

Findings

We sought to evaluate the role of physical examination and advanced imaging in diagnosing SLAP tears in overhead athletes. Surprisingly, we were unable to identify a single study that exclusively evaluated solely symptomatic throwing athletes. Rather, all studies consisted of a heterogeneous population. The diagnosis of symptomatic SLAP tears in overhead athletes remains challenging given the striking inconsistency in evaluating and diagnosing SLAP tears coupled with the lack of literature evaluating exclusively overhead athletes.¹,²,²⁸

Among the available literature, the evidence evaluating the diagnosis of SLAP tears remains poor. Cook et al. concluded that neither a single exam in isolation nor a combination of exam findings provided any substantial value in diagnosing a SLAP tear.¹⁸ Similar results were reported by Oh et al.²⁵ and Michener et al.²¹ Several systematic reviews and meta‐analyses have demonstrated minimal clinical utility for physical exam findings in accurately diagnosing SLAP tears.¹⁹,²²–²⁴,²⁶,²⁷

For studies evaluating advanced imaging, several authors noted the superiority of MRA over conventional MRI for detecting SLAP tears.⁹–¹²,¹⁵ A meta‐analysis by Arirachakaran et al. evaluating over 2000 shoulders reported a sensitivity of 0.87 (95% confidence interval [CI]: 0.82–0.91), specificity of 0.92 (95% CI: 0.85–0.95) and a positive likelihood ratio of 10.28 (95% CI: 5.84–18.08) with MRA.¹¹ Other authors, such as Modi et al., have demonstrated improved diagnostic accuracy with abduction external rotation positioning of the arm during MRA.¹⁴

Resolution of clinical scenario

• Physical examination alone adds limited diagnostic value for detecting clinically relevant SLAP tears.
  
• Advanced imaging with MRA appears to be more reliable compared to noncontrast MRI for diagnosing SLAP tears. Positioning the arm in the abduction external rotation position may increase the diagnostic abilities of MRA.

Rationale

Reported outcomes following operative treatment of SLAP tears are highly variable and include heterogeneous patient populations and treatment techniques.²⁹–³¹

Clinical comment

SLAP tears can result in significant disability among overhead throwing athletes. Optimal treatment of SLAP tears in this patient population remains controversial.

Available literature and quality of the evidence

Findings

Overall, pooled RTP for an overhead athlete following operative treatment of SLAP tears was 56.5% (156/276, range 32–85%). Additionally, 7–64% of athletes were able to return to their prior performance (RTPP)/level of competition following operative intervention. Several authors evaluated RTP in baseball pitchers compared to position players.³⁵–³⁷

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