Superior Labral Tears and Throwing Shoulder Injuries


127 Superior Labral Tears and Throwing Shoulder Injuries


Michael T. Freehill MD1, Jacob M. Kirsch MD2, Hiroyuki Sugaya MD3, and Jon J. P. Warner MD4


1 Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA


2 Boston Sports & Shoulder Center, Waltham, MA, USA


3 Funabashi Orthopaedic Sports Medicine Center, Funabashi, Chiba, Japan


4 Massachusetts General Hospital, Boston, MA, USA


Clinical scenario



  • A 25‐year‐old baseball pitcher has several months of atraumatic shoulder pain in his dominant arm.
  • He has decreased throwing velocity and ability locating pitches. He also reports occasional “popping” and “clicking” in his shoulder while throwing.
  • On examination, he has a positive O’Brien’s, Biceps Load II and modified Dynamic Labral Shear test. Magnetic resonance arthrogram (MRA) demonstrates increased signal in the superior labrum.

Top three questions



  1. In overhead throwing athletes, how reliable is the physical exam compared to imaging studies in the diagnosis of symptomatic superior labral tear anterior to posterior (SLAP) tears?
  2. In overhead throwing athletes with symptomatic SLAP tears, does primary operative intervention result in improved return to play (RTP) compared to nonoperative treatment?
  3. Are overhead nonthrowing athletes better able to return to competition following surgical treatment of SLAP tears compared to overhead throwing athletes?

Question 1: In overhead throwing athletes, how reliable is the physical exam compared to imaging studies in the diagnosis of symptomatic superior labral tear anterior to posterior (SLAP) tears?


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.35 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


Imaging



  • Level I: 1 study8
  • Level II: 2 studies9,10
  • Level III: 6 studies1116
  • Unassigned level of evidence: 1 study.17

Physical exam



  • Level I: 1 study18
  • Level II: 3 studies1921
  • Level III: 4 studies.2225
  • Unassigned level of evidence: 2 studies.26,27

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.19,2224,26,27


For studies evaluating advanced imaging, several authors noted the superiority of MRA over conventional MRI for detecting SLAP tears.912,15 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.

Question 2: In overhead throwing athletes with symptomatic SLAP tears, does primary operative intervention result in improved return to play (RTP) compared to nonoperative treatment?


Rationale


Reported outcomes following operative treatment of SLAP tears are highly variable and include heterogeneous patient populations and treatment techniques.2931


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


Operative



  • Level III: 2 studies32,33
  • Level IV: 5 studies.3438

Nonoperative



  • Level IV: 1 study.35

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.3537

Only gold members can continue reading. Log In or Register to continue

Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Superior Labral Tears and Throwing Shoulder Injuries
Premium Wordpress Themes by UFO Themes