Superior Labrum Lesions Treatment & Management
- Author: Riley J Williams, III, MD; Chief Editor: Craig C Young, MD more...
SLAP lesion rehabilitation requires a treatment plan that is adapted to the needs of the patient that enables the patient to return to his or her preinjury activity level. The extent of the lesion and any associated pathology guide the clinician in avoiding activities or positions that exacerbate the injury. In preparing a conservative treatment plan, therapy should focus on reducing pain and inflammation, restoring ROM, and strengthening scapulothoracic and glenohumeral musculature to improve static and active stability of the joint. Emphasize closed-chain exercises that strengthen the scapula and rotator cuff muscles.
Consider the biceps tendon carefully because it is often lifted off the glenoid in patients with SLAP lesions. The biceps has been shown to contribute to glenohumeral joint stability. The loss of the biceps’s stabilizing function must be compensated for in restoring shoulder function, while concurrently preventing further injury at the biceps tendon insertion. Avoid or carefully monitor exercises that stress the biceps tendon.
Most authors agree that conservative management of SLAP lesions is generally unsuccessful. Consequently, judicious use of operative intervention can aid the clinician in both establishing a diagnosis and administering effective treatment. The classification of SLAP lesions as described by Snyder et al (see Introduction, SLAP classification) is an arthroscopic classification. As such, shoulder arthroscopy is the mainstay of treatment for most patients with labral pathology. The type of pathology encountered at surgery determines the appropriate treatment of SLAP lesions.
Type I lesions should be treated with simple debridement. Care should be taken to avoid iatrogenic injury to the labrum or biceps anchor. Type II lesions should be debrided and then repaired utilizing arthroscopic suturing techniques. The primary goal of surgery for these lesions is firm reattachment of the biceps tendon to the superior glenoid rim. For type III lesions, the intervening bucket-handle tear of the labrum should be excised. The biceps anchor can then be probed to assess stability. An unstable biceps anchor should be repaired.
Management of type IV lesions is dependent upon the degree of tearing within the substance of the biceps tendon. The clinician must make a visual assessment of the amount of tendon that is affected by the SLAP lesion. If the SLAP lesion includes less than 30% of the substance of the tendon, then the biceps anchor is left intact and the affected portion of the tendon is resected. If the involved portion is greater than 30% of the tendon substance, age becomes a mitigating factor. In younger patients, thorough attempts to reattach the labrum and biceps tendon should be made. In older patients, labral debridement and biceps tenodesis are usually sufficient. All associated shoulder pathology should be addressed at the time of surgery (eg, rotator cuff lesions, subacromial impingement, AC joint degeneration, glenohumeral instability).
Please see our Quicktime movie, which illustrates the arthroscopic repair of a type II SLAP lesion.
Operative management results
Simple debridement of unstable SLAP lesions alone does not provide long-term satisfactory results. In a study by Cordasco et al, the authors demonstrated that only 63% of 27 patients with unstable SLAP lesions who underwent debridement alone had pain relief at 2 years. Moreover, only 45% of these patients were able to return to their previous level of activity. The presence of occult glenohumeral instability was determined to be the primary mode of failure in this patient group.
Yoneda et al described the use of a high profile staple to repair type II lesions in 10 cases. These staples required removal at 3-6 months, at which time complete healing was noted in 4 patients and superficial healing was noted in the remaining 6 patients. "Good" to "excellent" results were reported in 8 of 10 patients. Patients with impingement-type symptoms tended to report more satisfactory results than patients who were believed to have instability (eg, multidirectional instability).
In another study, Field et al described a method of SLAP lesion repair (type II and type IV) using a transosseous suture technique. The sutures were placed in the unstable labrum and anchored to the glenoid using drill holes in the glenoid neck, which exit at the infraspinatus fossa. Pain and functional scoring improved in all 20 patients at 12-42 months follow-up. All of the participating overhead throwing athletes (6 of 6) were able to return to throwing activities without loss of function or velocity. No complications from the technique were reported.
Resch et al reported the results of the titanium screw and bioabsorbable tack fixation of 14 of 18 SLAP lesions. Six lesions were repaired using a screw, which was removed at 3-5 months. The remaining 8 lesions were fixed using a bioabsorbable tack. At 6-30 month follow-up, 8 patients were able to return to unlimited activity. Four patients improved but had functioning at a level that did not approach their preinjury level. Two patients demonstrated no improvement. Of note, only 1 of 4 patients treated with debridement alone showed improvement at the latest follow-up examination.
In one of the largest case series, Snyder et al reported the results of over 140 patients treated operatively for superior labral complex lesions. As previously mentioned, the authors noted a 6% incidence of SLAP lesions in persons undergoing shoulder arthroscopy for all diagnoses over an 8-year period. The percentages of the type of SLAP lesions encountered were as follows: type I, 21%; type II, 55%; type III, 9%; type IV, 10%; and complex lesions, 5%. Associated lesions included Bankart lesions (22%) and lesions of the rotator cuff (11%). Only 28% of the SLAP lesions were found without associated pathology. Type I lesions were debrided. Type II lesions were debrided with abrasion of the underlying glenoid rim (± suture anchor repair). Type III and IV lesions were treated with debridement or suture repair, depending upon the extent of labral damage.
Repeat arthroscopy was performed on 18 shoulders. Three of 5 type II lesions healed with debridement and glenoid abrasion. Four of 5 type II and 2 of 2 type IV lesions, which were treated with an absorbable anchor, healed completely. Three type III and 1 type IV lesion, which were treated with debridement alone, had a normal appearing labrum at repeat arthroscopy. Finally, 2 complex type II and III lesions, which were treated with anchor fixation, were healed at follow-up examination. No clinical follow-up was reported on this series of patients; however, the authors reported detailed demographic data on the etiology of SLAP lesions in the studied group.
O'Brien et al reviewed the short-term follow-up (mean 3.7 years) of 31 patients who had undergone arthroscopic suture anchor repair of type II lesions through a trans–rotator cuff portal. The average L'Insalata score was 87.0 points, and the average American Shoulder and Elbow Surgeons score (ASES) was 87.2 points. Sixteen of the 31 patients returned to their preinjury level of sports, whereas 11 of the 31 patients returned to limited activity, and 2 patients were inactive at the time of follow-up.
In a review of 34 patients with isolated SLAP lesions that underwent arthroscopic repair with suture anchors, Kim et al (2002) found that 94% had a satisfactory result, and 91% returned to their preinjury level of shoulder function. Inferior results were noted in overhead throwing athletes compared with the remainder of the cohort. However, a subsequent retrospective study by Ide et al demonstrated "good" to "excellent" subjective results in 90% of overhead throwing athletes treated for type II SLAP tears.
The results of a prospective, double-blinded, randomized clinical trial suggest that patients who underwent repair of an isolated type II SLAP lesion through a single anterior portal realized similar clinical and functional outcomes whether a vertical or horizontal suture technique was used. Both techniques were shown to be comparably beneficial.
Recently, the treatment of type SLAP lesions in conjunction with other intra- and extraarticular shoulder pathology has been studied to determine the effect of combined interventions on functional outcome. Coleman et al retrospectively compared the short-term (mean 3.4 years) subjective outcomes of patients undergoing isolated type II SLAP repair with those undergoing combined SLAP repair and acromioplasty. Subjective scores were similar for both groups, with a higher percentage of "good" or "excellent" results in patients undergoing the combined procedure (81% vs 65%). Moreover, 21% of patients in the SLAP repair group had evidence of postoperative impingement, compared with none of the patients in the combined group.
The combined treatment of SLAP lesions and rotator cuff tears also appears to yield acceptable clinical results. Voos et al retrospectively reviewed the outcomes of 30 patients with combined labral and rotator cuff pathology. Arthroscopic treatment of both lesions resulted in significant improvements in ROM and L'Insalata and ASES scores. Twenty-seven (90%) of patients reported "good" or "excellent" results, whereas 23 of 30 (77%) returned to their preinjury level of activity.
Biomechanical and technical considerations
The biomechanical efficacy of suture anchor repair for type II SLAP lesions has been evaluated in 2 cadaveric investigations. Panossian et al studied the effects of type II slap lesions on glenohumeral rotation and translation before and following arthroscopic repair. In this model, creation of a type II SLAP lesion resulted in significant increases in total ROM, external rotation, internal rotation, anterior-posterior translation, and inferior translation. After arthroscopic repair, total ROM, internal rotation, external rotation, and translation significantly decreased, returning to baseline values.
Domb et al compared the biomechanical integrity of 3 commonly employed suture anchor configurations for the treatment of type II SLAP lesions : (1) single simple suture anterior to the biceps; (2) 2 simple sutures, 1 anterior and 1 posterior to the biceps; and (3) a single mattress suture through the biceps anchor, as illustrated below. Following cyclical traction applied to the biceps, the load to failure was greater with a single mattress suture through the biceps anchor as compared to 1 or 2 simple anchors around the labrum.
These cadaveric studies suggest that for type II lesions, suture anchor repair of the labrum appears to result in decreased glenohumeral translation, and that suture anchor configuration may play a role in overall strength of the repair. Corroboration with further biomechanical studies and clinical comparisons are needed to determine the relevance of these cadaveric studies.
The notion proposed by Mileski and Snyder in 1998 regarding the ineffectiveness of conservative measures in SLAP lesion treatment is acceptable. A short course (eg, 6-8 wk) of rehabilitation is not an unreasonable approach for recreational athletes or older, less active patients. Patients who respond to these measures may avoid surgery altogether. Unfortunately, pain and mechanical symptoms often persist despite aggressive rehabilitative measures in most young, active individuals.
The use of shoulder arthroscopy as a diagnostic and therapeutic tool is advocated. Patients who demonstrate symptoms and physical findings consistent with SLAP lesions but do not show a lesion on imaging studies may require shoulder arthroscopy to confirm the diagnosis. Once the presence of a SLAP lesion is confirmed, operative intervention can be pursued, depending upon the morphology of the lesion. For lesions that require fixation (ie, type II and some type IV), the use of bioabsorbable or metallic suture anchors is advocated. The use of suture anchors is now the gold standard as it provides an excellent approximation of the labrum to the bony glenoid and does not generate particulate wear (see the image below). However, suture management and anchor placement may present a challange. Simplified suture passing techniques and single-portal approaches may help to overcome these technical hurdles.[42, 43]
Newer methods of fixation that are being explored include knotless suture anchors and biodegradable tack fixation, which may prove easier, faster, and equally effective.[44, 45] However, further comparative studies are needed to evaluate these novel fixation methods. Overall, appropriate operative management of SLAP lesions gives both recreational and high-level overhead throwing athletes a reasonable opportunity to return to their preinjury activity level.
Phase I (immediate)
The shoulder is immobilized in a sling for approximately 3 weeks following surgery to protect the labral fixation and biceps tendon. Modalities (eg, cryotherapy, electrical stimulation) may be used as needed to reduce pain and inflammation. Gripping exercises and wrist and elbow active ROM (AROM) exercises may begin immediately. Controlled passive ROM (PROM) may be initiated during the first postoperative week. Passive exercises are performed in a supported position to avoid stress to the biceps tendon. Finally, submaximal pain-free deltoid isometrics may be initiated in a neutral position, as symptoms allow.
Phase II (weeks 3-6)
Sling use can be discontinued as tolerated. Active-assisted forward flexion may progress with the use of pulleys or the performance of wand exercises in a supine position. The time frame for initiating active-assisted external rotation is dictated by the patient and should be limited to 30° until 6 weeks. Reestablishing rotator cuff strength before initiating active elevation is important. The patient may initiate submaximal internal rotation and external rotation isometrics to begin strengthening the rotator cuff. Scapular strengthening can be initiated by using manual resistance and advancing to scapula elevation/depression and protraction/retraction ROM. Care should be taken to limit glenohumeral motion.
Phase III (weeks 6-8)
During this phase, active-assisted ROM (AAROM) is initiated for forward flexion and external rotation movements. Scapular strengthening is advanced, with an emphasis on closed-chain exercises. The patient may advance internal rotation and external rotation strengthening by using elastic resistance if adequate strength is present. When rotator cuff and scapular strength are sufficient, the patient may initiate active forward flexion in the scapular plane. Resistive shoulder extension is initiated if rotator cuff strength is adequate. Elastic resistance can be used to begin strengthening of the latissimus dorsi. Finally, upper body ergometry is introduced to begin to recondition the upper extremity. ROM is limited to 90° of flexion to avoid overly stressing the rotator cuff.
Phase IV (weeks 8-10)
Full shoulder ROM should be restored and some flexibility exercises can be incorporated with continued strengthening of the scapula, deltoid, triceps, and latissimus during this phase. Biceps strengthening can be initiated but should be monitored carefully.
Phase V (weeks 10-14)
Normal shoulder flexibility should be restored. Eccentric training should be emphasized in the athletic patient. Furthermore, endurance training should be initiated with the use of upper body ergometry, isokinetics, and neuromuscular drills. A plyometric program can be initiated if the patient is properly conditioned.
Phase VI (weeks 14+)
This phase includes returning the patient to a particular activity and maintaining upper extremity flexibility. Training principles should be incorporated into the strengthening program for the athletic patient. When applicable, extreme ROMs should be avoided. Furthermore, the asymptomatic patient who has a good strength base may advance to a gradual sport-specific interval program. During this program, care should be taken to advance activity gradually and avoid reinjury.
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