Superior Labral Lesions Treatment & Management

Updated: Sep 14, 2020
  • Author: S Ashfaq Hasan, MD; Chief Editor: S Ashfaq Hasan, MD  more...
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Treatment

Approach Considerations

Surgical treatment of superior labral (labrum) lesions is indicated in patients who have persistent symptoms despite 3 months of nonoperative treatment. These patients should have the following:

  • Persistent posterior shoulder pain, with or without mechanical symptoms
  • Findings on physical examination consistent with a SLAP (superior labrum, anterior and posterior) lesion
  • Ideally, have supportive findings on magnetic resonance imaging (MRI)

It should be noted, however, that physical findings, as well as MRI findings, are often equivocal. If a high clinical suspicion exists, with the patient continuing to be symptomatic after an appropriate amount of conservative treatment, then strong consideration should be given to diagnostic arthroscopy.

In 2018, the National Athletic Trainers' Association (NATA) issued a position statement addressing the management of SLAP injuries in overhead athletes (see Guidelines). [49]

Future and controversies

There is a growing body of literature addressing the use of biceps tenodesis and labral debridement for unstable SLAP lesions as an alternative to arthroscopic labral repair. This is thought to be especially pertinent in patients older than 40 years, as well as those with an associated rotator cuff tear, but it has also been investigated in the athletically active population, in view of the high failure rate reported for arthroscopic superior labral repair in multiple studies.

Gottschalk et al reported their results for biceps tenodesis for isolated (no rotator cuff tears) type II or IV SLAP lesions in 26 patients (average age, 46.7 years). [50] They reported a significant improvement in ASES and VAS scores, with no significant difference based on SLAP lesion type, patient age, or patient sex. In all, 26 of 29 (89.66%) patients were able to return to their previous level of activity.

In a systematic review of the literature, Erickson et al investigated outcome of superior labral repair in patients older than 40 years. [51] They concluded that age greater than 40 years and workers' compensation status are independent risk factors for increased surgical complications and that the cumulative evidence supports labral debridement or biceps tenotomy over labral repair when an associated rotator cuff injury is present in that patient population.

Boileau et al compared arthroscopic repair of a type II superior labral tear with performance of a biceps tenodesis and concluded that the biceps tenodesis group had a higher postoperative Constant score and a significantly higher rate of return to a preoperative level of activity and sports participation. [52]  Thirteen (87%) of the 15 patients treated with a biceps tenodesis were able to fully resume sports participation, compared with only two (20%) of the 10 patients treated with SLAP repair.

These findings should be treated with caution, however. The overall number of patients in the study was small, and the demographic characteristics, as well as the activity levels, of the two groups were dissimilar, with the SLAP repair group consisting of 10 males with an average age of 37 years and the tenodesis group consisting of nine females and six males with an average age of 52 years.

In a systematic review and meta-analysis, Hurley et al reviewed the literature to compare the outcomes of biceps tenodesis with those of SLAP repair. [27] They found that biceps tenodesis resulted in higher rates of patient satisfaction and return to sports as compared with SLAP repair. They also found functional outcome scores to be similar regardless of technique.

The role of biceps tenodesis in the high-performance throwing athlete remains unclear, with most sports surgeons tending to be reluctant to perform a biceps tenodesis in that patient population because of uncertainty about the procedure's effect on throwing mechanics. 

Chalmers et al used surface electromyography (EMG) and motion analysis to compare alterations in pitching mechanics and motion in three groups—uninjured control subjects, patients treated with SLAP repair, and patients treated with subpectoral biceps tenodesis—and found that whereas both tenodesis and SLAP repair can restore physiologic neuromuscular control, SLAP repair may alter trunk biomechanics. [53]  However, in a study of return to sport in major league baseball (MLB) players after biceps tenodesis, Chalmers et al reported an 80% rate of return to sport for position players versus only 17% for pitchers. [54]

Taken together, these studies suggest that whereas biceps tenodesis may not affect pitching biomechanics, it may still have a significant effect on the ability to regain preinjury pitching effectiveness, perhaps secondary to loss of velocity and control. Thus, biceps tenodesis should be undertaken with caution in the throwing athlete, and it may be best reserved for cases where SLAP repair has failed or cases involving frank pathology of the long head of the biceps. 

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Medical Therapy

Initial treatment of suspected SLAP lesions should be nonoperative. The emphasis should be on rest, which means an initial period of no throwing in the overhead athlete. A course of nonsteroidal anti-inflammatory medication may be considered.

A physical therapy program consisting of posterior capsular stretching, as well as scapula stabilization and rotator-cuff strengthening, should be initiated. Capsular stretching, especially of the posteroinferior capsule, is important to help regain internal rotation. Stretches should include cross-body adduction stretches and the “sleeper” stretch.

Edwards et al reported on nonoperative management of type II lesions in a retrospective questionnaire-based study and showed that successful nonoperative management resulted in improved pain relief and functional outcomes as compared with pretreatment assessments. [55]

Failure to respond to conservative treatment after 3 months may indicate the need for operative fixation.

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Surgical Therapy

Initially, a complete diagnostic arthroscopy is performed. The rotator cuff should be carefully inspected for any partial- or full-thickness tears. The biceps anchor is inspected. Be aware of the potential normal variants (see Overview). Type III and type IV SLAP lesions are fairly obvious arthroscopically. The difficulty can sometimes come in differentiating a type I lesion from a type II lesion, as well as accurately diagnosing type II lesions and variants thereof.

Type I lesions are often associated with a meniscoid superior labrum where the lateral aspect is draped over the rim of the glenoid superiorly and the attachment is more peripheral. This particular morphology is more susceptible to developing degenerative tears, which is the pathology observed in type I lesions. Care must be taken not to assume that this meniscoid labrum represents a displaced type II lesion.

A probe is placed under the superior labrum, and a firm attachment is demonstrated. In inspecting the superior labral attachment, the key factor to evaluate is whether more than 5 mm of superior glenoid is exposed under the labrum. A superior sublabral recess is often observed and is a normal finding. However, if this recess is greater than 5 mm, the biceps anchor is highly likely to be unstable. [56, 57]

The superior labrum, both anterior and posterior to the biceps root, should be carefully probed. Placing the arm in approximately 70-90° of abduction and then progressively externally rotating the arm can demonstrate the peel-back sign, which is observed with type II posterior lesions, as well as with combined anterior and posterior type II lesions. If the biceps root at the level of the supraglenoid tubercle is uncovered with this maneuver, then the peel-back sign is positive and the superior labrum must be repaired. The peel-back sign is not usually observed with type II anterior SLAP lesions.

A positive drive-through sign where the arthroscope can be easily passed from the superior aspect of the joint to the inferior recess without any manual distraction can be observed with all three variants of type II SLAP lesions. This anterior pseudolaxity is usually resolved with repair of the SLAP lesion, and the drive-through sign is eliminated.

Surgical treatment of a type I lesion consists of debridement. Similarly, in a type III lesion, the bucket-handle tear of the meniscus can be debrided because the biceps anchor is usually intact. The labrum should, however, be carefully probed, and it should be repaired if it has an unstable attachment. In a type II lesion, the biceps anchor is repaired back down to the superior labrum with suture anchors.

In type IV lesions, if less than 30% of the tendon is involved and the biceps anchor is intact, then the involved labrum and tendon can be resected back to a stable rim. If more than 30% tendon involvement is noted in an older patient, a biceps tenodesis is prefered. In the younger, more active individual, suture repair of the tendon, along with suture anchor repair of the labrum, should be considered; however, severe biceps tendon tearing is best treated by tenodesis.

Various techniques have been described to repair the superior labrum arthroscopically. [58, 24, 59] These include the use of metal staples, metal screws, bioabsorbable tacks, and a transglenoid technique. Metal staples and screws require a second surgery for removal and are no longer used. Good results have been reported with the use of bioabsorbable tacks; however, concerns over potential particulate debris and foreign body reaction have led many surgeons to use suture anchors loaded with nonabsorbable suture.

Preparation for surgery

The procedure can be performed with interscalene block and intravenous sedation or with interscalene block and general endotracheal anesthesia. An examination with the patient under anesthesia is conducted to assess for any capsular contracture or instability. The patient may be placed in either the beach-chair or the lateral decubitus position, depending on the surgeon's preference.

Operative details

A standard posterior viewing portal is made. An anteroinferior portal is made just above the subscapularis tendon by means of an outside-in spinal needle localization technique. Similarly, an anterosuperior portal is made. The incision for this portal is just off the anterolateral corner of the acromion and enters the joint through the rotator interval laterally.

Cannulas are placed in both portals, with a large cannula placed in the anterosuperior portal. The area of labral detachment is debrided and any fibrous tissue is removed with a soft-tissue resector. The bone is then lightly decorticated with a burr. (See the images below.)

Area of labral detachment is debrided to expose a Area of labral detachment is debrided to expose a bony bed. The awl for the anchor is introduced either through the anterosuperior portal or can be introduced percutaneously from a posterolateral portal.
Bioabsorbable anchor double-loaded with nonabsorba Bioabsorbable anchor double-loaded with nonabsorbable number 2 suture is then implanted
The suture limbs are passed through the labrum. Ei The suture limbs are passed through the labrum. Either a simple or mattress stitch can be utilized. Various suture passing techniques can be used to accomplish this.
In a 1-anchor repair, 1 suture can passed through In a 1-anchor repair, 1 suture can passed through the labrum posterior to the biceps and the other anterior to the biceps and tied down. Multiple anchors should be used if necessary.

The instrumentation for anchor placement can then be introduced either though the cannula in the anterosuperior portal or percutaneously through the musculotendinous junction of the supraspinatus to form a posterolateral portal. Anchors placed at the biceps root or anterior to it can be inserted through the rotator interval portal. Anchors posterior to the biceps root are best placed in a percutaneous fashion through the port of Wilmington in order to achieve the best trajectory for anchor placement and minimize the risk of anchor perforation through the medial glenoid cortex, which could compromise anchor fixation and potentially injure the suprascapular nerve.

The number of suture anchors used depends on the extent of the tear. Either double- or single-loaded suture anchors may be used. Initially, the more posterior limb of one suture pair is retrieved into and out of the anteroinferior cannula. Various techniques are available by which this suture can then be passed through the labrum.

A common technique is to use a 45° suture lasso that is introduced through the anterosuperior cannula and through which a looped wire can be passed and retrieved through the anteroinferior cannula. The looped wire is then used to shuttle the limb of the suture, which now resides in the anteroinferior cannula, back through the labrum to create a simple stitch through the labrum. Alternatively, both limbs of the suture can be passed to create a mattress stitch.

An arthroscopic knot is tied after both limbs of the anchor suture have been retrieved into the anterosuperior cannula. Care is taken to orient the knot away from the articular surface. When passing the sutures through the labrum, it is important to avoid strangulating the biceps root.

If the anchor is double-loaded, the second suture is then passed through the labrum in a similar fashion and tied down. Knotless anchors with a self-capturing suture loop can also be used for the labral repair.

Ensure that the posterosuperior labrum is adequately stabilized in order to neutralize the peel-back forces. In introducing a posterosuperior anchor, as noted earlier, using a posterolateral portal is usually necessary because the posterosuperior glenoid has a steep angle that makes instrumentation from the more anterior portal difficult. This posterolateral portal can be made without a cannula by passing the sheath for the anchor instruments directly through the rotator cuff at the musculotendinous junction, medial to the rotator cable.

Single-portal SLAP lesion repair is described by Daluga and Daluga. [60]

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Postoperative Care

The patient is kept in a sling for 4 weeks. Codman exercises are initiated at week 2. Passive range-of-motion (ROM) exercises, including elevation and external rotation by the side, are also initiated at week 2. No external rotation in abduction is allowed for the first 6 weeks, because of the peel-back mechanism. ROM exercises, including passive posterior capsule and internal rotation stretching, are progressed during weeks 3-6.

At 6 weeks, progressive strengthening of the rotator cuff, scapula stabilizers, biceps, and the deltoid is initiated. Throwing athletes are allowed to begin an interval throwing program at 4 months. At 6 months, throwing from a mound is allowed. Pitchers may resume throwing at full velocity at 7 months postoperatively. Throughout the rehabilitation, as well as after, the patient should continue stretching the posteroinferior capsule daily. A recurrence of the capsular contracture can once again put the shoulder at risk for developing a SLAP lesion.

For nonathletes, the initial 4-month rehabilitation period is identical to that for throwers. At the 4-month mark, they can usually resume full activities.

In 2018, NATA issued a position statement addressing the outcomes of management of SLAP injuries in overhead athletes, along with return-to-play criteria (see Guidelines). [49]

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Complications

Neurologic injury is the most common complication reported after arthroscopic shoulder surgery. These complications can be minimized by careful attention to patient positioning, as well as a thorough knowledge of the neurovascular anatomy of the shoulder. When placing the patient in the beach-chair position, ensure that the head and neck are in a neutral position. Either hyperflexion or hyperextension could potentially lead to a neurologic injury.

Suprascapular nerve injury has been a rarely reported complication of superior labral repair. However, there has been a growing awareness of a possible relation between nerve injury and persistent postoperative pain and weakness after SLAP lesion repair. [61] Several cadaveric studies have investigated the risk of nerve injury during drilling and anchor insertion.

Koh et al placed an anchor for an anterior SLAP repair (00:30-1:00 o’clock in a right shoulder) via an anterosuperior portal in 12 cadaveric specimens and documented a 100% penetration of the medial glenoid cortex, with four of the 12 anchors directly contacting the suprascapular nerve. [62] The average tunnel depth was 14.2 mm, and the average distance from the tunnel exit to the suprascapular nerve was 7.8 mm.

Chan et al performed a similar study in 21 cadaveric specimens (42 paired bilateral shoulders). [63] They placed anchors at the 1-, 11-, and 9- to 10-o’clock positions (referencing a right shoulder), corresponding to anterosuperior, high posterosuperior, and low posterosuperior anchors, respectively. The anterosuperior anchor was placed via an anterosuperior portal, whereas the two anchors posterior to the biceps were placed through a posterolateral portal.

They documented a 29% (12/42) perforation rate in placing the anterosuperior anchor with a mean tunnel depth of 18 mm. [63] Only one perforation resulted in anchor contact with the suprascapular nerve. The low posterosuperior portal had only a 14% perforation (6/42); however, because of a short mean tunnel distance (11±5 mm), direct contact occurred with the suprascapular nerve in four (66%) of six perforations. Overall, a higher rate of penetration was noted in scapulae of a shorter height. Importantly, no perforations through the medial glenoid wall were noted for the high posterosuperior anchor.

In summary, there appears to be a risk of suprascapular nerve injury associated with drilling and placing anchors in the superior labrum. This may be of greatest concern when anchors are placed through an anterosuperior portal, especially if an attempt is made to place anchors posterior to the biceps through an anterosuperior portal. Anchors posterior to the biceps should be placed through a posterolateral portal.

In the aforementioned cadaveric studies, the bony tunnel length ranged from 5.5-20 mm and the distance from the tunnel exit point to the suprascapular nerve ranged from 4.9 to 11.2 mm. [63, 62] Given that most commercially available anchor systems require drilling to the depth of 18-20 mm and the anchor lengths range from 11 to 14.5 mm, it is certainly possible that both the drill bit and anchor may broach the medial glenoid cortex, increasing the risk of suprascapular nerve injury.

Further research to investigate the use of angled or curved drill guides to help improve tunnel trajectory and bony containment of the anchor, as well as the development of shorter drills and anchors, may be beneficial to minimize the risk of suprascapular nerve injury.

Articular cartilage injury is also of concern. When placing the suture anchors, ensure that the anchors are well seated below the subchondral bone. If the anchors are too prominent, they may cause a chondral injury. The sutures should be tugged on to ensure that the anchors are well seated. Anchor migration, apart from compromising the repair, can result in significant chondral injury.

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