Superior Labrum Lesions

United States statistics

Snyder et al reported the result of over 140 patients who were treated operatively for superior labral lesions.[3] 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 types 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 SLAP lesions were found without associated pathology.

Kim et al reported that of 544 shoulder arthroscopy procedures, 139 (26%) demonstrated a SLAP lesion.[4] Of the SLAP lesions, 103 (74%) were type I, 29 (21%) were type II, 1 (0.7%) was type III, and 6 (4%) were type IV. Most (123) of the SLAP lesions were found to be associated with other intra-articular lesions.

A study by Gaudelli et al reported that a type IV SLAP lesion can be expected in 22% of patients with recurrent shoulder instability.[5]

Kampa and Clasper evaluated the presentation and incidence of SLAP lesions in military and civilian populations.[6] Of 178 patients who underwent arthroscopy for complaints of either pain, instability, or pain and instability, 39 (22%) SLAP lesions were found. According to the Snyder classification (see Introduction, SLAP classification), 20.5% were type I, 69.3% were type II, 5.1% were type III, and 5.1% were type IV. The authors found that patients with a history of trauma or symptoms of instability were more likely to have a SLAP lesion than patients presenting with atraumatic etiologies. Military patients also had a higher incidence of these lesions relative to civilian patients.[7]

Collectively, these data suggest that patients who suffer traumatic injuries of the shoulder are at increased risk for sustaining an injury to the superior labrum, and that the severity of the resulting lesion is variable. Traumatic SLAP lesions are often associated with other intra-articular shoulder injuries, and the examining physician must have a high index of suspicion for coexisting pathology.

Grossly, the glenoid labrum surrounds the entire circumference of the glenoid surface. Moseley and Overgaard[8] in 1962 and Detrisac and Johnson[9] in 1986 described the labrum as a redundant fold of capsular (fibrous) tissue. Superiorly, the labrum is contiguous with the tendon insertion of the LHB as it attaches to the supraglenoid tubercle. The anterior labrum fibers may insert into the middle glenohumeral ligament (joint capsule). The superior labrum is more meniscuslike in structure because its fibers are loosely attached to the glenoid rim and may overlap the superior glenoid surface, whereas the inferior labrum is attached more tightly to the glenoid rim and is typically round in appearance.

The entire labral complex is attached at all points to either the bony glenoid rim or joint capsule about the glenoid, except in the anterosuperior margin. A sublabral foramen is present in most individuals; this labral foramen may be confused on MRI or at arthroscopy with a labral tear.

The Buford complex represents another anatomic variant and is described as a cordlike thickening of the middle glenohumeral ligament and absence of the anterosuperior labrum. This anatomic finding must be recognized as a normal variant because attempts to repair or debride this region may result in abnormal capsular constraint, shoulder stiffness, or glenohumeral instability. Interestingly, a retrospective review suggested that the presence of a Buford complex may correlate with the presence of a SLAP lesion in patients.[10]

Histology

Cooper et al examined the anatomy and histology of the glenoid labrum.[11] The authors noted an existing fibrocartilaginous transition zone at the superior glenoid margin between the fibrocartilaginous labrum and the hyaline cartilage of the glenoid surface. This study also confirmed the gross observation that the superior labrum fibers insert directly into the fibers of the LHB, distal to the biceps insertion into the supraglenoid tubercle. Histologic examination also revealed that the labrum consists of densely packed collagen bundles and fibrochondrocytes.

The primary labrum vascular supply originates from the suprascapular, circumflex scapular, and posterior humeral circumflex arteries. Only the periphery of the labrum appears to be vascularized, and no contribution to the labral blood supply is derived from the underlying bone. Prodromos et al observed that fetal and newborn shoulders possess an extensive blood supply throughout the labrum, whereas adult specimens have only sparse peripheral vasculature.[12] Apparently, labral vascularity, much like the meniscus, recedes with advanced age.

As previously mentioned, the LHB brachii muscle is also anatomically important in the discussion of SLAP lesions (see Introduction, Background). This LHB tendon arises from the supraglenoid tubercle, and fibers from the superior labrum attach to the biceps tendon in this region. Following the examination of over 100 cadaver specimens, Vangsness et al estimated that approximately 50% of the biceps tendon originates from the superior labrum.[13] The most common labral origin of the biceps is the posterior-superior region.

Long before the advent of shoulder arthroscopy, labral tears were described in association with anterior shoulder subluxation and dislocation, suggesting a role for the labrum in glenohumeral stability maintenance. McGlynn and Caspari described the intra-articular findings of subluxating shoulders noted at the time of arthroscopy.[14] As suggested by previous studies, fraying, tearing, or detachment of the glenoid labrum was a common finding in this group of 19 unstable shoulders.

In defining the relevant factors contributing to anterior shoulder stability, Turkel et al noted that the inferior glenohumeral ligament, which attaches to the glenoid via the labrum, is essential in preventing anterior shoulder instability.[15] The glenoid labrum increases the area and depth of the glenoid cavity, contributing to articular stability of the glenohumeral joint. The labrum has been suggested to act as a chock block to the humeral head as it attempts to translate anteriorly or posteriorly upon the glenoid surface.

Andrews et al demonstrated that superior labrum lesions were observed in a group of overhead throwing athletes who underwent arthroscopic examination of the shoulder.[1] On the basis of observed lesions in this group of athletes, the authors suggested that the biceps tendon is subjected to large forces during the act of throwing. Intraoperative stimulation of the biceps during arthroscopic shoulder surgery also revealed that the LHB tends to pull the labrum off the superior glenoid rim (especially in the presence of a SLAP lesion). Therefore, excessive forces generated by the biceps tendon during overhead throwing activities may lead to the generation of superior labral tears.

In a study from the University of Pittsburgh, Rodosky et al analyzed the role of the LHB and superior labrum in anterior shoulder instability.[16] A dynamic cadaveric shoulder model was used to simulate the forces of the late-cocking phase of the throwing motion. Strain gauges were placed in the inferior glenohumeral ligaments of 7 nonembalmed cadaver shoulders. Tests of anterior glenohumeral translation were made with and without the presence of superior labral lesions (analogous type II lesions). Varying forces were applied to the biceps tendon (0-100% extrapolated maximum force) in all tested specimens.

In normal shoulders (ie, no SLAP lesion), peak torque increased 22% and peak torsional rigidity increased 32% in shoulders with maximal biceps (loading versus unloaded shoulders).[16] In shoulders with a simulated SLAP lesion and no biceps loading, the observed peak torque was 12% lower than that of normal specimens, and a 120% increase in inferior glenohumeral ligament strain was observed. In shoulders with simulated SLAP lesions and 100% biceps loading, the observed peak torque was 7% lower than that of normal specimens. Torsional rigidity was also decreased by the creation of a SLAP lesion with and without biceps loading. In this study, torsional rigidity represented a measure of the tested shoulder to resist rotational forces.

In another study, Pagnani et al examined the effect of superior glenoid labrum lesions on glenohumeral translation.[17] In this cadaveric study, the investigators applied sequential anterior, posterior, superior, and inferior forces of 50 Newtons (N) to the proximal humerus. A 22-N compressive force was also applied. During the application of the described loads, a 55-N force was applied to the LHB tendon. The shoulders were tested in 7 positions of glenohumeral elevation and rotation. Each specimen was tested with a normal superior labral complex, a partial superior labral tear, and a complete tear (including the biceps insertion on the supraglenoid tubercle).

The authors found that a partial tear of the superior labrum had no significant effect upon superoinferior or anteroposterior translation[17] ; however, the creation of a complete SLAP lesion resulted in significant increases in anterior and inferior translation at all arm elevations. Increased glenohumeral translation persisted even after the application of a 55-N force to the biceps tendon. Pagnani et al suggested that the LHB tends to stabilize the joint by generating joint compressive forces and by acting as a physical restraint to translation.

These data suggest that in external rotation and abduction, the forces generated by the biceps muscle result in an increase in torsional rigidity. These findings suggest that increased loads applied to the biceps tendon may protect the shoulder from anterior subluxation during the throwing motion.

Related Medscape Reference topics:

Elbow and Forearm Overuse Injuries

Overuse Injury

Rotator Cuff Injury

Related Medscape topic:

Resource Center Exercise and Sports Medicine

In a series, Snyder et al reported that a compressive force or traction injury to the affected extremity was the most common mechanism of injury.[2]  However, in 21% of these patients, the etiology of the SLAP lesion was insidious. Moreover, most throwing athletes examined by Andrews et al did not report a distinct traumatic event.[1]  Thus, although an isolated injury may cause a labral injury, SLAP lesions may also occur as a result of the repetitive microtrauma that is associated with the overhead throwing motion.

Numerous authors have described a peel-back method for the development of SLAP II lesions. When the shoulder is in an abducted and externally rotated position, the biceps tendon is thought to assume a more vertical and posteriorly directed posture, which transmits a force to the superior labrum and causes it to peel off of the glenoid. Grossman et al supported this hypothesis in a cadaveric model.[18]  A contracted posterior capsule and resulting internal rotation deficiency, which is commonly observed in overhead throwing athletes, may translate the humeral head anteriorly, further aggravating the patient's symptoms.

Related Medscape Reference topics:

Elbow and Forearm Overuse Injuries

Overuse Injury

Rotator Cuff Injury

The initial evaluation of an individual with a suspected SLAP lesion should include a thorough review of the patient's activities, history of previous shoulder injuries, subsequent interventions, and aggravating factors. The majority of SLAP lesions occur in conjunction with other shoulder disorders, making the diagnosis difficult to establish.

Nonspecific shoulder pain with overhead or cross-body activities is the most common presenting symptom of patients with SLAP lesions. Reports of popping, clicking, or catching at the shoulder joint are common. Patients may describe a deep, vague pain within the shoulder joint in association with weakness or stiffness. Additionally, symptoms of instability may be present if the tear extends into the anterior ligament and labrum, resulting in a Bankart lesion.

The patient's history may reveal a traction injury or a direct blow to the shoulder area proper. A fall onto an outstretched arm may also cause a SLAP lesion. Compression (direct blow) injuries are most often traumatic in nature and can be sustained during a fall onto the affected extremity. Overhead throwing athletes may also be prone to the development of SLAP lesions because of the repetitive traction forces of the throwing motion. In many of these cases, no antecedent injury or activity is reported.

Patients suspected of having a labral tear or SLAP lesion should undergo a thorough physical examination of the cervical spine, shoulder girdle, and upper extremity.

The physical examination should assess range of motion (ROM), glenohumeral stability, muscular strength, and neurologic function. Unfortunately, no single physical sign or test is specific for the detection of a SLAP lesion, and a diagnosis based solely upon the patient's history and the physical examination findings remains difficult. Some studies have advocated certain maneuvers that, when considered with other diagnostic modalities (eg, history, imaging), may be highly suggestive of labral pathology.

Note that commonly performed diagnostic maneuvers often elicit positive findings in patients with superior labral tears; thus, attention to detail is necessary when documenting physical findings. Associated lesions (eg, rotator cuff tears, instability) may produce confusing signs during the physical examination; thus, the correlation of all findings with information from the history and imaging studies is recommended.

The Speed biceps tension test (also Speed's test, biceps tendon test) may be useful in detecting SLAP lesions. This test is performed with the patient's forearm in maximal supination and the elbow extended. Then, the examiner resists active glenohumeral flexion, which may result in pain in the patient when the biceps attachment site is injured or inflamed.

Field and Savoie described the compression rotation test wherein the patient is placed in a lateral position and the affected arm is held in 90° of abduction.[19]  Pain is noted with internal and external rotation of the arm.

The O'Brien active compression test (also O'Brien sign, active compression test) is often utilized to detect labral pathology.[20]  This maneuver is performed with the examiner standing behind the patient. The patient stands upright with the affected arm flexed 90° and adducted 15° medial to the sagittal plane of the body. With the arm internally rotated (thumb down), the examiner places a downward force on the arm. Pain is localized to the shoulder joint or acromioclavicular (AC) joint. The test is then repeated with the forearm in maximal supination. A positive test result is recorded when pain is decreased by the second maneuver. Superficial pain is correlated with AC joint pathology, whereas a deep pain or click is correlated with labral abnormalities in 94% of the patients studied.[20]

Kibler described the anterior slide test to help diagnose anterior SLAP lesions. The patient is instructed to place both hands on the hips.[21]  The examiner stabilizes the scapula of the affected side with one hand over the acromion. The other hand is used to axially load the humerus in the anterior and superior direction. Pain with this motion is considered to be a positive result for an anterior-based SLAP lesion.

Kim et al (2003) described the biceps load test II.[4]  With the patient supine, the affected arm is flexed to 120° and maximally externally rotated, with the elbow at 90° of flexion. If pain is elicited with resisted elbow flexion, the test finding is positive. The authors stated a sensitivity of 89.7% and specificity of 96.9% in detecting SLAP lesions.

In a study by Kim et al (2007), the authors described the passive compression test to assess for SLAP lesions.[22]  The patient is asked to lie down in a lateral position with the affected shoulder up and the physician standing behind the patient. The physician stabilizes the patient’s affected shoulder by holding the AC joint and controls the patient’s elbow with the other hand. The examiner rotates the patient’s shoulder externally with 30° of abduction and then pushes the arm proximally while extending the arm, which results in passive compression of the superior labrum onto the glenoid. The test finding is considered positive if pain or a painful click is elicited in the glenohumeral joint. The sensitivity of this test was reported to be 81.8%, and the specificity was 85.7%.

It should be noted that patients may also demonstrate a positive Neer (pain with passive forward elevation of the affected arm) or Hawkins sign (pain with passive internal rotation of the affected arm at 90° of flexion) in the presence of superior labral pathology.

Parentis et al completed a prospective study aimed at determining the most effective provocative maneuver with which to diagnose type I and II SLAP lesions.[23]  The 2 most sensitive tests for type II SLAP lesions were found to be the active compression (65.2%) and Hawkins test (65.2%). None of the sensitive tests was highly specific for type I or type II lesions.

Swaringen et al reported that electromyographic analysis of physical examination tests for type II SLAP lesions demonstrated that the active compression test and biceps tension test had significantly higher electromyographic signals relative to other tests, and consequently, maneuvers which maximize muscle activation transmitted through the LHB may be the best to identify type II SLAP lesions.[24]

Imaging studies included in the workup are as follows:

• Radiographic examination: Routine radiographic examination, including anteroposterior (neutral), axillary, and supraspinatus outlet views of the shoulder joint should be obtained for all patients with suspected shoulder pathology. Although these studies are typically unrevealing, other conditions (eg, glenohumeral arthritis, AC joint arthritis, humeral head migration) may be demonstrated on radiographs. Occasionally, a SLAP fracture or superior humeral head compression fracture may be evident.

• Magnetic resonance studies

  • MRI is routinely used as part of the initial workup in patients with suspected SLAP lesions; however, if the results of these studies remain inconclusive in the presence of strong historical and physical evidence that suggest labral pathology, magnetic resonance (MR) arthrography is considered.[25, 26]

  • Numerous authors have confirmed the utility of gadolinium-enhanced MR arthrography in the detection of labral lesions and injury to the LHB. The sensitivity of this method has been reported to be 82-96%, and the specificity is 91-98%.[27, 28]

  • Monu et al suggested that coronal images were the most effective in revealing labral lesions on MRI (as shown below).[27] MRI findings that suggest damage to the labrum or LHB tendon include the following:

    • High signal intensity at the labrum/anchor interface

    • Increased signal at the superior glenoid fossa

    • Displacement of the superior labrum away from the glenoid surface

    • Presence of a glenoid-labral cyst

      Coronal magnetic resonance arthrogram. This image demonstrates detachment of the superior glenoid labrum.

  • Although the presence of labral pathology can be delineated via MR arthrography, the precise classification of SLAP lesions utilizing this method remains less reliable.

  • Knowledge of normal variants of the anterosuperior labrum, such as a sublabral foramen or Buford complex, is essential because these findings can be misleading in the context of the MRI.

Rehabilitation Program

Physical Therapy

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.

Surgical Intervention

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.[29]

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.[30] 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.[31] 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.[19] 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.[32] 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.[3] 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.[3] 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.[33] 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.[34] 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.[35]

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.[36]

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[37] 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.[38] 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.[39] 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[40] : (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.

Simple mattress suture configuration with a single anchor. (Arthroscopy. 2007 Feb;23(2):135-40.)

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.

Recommended treatment

The notion proposed by Mileski and Snyder in 1998 regarding the ineffectiveness of conservative measures in SLAP lesion treatment is acceptable.[41] 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]

Arthroscopic placement of a suture anchor in the superior glenoid.

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.

Rehabilitation Program

Physical Therapy

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.

NATA Recommendations for Management of SLAP Lesions and Return to Play in Overhead Athletes

Management

In 2018, the National Athletic Trainers' Association (NATA) issued the following recommendations for management of SLAP (superior labrum, anterior and posterior) lesions in overhead athletes[46] :

• Patients with SLAP lesions should undergo 3-6 months of nonoperative management with the goals of decreasing pain, improving shoulder function, and returning to previous activity levels (grade B recommendation)
• Nonoperative management may include prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections to decrease pain and inflammation (grade C recommendation)
• Supervised rehabilitation should address deficits in shoulder internal rotation (IR), total arc of motion, and horizontal-adduction range of motion (ROM), as well as periscapular and glenohumeral muscle strength, endurance, and neuromuscular control (grade C recommendation)
• To be considered for surgical intervention, a patient with a SLAP lesion should have failed to improve after 3-6 months of nonoperative management, as signaled by inability to regain pain-free ROM and near-normal rotator cuff strength and return to the prior or desired activity level (grade B recommendation)
• Repair of a type II SLAP lesion at the biceps anchor can be considered in those with episodes of biceps-anchor instability, shoulder instability, or persistent pain with overhead activity (grade B recommendation)
• Debridement of the labrum is an option for type and select type III (bucket-handle) lesions; biceps tenodesis or tenotomy may be considered if the biceps is hypertrophied, frayed, or synovitic; repair of the SLAP tear with biceps tenodesis or tenotomy is a possibility for those with an unstable biceps anchor; biceps tenodesis or tenotomy is not typically advocated in baseball players or athletes younger than 18 years (grade C recommendation)
• Other surgical considerations include release of the posterior glenohumeral capsule ligament (if thickened and contractured) in addition to SLAP repair and debridement of a ganglion or paralabral cyst, with or without concurrent SLAP repair (grade C recommendation)
• During repair of a SLAP lesion in an overhead-throwing athlete, anchor placement should preserve the required external-rotation (ER) ROM in the abducted and externally rotated position (grade B recommendation)

Outcomes and return to play

NATA recommendations regarding return to play for overhead athletes treated for SLAP lesions include the following[46] :

• Patients undergoing surgical or nonsurgical management of SLAP lesions should be educated to expect a patient-rated outcome (PRO) of 85% of normal function at an average of 2-3 years (grade C recommendation)
• Patients should be informed to expect 80% satisfaction within 2-3 years of surgery; however, the level of satisfaction is lower for overhead athletes (67% excellent rating) (grade C recommendation)
• Patients should understand the need to regain 90% of ROM in order to return to full activities; however, limited evidence suggests that ROM deficits up to 15º may persist at 2 years (grade C recommendation)
• Before starting a sport-specific or interval return-to-sport program, patients should be educated to regain at least 70% of strength as compared with the uninvolved side (grade C recommendation)
• Patients should be informed that the criterion for return to sport is primarily time-based; guidelines suggest return to sport-specific training at around 4 months post surgery and progression to full activities over the following 2-3 months (grade C recommendation)
• Patients should be informed that after nonoperative management, the rate of return to sport is in the range of 40-95%; however, these rates are based on only two studies (grade C recommendation)
• Patients should be informed that regardless of the type of treatment provided, an average of 75% of patients with a SLAP tear (range, 20–94%) are able to resume some level of sport activity (grade C recommendation)
• Patient education after surgical intervention should include the fact that the rate of return to sport for overhead athletes is lower than that for nonoverhead athletes or nonathletes; whereas 55% of all athletes return to the same or higher level of sport activity and 31% return at a lower level of participation or with limitations, only 45% of overhead athletes return to the same or a higher level, 34% return at a lower level or with continued limitations, and 24% cannot return (grade C recommendation)
• Consistency in reporting PROs, the time and level of return to play, and the type of treatment used is recommended for adequate and accurate determination of the success of management

Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed to reduce pain and inflammation in both the preoperative and postoperative treatment of patients with labral pathology.

Related Medscape Reference topic:

Toxicity, Nonsteroidal Anti-inflammatory Agents

Class Summary

NSAIDs have analgesic and antipyretic activities. The exact mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions. Treatment of pain tends to be patient specific.

Naproxen sodium (Naprelan, Anaprox, Naprosyn)

Indicated for the relief of pain and inflammation that is associated with osteoarthritis, rheumatoid arthritis, bursitis, tendinitis, and acute trauma.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Most patients with repaired superior labral lesions can expect to return to sport following a 4- to 6-month postoperative rehabilitation period. Overhead athletes, such as swimmers or throwers, may require more dedicated time with physical therapy because the actions for their sports activities require highly conditioned rotator cuff and scapula-stabilizing muscle function.

A study on 34 elite athletes (8 volleyball, 8 football, 7 basketball, 4 tennis, 2 handball, 2 weight lifting, 1 swimming, 1 soccer, 1 arm wresting) by Beyzadeoglu et al found that the majority (88.2%) of professional athletes returned to their preinjury levels following arthroscopic surgery for common shoulder pathologies and SLAP lesions.[47]