Good morning, thank you all very much for attention, as usual, excellent. So I was given an interesting talk here on what are slap tears and why is it not a slap tear. So go back, Steve, you know, your groundbreaking work on classifications. Talk with Steve yesterday, and this is kind of, I think I'm putting it into your right words, superior labrum, anterior-posterior to the biceps anchor that resulted in biceps instability. The treatment, therefore, would be stabilize the biceps anchor. He says 4% of the cases, I agree that it's a fairly rare problem. The question is, is that the problem we see in throwers, and that's what John Kelly asked me to talk about. Because if you look at, from that time as this has been brought forward as a paradigm of thought, is that there's really pretty much imprecision, inconsistency in the slap being able to tell the pathophysiology of how this injury that we see in throwers is produced. How can you evaluate this problem that this athlete brings to you and be accurate and reliable? How does this guide your treatment? And how does this correlate with outcomes? Unfortunately, at this point in time, it doesn't do that job. So we looked at this in two articles that we published in arthroscopy. First was on the diagnosis. It turns out that there's no consistency in the reported literature on how to make a diagnosis. There's a variation within the history, physical, imaging, and arthroscopic areas of making this diagnosis. It's mainly, from the literature, it's mainly a clinical impression. This guy's an athlete, and he's got pain in his shoulder, and therefore he has a slap lesion. The criteria were too individualized in terms of evaluation and who's making the diagnosis. So there was no consistency across the spectrum. When you looked at treatment, same thing. Wide variation in how they actually did the surgery. Where the anchors were placed. How many anchors were placed. But mainly, there was no indication of what they considered to be the criteria for complete repair. And just like Buddy said, if you don't know how to treat it to make it as close to normal as you can, then you're probably not doing the best job. So there's no consensus through the literature on what is an adequate label repair. And therefore, are these papers actually describing the same surgical technique? So I'm a member of ASES SLAP study group. Joe Eichinger is the chair of this. We have done a lot of work on this over the last two years. And we've done a literature review on the diagnosis of treatment. What is known, what is not known. And we are getting ready to produce a document with consensus recommendations and future directions for study of this problem in throwers. And we also have started a multi-center outcome study with specific criteria, treatment guidelines, and outcomes evaluation. So the question is, is the SLAP the real way? In the throwers, the significant injury is not anterior. It's usually not superior. It's mainly posterior, posterior inferior. And we know that if you over-constrained the biceps as part of this treatment, that you altered colorectal hemokinematics. And that's probably one of the main reasons. Also, we know that any way you look at it, the SLAP lesion on MRI is present in many asymptomatic athletes. And because that imaging is not specific for the actual clinical injury, there's a poor correlation of what you see on the imaging and any of your clinical exam tests. And Tony Romeo first told me this, you know, it went from nobody has a SLAP to everybody has a SLAP to nobody has a SLAP. And so the answer is somewhere in between. So the question our group came up with, is this the right description of the pathology and clinical presentation of this problem in the throwing athlete, in the overhead athlete? Does it describe pathology and physiology? Does it guide evaluation and does it guide treatment? And probably not, because it's not talking about what we're talking about. It's not the biceps at the superior part. It's the labrum around. So we came up with this term, clinically significant labral injury. And that means that this is an anatomic labral injury. It's either detached from the glenoid. It's split or it's in the end substance. It may occur lots of places around the glenoid, not superiorly and most of the time not anteriorly. But it has to be associated with clinical dysfunction. That's the point, that the labral injury has to be one of the reasons why the patient's in your office. It does result in loss of labral roles, therefore, and what's the labrum do? I'll show you in a minute, but it basically alters dynamic glenohumeral stability. And they have to have some specific history of physical findings to guide your thought process along that line. Image is confirmatory and there's special techniques that allow you to see the posterior labrum at a little bit better tangential view that will show this. And then you have to decide what are your specific arthroscopy findings that are going to say that this is something that you need to treat. So what are the labral roles and function? Very interesting, very good study by Greg Bain out of Australia, that the superior labrum is entirely different morphologically and anatomically than the inferior labrum. Inferior is very stiff, it's triangular, well attached to the glenoid, and it is there to counteract compression. So it works very well. However, the superior is rounded, more mobile, less firmly attached to the glenoid. So this is a picture that I think is very helpful. This is your left shoulder, there's your biceps, all the fibers, 95% of the fibers go into the posterior labrum. But right about at the mid glenoid right here, you see that the fibers start going, a large portion of the posterior and superior fibers run into the inferior band and the rest go into the glenoid. And this comment about instability, about making sure that posterior band is correct, that's one of the major influences of stability. The other thing is that this whole construct is situated so it becomes a tension band. As I was talking about the other day, this is a tension band, so you have to make sure that that has a capability of being a tension band to control the dynamic concavity compression in both cocking, but especially in a high velocity in the acceleration fall through. Therefore, the systole, the lesion, has to have a history, acute, acute and chronic, you lose function so that you can't throw, you have pain, you got hurt in certain positions, you got hurt back here. If it hurts out here, it may be labrum, but you got hurt where you're actually putting that dynamic load on there. There's internal derangement and then basically it shows that you have decreased concavity compression, sliding, popping, clicking, catching. The exam, there's a lot of things going on around the thrower, 50% in the hip, 94% in the scapula, 90% of rotational problems in the shoulder, and basically you then want to do your exam to see about the presence or absence of the labral lesion. Not that that's the only thing going on, there's a lot of things going on. We described this several years ago and Sean O'Driscoll showed it to me, I modified it by standing the patient rather than have him lay down, put your arm in 110 degrees of abduction, 90 degrees of external rotation in the plane of the scapula, and you put a downward motion to shear that internal impingement across the labrum. It's a level one study, when it's done correctly, it's written up in the AJSM, it does represent the labral peelback, high probability that there's actually an anatomic labral injury, but it's not the only surgical indication. So here's the statistics on it, very good specificity, accuracy, positive predictive value, high likelihood ratio. This is how you do it. They hurt right back where you put your scope, right in the posterior, right there, and it hurts right there as you bring it back down. You can stabilize the scapula in retraction, and by getting glenoid in a better position you can decrease the internal impingement, showing once again the scapula has a role to play in the production of the symptoms. Imaging, we came up with a way of looking at this, we call it an oblique axial, and what it does, it's a slightly different angulation of the beam, you can see the posterior glenoid much much better, see this is the same patient, there's the suggestion of the labral lesion there on this view, but if you see on this view right here, there's a little bit of a turn so you get a little bit more of a right angle, you see the huge amount of separation and delamination that goes on in these posterior labral injuries. In arthroscopy, we feel that this is the injury from extension of the superior labral injury. Superior labral injury is the price you pay to be able to get your arm back to throw. So it's either detachment, it can be an in substance delamination of flaps, and it has some involvement in the posterior band, and you lose your bumper, you lose your edge stability, therefore you lose your concavity compression. This is what it looks like on the right shoulder, you see there's the in substance and as well as the delamination, and it goes all the way down here to the 7 o'clock position, but this is interesting, here's your posterior band completely slack, this whole labrum has kind of fallen off the glenoid, so it's actually been pushed backwards. So you can go, here's a good view of this as opposed to another right shoulder posterior labrum, and you can see here's the in substance injury, and you see where the direction of the tear is going, into the posterior band, not into the inferior glenoid, and it goes all the way around, and it comes straight down into the posterior band, making the posterior band slack. It can go all the way up to the superior labrum, but once it goes all the way down into that area right there, you can fix it, and once again as you do that, you see that you develop posterior band stability by doing the posterior repair, and then you put the anchor right here, that's about as far as you need to go superiorly. Beware of the quote unquote failed slap repair, this is a picture from one of the literature, and you see there's that 12 o'clock suture and it's loose, there's your, as Craig Morgan calls the red brick trail, red trail right there just showing the problem, and here's an under repair, it had a 12 o'clock stitch, but here's the real problem, all the way posterior, so this quote unquote was a failed slap, it wasn't a failed slap, it was an inappropriately done slap repair, and therefore I don't think that's the right term to use. Summary, CSLI is a more appropriate term for throwers, it's more related to the symptom causing pathoanatomy and pathomechanics, there's a specific diagnosis process and criteria that you should use to demonstrate this in the throwers, and we're doing a prospective study for outcomes based on the criteria. Thank you very much.

slap tears

throwers

overhead athletes

diagnostic criteria

clinically significant labral injury