I'm going to be speaking about SLAP lesions, current indications, do's and don'ts of fixation. These are my disclosures, none of which are directly relevant to this talk. As an overview, I'm going to touch a little bit on the anatomy of the labrum and then discuss the classification of SLAP tears, how we diagnose these injuries, and then really focus on treatment options and end by reviewing a couple of surgical techniques. The labrum is a critical structure as it increases the surface area of the glenoid articulation and serves as the attachment site of the long head of the biceps. The superior, middle, and inferior glenohumeral ligaments are continuous with the labrum. There are three zones of the biceps labrum complex. The first is the biceps anchor itself, and that's the attachment site of the long head of the biceps tendon onto the superior labrum and the supraglenoid tubercle. The junction is the intra-articular portion of the tendon and its stabilizing pulley, whereas the bicipital tunnel is the extra-articular portion of the long head of the biceps and it's fully enclosed by a fibroosseous sheath. This extends from the articular border to the subpec region. The labrum does serve an important function, so an intact labrum improves joint stability by the concavity compression mechanism and by increasing the effective diameter of the glenoid. The long head of the biceps serves as a humeral head depressor and it provides anterior stabilization versus translation and limits external rotation of the glenohumeral joint in the abducted and externally rotated arm. In the presence of a superior labral tear, the glenohumeral joint is less able to withstand the external rotation forces in that abducted and externally rotated position. The excessive stress on the inferior glenohumeral ligament then leads to anterior instability. Now, in terms of classifying slap tears, these were first described by Snyder as types 1 through 4. Type 1 is a degenerative tear where the labrum and the biceps are still actually attached to the glenoid. Type 2 is the most common type of slap tear, and that is where there's fraying and the labrum and the biceps are actually physically detached from the superior glenoid. Type 3 involves a bucket handle lesion of the superior labrum and type 4 is a bucket handle with extension into the biceps. These are some pictures demonstrating these four types of slap tears. The top left is type 1, top right is type 2. On the bottom left, you see that bucket handle tear, which is a type 3, and the bottom right is a bucket handle with extension into the biceps, which is a type 4 slap tear. For diagnosing slap lesions, these often affect athletes in repetitive overhead sports like baseball, softball, tennis. The clinical diagnosis of slap lesions can be difficult because there's often a lot of associated pathology. Slap tears are commonly associated with Bankart lesions, cuff tears, and impingement. Slap tears usually result from a fall on an outstretched hand. We also see this though with repetitive overhead activities that require shoulder abduction and end-range external rotation. We also know the peelback mechanism involves abduction and external rotation. The rotational force at the biceps tendon, that leads to rotational force at the biceps tendon. Then a torsional force is transmitted through the tendon and leads to peeling back of the posterior labrum from the glenoid. Patients with slap tears often complain of anterior shoulder pain. They may also describe painful clicking or popping, especially during the cocking phase of throwing. They also note a gradual loss of throwing function, overhead motion, and throwing velocity. There are several clinical tests that we can use to help diagnose slap tears, some of which are listed here. I'm going to demonstrate a couple of these in the subsequent slides. O'Brien's test is when the shoulder is held at 90 degrees of flexion, 10 degrees of adduction, and maximal internal rotation with the elbow in full extension. As we're aware, the examiner then pushes down and asks the patient to resist that. A test is considered positive when there is pain over the anterior aspect of the shoulder in this position. The pain is often alleviated completely or at least decreased when this test is performed with the thumb pointing up. There's also the dynamic labral shear test, which is demonstrated in this video. The patient is sitting with the arm abducted to 90 degrees and the elbow is flexed to 90 degrees. The examiner then applies a gentle anteriorly directed force and brings the arm to about 150 degrees of abduction. A positive test is when there is deep or posterior pain that's produced at about 90-120 degrees of abduction. The patients may also feel or hear a click. In terms of imaging, of course, we're always going to start with plain films. When we really want to evaluate the labrum though, we'll order an MR arthrogram, unless perhaps you're at an institution with a 3-Tesla magnet, in which case you may not need an MR arthrogram, but usually we'll obtain the MRA. In general, it's difficult to detect lesions in the bicipital tunnel. When we're looking at treatment options, usually for slap tears, we're going to start with non-operative treatment. That includes anti-inflammatory medications, potentially steroid injections, and then rehab should really focus on core and periscopular stabilization, cuff strengthening, neuromuscular control, and posterior shoulder stretching. Operative treatment is somewhat controversial. So pre-op history and exam are absolutely critical. When we get to the point of considering surgery, we're talking about either repairing the slap tear or performing a bicep stenotomy or tenodesis. This is an algorithm which was published in a recent study. So usually, like I said, we'll start with non-op treatment for patients with slap tears. When patients fail non-op treatment and they're younger than age 40 and have a type 2 slap tear with no associated pathology, they will often undergo a slap repair. If there is concomitant pathology, then we'll adjust our treatment plan based on that. For patients over the age of 40 that fail non-op treatment and have a type 2 slap tear, we will then often perform a bicep stenodesis because those patients tend to do better with bicep stenodesis. There are many studies in the literature, some of which we'll touch on, showing a persistent pain with a slap repair in that age group. So this is a study published in 2011 where the authors wanted to report the outcome and return to prior level of play after isolated type 2 slap repairs in elite overhead athletes at one-year follow-up. They evaluated for any factors that affect outcomes and ability to return to play. And they also looked at KJOC and ASES scores. They had 23 elite athletes who were more than a year out from their repair, and they compared again KJOC and ASES scores to determine if there was an association. They found at a mean 38-month follow-up, 13 athletes were playing pain-free, six were playing with pain, and four were unable to play because of pain. The KJOC score demonstrated a better overall accuracy than ASES scores in evaluating return to pain-free pre-injury levels. The authors therefore concluded that return to pre-injury level of competition for these elite overhead athletes was about 57% despite high ASES scores. The return to play status definitely correlated with the presence of a partial thickness cuff tear, and the KJOC score, which is designed specifically for evaluating overhead athletes, was more accurate than the ASES score in this group of elite overhead athletes with slap tears. Another study published in 2013 wanted to prospectively analyze the clinical outcomes of the arthroscopic treatment of type II slap tears in a young, active patient population. They wanted to determine factors associated with treatment success and failure. The authors had 225 patients with type II slap tears that were enrolled over a four-year period, and they evaluated several outcome measures. They found that 179 of 225 patients completed follow-up, 37% of them were classified as failures, and advanced age within the cohort, which was defined as being older than 36, was the only factor associated with a statistically significant increase in the incidence of failure. So the authors concluded that arthroscopic slap repair provides a clinical and statistically significant improvement in shoulder outcomes, but that return to previous activity level may be more limited than previously thought. And certainly you have to take into account the patient's age. Biceps tenodesis is an option, especially in patients with associated cuff tears and failed slap lesions, may be helpful in more complex cases, including revision surgery. It's unclear still at this point if biceps tenodesis in the younger athlete is a viable primary option. There are some recent studies that actually show that patients in a younger age group, even as young as mid-20s, do well with the biceps tenodesis. In terms of performing this procedure, there are many different ways to perform it. It can be tenodesis high in the groove, it's super-PEC region, sub-PEC region. Sub-PEC biceps tenodesis is an open procedure. The benefit of this particular approach is that it decreases the potential for leaving residual diseased tendon and inflamed synovium within the bicipital groove. This is a study published in 2019 where the authors wanted to evaluate outcomes after biceps tenodesis in patients younger than 25 years. They evaluated reoperations and complications, and they wanted to critically appraise return to pre-injury level of play. They had 45 consecutive patients under the age of 25 who underwent sub-PEC biceps tenodesis for biceps tendinopathy or biceps labral complex injuries, including slap tears. They looked at several functional outcome measures. They had 34 of the 45 patients were athletes and 20 were playing at the collegiate level. All clinical outcome scores improved, and of the 34 athletes, 25 returned to sport with 19 returning to the same level and six returning to a lower level of play. The authors concluded that when indicated, biceps tenodesis offers an alternative to slap repair in young patients, and biceps tenodesis in this group provides satisfactory outcomes, including the fact that two-thirds of patients were able to return to play and there was a low revision rate. So this study looked specifically at return to sport. So they wanted to compare overall return to sport rate in patients with primary type two slap tears who were managed with arthroscopic slap repair versus biceps tenodesis. They found 15 studies that met their inclusion criteria and they gave a breakdown of those that had slap repair, slap repair versus, excuse me, slap repair with partial cuff debridement and biceps tenodesis. The overall return to sport rates were high for all three procedures. For biceps tenodesis specifically, it was about 84%. They concluded that primary arthroscopic slap repair, slap repair with partial cuff debridement and biceps tenodesis all provide high return to sport rates. Biceps tenodesis for slap lesions may demonstrate an overall higher return to sport rate when compared to traditional slap repair, especially in that older age group. And that is really, especially over the age of 40. But we do need higher levels of study controlling for age, level of activity and sport to determine the efficacy of biceps tenodesis as an alternative to slap repair for young athletes. So here I have a video demonstrating a slap repair and a few key points here. It's important to create an anterior or an anterosuperior portal and a trans rotator cuff portal. Here we're viewing from posteriorly, which is really standard for this type of procedure. We wanna make sure that we debride underneath the superior labrum, which is very similar of course to what we'll do for a Bankart repair. The anchor is placed just posterior to the biceps to avoid capturing the tendon. And then you can actually also hold the labrum with a grasper when you're tightening the suture. So you can see I'll fast forward a little bit here. This is just pulling the sutures out through the front. This particular anchor is a knotless anchor. And so I'll show you the final repair construct. This is as it's being tightened with a suture around the superior labrum. Again, we're just posterior to the biceps. And in just one second, we'll see the final repair construct here just being tightened with a knot pusher. In this particular video, we're seeing an open sub-pec biceps tenodesis. So the incision is made just on the inferior border of the pec major tendon and dissection is carried down through that sub-q tissue. We'll then identify the pec major tendon, create a small incision in the fascia that is just underneath the pec major, and then digitally dissect down to the anterior humeral cortex. You can then identify the biceps tendon and pull it out through the wound. A Keith needle with a number two fiber wire is used to create that Krakow suture beginning at the musculotendinous junction. And then a small drill hole is created in the anterior humeral cortex for the cortical button, which is usually placed unicortically. The button is inserted and then flipped. And then the biceps tendon is actually advanced down to the anterior humeral cortex. So in summary, slap tears are very common, especially in overhead athletes. There still is some controversy between the best technique for slap treatment in athletes. And we definitely need to take into account patient sport, position and age when determining the treatment plan. So thank you so much for your attention. I'd be happy to answer any questions during the period of the course.

SLAP lesions

labrum anatomy

SLAP tear classification

treatment options

surgical techniques