BLOG: Treatment and diagnosis of SLAP tears can sometimes prove difficult
Diagnosis and treatment of superior labral anterior to posterior tears can sometimes be controversial and pose a difficult decision-making process. The first line of treatment for most SLAP tears is usually rehabilitation. If that is not successful, the next step is often operative intervention.
Operative treatment of type I (superior labral anterior to posterior) SLAP tears is usually debridement. Treatment of type II SLAP tears is still somewhat controversial, especially in the overhead throwing athlete and older patient. Recent literature reports better outcomes with biceps tenodesis or tenotomy in patients older than 40 years and for some overhead athletes; although there are studies that show repair has success rates comparable to tenodesis in older individuals.
Categories of tears and diagnosis
SLAP lesions were first recognized in the 1980s by Dr. Andrews and later classified by Dr. Snyder into four categories. Dr. Maffat later expanded these to seven subtypes. Type I lesions exhibit degenerative fraying of the superior labrum at the inner margin which can be considered normal as one ages. Type 2 lesions, which are the most common, are characterized by erythema at the anchor insertion, separation of the labrum from the glenoid at the biceps insertion at the superior glenoid and a minimum of 5-mm excursion of the labrum. With the arm in abduction and external rotation, the peel-back phenomenon is confirmatory of the diagnosis of a type II tear. Type III tears have an intact biceps, but also have a bucket-handle type tear of the superior labrum. Type IV tears are identical to type III tear patterns with the tear extending into the biceps tendon.
Definitive diagnosis of SLAP tears by exam is difficult with most clinical examination provocative tests having 28% to 91% sensitivity and 14% to 76% specificity. MRI can be helpful with sensitivity of 50% with plain magnetic resonance (MR) and up to 90% with MR arthrography (MRA). However, MRA has a high incidence of false-positive readings. There have been articles attempting to promote the clinical predictive value of certain physical examination tests, but these are not yet validated.
Most agree initial management of patients with suspected or confirmed SLAP tears should be nonoperative with a period of rest, activity modification and anti-inflammatory medication. Physical therapy to correct any scapular dyskinesia or rotator cuff imbalance should also be instituted. Both open- and closed-chain exercises have shown to be beneficial.
Operative treatment of type I SLAP lesions is typically debridement of the frayed labrum and has been shown to have good outcomes. Type II lesions create a more difficult decision-making process. Repair is appropriate for younger patients, but caution is advised in the older patient and overhead throwing athlete. Repair has shown to provide up to 80% good to excellent results and 73% return to preinjury level of play in overhead throwing athletes. Yet, up to one-third of overhead athletes are unable to return to their previous level of play. Biceps tenodesis or tenotomy has been shown to have better results in the patients older than 40 years as discussed earlier. For throwing athletes, repair of the lesion is usually recommended, but occasionally biceps tenodesis may be a better option. Type III lesions usually respond to debridement of the bucketed fragment without need for repair. Type IV lesions are often treated similar to type II tears.
Stiffness from overtightening
Repeat surgery after isolated SLAP repair can be up to 10%, with many repeat interventions for other pathology. There is a trend with time for less isolated SLAP repairs and more for biceps tenodesis, especially in revision SLAP pathology and older patients.
The most common postoperative issue in the throwing athlete is stiffness from overtightening of the biceps-labrum complex, and thereby overtightening of the anterior capsule and superior and middle glenohumeral ligaments. It is recommended to place the anchors posterior to the biceps when repairing the SLAP lesion to try to avoid overtightening. Stiffness in the overhead throwing athlete is a difficult problem to treat if it occurs after SLAP repair.
SLAP tear case
This is the case of a 19-year-old male Division I baseball player with 6 months of pain with throwing. Patient has failed to improve with rehabilitation and surgical options were discussed. Diagnostic arthroscopy and SLAP repair were performed. Patient was rehabilitated postoperatively and returned to pitching without pain. – by Kosmas J. Kayes, MD
Kosmas J. Kayes, MD, is an orthopedic sports medicine fellow at the University of Kentucky Sports Medicine Program.
Disclosure: Kayes reports no financial disclosures.