summary A SLAP lesion (Superior Labrum from Anterior to Posterior tear) generally occurs as result of overuse injury to the shoulder in overhead athletes or traumatic falls in older patients and can result in deep shoulder pain and biceps tendonitis. Diagnosis generally requires MRI studies to assess the superior labrum and the integrity of the biceps tendon. Treatment may be nonoperative or operative depending on patient age, activity levels, severity of symptoms and associated instability. Epidemiology Incidence uncommon injuries, account for less than 5% of all shoulder injuries Demographics dominant shoulder of overhead and throwing athletes Risk factors glenohumeral internal rotation deficit Etiology Pathophysiology mechanisms of injury repetitive overhead activities (often seen in throwing athletes) fall on outstretched arm with tensed biceps traction on the arm pathoanatomy in throwers may be due to tightness of the posterior-IGHL which shifts the glenohumeral contact point posterosuperiorly and increases the shear force on the superior labrum SLAP lesion increases the strain on the anterior band of the IGHL and thus compromises stability of shoulder Associated conditions internal impingement GIRD rotator cuff tears (usually articular sided) instability (may be subtle) scapular dyskinesis Anatomy Anatomy of glenohumeral joint Variant anatomic anatomy variable anatomic relationships extremely common in the glenohumeral joint recognition of these critical but often challenging Biceps anatomy long head of biceps tendon most commonly has 50% fibers attaching to labrum and 50% to supraglenoid tubercle tubercle located over 6mm medial to glenoid surface biceps tendon attachment on glenoid (Tuoheti classification) Type I - completely posterior Type II - predominantly posterior Type I and II together comprise >70% Type III - anterior + posterior (25%) Type IV - anterior (5%) most common pattern of biceps tendon attachment to the superior labrum is posterior to the 12 o'clock position blood supply poorest tendon blood supply while traversing through joint function contributes to torsional and horizontal stability during late-cocking phase of throwing Glenoid labrum function chock block to subluxation composition composed of fibrocartilaginous tissue blood supply from suprascapular, circumflex scapular, posterior humeral circumflex arteries labrum receives blood from capsule and periosteal vessels and not from underlying bone anterior-superior labrum has poorest blood supply stability superior labrum attaches further (medial) from glenoid rim than rest of labrum anchors biceps tendon and is weak link that leads to SLAP lesion anatomic variants sublabral recess/foramen can be confused with a tear on MRI sublabral recess/foramen with thickened MGHL meniscoid appearance (1%) Buford complex cordlike MGHL with associated bare area of the anterosuperior labrum repair of Buford complex to glenoid will result is significant loss of external rotation superior attachment of MGHL on glenoid Classification SLAP Classification Type Description I Labral and biceps fraying, anchor intact (11% of cases) II Labral fraying with detached biceps tendon anchor (41% of cases) III Bucket handle tear, intact biceps tendon anchor (33% of cases) (Biceps separates from bucket handle tear) IV Bucket handle tear with detached biceps tendon anchor (15% of cases) (Biceps remains attached to bucket handle tear) V Type II + anteroinferior labral extension (Bankart lesion) VI Type II + unstable flap VII Type II + MGHL injury VIII Type II + posterior extension IX Circumferential X Type II + posteroinferior extension (reverse Bankart) Snyder Classification: Original classification which includes Types I-IV Maffet sub-classification: Includes the original I-IV and added Types V-VII Significant inter-and intra-observer varaibility when designating classification for SLAP tears Presentation History feeling "pop" sensation in shoulder during overhead activity or traumtic event Symptoms location vague deep shoulder pain timing often a lag between the time of injury and the onset of symptoms mechanical symptoms of popping and clicking weakness, easy fatigue, and decrease athletic performance Physical exam inspection evaluate scapular position and muscle atrophy bicipital groove tenderness motion pop may be reproduced during overhead range of motion particular attention to internal rotation and total rotational arc of motion always compare to contralateral side neurovascular atrophy of supra- and/or infraspinatus due to suprascapular neuropathy provocative tests there is no one specific test for SLAP lesions biceps provocation tests Speed's test Yergason's test Kim biceps load test SLAP lesion tests active compression test (O'Brien's test) crank test arm placed in full abduction and humerus loaded and rotated dynamic labral shear test Kibler anterior slide test apprehension positive in 85% of patients Imaging Radiographs findings often normal MRI +/- arthrogram indications high suspicion for labral tear findings T2 signal intensity between the superior labrum, lateral to glenoid rim, and posterior to the biceps sensitivity ~50% and specificity ~90% which increases with arthrogram may see an associated paralabral ganglion cyst, which is highly specific for labral tear usually in the spinoglenoid notch Treatment Nonoperative rest from sports followed by physical therapy and NSAIDs indications first line of treatment address GIRD if present rehab focusing on scapular dyskinesia and rotator cuff strengthening for all patients Operative arthroscopic debridement indications Types I, III, and IV tears involving <1/3rd of the biceps tendon, causing severe symptoms that have failed nonoperative management arthroscopic debridement with repair of the labrum/biceps versus debridement with biceps tenotomy/tenodesis indications highly controversial Type 2 tears traditionally repaired in overhead athletes return to play rates after SLAP repairs are significantly lower for pitchers compared to non-pitchers general consensus bodes for tenotomy/tenodesis among those over 40 years of age arthroscopic debridement with repair or debridement of the labrum with biceps tenotomy/tenodesis indications Type IV tears with >1/3rd of the biceps tendon involved, causing severe symptoms that have failed nonoperative management Techniques Arthroscopic debridement versus stabilization of the labrum and biceps tendon versus tenotomy/tenodesis approach standard arthroscopic approach to the shoulder soft tissue look for erythema and tearing under labrum to differentiate from normal recess "peel back" test shows "peel back" of the labrum with 90° of external rotation and abduction debride loose flaps of labrum/biceps decompress any cysts SLAP repair utilize accessory or percutaneous portals as necessary for anchor placement near glenoid rim sutures placed depending on tear anatomy traditionally thought sutures placed anterior to biceps anchor risk increased stiffness post-operatively biceps tenotomy/tenodesis tenotomize biceps near attachment to labrum with arthroscopic scissors or shaver device tenodesis may be done all-arthroscopically or through mini-open incision variety of tenodesis devices used for biceps fixation into proximal humerus rehabilitation week 1-4 passive and active assisted flexion in the scapular plane avoid extremes of abduction and external rotation, and resisted biceps exercises week 4-6 progress to active ROM, isometrics week 6-12 functional exercise and light strengthening week 12+ advance strength and ROM, sport-specifics typical return to sport around 6 months Complications Stiffness incidence most common complication following SLAP repair, around 78% of all patients risk factors incidental SLAP lesions repaired in older patients (>45 years) having arthroscopic rotator cuff repair treatment early passive and active assisted range of motion (pendulum) exercises begun 1 week following repair if stiffness does not resolve with physical therapy, capsular release is indicated Suprascapular nerve injury overdrilling the glenoid can injury the suprascapular nerve Failed SLAP repair and persistent symptoms many causes including articular cartilage injuries, hardware failure and anchor pullout failures associated with age >36 years biceps tenodesis better option in this age group Prognosis Return to Play variable and unpredictable rates of return among elite-level throwers
Technique Guide CPT Codes: 29807 Arthroscopy, shoulder, surgical; repair of slap lesion Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. SLAP Repair Derek W. Moore Shoulder & Elbow - SLAP Lesion
QUESTIONS 1 of 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Previous Next (OBQ18.220) A 55-year-old male patient presents with right shoulder pain that is worse with overhead activity. The patient works as a computer programmer and is a recreational swimmer and has noted worsening pain with his breaststroke. Figure A is the coronal T2 MRI arthrogram of the affected shoulder. The patient decides to undergo an arthroscopic repair. What factor is associated with repair failure? QID: 213116 FIGURES: A Type & Select Correct Answer 1 Recreational swimmer 7% (137/1937) 2 Age greater than 36 years 67% (1295/1937) 3 Male gender 11% (212/1937) 4 Sedentary career 2% (46/1937) 5 Snyder type 2 lesion 12% (231/1937) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.101) Figure A is the MR image of the left shoulder of an active 47-year-old painter who has been experiencing shoulder pain for 9 months. In addition to the finding shown in Figure A, MRI examination of the intra-articular portion of the biceps tendon shows fraying greater than 50%. He has not obtained relief from an 8 month course of non-operative management including non-steroidal anti-inflammatory medications, physical therapy and corticosteroid injection. What is the best next step in treatment? QID: 4736 FIGURES: A Type & Select Correct Answer 1 New course of physical therapy 0% (19/5671) 2 Activity shutdown with 6 weeks sling immobilization 0% (19/5671) 3 Arthroscopic superior labrum anterior to posterior (SLAP) tear repair 15% (845/5671) 4 Arthroscopic debridement and possible biceps tenotomy versus tenodesis 83% (4697/5671) 5 Arthroscopic rotator cuff repair and acromioplasty 1% (63/5671) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ12.110) Which of the following rehabilitation exercises is most appropriate immediately following the repair of the injury seen in figure A? QID: 4470 FIGURES: A Type & Select Correct Answer 1 Passive external rotation at 90 degrees of abduction 11% (550/4942) 2 Isotonic rotator cuff strengthening 15% (729/4942) 3 Isokinetic resistive elbow flexion 9% (426/4942) 4 Passive and active assisted flexion in scapular plane 63% (3131/4942) 5 Concentric latissimus pull down exercises 2% (75/4942) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ12.1) Figure A is an arthrosopic image from a right shoulder in the lateral decubitus position as viewed from the posterior portal. Which one of the following rehabilitation techniques should be avoided in the patient that is 2 weeks post-operative from the surgical repair shown in Figure A? QID: 4361 FIGURES: A Type & Select Correct Answer 1 Active assisted elevation in the scapular plane 20% (1300/6612) 2 Passive forearm pronation 3% (195/6612) 3 Passive external rotation at 90 degrees of abduction 67% (4419/6612) 4 Open chain passive elbow flexion 7% (453/6612) 5 Passive assisted elevation in the scapular plane 2% (140/6612) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (SBQ11OS.43.1) A 47-year-old man presents to your clinic with chronic persistent deep-seated right shoulder pain. He is able to perform most daily activities but experiences sharp shooting pain within the anterior aspect of the shoulder whenever he thows a baseball with his son. His primary care physician referred him to physical therapy first, which resulted in limited improvement in his symptoms, but he remains dissatisfied. Examination reveals symmetric rotator cuff strength and no instability. Speed's and O'brien's tests are positive. His MRI is shown in Figure A. Which of the following is correct with respect to the pathologic structure? QID: 213843 FIGURES: A Type & Select Correct Answer 1 Anchors the biceps tendon in a predominantly anterior position 29% (475/1635) 2 Supplied by a single arterial source 4% (61/1635) 3 The anterior superior portion is most susceptible to vascular insufficiency 37% (613/1635) 4 Degeneration usually leads to cyst formation within the suprascapular notch 17% (285/1635) 5 Repair should be accompanied by post-operative limitation in abduction and internal rotation 11% (180/1635) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.46) What percent of shoulders have a posterior or posterior dominant attachment of the long head of the biceps onto the glenoid? QID: 3134 Type & Select Correct Answer 1 0% 1% (50/3687) 2 15% 34% (1268/3687) 3 30% 24% (869/3687) 4 70% 39% (1449/3687) 5 100% 1% (36/3687) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ10.37) A 26-year-old outfielder undergoes arthroscopic repair of a right shoulder type 2 SLAP tear with two labral anchors in the 11 and 1 o’clock positions. Postoperative rehabilitation for this SLAP repair should include: QID: 3125 Type & Select Correct Answer 1 Immediate full active range of motion that simulates sport-specific activities 0% (14/2823) 2 Full-time sling wear with no active nor passive motion for at least 6 weeks until labral tissues heal 6% (159/2823) 3 Rotator cuff strengthening by post-operative week two to prevent disuse atrophy and shoulder instability 4% (120/2823) 4 Limited passive motion for 4 weeks then progressive active motion until 8 weeks followed by sport specific strengthening until at least 12 to 16 weeks postoperatively 87% (2454/2823) 5 Eccentric open chain biceps contraction exercises beginning at postoperative week 2 to retrain the biceps muscle and stimulate SLAP healing at the biceps anchor on the glenoid 2% (63/2823) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07SM.81) Medial dislocation of the long head of the biceps tendon in the shoulder is most commonly caused by a QID: 8743 Type & Select Correct Answer 1 tear of the subscapularis tendon. 78% (743/953) 2 tear of the supraspinatus tendon. 2% (20/953) 3 tear of the transverse ligament. 9% (87/953) 4 type I SLAP tear. 4% (39/953) 5 congenitally shallow bicipital groove. 7% (63/953) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07SM.12) Which of the following is considered an advantage of arthroscopic distal clavicle excision compared with open distal clavicle excision? QID: 8674 Type & Select Correct Answer 1 Fewer complications 6% (44/677) 2 Lower infection rate 16% (105/677) 3 Evaluation of the glenohumeral joint 68% (461/677) 4 Preservation of the inferior acromioclavicular ligament 8% (52/677) 5 Decreased surgical time 2% (14/677) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ04.40) Which of the following best describes a Buford complex? QID: 101 Type & Select Correct Answer 1 Normal anatomic variant characterized by a cord-like MGHL and an absent anterosuperior labrum 65% (963/1475) 2 Normal anatomic variant characterized by a cord-like SGHL and an absent posterosuperior labrum 5% (73/1475) 3 Abnormal arthroscopic finding characterized by a cord-like MGHL and an absent anterosuperior labrum 7% (107/1475) 4 Abnormal arthroscopic finding characterized by a cord-like SGHL and an absent posterosuperior labrum 2% (36/1475) 5 Normal anatomic variant characterized by a cord-like MGHL and a sublabral foramen at the anterosuperior labrum 20% (290/1475) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ04.236) A 32-year-old overhead athlete catches himself with his right hand while slipping on ice and injures his right shoulder. He fails to improve with therapy, anti-inflammatory medicines, and rest. His MRI is demonstrated in Figure A. What is the most likely diagnosis? QID: 1341 FIGURES: A Type & Select Correct Answer 1 HAGL 25% (403/1590) 2 SLAP tear 62% (983/1590) 3 ALPSA 7% (110/1590) 4 Bankart 5% (81/1590) 5 Loose body 0% (5/1590) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (32) Podcasts (1) Login to View Community Videos Login to View Community Videos Superior Labrum Anterior to Posterior Tears and Lesions of the Proximal Biceps Tendon. Kemal Gokkus Shoulder & Elbow - SLAP Lesion 2 weeks ago 16 views 5.0 (1) 2019 FORE/AANA World Series of Live Surgery (Prev. CHI Sports) SLAP Lesions: Fact or Fiction - Nikhil M. Verma, MD Nikhil Verma Shoulder & Elbow - SLAP Lesion 4 weeks ago 63 views 0.0 (0) Login to View Community Videos Login to View Community Videos 2019 Baseball Sports Medicine: Game-Changing Concepts SLAP Tear Treatment Evolution - Christopher S. Ahmad, MD Christopher S. Ahmad Shoulder & Elbow - SLAP Lesion 4 weeks ago 51 views 0.0 (0) Shoulder & Elbow⎪SLAP Lesion Shoulder & Elbow - SLAP Lesion Listen Now 21:4 min 1/31/2020 852 plays 4.8 (5) See More See Less