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Introduction
  • Overview
    • Superior Labrum from Anterior to Posterior tears that may or may not involve the biceps attachment
  • 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
  • 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 % Images
I
Labral and biceps fraying, anchor intact
11%
II
Labral fraying with detached biceps tendon anchor
41%
III
Bucket handle tear, intact biceps tendon anchor (biceps separates from bucket handle tear)
33%
IV

Bucket handle tear with detached biceps tendon anchor (remains attached to bucket handle tear)

15%
V
Type II + anteroinferior labral extension (Bankart lesion)
m
m
VI
Type II + unstable flap
m
m
VII
Type II + MGHL injury
m
m
             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
  • Return to Play
    • variable and unpredictable rates of return among elite-level throwers
  • 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
 

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Questions (16)
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(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? Tested Concept

QID: 4736
FIGURES:
1

New course of physical therapy

0%

(13/4861)

2

Activity shutdown with 6 weeks sling immobilization

0%

(11/4861)

3

Arthroscopic superior labrum anterior to posterior (SLAP) tear repair

16%

(761/4861)

4

Arthroscopic debridement and possible biceps tenotomy versus tenodesis

82%

(3993/4861)

5

Arthroscopic rotator cuff repair and acromioplasty

1%

(61/4861)

L 2 B

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(OBQ12.110) Which of the following rehabilitation exercises is most appropriate immediately following the repair of the injury seen in figure A? Tested Concept

QID: 4470
FIGURES:
1

Passive external rotation at 90 degrees of abduction

11%

(501/4609)

2

Isotonic rotator cuff strengthening

15%

(676/4609)

3

Isokinetic resistive elbow flexion

9%

(394/4609)

4

Passive and active assisted flexion in scapular plane

64%

(2938/4609)

5

Concentric latissimus pull down exercises

2%

(70/4609)

L 3 C

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(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? Tested Concept

QID: 4361
FIGURES:
1

Active assisted elevation in the scapular plane

20%

(1228/6228)

2

Passive forearm pronation

3%

(185/6228)

3

Passive external rotation at 90 degrees of abduction

67%

(4158/6228)

4

Open chain passive elbow flexion

7%

(421/6228)

5

Passive assisted elevation in the scapular plane

2%

(132/6228)

L 3 B

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(OBQ10.46) What percent of shoulders have a posterior or posterior dominant attachment of the long head of the biceps onto the glenoid? Tested Concept

QID: 3134
1

0%

1%

(46/3369)

2

15%

34%

(1156/3369)

3

30%

23%

(788/3369)

4

70%

40%

(1333/3369)

5

100%

1%

(33/3369)

L 4 D

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(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: Tested Concept

QID: 3125
1

Immediate full active range of motion that simulates sport-specific activities

0%

(10/2492)

2

Full-time sling wear with no active nor passive motion for at least 6 weeks until labral tissues heal

6%

(141/2492)

3

Rotator cuff strengthening by post-operative week two to prevent disuse atrophy and shoulder instability

4%

(92/2492)

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

88%

(2192/2492)

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%

(44/2492)

L 1 C

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(SAE07SM.81) Medial dislocation of the long head of the biceps tendon in the shoulder is most commonly caused by a Tested Concept

QID: 8743
1

tear of the subscapularis tendon.

74%

(404/549)

2

tear of the supraspinatus tendon.

3%

(15/549)

3

tear of the transverse ligament.

11%

(59/549)

4

type I SLAP tear.

4%

(23/549)

5

congenitally shallow bicipital groove.

9%

(47/549)

L 2 E

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(SAE07SM.12) Which of the following is considered an advantage of arthroscopic distal clavicle excision compared with open distal clavicle excision? Tested Concept

QID: 8674
1

Fewer complications

7%

(33/441)

2

Lower infection rate

14%

(61/441)

3

Evaluation of the glenohumeral joint

70%

(310/441)

4

Preservation of the inferior acromioclavicular ligament

6%

(28/441)

5

Decreased surgical time

2%

(9/441)

L 3 E

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(OBQ04.40) Which of the following best describes a Buford complex? Tested Concept

QID: 101
1

Normal anatomic variant characterized by a cord-like MGHL and an absent anterosuperior labrum

65%

(823/1274)

2

Normal anatomic variant characterized by a cord-like SGHL and an absent posterosuperior labrum

5%

(68/1274)

3

Abnormal arthroscopic finding characterized by a cord-like MGHL and an absent anterosuperior labrum

7%

(94/1274)

4

Abnormal arthroscopic finding characterized by a cord-like SGHL and an absent posterosuperior labrum

3%

(32/1274)

5

Normal anatomic variant characterized by a cord-like MGHL and a sublabral foramen at the anterosuperior labrum

20%

(252/1274)

L 4 C

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(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? Tested Concept

QID: 1341
FIGURES:
1

HAGL

24%

(325/1328)

2

SLAP tear

63%

(833/1328)

3

ALPSA

7%

(89/1328)

4

Bankart

5%

(69/1328)

5

Loose body

0%

(5/1328)

L 3 D

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