Current Concepts in the Evaluation and Management of Type II Superior Labral Lesions of the Shoulder

William A Hester, Michael J O'Brien, Wendell M R Heard, Felix H Savoie, William A Hester, Michael J O'Brien, Wendell M R Heard, Felix H Savoie

Abstract

Background: Superior labrum tears extending from anterior to posterior (SLAP lesion) are a cause of significant shoulder pain and disability. Management for these lesions is not standardized. There are no clear guidelines for surgical versus non-surgical treatment, and if surgery is pursued there are controversies regarding SLAP repair versus biceps tenotomy/tenodesis.

Objective: This paper aims to briefly review the anatomy, classification, mechanisms of injury, and diagnosis of SLAP lesions. Additionally, we will describe our treatment protocol for Type II SLAP lesions based on three groups of patients: throwing athletes, non-throwing athletes, and all other Type II SLAP lesions.

Conclusion: The management of SLAP lesions can be divided into 4 broad categories: (1) nonoperative management that includes scapular exercise, restoration of balanced musculature, and that would be expected to provide symptom relief in 2/3 of all patients; (2) patients with a clear traumatic episode and symptoms of instability that should undergo SLAP repair without (age < 40) or with (age > 40) biceps tenotomy or tenodesis; (3) patients with etiology of overuse without instability symptoms should be managed by biceps tenotomy or tenodesis; and (4) throwing athletes that should be in their own category and preferentially managed with rigorous physical therapy centered on hip, core, and scapular exercise in addition to restoration of shoulder motion and rotator cuff balance. Peel-back SLAP repair, Posterior Inferior Glenohumeral Ligament (PIGHL) release, and treatment of the partial infraspinatus tear with debridement, PRP, or (rarely) repair should be reserved for those who fail this rehabilitation program.

Keywords: Biceps tenodesis; Biceps tenotomy; SLAP lesion; SLAP repair; SLAP tear; Shoulder.

Figures

Fig. (1)
Fig. (1)
Right shoulder viewed from the posterior portal in the lateral decubitus position showing a peel-back lesion.
Fig. (2)
Fig. (2)
Right shoulder with the patient in the lateral decubitus position showing a Type II SLAP lesion as viewed from the posterior portal with probe coming in from the anterior portal. The biceps anchor attachment has been disrupted.
Fig. (3)
Fig. (3)
Right shoulder with the patient in the lateral decubitus position, view from the anterior portal. The initial suture anchor for SLAP repair has been placed between the 10 o’clock and 11 o’clock position on the glenoid through the port of Wilmington.
Fig. (4)
Fig. (4)
Right shoulder with the patient in the lateral decubitus position as viewed from an anterior portal. A 12 o’clock suture will be passed by shuttling a PDS suture using a spinal needle via the Neviaser portal.
Fig. (5)
Fig. (5)
Right shoulder (lateral decubitus position) as viewed from the posterior portal with SLAP repair and biceps tenotomy completed. The biceps can be left in the tenotomized state, or a tenodesis may be performed with the surgeon’s preferred technique.
Fig. (6)
Fig. (6)
Right shoulder (lateral decubitus position) as viewed from the posterior portal with SLAP repair completed.
Fig. (7)
Fig. (7)
Right shoulder with patient in the lateral decubitus position as viewed from the posterior portal. The labrum and biceps anchor have been stripped from the superior glenoid consistent with a Type II SLAP lesion.
Fig. (8)
Fig. (8)
Left shoulder with the patient in the lateral decubitus position, view from the posterior portal. The arm is abducted and externally rotated, showing the posterior superior labrum separating from the superior glenoid as seen with a peel-back lesion.

References

    1. Andrews J.R., Carson W.G., Jr, McLeod W.D. Glenoid labrum tears related to the long head of the biceps. Am. J. Sports Med. 1985;13(5):337–341. doi: 10.1177/036354658501300508.
    1. Snyder S.J., Karzel R.P., Del Pizzo W., Ferkel R.D., Friedman M.J. SLAP lesions of the shoulder. Arthroscopy. 1990;6(4):274–279. doi: 10.1016/0749-8063(90)90056-J.
    1. Cooper D.E., Arnoczky S.P., O’Brien S.J., Warren R.F., DiCarlo E., Allen A.A. Anatomy, histology, and vascularity of the glenoid labrum. An anatomical study. J. Bone Joint Surg. Am. 1992;74(1):46–52. doi: 10.2106/00004623-199274010-00007.
    1. Moseley H.F., Overgaard B. The anterior capsule mechanism in recurrent anterior dislocation of the shoulder: Morphological and clinical studies with special reference to the glenoid labrum and glenohumeral ligaments. J Bone Joint Surg. 1962;44B(4):913–927. doi: 10.1302/0301-620X.44B4.913.
    1. Prodromos C.C., Ferry J.A., Schiller A.L., Zarins B. Histological studies of the glenoid labrum from fetal life to old age. J. Bone Joint Surg. Am. 1990;72(9):1344–1348. doi: 10.2106/00004623-199072090-00010.
    1. Powell S.E., Nord K.D., Ryu R.K. The diagnosis, classification, and treatment of SLAP lesions. Oper. Tech. Sports Med. 2004;12:99–110. doi: 10.1053/j.otsm.2004.07.001.
    1. Maffet M.W., Gartsman G.M., Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am. J. Sports Med. 1995;23(1):93–98. doi: 10.1177/036354659502300116.
    1. Bey M.J., Elders G.J., Huston L.J., Kuhn J.E., Blasier R.B., Soslowsky L.J. The mechanism of creation of superior labrum, anterior, and posterior lesions in a dynamic biomechanical model of the shoulder: the role of inferior subluxation. J. Shoulder Elbow Surg. 1998;7(4):397–401. doi: 10.1016/S1058-2746(98)90031-3.
    1. Clavert P., Bonnomet F., Kempf J.F., Boutemy P., Braun M., Kahn J.L. Contribution to the study of the pathogenesis of type II superior labrum anterior-posterior lesions: A cadaveric model of a fall on the outstretched hand. J. Shoulder Elbow Surg. 2004;13(1):45–50. doi: 10.1016/j.jse.2003.09.008.
    1. Pradhan R.L., Itoi E., Hatakeyama Y., Urayama M., Sato K. Superior labral strain during the throwing motion. A cadaveric study. Am. J. Sports Med. 2001;29(4):488–492. doi: 10.1177/03635465010290041801.
    1. Burkhart S.S., Morgan C.D., Kibler W.B. The disabled throwing shoulder: Spectrum of pathology. Part II: Evaluation and treatment of SLAP lesions in throwers. Arthroscopy. 2003;19(5):531–539. doi: 10.1053/jars.2003.50139.
    1. Kuhn J.E., Lindholm S.R., Huston L.J., Soslowsky L.J., Blasier R.B. Failure of the biceps superior labral complex: A cadaveric biomechanical investigation comparing the late cocking and early deceleration positions of throwing. Arthroscopy. 2003;19(4):373–379. doi: 10.1053/jars.2003.50044.
    1. Shepard M.F., Dugas J.R., Zeng N., Andrews J.R. Differences in the ultimate strength of the biceps anchor and the generation of type II superior labral anterior posterior lesions in a cadaveric model. Am. J. Sports Med. 2004;32(5):1197–1201. doi: 10.1177/0363546503262643.
    1. Burkhart S.S., Morgan C.D. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy. 1998;14(6):637–640. doi: 10.1016/S0749-8063(98)70065-9.
    1. O’Brien S.J., Pagnani M.J., Fealy S., McGlynn S.R., Wilson J.B. The active compression test: A new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am. J. Sports Med. 1998;26(5):610–613. doi: 10.1177/03635465980260050201.
    1. Snyder S.J., Karzel R.P., Del Pizzo W., Ferkel R.D., Friedman M.J. SLAP lesions of the shoulder. Arthroscopy. 1990;6(4):274–279. doi: 10.1016/0749-8063(90)90056-J.
    1. Kibler W.B. Specificity and sensitivity of the anterior slide test in throwing athletes with superior glenoid labral tears. Arthroscopy. 1995;11(3):296–300. doi: 10.1016/0749-8063(95)90006-3.
    1. Liu S.H., Henry M.H., Nuccion S.L. A prospective evaluation of a new physical examination in predicting glenoid labral tears. Am. J. Sports Med. 1996;24(6):721–725. doi: 10.1177/036354659602400604.
    1. Yergason R.M. Supination sign. J. Bone Joint Surg. 1931;13:160.
    1. Hegedus E.J., Goode A.P., Cook C.E., Michener L., Myer C.A., Myer D.M., Wright A.A. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br. J. Sports Med. 2012;46(14):964–978. doi: 10.1136/bjsports-2012-091066.
    1. Parentis M.A., Glousman R.E., Mohr K.S., Yocum L.A. An evaluation of the provocative tests for superior labral anterior posterior lesions. Am. J. Sports Med. 2006;34(2):265–268. doi: 10.1177/0363546505279911.
    1. Field L.D., Savoie F.H., III Arthroscopic suture repair of superior labral detachment lesions of the shoulder. Am. J. Sports Med. 1993;21(6):783–790. doi: 10.1177/036354659302100605.
    1. Ben Kibler W., Sciascia A.D., Hester P., Dome D., Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am. J. Sports Med. 2009;37(9):1840–1847. doi: 10.1177/0363546509332505.
    1. Iqbal H.J., Rani S., Mahmood A., Brownson P., Aniq H. Diagnostic value of MR arthrogram in SLAP lesions of the shoulder. Surgeon. 2010;8(6):303–309. doi: 10.1016/j.surge.2010.06.006.
    1. Chandnani V.P., Yeager T.D., DeBerardino T., Christensen K., Gagliardi J.A., Heitz D.R., Baird D.E., Hansen M.F. Glenoid labral tears: Prospective evaluation with MRI imaging, MR arthrography, and CT arthrography. AJR Am. J. Roentgenol. 1993;161(6):1229–1235. doi: 10.2214/ajr.161.6.8249731.
    1. Mohana-Borges A.V., Chung C.B., Resnick D. Superior labral anteroposterior tear: Classification and diagnosis on MRI and MR arthrography. AJR Am. J. Roentgenol. 2003;181(6):1449–1462. doi: 10.2214/ajr.181.6.1811449.
    1. Jia X., Yokota A., McCarty E.C., Nicholson G.P., Weber S.C., McMahon P.J., Dunn W.R., McFarland E.G. Reproducibility and reliability of the Snyder classification of superior labral anterior posterior lesions among shoulder surgeons. Am. J. Sports Med. 2011;39(5):986–991. doi: 10.1177/0363546510392332.
    1. Gobezie R., Zurakowski D., Lavery K., Millett P.J., Cole B.J., Warner J.J. Analysis of interobserver and intraobserver variability in the diagnosis and treatment of SLAP tears using the Snyder classification. Am. J. Sports Med. 2008;36(7):1373–1379. doi: 10.1177/0363546508314795.
    1. McFarland E.G., Tanaka M.J., Garzon-Muvdi J., Jia X., Petersen S.A. Clinical and imaging assessment for superior labrum anterior and posterior lesions. Curr. Sports Med. Rep. 2009;8(5):234–239. doi: 10.1249/JSR.0b013e3181b7f042.
    1. Fedoriw W.W., Ramkumar P., McCulloch P.C., Lintner D.M. Return to play after treatment of superior labral tears in professional baseball players. Am. J. Sports Med. 2014;42(5):1155–1160. doi: 10.1177/0363546514528096.
    1. Friel N.A., Karas V., Slabaugh M.A., Cole B.J. Outcomes of type II superior labrum, anterior to posterior (SLAP) repair: Prospective evaluation at a minimum two-year follow-up. J. Shoulder Elbow Surg. 2010;19(6):859–867. doi: 10.1016/j.jse.2010.03.004.
    1. Sayde W.M., Cohen S.B., Ciccotti M.G., Dodson C.C. Return to play after Type II superior labral anterior-posterior lesion repairs in athletes: A systematic review. Clin. Orthop. Relat. Res. 2012;470(6):1595–1600. doi: 10.1007/s11999-012-2295-6.
    1. Neuman B.J., Boisvert C.B., Reiter B., Lawson K., Ciccotti M.G., Cohen S.B. Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction. Am. J. Sports Med. 2011;39(9):1883–1888. doi: 10.1177/0363546511412317.
    1. Rhee Y.G., Lee D.H., Lim C.T. Unstable isolated SLAP lesion: clinical presentation and outcome of arthroscopic fixation. Arthroscopy. 2005;21(9):1099–1104. doi: 10.1016/j.arthro.2005.05.016.
    1. Neri B.R., ElAttrache N.S., Owsley K.C., Mohr K., Yocum L.A. Outcome of type II superior labral anterior posterior repairs in elite overhead athletes: Effect of concomitant partial-thickness rotator cuff tears. Am. J. Sports Med. 2011;39(1):114–120. doi: 10.1177/0363546510379971.
    1. Alberta F.G., ElAttrache N.S., Bissell S., Mohr K., Browdy J., Yocum L., Jobe F. The development and validation of a functional assessment tool for the upper extremity in the overhead athlete. Am. J. Sports Med. 2010;38(5):903–911. doi: 10.1177/0363546509355642.
    1. Van Kleunen J.P., Tucker S.A., Field L.D., Savoie F.H., III Return to high-level throwing after combination infraspinatus repair, SLAP repair, and release of glenohumeral internal rotation deficit. Am. J. Sports Med. 2012;40(11):2536–2541. doi: 10.1177/0363546512459481.
    1. Brockmeier S.F., Voos J.E., Williams R.J., III, Altchek D.W., Cordasco F.A., Allen A.A., Hospital for Special Surgery Sports Medicine and Shoulder Service Outcomes after arthroscopic repair of type-II SLAP lesions. J. Bone Joint Surg. Am. 2009;91(7):1595–1603. doi: 10.2106/JBJS.H.00205.
    1. Burkhart S.S., Morgan C.D. The peel-back mechanism: Its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy. 1998;14(6):637–640. doi: 10.1016/S0749-8063(98)70065-9.
    1. Katz L.M., Hsu S., Miller S.L., Richmond J.C., Khetia E., Kohli N., Curtis A.S. Poor outcomes after SLAP repair: descriptive analysis and prognosis. Arthroscopy. 2009;25(8):849–855. doi: 10.1016/j.arthro.2009.02.022.
    1. Kibler W.B., Sciascia A. Current practice for the surgical treatment of SLAP lesions: A systematic review. Arthroscopy. 2016;32(4):669–683. doi: 10.1016/j.arthro.2015.08.041.
    1. McCormick F., Nwachukwu B.U., Solomon D., Dewing C., Golijanin P., Gross D.J., Provencher M.T. The efficacy of biceps tenodesis in the treatment of failed superior labral anterior posterior repairs. Am. J. Sports Med. 2014;42(4):820–825. doi: 10.1177/0363546513520122.
    1. Katz L.M., Hsu S., Miller S.L., Richmond J.C., Khetia E., Kohli N., Curtis A.S. Poor outcomes after SLAP repair: Descriptive analysis and prognosis. Arthroscopy. 2009;25(8):849–855. doi: 10.1016/j.arthro.2009.02.022.
    1. Brockmeyer M., Tompkins M., Kohn D.M., Lorbach O. SLAP lesions: A treatment algorithm. Knee Surg. Sports Traumatol. Arthrosc. 2016;24(2):447–455. doi: 10.1007/s00167-015-3966-0.
    1. Ek E.T., Shi L.L., Tompson J.D., Freehill M.T., Warner J.J. Surgical treatment of isolated type II superior labrum anterior-posterior (SLAP) lesions: Repair versus biceps tenodesis. J. Shoulder Elbow Surg. 2014;23(7):1059–1065. doi: 10.1016/j.jse.2013.09.030.
    1. Wilk K.E., Reinold M.M., Dugas J.R., Arrigo C.A., Moser M.W., Andrews J.R. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. J. Orthop. Sports Phys. Ther. 2005;35(5):273–291. doi: 10.2519/jospt.2005.35.5.273.
    1. Chalmers PN, Monson B, Frank RM, et al. Combined SLAP repair and biceps tenodesis for superior labral anterior-posterior tears. Knee Surg Sports Traumatol Arthrosc [Epub ahead of print]. Available from: . 2015 Sep 2; cited 2016 May 18.
    1. Provencher M.T., McCormick F., Dewing C., McIntire S., Solomon D. A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: Outcomes and factors associated with success and failure. Am. J. Sports Med. 2013;41(4):880–886. doi: 10.1177/0363546513477363.
    1. Boileau P., Parratte S., Chuinard C., Roussanne Y., Shia D., Bicknell R. Arthroscopic treatment of isolated type II SLAP lesions: Biceps tenodesis as an alternative to reinsertion. Am. J. Sports Med. 2009;37(5):929–936. doi: 10.1177/0363546508330127.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj