WEBVTT 00:00:00.000 --> 00:00:01.860 Welcome to the Deep Dive, where we cut through 00:00:01.860 --> 00:00:04.740 the information overload and give you the essential 00:00:04.740 --> 00:00:07.080 insights from a stack of sources. Think of it 00:00:07.080 --> 00:00:08.900 as getting the key knowledge without you having 00:00:08.900 --> 00:00:11.080 to sift through all the academic journals yourself. 00:00:11.640 --> 00:00:14.119 Our mission is to make you well -informed, quickly, 00:00:14.359 --> 00:00:16.920 with just enough detail to make it stick. Today, 00:00:16.960 --> 00:00:19.480 we are taking a deep dive into a shoulder injury 00:00:19.480 --> 00:00:21.940 that's surprisingly common, particularly among 00:00:21.940 --> 00:00:24.399 athletes who throw or do a lot of overhead work. 00:00:24.679 --> 00:00:27.199 But it also presents, well, a real puzzle for 00:00:27.199 --> 00:00:29.820 diagnosis and treatment. We're talking about 00:00:29.820 --> 00:00:32.600 superior labrum, anterior and posterior tears, 00:00:33.140 --> 00:00:36.520 or SLAP lesions. This isn't just some abstract 00:00:36.520 --> 00:00:38.880 medical term, it's something that sidelines athletes 00:00:38.880 --> 00:00:41.859 and causes persistent pain for many people. To 00:00:41.859 --> 00:00:43.579 understand it properly, we've pulled insights 00:00:43.579 --> 00:00:45.840 from peer -reviewed orthopedic literature, including 00:00:45.840 --> 00:00:47.859 articles from the Journal of the American Academy 00:00:47.859 --> 00:00:51.899 of Orthopedic Surgeons, JAAOS, and reliable foundational 00:00:51.899 --> 00:00:54.600 resources like OrthoBullets. It's a complex corner 00:00:54.600 --> 00:00:56.780 of orthopedics, isn't it? Filled with nuanced 00:00:56.780 --> 00:00:59.960 anatomy and... evolving treatment approaches 00:00:59.960 --> 00:01:01.560 and we're going to guide you through the most 00:01:01.560 --> 00:01:04.079 important bits. I've always been fascinated by 00:01:04.079 --> 00:01:06.719 SLAP tiers because they seem to be talked about 00:01:06.719 --> 00:01:09.239 constantly in sports medicine but figuring out 00:01:09.239 --> 00:01:11.299 what's really going on and how to best fix them. 00:01:11.640 --> 00:01:13.980 Well it seems to be a source of ongoing debate. 00:01:14.219 --> 00:01:17.000 Oh absolutely. They are a real challenge in clinical 00:01:17.000 --> 00:01:19.439 practice. The symptoms can overlap with other 00:01:19.439 --> 00:01:22.120 shoulder issues. You know imaging requires a 00:01:22.120 --> 00:01:24.620 discerning eye and as the sources highlight deciding 00:01:24.620 --> 00:01:26.760 on the optimal management strategy especially 00:01:26.760 --> 00:01:29.030 for different patient profiles. files involves 00:01:29.030 --> 00:01:31.230 navigating quite a few factors. There's no simple 00:01:31.230 --> 00:01:33.629 formula, really, which is why understanding the 00:01:33.629 --> 00:01:35.909 underlying anatomy and pathology is so critical. 00:01:36.730 --> 00:01:38.849 OK, let's unpack this then, starting with the 00:01:38.849 --> 00:01:43.049 absolute basics. We hear SLAP lesion. What exactly 00:01:43.049 --> 00:01:45.930 is this tear, and where is it located in the 00:01:45.930 --> 00:01:47.810 shoulder? Right. So at its most fundamental, 00:01:48.250 --> 00:01:51.450 a SLAP lesion is an injury to the superior labrum 00:01:51.450 --> 00:01:55.439 of the shoulder. The acronym SLAP stands for 00:01:55.439 --> 00:01:59.219 superior labrum anterior and posterior. This 00:01:59.219 --> 00:02:01.500 means the tear is specifically located in the 00:02:01.500 --> 00:02:04.060 top, the superior portion of the ring of cartilage 00:02:04.060 --> 00:02:06.939 surrounding the shoulder socket. And the crucial 00:02:06.939 --> 00:02:09.379 characteristic defining this SLAP tear is that 00:02:09.379 --> 00:02:11.960 this tear involves the superior labrum, and critically 00:02:11.960 --> 00:02:14.500 it extends from the front, the anterior, to the 00:02:14.500 --> 00:02:17.280 back, the posterior, encompassing the area where 00:02:17.280 --> 00:02:19.560 the long head of the biceps tendon attaches to 00:02:19.560 --> 00:02:22.310 the labrum. Ah, I see. So it's not just any tear 00:02:22.310 --> 00:02:24.490 of that cartilage ring. It's a specific tear 00:02:24.490 --> 00:02:26.530 in the upper part, right where the biceps hooks 00:02:26.530 --> 00:02:29.810 in. Precisely. Yeah, exactly. To fully appreciate 00:02:29.810 --> 00:02:31.870 this, let's maybe take a moment for a quick tour 00:02:31.870 --> 00:02:33.930 of the shoulder anatomy, as described in the 00:02:33.930 --> 00:02:36.590 sources. The shoulder is basically a ball and 00:02:36.590 --> 00:02:39.289 socket joint. You have the ball, which is the 00:02:39.289 --> 00:02:41.650 head of your humerus, your upper arm bone. Right. 00:02:41.849 --> 00:02:43.969 And it fits into a rather shallow socket on your 00:02:43.969 --> 00:02:46.810 shoulder blade called the glenoid. Now, because 00:02:46.810 --> 00:02:50.129 that glenoid socket is relatively flat, the labrum 00:02:50.129 --> 00:02:52.810 comes into play. And the labrum is sort of like 00:02:52.810 --> 00:02:55.949 a bumper or a seal? Yes. Think of the labrum 00:02:55.949 --> 00:02:58.110 as a rim or a bumper. That's a good way to put 00:02:58.110 --> 00:03:01.590 it. It's a ring of tough fibrocartilaginous tissue 00:03:01.590 --> 00:03:03.810 that attaches around the edge of the glenoid 00:03:03.810 --> 00:03:06.969 socket. Its main job is really to deepen that 00:03:06.969 --> 00:03:09.069 socket, making the shoulder joint inherently 00:03:09.069 --> 00:03:12.090 more stable. It increases the contact area between 00:03:12.090 --> 00:03:14.189 the humerus and the glenoid. It helps keep the 00:03:14.189 --> 00:03:17.120 ball centered in the socket. Beyond deepening 00:03:17.120 --> 00:03:19.639 the socket, the labrum also serves as an important 00:03:19.639 --> 00:03:21.460 attachment point for some of the key ligaments 00:03:21.460 --> 00:03:23.340 that provide stability to the shoulder joint. 00:03:23.819 --> 00:03:26.139 And, as we just mentioned, it's the attachment 00:03:26.139 --> 00:03:28.259 site for the long head of the biceps tendon. 00:03:28.780 --> 00:03:30.680 Right, let's zero in on that biceps connection 00:03:30.680 --> 00:03:34.060 then. It seems absolutely central to SLAP tears. 00:03:34.099 --> 00:03:36.740 How does the long head of the biceps attach there? 00:03:36.840 --> 00:03:39.419 Okay, the long head of the biceps tendon actually 00:03:39.419 --> 00:03:42.020 originates just above the shoulder socket at 00:03:42.020 --> 00:03:44.580 a point called the supraglenoid tubercle on the 00:03:44.580 --> 00:03:47.189 scapula. It then travels through the shoulder 00:03:47.189 --> 00:03:50.689 joint before blending with and attaching to the 00:03:50.689 --> 00:03:53.590 superior portion of the labrum. According to 00:03:53.590 --> 00:03:56.090 anatomical descriptions in the sources, the long 00:03:56.090 --> 00:03:58.250 head of the biceps tendon commonly has a sort 00:03:58.250 --> 00:04:01.090 of split attachment. Roughly 50 % of its fiber 00:04:01.090 --> 00:04:03.030 is attached directly to the superior labrum. 00:04:04.250 --> 00:04:07.650 And the other 50 % attached to that bony supraglinoid 00:04:07.650 --> 00:04:10.590 tubercle. The tubercle itself is located about 00:04:10.590 --> 00:04:13.669 six millimeters medial or towards the body's 00:04:13.669 --> 00:04:16.670 midline. from the actual articular surface of 00:04:16.670 --> 00:04:19.649 the glenoid. This point of attachment is generally 00:04:19.649 --> 00:04:22.649 located posterior to the 12 o 'clock position 00:04:22.649 --> 00:04:25.029 on the superior glenoid when you're looking at 00:04:25.029 --> 00:04:27.949 it arthroscopically. And you mentioned anatomical 00:04:27.949 --> 00:04:30.269 variations in how the biceps attaches. Does that 00:04:30.269 --> 00:04:32.550 add another layer of complexity? It absolutely 00:04:32.550 --> 00:04:35.589 does, yes. The way the biceps tendon attaches 00:04:35.589 --> 00:04:38.110 to the superior labrum isn't identical in everyone. 00:04:38.910 --> 00:04:40.910 There's this thing called the two -ahead classification 00:04:40.910 --> 00:04:43.220 system. referenced in the sources, describes 00:04:43.220 --> 00:04:45.680 some of these patterns. Type I is where the attachment 00:04:45.680 --> 00:04:48.120 is completely posterior to that 12 o 'clock position 00:04:48.120 --> 00:04:51.139 on the glenoid. Type II is predominantly posterior. 00:04:51.560 --> 00:04:53.819 Type III has fibers attaching both anteriorly 00:04:53.819 --> 00:04:56.620 and posteriorly. and type four is when the entire 00:04:56.620 --> 00:04:59.000 attachment is anterior to the 12 o 'clock position. 00:04:59.639 --> 00:05:01.639 The sources indicate that top eye and two attachments 00:05:01.639 --> 00:05:04.040 are by far the most common, accounting for over 00:05:04.040 --> 00:05:07.379 70 % of the anatomical variations observed. Understanding 00:05:07.379 --> 00:05:09.720 these normal variations is important because, 00:05:09.899 --> 00:05:11.939 well, they can influence how a tear presents 00:05:11.939 --> 00:05:14.800 or how a surgeon views the anatomy during surgery. 00:05:15.720 --> 00:05:18.279 Another relevant anatomical detail is that the 00:05:18.279 --> 00:05:21.079 long head of the biceps tendon, It actually has 00:05:21.079 --> 00:05:24.459 its porous blood supply. Precisely where it versus 00:05:24.459 --> 00:05:27.579 through the shoulder joint. This limited blood 00:05:27.579 --> 00:05:30.139 flow could potentially impact its ability to 00:05:30.139 --> 00:05:33.180 heal after injury. Limited blood flow. That sounds 00:05:33.180 --> 00:05:35.160 like a key piece of information. And what about 00:05:35.160 --> 00:05:37.439 the labrum itself? Does its blood supply vary? 00:05:37.980 --> 00:05:40.759 Yes, it does. The labrum receives its blood supply 00:05:40.759 --> 00:05:43.480 not from the underlying bone, but from the surrounding 00:05:43.480 --> 00:05:47.420 joint capsule and periosteal vessels. And critically, 00:05:47.620 --> 00:05:49.819 the anterior superior portion of the labrum seems 00:05:49.819 --> 00:05:52.279 to have the poorest blood supply compared to 00:05:52.279 --> 00:05:53.939 other parts of the rim. Couple this with the 00:05:53.939 --> 00:05:55.959 fact that the superior labrum attaches slightly 00:05:55.959 --> 00:05:58.639 further medially on the glenoid compared to the 00:05:58.639 --> 00:06:00.800 inferior labrum, making it a bit less firmly 00:06:00.800 --> 00:06:03.379 supported at its base, you could say. And it 00:06:03.379 --> 00:06:06.339 becomes clearer why this specific area where 00:06:06.339 --> 00:06:08.980 the biceps tendon anchors can be considered something 00:06:08.980 --> 00:06:12.180 of a weak link if prone to injury under certain 00:06:12.180 --> 00:06:15.740 forces, resulting in a SLAP tear. So the very 00:06:15.740 --> 00:06:18.879 anatomy of that superior labrum and biceps anchor 00:06:18.879 --> 00:06:22.120 area kind of predisposes it to tearing. And speaking 00:06:22.120 --> 00:06:25.120 of anatomy looking like tears, you mentioned 00:06:25.120 --> 00:06:28.060 those tricky anatomical variants that can sometimes 00:06:28.060 --> 00:06:30.660 fool even experienced eyes. That sounds like 00:06:30.660 --> 00:06:33.959 a major diagnostic hurdle. It's a very significant 00:06:33.959 --> 00:06:36.079 point, yes. particularly for surgeons looking 00:06:36.079 --> 00:06:38.680 inside the joint. There are two main anatomical 00:06:38.680 --> 00:06:40.839 variants in the superior labrum area that can 00:06:40.839 --> 00:06:44.480 easily be mistaken for a tear on imaging or during 00:06:44.480 --> 00:06:46.620 arthroscopy if you're not acutely aware of them. 00:06:46.779 --> 00:06:49.899 One is called the sublaboral recess or sublaboral 00:06:49.899 --> 00:06:53.639 foramen. This is a normal non -pathological separation 00:06:53.639 --> 00:06:56.779 or space between the superior labrum and the 00:06:56.779 --> 00:06:59.519 underlying glenoid bone. It's just how the anatomy 00:06:59.519 --> 00:07:02.319 is configured in some people. It can sometimes 00:07:02.319 --> 00:07:04.920 be associated with a thicker than usual middle 00:07:04.920 --> 00:07:06.899 glenohumeral ligament, which is another ligament 00:07:06.899 --> 00:07:09.819 in the shoulder. The key challenge is distinguishing 00:07:09.819 --> 00:07:12.500 this normal space from a true tear, where the 00:07:12.500 --> 00:07:14.839 labrum is detached and actually causing symptoms. 00:07:15.720 --> 00:07:18.579 On an MRI arthrogram, dye might enter this normal 00:07:18.579 --> 00:07:20.620 recess, which can be confusing. I can see that. 00:07:20.819 --> 00:07:22.819 But the pattern is usually distinct from dye 00:07:22.819 --> 00:07:25.350 entering a tear. It tends to be smoother. OK, 00:07:25.430 --> 00:07:27.790 and the second variant? The second crucial variant 00:07:27.790 --> 00:07:31.629 is the Buford complex. This is a specific anatomical 00:07:31.629 --> 00:07:33.829 arrangement where the middle glenohumeral ligament 00:07:33.829 --> 00:07:36.370 is very thick and cord -like, and it originates 00:07:36.370 --> 00:07:38.810 directly from the superior labrum. When this 00:07:38.810 --> 00:07:41.069 happens, there is a congenital absence, or a 00:07:41.069 --> 00:07:44.629 bare area, of the antero -superior labrum. It 00:07:44.629 --> 00:07:46.769 looks like a piece of the labrum is missing or 00:07:46.769 --> 00:07:49.810 torn anteriorly. But it's not. But it's actually 00:07:49.810 --> 00:07:52.029 a normal developmental variant present in a small 00:07:52.029 --> 00:07:54.720 percentage of the population. And why is recognizing 00:07:54.720 --> 00:07:57.420 the Buford complex so critical? What happens 00:07:57.420 --> 00:07:59.740 if a surgeon mistakes it for a tear and tries 00:07:59.740 --> 00:08:03.079 to fix that bare area? This is where the clinical 00:08:03.079 --> 00:08:06.199 pitfall lies. It's really important. If a surgeon 00:08:06.199 --> 00:08:09.259 doesn't recognize the Buford complex and mistakenly 00:08:09.259 --> 00:08:12.060 repair that bare, antro -superior area of the 00:08:12.060 --> 00:08:14.300 labrum to the glenoid, believing it's a tear, 00:08:14.560 --> 00:08:17.180 they will significantly restrict the patient's 00:08:17.180 --> 00:08:19.730 external rotation of the shoulder. Oh, wow. because 00:08:19.730 --> 00:08:22.430 that thick cord -like ligament is meant to be 00:08:22.430 --> 00:08:24.670 in that position, trying to anchor tissue there 00:08:24.670 --> 00:08:26.569 that isn't supposed to be just restricts normal 00:08:26.569 --> 00:08:29.410 shoulder movement. Recognizing these variants, 00:08:29.589 --> 00:08:31.850 the sublaboral recess, and especially the Buford 00:08:31.850 --> 00:08:34.909 complex, is absolutely paramount for accurate 00:08:34.909 --> 00:08:37.649 diagnosis and avoiding unnecessary surgery that 00:08:37.649 --> 00:08:39.750 can actually cause functional problems. That 00:08:39.750 --> 00:08:42.110 really emphasizes how understanding the normal 00:08:42.110 --> 00:08:44.149 variations is just as important as understanding 00:08:44.149 --> 00:08:46.250 the pathology. It's not just a simple case of, 00:08:46.350 --> 00:08:50.879 is there a tear or isn't there? Okay, so we know 00:08:50.879 --> 00:08:53.340 what SLAP lesion is anatomically and some of 00:08:53.340 --> 00:08:55.440 the quirks in that region. Who was most likely 00:08:55.440 --> 00:08:58.179 to get one of these tears and what typically 00:08:58.179 --> 00:09:01.220 causes them? Well, while SLAP lesions account 00:09:01.220 --> 00:09:03.539 for a relatively small percentage of all shoulder 00:09:03.539 --> 00:09:06.539 injuries, less than 5 % according to the sources. 00:09:06.639 --> 00:09:09.399 Less than 5%. They are disproportionately seen 00:09:09.399 --> 00:09:12.480 in specific groups. The classic patient is the 00:09:12.480 --> 00:09:15.259 overhead or throwing athlete. Often in their 00:09:15.259 --> 00:09:17.899 dominant arm think baseball pitchers, javelin 00:09:17.899 --> 00:09:20.279 throwers, volleyball or tennis players, that 00:09:20.279 --> 00:09:23.059 sort of thing. However, they can also occur in 00:09:23.059 --> 00:09:25.080 older patients, particularly as a result of a 00:09:25.080 --> 00:09:28.200 traumatic fall onto an outstretched arm. Are 00:09:28.200 --> 00:09:30.840 there specific risk factors or certain movements 00:09:30.840 --> 00:09:33.919 that are known to cause these tears? Yes, repetitive 00:09:33.919 --> 00:09:36.440 overhead activities are the prime suspect in 00:09:36.440 --> 00:09:39.480 athletes. The sheer volume and force of throwing 00:09:39.480 --> 00:09:42.240 or soothing motions put immense stress on that 00:09:42.240 --> 00:09:45.019 superior labrum and biceps anchor. Other common 00:09:45.019 --> 00:09:47.600 mechanisms of injury include falling directly 00:09:47.600 --> 00:09:50.139 onto an outstretched arm, especially if the arm 00:09:50.139 --> 00:09:52.940 is slightly bent and the biceps muscle is tensed 00:09:52.940 --> 00:09:55.919 at the time of impact. A sudden forceful pull 00:09:55.919 --> 00:09:58.360 on the arm, like trying to catch a heavy object 00:09:58.360 --> 00:10:01.240 unexpectedly, or rapid forceful movements of 00:10:01.240 --> 00:10:03.679 the arm above shoulder level can also generate 00:10:03.679 --> 00:10:06.850 enough force to tear the superior labrum. And 00:10:06.850 --> 00:10:09.710 interestingly, a shoulder dislocation can sometimes 00:10:09.710 --> 00:10:12.789 peel the labrum off the glenoid rim, occasionally 00:10:12.789 --> 00:10:15.309 including the superior portion involved in a 00:10:15.309 --> 00:10:18.470 SLAP tear. You mentioned a theory about throwers 00:10:18.470 --> 00:10:21.110 specifically linking tightness to the injury. 00:10:21.250 --> 00:10:23.409 Can you elaborate a bit on that biomechanics? 00:10:23.789 --> 00:10:25.669 Absolutely. This is where some of the deeper 00:10:25.669 --> 00:10:28.440 insight into the pathology comes from. There's 00:10:28.440 --> 00:10:30.460 a well regarded theory that in throwing athletes 00:10:30.460 --> 00:10:32.580 who often develop tightness in the posterior 00:10:32.580 --> 00:10:35.580 capsule and the posterior inferior glenohumeral 00:10:35.580 --> 00:10:37.500 ligament. Right, the back of the shoulder. Exactly. 00:10:37.639 --> 00:10:40.000 Which is a key stabilizing structure at the back 00:10:40.000 --> 00:10:42.700 and bottom of the shoulder. This tightness can 00:10:42.700 --> 00:10:45.139 alter the mechanics of the throwing motion. As 00:10:45.139 --> 00:10:47.039 the arm moves through the late cocking phase 00:10:47.039 --> 00:10:50.320 and into acceleration, this posterior tightness 00:10:50.320 --> 00:10:53.200 can cause the ball of the humerus to shift post 00:10:53.200 --> 00:10:56.080 -rosuperiorly upwards and backwards relative 00:10:56.080 --> 00:10:59.720 to the glenoid socket. This abnormal shift increases 00:10:59.720 --> 00:11:02.360 the sheer force applied to the superior labrum, 00:11:02.919 --> 00:11:04.720 effectively sort of grinding or peeling it away 00:11:04.720 --> 00:11:06.840 from the bone, especially where the biceps tend 00:11:06.840 --> 00:11:09.600 to detaches. Furthermore, the sources point out 00:11:09.600 --> 00:11:13.179 that once a SLAP lesion is present, this detached 00:11:13.179 --> 00:11:16.399 superior labrum and biceps anchor can then increase 00:11:16.399 --> 00:11:19.179 the strain on the anterior band of the inferior 00:11:19.179 --> 00:11:21.700 glenohumeral ligament. Which is the main stabilizer 00:11:21.700 --> 00:11:23.820 at the front. Precisely, the primary anterior 00:11:23.820 --> 00:11:25.559 stabilizer of the shoulder. This can lead to 00:11:25.559 --> 00:11:28.120 a sort of vicious cycle where the SLAP tear contributes 00:11:28.120 --> 00:11:30.620 to subtle instability, further disrupting normal 00:11:30.620 --> 00:11:33.519 mechanics. That's fascinating. So the injury 00:11:33.519 --> 00:11:35.419 itself can potentially worsen the underlying 00:11:35.419 --> 00:11:38.210 problem or contribute to instability. It's not 00:11:38.210 --> 00:11:40.309 just about the tear itself, but how the tear 00:11:40.309 --> 00:11:42.929 changes the shoulders function. And you noted 00:11:42.929 --> 00:11:44.929 that in older patients, it might not be from 00:11:44.929 --> 00:11:47.350 trauma, but just wear and tear. Correct, yeah. 00:11:47.669 --> 00:11:50.730 In individuals over the age of, say, 30 or 40, 00:11:51.269 --> 00:11:53.590 it's not uncommon to see some degree of fraying 00:11:53.590 --> 00:11:56.350 or degenerative changes in the superior labrum 00:11:56.350 --> 00:11:59.870 on MRI or during arthroscopy. This could just 00:11:59.870 --> 00:12:02.889 be a normal part of aging. and doesn't necessarily 00:12:02.889 --> 00:12:05.529 cause symptoms or require treatment unless there 00:12:05.529 --> 00:12:08.389 was a specific traumatic event superimposed on 00:12:08.389 --> 00:12:10.929 these degenerative changes. Right. Differentiating 00:12:10.929 --> 00:12:13.350 between a symptomatic tear and just age -related 00:12:13.350 --> 00:12:15.350 fraying is another critical diagnostic step. 00:12:15.470 --> 00:12:18.190 It's not always easy. And are SLAP tears usually 00:12:18.190 --> 00:12:20.470 isolated injuries or do they often come with 00:12:20.470 --> 00:12:22.870 other problems in the shoulder joint? They frequently 00:12:22.870 --> 00:12:25.870 have company, yes. SLAP lesions are often associated 00:12:25.870 --> 00:12:27.330 with other shoulder conditions, particularly 00:12:27.330 --> 00:12:29.389 in throwing athletes. These can include things 00:12:29.389 --> 00:12:31.710 like internal impingement. Or the cuff gets pinched. 00:12:31.830 --> 00:12:34.070 Yeah, where the rotator cuff tendon gets pinched 00:12:34.070 --> 00:12:37.230 in certain overhead positions. Also glenohumeral 00:12:37.230 --> 00:12:40.350 internal rotation deficit, or GIRD, which is 00:12:40.350 --> 00:12:42.929 that posterior tightness we discussed. Rotator 00:12:42.929 --> 00:12:45.350 cuff tears are common too. Often partial thickness 00:12:45.350 --> 00:12:48.549 tears on the articular or joint side. Subtle 00:12:48.549 --> 00:12:50.809 shoulder instability and scapular dyskinesis 00:12:50.809 --> 00:12:52.950 that's abnormal movement or positioning of the 00:12:52.950 --> 00:12:55.850 shoulder blade during arm motion. Okay. Addressing 00:12:55.850 --> 00:12:58.190 these associated conditions is often really important 00:12:58.190 --> 00:13:00.450 for successful management, whether you go surgical 00:13:00.450 --> 00:13:03.710 or non -operative. Okay. We understand the anatomy, 00:13:03.789 --> 00:13:06.309 who gets them, and how they might happen. Now, 00:13:06.330 --> 00:13:08.950 for the detective work, how do doctors actually 00:13:08.950 --> 00:13:11.759 figure out if someone has a celipate tear? What 00:13:11.759 --> 00:13:14.019 does the patient feel and what does the examination 00:13:14.019 --> 00:13:16.740 involve? Right. Well, from the patient's perspective, 00:13:17.340 --> 00:13:19.620 the symptoms of a cell A pay tear can be somewhat 00:13:19.620 --> 00:13:22.340 inconsistent and often mimic other shoulder problems, 00:13:22.559 --> 00:13:24.059 which, as we said, is part of the diagnostic 00:13:24.059 --> 00:13:27.259 challenge. Common complaints include a deep aching 00:13:27.259 --> 00:13:29.139 pain within the shoulder that's often difficult 00:13:29.139 --> 00:13:31.919 to localize precisely. People struggle to point 00:13:31.919 --> 00:13:34.549 exactly where it hurts. A key symptom is often 00:13:34.549 --> 00:13:37.230 mechanical people describe hearing or feeling 00:13:37.230 --> 00:13:40.789 popping, clicking, catching, or grinding sensations 00:13:40.789 --> 00:13:43.399 in the shoulder with certain movements. Pain 00:13:43.399 --> 00:13:45.799 is typically aggravated by specific positions, 00:13:46.360 --> 00:13:48.299 especially those involving overhead activities 00:13:48.299 --> 00:13:52.100 or when lifting heavy objects. Athletes, particularly 00:13:52.100 --> 00:13:54.519 throwers, might notice a significant decrease 00:13:54.519 --> 00:13:56.620 in their performance, maybe loss of velocity 00:13:56.620 --> 00:13:59.500 or control, feeling weakness, or experiencing 00:13:59.500 --> 00:14:01.679 what's sometimes called a dead arm sensation 00:14:01.679 --> 00:14:04.519 after throwing. The dead arm, yeah. Some patients 00:14:04.519 --> 00:14:06.899 also report a feeling of apprehension, or like 00:14:06.899 --> 00:14:09.500 the shoulder might pop out. And studies suggest 00:14:09.500 --> 00:14:11.740 apprehension tests are actually positive in a 00:14:11.740 --> 00:14:15.179 high percentage, around 85 % of patients with 00:14:15.179 --> 00:14:19.259 SLAP tears. 85%, that's quite high. It is. Reduced 00:14:19.259 --> 00:14:21.820 range of motion or easy fatigue ability can also 00:14:21.820 --> 00:14:24.419 occur. And it's worth noting that sometimes symptoms 00:14:24.419 --> 00:14:26.679 might not fully manifest immediately after the 00:14:26.679 --> 00:14:29.200 injury, but rather develop gradually over time. 00:14:29.480 --> 00:14:31.620 So the symptoms are broad and can sound like 00:14:31.620 --> 00:14:33.620 other things. How does a doctor approach trying 00:14:33.620 --> 00:14:36.519 to pin down if it's actually a SLI peer? Well, 00:14:36.600 --> 00:14:39.340 the diagnostic process begins, as with any injury 00:14:39.340 --> 00:14:42.240 really, with a detailed medical history. The 00:14:42.240 --> 00:14:44.139 doctor will ask about the onset of the pain, 00:14:44.259 --> 00:14:46.340 whether there's a specific injury or if it came 00:14:46.340 --> 00:14:48.860 on gradually. What activities make it worse? 00:14:49.129 --> 00:14:52.690 especially work or sports, the exact location 00:14:52.690 --> 00:14:55.950 and character of the pain, and any previous treatments 00:14:55.950 --> 00:14:58.649 they might have tried. The patient's age and 00:14:58.649 --> 00:15:01.330 activity level are also critical pieces of information. 00:15:02.789 --> 00:15:05.230 Following the history, a thorough physical examination 00:15:05.230 --> 00:15:08.389 is performed. This involves assessing the shoulder's 00:15:08.389 --> 00:15:10.850 range of motion in different planes, evaluating 00:15:10.850 --> 00:15:13.470 muscle strength, and testing the overall stability 00:15:13.470 --> 00:15:16.019 of the joint. A key component of the physical 00:15:16.019 --> 00:15:19.179 exam for suspected SLA key tears involves performing 00:15:19.179 --> 00:15:21.379 what are called provocative tests. Provocative 00:15:21.379 --> 00:15:23.799 tests. These are specific maneuvers where the 00:15:23.799 --> 00:15:26.039 doctor moves the patient's arm into positions 00:15:26.039 --> 00:15:28.000 designed to put stress on the superior labrum 00:15:28.000 --> 00:15:30.179 and biceps anchor to see if they can reproduce 00:15:30.179 --> 00:15:32.399 the patient's pain or mechanical symptoms. Are 00:15:32.399 --> 00:15:34.799 these provocative tests definitive? Like, if 00:15:34.799 --> 00:15:36.940 one test is positive, you know for sure it's 00:15:36.940 --> 00:15:40.220 a SLA P tear. Ah, this is a critical point from 00:15:40.220 --> 00:15:43.059 the sources and really highlights the diagnostic 00:15:43.059 --> 00:15:47.340 difficulty. There is no single physical examination 00:15:47.340 --> 00:15:50.539 test that is perfectly sensitive or specific 00:15:50.539 --> 00:15:54.139 for diagnosing a SLAP lesion on its own. Right. 00:15:54.399 --> 00:15:58.440 No silver bullet test. Exactly. A diagnosis is 00:15:58.440 --> 00:16:00.779 based on the combination of the patient's history, 00:16:01.259 --> 00:16:03.720 their reported symptoms, and the findings from 00:16:03.720 --> 00:16:06.460 multiple provocative tests, along with of course 00:16:06.460 --> 00:16:08.279 the imaging results. It's putting all the pieces 00:16:08.279 --> 00:16:10.429 together. Can you walk us through a couple of 00:16:10.429 --> 00:16:13.250 these provocative tests and maybe explain why 00:16:13.250 --> 00:16:16.370 they might reproduce symptoms if a SLIP is present? 00:16:16.750 --> 00:16:19.309 What's the thinking behind them? Certainly. The 00:16:19.309 --> 00:16:21.710 sources list several. Some are general biceps 00:16:21.710 --> 00:16:24.649 provocation tests like Speed's test or Jurgesson's 00:16:24.649 --> 00:16:26.269 test, though these can be positive with other 00:16:26.269 --> 00:16:28.269 biceps issues too, so they're not super specific. 00:16:28.889 --> 00:16:31.769 More specific SLAP tests include the active compression 00:16:31.769 --> 00:16:34.029 test, often known as O 'Brien's test. O 'Brien's 00:16:34.029 --> 00:16:35.289 test, yeah, I've heard of that one. The crank 00:16:35.289 --> 00:16:37.309 test, the dynamic labral shear test, and the 00:16:37.309 --> 00:16:39.029 Kibler anterior slide test. There are quite a 00:16:39.029 --> 00:16:41.549 few. Let's look at the O 'Brien's test as it's 00:16:41.549 --> 00:16:44.440 commonly used. The patient flexes their arm forward 00:16:44.440 --> 00:16:47.419 to 90 degrees, adducts it about 10, 15 degrees 00:16:47.419 --> 00:16:50.139 across the body, and internally rotates it so 00:16:50.139 --> 00:16:53.240 the thumb points down. Right, thumb down, arm 00:16:53.240 --> 00:16:56.279 across. Exactly. The doctor then applies downward 00:16:56.279 --> 00:16:59.840 resistance, and the patient resists. This position, 00:17:00.200 --> 00:17:02.559 with the arm slightly across the body and internally 00:17:02.559 --> 00:17:05.319 rotated, is thought to put a twisting or torsional 00:17:05.319 --> 00:17:08.099 stress on the superior labrum and biceps anchor. 00:17:08.859 --> 00:17:11.480 Then the arm is externally rotated, so the palm 00:17:11.480 --> 00:17:14.230 is up, and the resistance is applied again. A 00:17:14.230 --> 00:17:16.509 positive test is if the pain or clicking experience 00:17:16.509 --> 00:17:19.049 with the thumb down position is reduced or eliminated 00:17:19.049 --> 00:17:21.430 when the palm is up, particularly if the pain 00:17:21.430 --> 00:17:24.210 is felt deep inside the shoulder. The idea is 00:17:24.210 --> 00:17:26.269 that with the thumb down, the superior labrum 00:17:26.269 --> 00:17:28.750 is being loaded and perhaps peeled away slightly, 00:17:29.190 --> 00:17:31.490 while with the palm up, that stress is relieved. 00:17:31.650 --> 00:17:33.589 I see. And the crank test, how does that one 00:17:33.589 --> 00:17:35.569 work? For the crank test, the arm is abducted, 00:17:35.730 --> 00:17:38.269 so lift it away from the body to about 120 degrees. 00:17:38.730 --> 00:17:41.509 The doctor applies an axial load, basically pushing 00:17:41.509 --> 00:17:43.609 the humerus head into the socket gently, and 00:17:43.609 --> 00:17:45.910 then rotates the arm internally and externally. 00:17:46.410 --> 00:17:48.829 This maneuver is designed to try and catch or 00:17:48.829 --> 00:17:51.970 pinch a torn labral flap between the humerus 00:17:51.970 --> 00:17:54.549 head and the glenoid. It's trying to reproduce 00:17:54.549 --> 00:17:56.849 those catching or clicking mechanical symptoms. 00:17:57.450 --> 00:18:00.250 The presence of pain or a click, especially during 00:18:00.250 --> 00:18:02.950 external rotation with that axial load, can suggest 00:18:02.950 --> 00:18:06.190 a superior label tear. Right. But again, it's 00:18:06.190 --> 00:18:08.970 crucial to remember a positive result on any 00:18:08.970 --> 00:18:11.710 single test isn't proof positive. It just raises 00:18:11.710 --> 00:18:13.650 suspicion that needs to be confirmed by other 00:18:13.650 --> 00:18:16.329 means like imaging. That makes sense. You're 00:18:16.329 --> 00:18:19.230 essentially trying to manually stress that specific 00:18:19.230 --> 00:18:21.789 area where the tear might be to see if you can 00:18:21.789 --> 00:18:24.609 reproduce the patient's symptoms. Given that 00:18:24.609 --> 00:18:27.109 physical tests aren't definitive, imaging must 00:18:27.109 --> 00:18:29.980 play a really crucial role then. What do they 00:18:29.980 --> 00:18:32.359 use and how good is it at actually seeing these 00:18:32.359 --> 00:18:35.119 tears? You're right. Imaging is essential. Standard 00:18:35.119 --> 00:18:37.380 x -rays are usually the first step, but they 00:18:37.380 --> 00:18:40.000 primarily show bone, not soft tissues like the 00:18:40.000 --> 00:18:42.339 labrum. So they'll likely be normal. Exactly. 00:18:42.920 --> 00:18:45.259 X -rays in a patient with a cesolactare are typically 00:18:45.259 --> 00:18:47.680 normal. They're mostly useful for ruling out 00:18:47.680 --> 00:18:49.859 other potential causes of pain, like arthritis, 00:18:50.420 --> 00:18:54.200 bone spurs, or maybe a fracture. Okay. To visualize 00:18:54.200 --> 00:18:56.809 the labrum itself, Magnetic Resonance Imaging, 00:18:57.089 --> 00:19:00.569 or MRI, is the primary tool. On a standard MRI, 00:19:00.970 --> 00:19:03.890 a cell AP p -tear might appear as increased signal 00:19:03.890 --> 00:19:07.349 a brighter area on certain sequences, particularly 00:19:07.349 --> 00:19:09.930 T2 -weighted images between the superior labrum 00:19:09.930 --> 00:19:12.650 and the glenoid bone, usually posterior to where 00:19:12.650 --> 00:19:15.769 the biceps attaches. However, standard MRI sensitivity 00:19:15.769 --> 00:19:18.170 for detaching a cell AP p -tears is only around 00:19:18.170 --> 00:19:21.039 50%. 50%. That sounds pretty low, especially 00:19:21.039 --> 00:19:23.720 for such a key diagnostic tool. It is quite low. 00:19:23.799 --> 00:19:25.660 It means it misses about half of them, although 00:19:25.660 --> 00:19:28.279 its specificity is higher, around 90%. So if 00:19:28.279 --> 00:19:30.559 it sees something, it's likely real, but it misses 00:19:30.559 --> 00:19:32.599 a lot. So how do they improve its accuracy? There 00:19:32.599 --> 00:19:35.119 must be a better way. This is where an MRI arthrogram 00:19:35.119 --> 00:19:37.660 becomes invaluable. This involves injecting a 00:19:37.660 --> 00:19:40.460 contrast agent, basically a dye, directly into 00:19:40.460 --> 00:19:42.619 the shoulder joint before the MRI scan is performed. 00:19:42.779 --> 00:19:45.289 Ah, injecting dye into the joint first. Exactly. 00:19:45.609 --> 00:19:48.269 The dye fills the joint space. If there's a tear 00:19:48.269 --> 00:19:50.609 in the labrum... the dye will leak into that 00:19:50.609 --> 00:19:52.690 tear, highlighting the defect and making it much 00:19:52.690 --> 00:19:55.430 more visible on the scan. The sources are clear 00:19:55.430 --> 00:19:58.490 that an MRI arthrogram significantly increases 00:19:58.490 --> 00:20:01.349 the accuracy for diagnosing labral tears compared 00:20:01.349 --> 00:20:04.369 to a standard MRI. It's really the gold standard 00:20:04.369 --> 00:20:06.769 for imaging these. You can visually distinguish 00:20:06.769 --> 00:20:09.289 between, say, a normal sublabor recess where 00:20:09.289 --> 00:20:11.309 the dye might pool slightly in a smooth pattern 00:20:11.309 --> 00:20:14.190 and a true tear, where the dye seeps irregularly 00:20:14.190 --> 00:20:17.210 into the torn tissue or the defect. The presence 00:20:17.210 --> 00:20:20.180 of a paralabral gangly insist is another important 00:20:20.180 --> 00:20:22.880 imaging finding. These are fluid -filled sacs 00:20:22.880 --> 00:20:25.799 that often form adjacent to a labral tear, particularly 00:20:25.799 --> 00:20:28.200 in the spinoculnoid notch near the shoulder blade. 00:20:28.259 --> 00:20:31.019 Assist near the tear. Yes. And their presence 00:20:31.019 --> 00:20:33.859 on MRI is considered highly specific for an underlying 00:20:33.859 --> 00:20:36.660 labral tear, even if the tear itself is subtle 00:20:36.660 --> 00:20:39.539 or difficult to see directly on the scan. It's 00:20:39.539 --> 00:20:43.269 a strong secondary sign. The diagnosis is really 00:20:43.269 --> 00:20:45.609 a puzzle pieced together from the patient's story, 00:20:45.970 --> 00:20:48.289 the physical exam findings, even if they're not 00:20:48.289 --> 00:20:51.190 definitive individually, and then ideally, a 00:20:51.190 --> 00:20:53.670 specific type of imaging, like an MRI arthrogram. 00:20:54.349 --> 00:20:56.809 Once a tear is identified, the sources talk about 00:20:56.809 --> 00:21:00.250 classification systems. Why bother classifying 00:21:00.250 --> 00:21:02.930 these tears? What's the point? Classification 00:21:02.930 --> 00:21:05.230 systems are used mainly to standardize the description 00:21:05.230 --> 00:21:07.319 of the tear pattern. This helps in communication 00:21:07.319 --> 00:21:11.019 among clinicians, surgeons, physios, and importantly, 00:21:11.259 --> 00:21:13.180 it helps guide treatment decisions. Different 00:21:13.180 --> 00:21:14.940 types of tears might be managed differently. 00:21:15.680 --> 00:21:17.799 The most widely referenced system is the Snyder 00:21:17.799 --> 00:21:20.339 classification, which uniquely describes four 00:21:20.339 --> 00:21:22.940 main types based on the anatomical location and 00:21:22.940 --> 00:21:24.700 the involvement of the biceps tendon anchor. 00:21:25.140 --> 00:21:27.559 Could you briefly explain those Snyder types 00:21:27.559 --> 00:21:30.240 for us? Type I to IV? Certainly. Let's run through 00:21:30.240 --> 00:21:32.559 them. Type I. This is considered more of a degenerative 00:21:32.559 --> 00:21:35.279 tear. It involves fraying of the superior labrum 00:21:35.279 --> 00:21:37.819 and sometimes the biceps tendon itself, but the 00:21:37.819 --> 00:21:39.819 key thing is the biceps anchor remains firmly 00:21:39.819 --> 00:21:42.079 attached to the glenoid. These account for about 00:21:42.079 --> 00:21:45.700 11 % of SLAP lesions. Just fraying anchors okay. 00:21:45.819 --> 00:21:48.960 Got it. Type 2. This is the most common type, 00:21:49.059 --> 00:21:51.059 particularly in throwing athletes, making up 00:21:51.059 --> 00:21:54.240 around 41 % of cases. It involves fraying of 00:21:54.240 --> 00:21:57.279 the superior labrum and a detachment of the biceps 00:21:57.279 --> 00:22:00.380 tendon anchor from the superior glenoid. The 00:22:00.380 --> 00:22:02.319 labrum and biceps anchor are essentially peeled 00:22:02.319 --> 00:22:04.140 away from the bone. Okay, that's the detached 00:22:04.140 --> 00:22:06.680 anchor one. Exactly. Type 3. This is described 00:22:06.680 --> 00:22:09.039 as a bucket -handle tear of the superior labrum. 00:22:09.579 --> 00:22:11.900 A flap of the labrum tears and can displace into 00:22:11.900 --> 00:22:14.220 the joint, but critically, the biceps tendon 00:22:14.220 --> 00:22:16.920 anchor remains intact and attached to the glenoid. 00:22:17.519 --> 00:22:19.799 The biceps actually separates from the torn labral 00:22:19.799 --> 00:22:22.759 flap. These are about 33 % of cases. So the labrum 00:22:22.759 --> 00:22:25.299 tears, but the biceps anchor stays put. Correct. 00:22:25.440 --> 00:22:27.990 And type 4. This is also a bucket -handle tear, 00:22:28.089 --> 00:22:30.750 like type 3, but in this case, the tear extends 00:22:30.750 --> 00:22:33.430 into the biceps tendon itself, and the biceps 00:22:33.430 --> 00:22:35.789 tendon anchor is also detached and remains attached 00:22:35.789 --> 00:22:37.930 to the torn labral flap. These are less common, 00:22:38.049 --> 00:22:40.329 around 15%. Right, so the tear goes into the 00:22:40.329 --> 00:22:42.410 biceps tendon too, and the anchor comes off with 00:22:42.410 --> 00:22:44.089 it. Precisely. And there are more types added 00:22:44.089 --> 00:22:46.170 later. I think you mentioned MAFIT. Yes, that's 00:22:46.170 --> 00:22:49.309 right. The MAFIT classification and others expanded 00:22:49.309 --> 00:22:51.849 the system to include tears extending into other 00:22:51.849 --> 00:22:54.390 parts of the labrum, or associated with other 00:22:54.390 --> 00:22:57.750 ligamentous injuries. For example, type V is 00:22:57.750 --> 00:23:00.609 a type II tear that extends down and forward 00:23:00.609 --> 00:23:03.890 into the antero -inferior labrum, similar to 00:23:03.890 --> 00:23:06.150 a bankart lesion which you see in dislocations. 00:23:06.829 --> 00:23:10.470 Type VI is a type II with an unstable labral 00:23:10.470 --> 00:23:13.890 flap, and type VII involves extension into the 00:23:13.890 --> 00:23:16.930 middle glenohumeral ligament. There are even 00:23:16.930 --> 00:23:20.579 more types described, up to X, but... While these 00:23:20.579 --> 00:23:23.759 extended classifications exist, the Snyder R5 00:23:23.759 --> 00:23:26.000 are really the foundational ones clinicians often 00:23:26.000 --> 00:23:28.619 refer back to. Given the complexity in those 00:23:28.619 --> 00:23:30.740 variants we talked about, is classifying these 00:23:30.740 --> 00:23:33.019 tears always straightforward even when the surgeon 00:23:33.019 --> 00:23:35.480 is looking right at it during surgery? Unfortunately, 00:23:35.680 --> 00:23:37.460 no. This is another challenge highlighted in 00:23:37.460 --> 00:23:40.079 the sources. There's significant inter -observer 00:23:40.079 --> 00:23:42.240 variability. Meaning different surgeons might 00:23:42.240 --> 00:23:44.480 grade it differently. Exactly, and even intra 00:23:44.480 --> 00:23:46.640 -observer variability, where the same surgeon 00:23:46.640 --> 00:23:49.000 might classify the same care differently if they 00:23:49.000 --> 00:23:51.579 looked at it again at different times. This variability 00:23:51.579 --> 00:23:54.240 really underscores the subjective nature of assessing 00:23:54.240 --> 00:23:57.599 these tears. Even with direct visualization during 00:23:57.599 --> 00:24:00.720 arthroscopy. It reinforces that it's not just 00:24:00.720 --> 00:24:03.720 a simple clear -cut diagnosis or classification. 00:24:04.240 --> 00:24:07.059 There's judgment involved. Okay, so we've diagnosed 00:24:07.059 --> 00:24:09.220 it. We've classified it maybe with some variability. 00:24:10.000 --> 00:24:15.000 How do you treat a cell AP tear? Is surgery always 00:24:15.000 --> 00:24:17.980 the answer or is there a non -operative approach 00:24:17.980 --> 00:24:20.279 first? The good news is that surgery is not always 00:24:20.279 --> 00:24:22.839 necessary. And the sources strongly recommend 00:24:22.839 --> 00:24:24.920 starting with non -operative treatment in most 00:24:24.920 --> 00:24:27.240 cases. This is considered the first line of management. 00:24:27.420 --> 00:24:29.859 OK, so try physio first. What does non -operative 00:24:29.859 --> 00:24:32.339 treatment typically involve? Non -operative management 00:24:32.339 --> 00:24:35.319 includes several components. Firstly, rest or 00:24:35.319 --> 00:24:37.319 a modification of activities, especially avoiding 00:24:37.319 --> 00:24:39.119 the movements that cause pain that's particularly 00:24:39.119 --> 00:24:41.220 important for athletes, obviously. Secondly, 00:24:41.680 --> 00:24:44.420 a structured physical therapy program, or physio, 00:24:44.700 --> 00:24:47.559 is crucial. This therapy focuses on regaining 00:24:47.559 --> 00:24:50.160 full, pain -free range of motion, strengthening 00:24:50.160 --> 00:24:52.420 the muscles around the shoulder, especially the 00:24:52.420 --> 00:24:54.319 rotator cuff and the muscles that control the 00:24:54.319 --> 00:24:56.680 shoulder blade. Addressing that scapular dyskinesis 00:24:56.680 --> 00:24:59.259 you mentioned. Precisely. Addressing scapular 00:24:59.259 --> 00:25:01.980 dyskinesis, and importantly, stretching out any 00:25:01.980 --> 00:25:05.299 associated tightness like GIRD, that posterior 00:25:05.299 --> 00:25:09.440 tightness. Thirdly, non -steroidal anti -inflammatory 00:25:09.440 --> 00:25:12.680 medications, NSAIDIDES, can be used to help manage 00:25:12.680 --> 00:25:16.069 pain and reduce inflammation. This non -operative 00:25:16.069 --> 00:25:18.269 approach is typically pursued for a significant 00:25:18.269 --> 00:25:21.029 period usually between three and six months to 00:25:21.029 --> 00:25:22.950 really see if symptoms improve. Three to six 00:25:22.950 --> 00:25:25.130 months, okay. Corticosteroid injections into 00:25:25.130 --> 00:25:27.329 the shoulder joint can also be used often to 00:25:27.329 --> 00:25:30.589 help calm inflammation and sometimes as a diagnostic 00:25:30.589 --> 00:25:32.789 aid if the exact source of the pain is a bit 00:25:32.789 --> 00:25:35.329 unclear. How effective is this non -operative 00:25:35.329 --> 00:25:37.430 approach, especially for that high -demand overhead 00:25:37.430 --> 00:25:39.730 athlete the pitcher may be, who wants to get 00:25:39.730 --> 00:25:42.230 back to throwing at full speed? Ah, this is a 00:25:42.230 --> 00:25:43.970 key distinction made in the sources and it's 00:25:43.970 --> 00:25:46.470 quite important. While non -operative treatment 00:25:46.470 --> 00:25:49.089 can be successful for some individuals, particularly 00:25:49.089 --> 00:25:51.410 those with lower activity demands or maybe more 00:25:51.410 --> 00:25:54.450 degenerative tiers, the data on high -level pitching 00:25:54.450 --> 00:25:56.930 athletes is less encouraging. The number of pitchers 00:25:56.930 --> 00:25:58.970 who successfully return to their prior level 00:25:58.970 --> 00:26:01.349 of performance using only non -surgical methods 00:26:01.349 --> 00:26:04.640 has been described in the literature as Unsatisfactory. 00:26:05.640 --> 00:26:08.039 Unsatisfactory. That's quite blunt. It is. It's 00:26:08.039 --> 00:26:10.559 a critical insight. It suggests that for this 00:26:10.559 --> 00:26:14.140 specific, highly demanding population, non -operative 00:26:14.140 --> 00:26:17.240 treatment, while a necessary first step, often 00:26:17.240 --> 00:26:18.519 doesn't actually get them back to where they 00:26:18.519 --> 00:26:21.599 need to be competitively. That makes sense, unfortunately, 00:26:21.640 --> 00:26:24.359 for them. So if non -operative treatment fails, 00:26:24.700 --> 00:26:27.140 or perhaps if the tear is severe or unstable 00:26:27.140 --> 00:26:29.680 from the outset, surgery comes into consideration. 00:26:29.920 --> 00:26:32.269 What does that involve? Surgical treatment for 00:26:32.269 --> 00:26:35.089 SLAP lesions is typically performed arthroscopically 00:26:35.089 --> 00:26:38.130 keyhole surgery using small incisions, a camera, 00:26:38.369 --> 00:26:40.750 the arthroscope, and specialized miniature instruments. 00:26:41.430 --> 00:26:43.490 The goal of surgery is to address the tear based 00:26:43.490 --> 00:26:46.089 on its type, the patient's age, their activity 00:26:46.089 --> 00:26:48.410 level, and the surgeon's assessment of stability 00:26:48.410 --> 00:26:51.329 and tissue quality. This is also the area where, 00:26:51.529 --> 00:26:54.190 particularly for type 2 tears, there is significant 00:26:54.190 --> 00:26:57.130 ongoing discussion and, as the sources call it, 00:26:57.390 --> 00:26:59.220 quite a bit of controversy. Right, you mentioned 00:26:59.220 --> 00:27:02.480 controversy around type 2 tears. What's the debate 00:27:02.480 --> 00:27:05.299 here? What are the options? Okay, the core debate 00:27:05.299 --> 00:27:07.940 for type 2 tears, remember they're the most common 00:27:07.940 --> 00:27:10.740 in throwers and involve the detached biceps anchor, 00:27:11.279 --> 00:27:13.799 is whether to actually repair the torn labrum 00:27:13.799 --> 00:27:16.779 and reattach the biceps anchor back to the bone. 00:27:16.990 --> 00:27:18.930 The traditional approach. The traditional approach, 00:27:18.930 --> 00:27:22.829 yes. Or, alternatively, whether to perform a 00:27:22.829 --> 00:27:25.490 procedure on the biceps tendon itself, either 00:27:25.490 --> 00:27:28.690 a tenotomy or a tenodesis, and essentially leave 00:27:28.690 --> 00:27:31.690 the superior labrum alone, or perhaps just de 00:27:31.690 --> 00:27:33.910 -bride it, trim it up. Okay, let's clarify those 00:27:33.910 --> 00:27:36.630 biceps procedures again. What exactly are tenotomy 00:27:36.630 --> 00:27:39.369 and tenodesis? Right. Biceps tenotomy is simply 00:27:39.369 --> 00:27:41.490 cutting the long head of the biceps tendon near 00:27:41.490 --> 00:27:43.849 its attachment inside the shoulder joint, allowing 00:27:43.849 --> 00:27:46.150 it to retract down the arm. It essentially removes 00:27:46.150 --> 00:27:48.420 the and pull on the superior labrum. Just cut 00:27:48.420 --> 00:27:51.380 it loose. Pretty much. Biceps tendinesis also 00:27:51.380 --> 00:27:53.660 involves cutting the tendon, but then the cut 00:27:53.660 --> 00:27:55.839 end is reattached, usually with an anchor or 00:27:55.839 --> 00:27:58.900 screw, to the humerus, the upper arm bone, lower 00:27:58.900 --> 00:28:01.559 down, typically outside the shoulder joint itself. 00:28:01.799 --> 00:28:04.059 Okay, cut and reattach it lower down. Exactly. 00:28:04.670 --> 00:28:06.950 Tenodesis is generally preferred over tenotomy 00:28:06.950 --> 00:28:09.309 in active patients because it helps maintain 00:28:09.309 --> 00:28:12.410 biceps strength and the normal shape of the muscle, 00:28:13.049 --> 00:28:14.950 preventing the potential cosmetic deformity called 00:28:14.950 --> 00:28:17.730 a Popeye muscle bulge that can sometimes occur 00:28:17.730 --> 00:28:20.130 with just a tenotomy. Right, the Popeye bulge. 00:28:20.650 --> 00:28:23.470 So traditionally, type 2 tears, especially in 00:28:23.470 --> 00:28:26.569 younger athletes, were repaired. Why the shift 00:28:26.569 --> 00:28:29.170 towards considering tenodesis more often now? 00:28:29.420 --> 00:28:31.940 This is really where the outcomes data is influencing 00:28:31.940 --> 00:28:34.660 practice. While repairing the labrum and biceps 00:28:34.660 --> 00:28:37.759 anchor seems intuitively correct, you know, restoring 00:28:37.759 --> 00:28:39.859 the anatomy. Yeah, it sounds like the right thing 00:28:39.859 --> 00:28:42.519 to do. It does. But recent investigations have 00:28:42.519 --> 00:28:45.700 shown a notable disconnect. A high incidence 00:28:45.700 --> 00:28:48.940 of SLAP repairs being performed, but often disappointing 00:28:48.940 --> 00:28:51.769 return to play rates. particularly for pitchers. 00:28:52.170 --> 00:28:53.829 Studies cited in the sources have shown that 00:28:53.829 --> 00:28:56.609 return -to -play rates after SLAP repairs are 00:28:56.609 --> 00:28:58.950 significantly lower for pitchers compared to 00:28:58.950 --> 00:29:01.109 athletes in other overhead sports like tennis 00:29:01.109 --> 00:29:03.450 or volleyball. Lower for pitchers specifically. 00:29:03.809 --> 00:29:06.690 Interesting. Yes. And importantly, return -to 00:29:06.690 --> 00:29:08.630 -play rates for throwers are actually similar 00:29:08.630 --> 00:29:12.089 whether they undergo a SLAP repair or a biceps 00:29:12.089 --> 00:29:14.970 tenodesis. So the repair doesn't seem to offer 00:29:14.970 --> 00:29:18.009 an advantage for getting back to pitching. Specifically. 00:29:18.289 --> 00:29:20.470 So similar outcomes for return to play, but maybe 00:29:20.470 --> 00:29:23.210 other factors. Exactly. Furthermore, the sources 00:29:23.210 --> 00:29:26.029 highlight a strong association between age and 00:29:26.029 --> 00:29:29.769 the success of SLAP repair. Failures after SLAP 00:29:29.769 --> 00:29:31.890 repair are specifically linked to patients over 00:29:31.890 --> 00:29:35.450 the age of 36. Over 36. OK. This suggests that 00:29:35.450 --> 00:29:38.089 perhaps tissue quality or healing potential might 00:29:38.089 --> 00:29:40.569 be poorer in older patients, making the repair 00:29:40.569 --> 00:29:43.369 less likely to hold reliably or possibly leading 00:29:43.369 --> 00:29:45.349 to complications like stiffness, which we'll 00:29:45.349 --> 00:29:47.799 talk about. Because of these findings, poorer 00:29:47.799 --> 00:29:50.019 return to throwing after repair compared to non 00:29:50.019 --> 00:29:52.160 -throwing sports, similar return to throwing 00:29:52.160 --> 00:29:54.900 between repair and tenodesis, and higher failure 00:29:54.900 --> 00:29:57.259 and stiffness rates in older patients after repair, 00:29:57.660 --> 00:29:59.640 the general consensus among orthopedic surgeons. 00:30:00.259 --> 00:30:02.180 As reflected in the literature, is increasingly 00:30:02.180 --> 00:30:05.319 favoring bicep synotomy or tenodesis, especially 00:30:05.319 --> 00:30:07.500 in patients over the age of 40. Right, so over 00:30:07.500 --> 00:30:10.279 40 lean towards the biceps procedure. Generally, 00:30:10.460 --> 00:30:13.680 yes. For younger, high -level overhead athletes, 00:30:14.180 --> 00:30:16.359 the decision is still debated, it's more nuanced, 00:30:16.779 --> 00:30:18.819 but the pendulum is certainly swinging towards 00:30:18.819 --> 00:30:20.980 considering biceps procedures more frequently. 00:30:21.579 --> 00:30:24.079 Even in this group, if return to high -level 00:30:24.079 --> 00:30:26.960 throwing is the primary goal, simply due to the 00:30:26.960 --> 00:30:29.240 less -than -ideal results seen with repair in 00:30:29.240 --> 00:30:32.160 that specific population. That's a really significant 00:30:32.160 --> 00:30:35.220 shift in thinking, isn't it? Moving away from 00:30:35.220 --> 00:30:38.299 trying to restore the anatomy with repair towards 00:30:38.299 --> 00:30:41.019 essentially just offloading the biceps tension 00:30:41.019 --> 00:30:43.279 because the repair outcomes, particularly for 00:30:43.279 --> 00:30:45.859 throwers or older patients, haven't been as successful 00:30:45.859 --> 00:30:48.359 as everyone hoped. What about the other types 00:30:48.359 --> 00:30:50.980 of tears, types 1, 3, and 4? Right, for type 00:30:50.980 --> 00:30:53.359 I tears, which are just fraying with an intact 00:30:53.359 --> 00:30:55.960 anchor, and maybe some type III or V tears involving 00:30:55.960 --> 00:30:58.140 less than one -third of the biceps tendon without 00:30:58.140 --> 00:31:00.220 significant symptoms after non -operative treatment, 00:31:00.700 --> 00:31:03.079 simple arthroscopic debridement is often sufficient. 00:31:03.240 --> 00:31:05.319 Just trimming the frayed bits. Exactly, just 00:31:05.319 --> 00:31:07.559 trimming away the unstable frayed edges of the 00:31:07.559 --> 00:31:11.400 labrum or biceps. For type 4 tears, where more 00:31:11.400 --> 00:31:13.500 than one -third of the biceps tendon is involved, 00:31:13.720 --> 00:31:15.599 causing severe symptoms that haven't responded 00:31:15.599 --> 00:31:18.099 to non -operative care, the options are typically 00:31:18.099 --> 00:31:21.099 debridement plus either labor repair or biceps 00:31:21.099 --> 00:31:24.059 tendon imidinodesis. The choice here would again 00:31:24.059 --> 00:31:26.200 depend heavily on the patient's age, activity 00:31:26.200 --> 00:31:28.440 level, and the surgeon's preference, considering 00:31:28.440 --> 00:31:30.420 all the same factors we just discussed for type 00:31:30.420 --> 00:31:33.519 2. So treatment is highly individualized based 00:31:33.519 --> 00:31:37.009 on tear type. age, activity goals, and this evolving 00:31:37.009 --> 00:31:40.079 evidence. Once surgery is done, whichever route 00:31:40.079 --> 00:31:42.579 is chosen, what does the road to recovery look 00:31:42.579 --> 00:31:45.720 like? Rehabilitation must be absolutely critical. 00:31:46.160 --> 00:31:48.299 Oh, rehabilitation is absolutely paramount to 00:31:48.299 --> 00:31:50.420 the success of any surgical intervention for 00:31:50.420 --> 00:31:53.180 a cesilite tear, whether it's a repair or a biceps 00:31:53.180 --> 00:31:55.680 procedure. It's not optional, it's essential. 00:31:55.980 --> 00:31:58.839 It's a structured multi -stage process that progresses 00:31:58.839 --> 00:32:01.319 gradually to protect the healing issues while 00:32:01.319 --> 00:32:03.160 carefully restoring motion and strength. Okay, 00:32:03.240 --> 00:32:05.480 what's the initial phase like after the surgery? 00:32:05.720 --> 00:32:08.559 Immediately after surgery, the shoulder is typically 00:32:08.559 --> 00:32:11.819 immobilized in a sling. The duration varies depending 00:32:11.819 --> 00:32:13.940 on the surgery's complexity and the surgeon's 00:32:13.940 --> 00:32:16.160 protocol, but usually ranges from about two to 00:32:16.160 --> 00:32:19.400 six weeks. The initial phase, typically the first 00:32:19.400 --> 00:32:22.099 one to four weeks, focuses heavily on protection 00:32:22.099 --> 00:32:24.619 and controlled motion. Patients are usually allowed 00:32:24.619 --> 00:32:27.339 gentle passive range of motion, where the therapist 00:32:27.549 --> 00:32:30.470 moves the arm, and maybe some active assisted 00:32:30.470 --> 00:32:32.970 range of motion exercises, often in the scapular 00:32:32.970 --> 00:32:35.069 plane, which is arm moving slightly forward from 00:32:35.069 --> 00:32:37.809 the side, kind of a safe zone. Crucially, during 00:32:37.809 --> 00:32:40.990 this phase, it is vital to avoid any extremes 00:32:40.990 --> 00:32:43.430 of abduction and external rotation. Right. Don't 00:32:43.430 --> 00:32:45.910 stretch it out too much. Exactly. And absolutely 00:32:45.910 --> 00:32:48.529 no resisted biceps exercises, especially if the 00:32:48.529 --> 00:32:50.849 biceps anchor was repaired, to protect that healing 00:32:50.849 --> 00:32:52.900 site. You don't want to pull on it. Makes sense. 00:32:53.279 --> 00:32:55.839 What happens as you move beyond that initial 00:32:55.839 --> 00:32:57.920 protective phase, say after the first month or 00:32:57.920 --> 00:33:01.140 so? Around weeks 4 -6, as healing progresses 00:33:01.140 --> 00:33:04.240 and pain allows, the patient typically transitions 00:33:04.240 --> 00:33:07.099 to active range of motion exercises, trying to 00:33:07.099 --> 00:33:09.160 move the arm themselves under their own power. 00:33:09.940 --> 00:33:12.059 They also usually start isometric strengthening 00:33:12.059 --> 00:33:14.240 tensing muscles without actually moving the joint. 00:33:14.410 --> 00:33:17.809 The mid -stage, generally from week 6 -12, involves 00:33:17.809 --> 00:33:19.990 progressing to more functional exercises and 00:33:19.990 --> 00:33:22.049 beginning light -resistant strengthening, really 00:33:22.049 --> 00:33:24.609 focusing on the rotator cuff and those periscapular 00:33:24.609 --> 00:33:26.450 muscles, the ones controlling the shoulder blade. 00:33:27.029 --> 00:33:29.569 The goal is to build foundational strength and 00:33:29.569 --> 00:33:31.869 control. Okay, building back the support system. 00:33:32.069 --> 00:33:34.529 Precisely. The late stage, from 12 weeks onwards, 00:33:35.130 --> 00:33:37.809 involves advancing strengthening exercises, restoring 00:33:37.809 --> 00:33:40.490 full range of motion, and initiating sport -specific 00:33:40.490 --> 00:33:43.329 training if the patient is an athlete. This might 00:33:43.329 --> 00:33:45.630 involve progressive drills mimicking the movements 00:33:45.630 --> 00:33:47.970 required for their sport, like starting a throwing 00:33:47.970 --> 00:33:50.809 program. When can someone realistically expect 00:33:50.809 --> 00:33:53.450 to return to full activity or sport after all 00:33:53.450 --> 00:33:56.069 this? A typical return to full activity or sport 00:33:56.069 --> 00:33:58.990 after SLIP surgery is often quoted around six 00:33:58.990 --> 00:34:01.869 months. However, this timeline is highly variable. 00:34:02.039 --> 00:34:04.779 It really depends on the specific type and severity 00:34:04.779 --> 00:34:07.119 of the injury, the patient's individual healing 00:34:07.119 --> 00:34:10.099 rate, their overall health, and critically, their 00:34:10.099 --> 00:34:12.460 activity goals. Six months is just a ballpark 00:34:12.460 --> 00:34:15.519 figure, them. Very much so. For throwing athletes, 00:34:15.760 --> 00:34:17.800 an early interval throwing program might begin 00:34:17.800 --> 00:34:20.300 around three, four months. But a full return 00:34:20.300 --> 00:34:22.659 to competitive pitching can easily take six months 00:34:22.659 --> 00:34:25.380 or even longer, sometimes nine months to a year, 00:34:25.619 --> 00:34:28.750 to feel truly back to normal. The sources emphasize 00:34:28.750 --> 00:34:30.849 that complete recovery can take several months, 00:34:31.250 --> 00:34:34.130 particularly in more complicated cases. And diligently 00:34:34.130 --> 00:34:36.449 following the surgeon's post -operative instructions 00:34:36.449 --> 00:34:39.769 and the prescribed rehabilitation plan is absolutely 00:34:39.769 --> 00:34:41.969 vital for optimizing the outcome. You simply 00:34:41.969 --> 00:34:43.989 can't rush the biology of healing. That sounds 00:34:43.989 --> 00:34:46.349 like a long and very dedicated process. What 00:34:46.349 --> 00:34:48.530 are the potential roadblocks or complications 00:34:48.530 --> 00:34:51.869 that can occur after SLAP surgery? What can go 00:34:51.869 --> 00:34:54.590 wrong? Well, like any surgical procedure. There 00:34:54.590 --> 00:34:57.690 are potential complications. For SLAP repair 00:34:57.690 --> 00:34:59.949 specifically, the most common complication reported 00:34:59.949 --> 00:35:02.929 in the sources is post -operative stiffness. 00:35:03.789 --> 00:35:05.650 It occurs in a significant percentage of patients, 00:35:05.769 --> 00:35:10.309 one source mentioned, around 78%. 78%. That's 00:35:10.309 --> 00:35:13.230 a very high number for stiffness. Are there specific 00:35:13.230 --> 00:35:15.949 factors that make someone more likely to experience 00:35:15.949 --> 00:35:20.159 stiffness after a SLAP repair? Yes, the sources 00:35:20.159 --> 00:35:22.780 identify significant risk factors for post -operative 00:35:22.780 --> 00:35:26.420 stiffness after SLAP repair. A particularly strong 00:35:26.420 --> 00:35:29.360 risk factor seems to be performing an incidental 00:35:29.360 --> 00:35:32.440 SLAP repair in older patients, specifically those 00:35:32.440 --> 00:35:35.000 over the age of 45, when doing surgery for a 00:35:35.000 --> 00:35:37.239 different primary problem, such as a rotator 00:35:37.239 --> 00:35:40.239 cuff repair. So finding a cell AP tear while 00:35:40.239 --> 00:35:42.239 fixing something else and deciding to repair 00:35:42.239 --> 00:35:44.719 it in an older patient is risky for stiffness. 00:35:45.059 --> 00:35:47.059 Exactly. It reinforces the clinical trend away 00:35:47.059 --> 00:35:49.059 from routinely repairing these lesions in older 00:35:49.059 --> 00:35:51.639 patients and perhaps opting for a biceps procedure 00:35:51.639 --> 00:35:54.219 instead, which tends to have less risk of stiffness. 00:35:54.639 --> 00:35:56.420 And if someone does develop stiffness, how is 00:35:56.420 --> 00:35:58.880 it treated? Can it be fixed? Early recognition 00:35:58.880 --> 00:36:02.280 and intervention are key. Rehabilitation protocols 00:36:02.280 --> 00:36:04.619 are designed to start controlled motion relatively 00:36:04.619 --> 00:36:07.599 early, even in the protective phase. Things like 00:36:07.599 --> 00:36:09.840 pendulum swings are often encouraged, sometimes 00:36:09.840 --> 00:36:12.539 beginning as early as one week post -op, specifically 00:36:12.539 --> 00:36:15.980 to help prevent stiffness setting in. If stiffness 00:36:15.980 --> 00:36:18.780 develops and persists despite dedicated physio, 00:36:19.159 --> 00:36:21.519 a secondary procedure called a capsular release 00:36:21.519 --> 00:36:24.639 might be necessary. This involves arthroscopically 00:36:24.639 --> 00:36:26.820 releasing the tightened tissues, the capsule, 00:36:27.079 --> 00:36:30.480 around the joint to restore motion. Okay. Are 00:36:30.480 --> 00:36:32.820 there other potential complications besides stiffness? 00:36:33.579 --> 00:36:36.219 Yes, other potential complications include, though 00:36:36.219 --> 00:36:38.840 less commonly, injury to the suprascapular nerve. 00:36:39.619 --> 00:36:41.500 This is a nerve near the shoulder blade that 00:36:41.500 --> 00:36:44.019 controls some of the rotator cuff muscles. This 00:36:44.019 --> 00:36:45.980 could potentially happen if the glenoid bone 00:36:45.980 --> 00:36:48.159 is over -drilled during the process of placing 00:36:48.159 --> 00:36:50.900 anchors for a prey pair, as the nerve runs quite 00:36:50.900 --> 00:36:53.780 close by. Careful technique is needed. Right. 00:36:53.960 --> 00:36:56.000 And unfortunately, sometimes the SLAP repair 00:36:56.000 --> 00:36:58.719 simply fails or the patient continues to experience 00:36:58.719 --> 00:37:00.820 symptoms despite the surgery. What typically 00:37:00.820 --> 00:37:03.480 causes a failed SLAP repair? Why might it not 00:37:03.480 --> 00:37:06.280 work? Failures can be multifactorial. There isn't 00:37:06.280 --> 00:37:09.579 always one single reason. Causes can include 00:37:09.579 --> 00:37:12.519 the repair anchors pulling out of the bone, failure 00:37:12.519 --> 00:37:14.760 of the labral tissue itself to heal back to the 00:37:14.760 --> 00:37:17.760 bone properly, or perhaps the presence of associated 00:37:17.760 --> 00:37:20.940 injuries. like articular cartilage damage that 00:37:20.940 --> 00:37:23.219 weren't fully addressed initially or that progressed 00:37:23.219 --> 00:37:26.539 over time. The sources again highlight the association 00:37:26.539 --> 00:37:29.280 of failures with age, specifically noting that 00:37:29.280 --> 00:37:31.119 failures are more common in patients over the 00:37:31.119 --> 00:37:33.619 age of 36. Right, reinforcing that age factor 00:37:33.619 --> 00:37:36.480 again. Exactly. Further supporting the rationale 00:37:36.480 --> 00:37:39.099 for considering biceps tenodesis in this age 00:37:39.099 --> 00:37:41.780 group. It's also really important to note that 00:37:41.780 --> 00:37:44.820 the outcomes after surgical management of a failed 00:37:44.820 --> 00:37:48.019 SLAP repair. So going back in to try and revise 00:37:48.019 --> 00:37:50.699 the initial surgery are generally inferior to 00:37:50.699 --> 00:37:53.079 the outcomes achieved after a successful primary 00:37:53.079 --> 00:37:54.880 repair. So it's much better to get it right the 00:37:54.880 --> 00:37:57.099 first time. Absolutely. It really emphasizes 00:37:57.099 --> 00:37:58.960 the importance of selecting the right procedure 00:37:58.960 --> 00:38:00.699 for the right patient the first time around. 00:38:01.380 --> 00:38:03.840 So getting that initial treatment decision correct 00:38:03.840 --> 00:38:07.059 based on all the factors, age, activity, tear 00:38:07.059 --> 00:38:10.260 type, evidence, is really paramount for the best 00:38:10.260 --> 00:38:13.280 chance of success. Putting it all together then, 00:38:13.699 --> 00:38:16.219 what's the overall prognosis for someone who 00:38:16.219 --> 00:38:18.179 undergoes treatment for a cell AP tear? What 00:38:18.179 --> 00:38:21.119 can they expect? Well, the prognosis for a cell 00:38:21.119 --> 00:38:23.400 AP after treatment is generally positive in terms 00:38:23.400 --> 00:38:25.260 of reducing pain and improving shoulder strength 00:38:25.260 --> 00:38:27.659 for the majority of patients, particularly those 00:38:27.659 --> 00:38:29.699 with symptoms directly attributable to the tear 00:38:29.699 --> 00:38:31.639 who undergo appropriate surgical intervention 00:38:31.639 --> 00:38:33.739 after feeling a good course of non -operative 00:38:33.739 --> 00:38:36.710 care. However, as we've discussed quite a bit, 00:38:37.170 --> 00:38:39.429 the ability to return to a prior high level of 00:38:39.429 --> 00:38:41.929 performance, especially for elite overhead throwers, 00:38:42.289 --> 00:38:44.809 remains variable and can be unpredictable. It's 00:38:44.809 --> 00:38:47.250 not guaranteed. Achieving a successful outcome 00:38:47.250 --> 00:38:49.590 relies heavily on the correct diagnosis in the 00:38:49.590 --> 00:38:51.750 first place, appropriate treatment selection 00:38:51.750 --> 00:38:54.710 tailored to the individual, addressing any associated 00:38:54.710 --> 00:38:57.489 shoulder pathologies concurrently, and critically, 00:38:57.719 --> 00:38:59.900 the patient's commitment to that structured and 00:38:59.900 --> 00:39:02.239 often lengthy post -operative rehabilitation 00:39:02.239 --> 00:39:05.400 process. It really is a complex injury requiring 00:39:05.400 --> 00:39:07.980 a comprehensive approach from everyone involved. 00:39:08.199 --> 00:39:10.460 This has truly been a deep dive into the world 00:39:10.460 --> 00:39:13.659 of SLAP lesions. We've covered the nuanced anatomy, 00:39:14.059 --> 00:39:16.320 including those tricky variants like the Buford 00:39:16.320 --> 00:39:18.980 complex, gone through the detective work of diagnosis 00:39:18.980 --> 00:39:21.619 using history, physical exam, and specialized 00:39:21.619 --> 00:39:24.800 imaging like MRI orthograms, and explored the 00:39:24.800 --> 00:39:26.860 evolving and sometimes controversial landscape 00:39:26.860 --> 00:39:28.960 of treatment decisions, particularly that shift 00:39:28.960 --> 00:39:31.579 towards biceps procedures for type 2 pairs in 00:39:31.579 --> 00:39:34.119 certain patient populations. Plus the challenges 00:39:34.119 --> 00:39:36.619 of rehabilitation and potential complications 00:39:36.619 --> 00:39:39.880 like that risk of stiffness. It's absolutely 00:39:39.880 --> 00:39:41.900 clear that this is far from a simple injury, 00:39:42.159 --> 00:39:44.719 and managing it effectively requires a deep understanding 00:39:44.719 --> 00:39:47.059 of all these interconnected factors. That's a 00:39:47.059 --> 00:39:49.840 very accurate summary, I think. The diagnostic 00:39:49.840 --> 00:39:52.920 challenges, the importance of recognizing anatomical 00:39:52.920 --> 00:39:55.420 variants, the controversy surrounding the optimal 00:39:55.420 --> 00:39:58.179 management of type 2 care, especially in different 00:39:58.179 --> 00:40:00.719 age groups and activity levels, and the critical 00:40:00.719 --> 00:40:03.980 role of rehabilitation. Those are all key takeaways 00:40:03.980 --> 00:40:06.650 from the literature we reviewed today. And understanding 00:40:06.650 --> 00:40:09.530 why certain decisions are made, like opting for 00:40:09.530 --> 00:40:12.050 a biceps tenodesis over a repair in an older 00:40:12.050 --> 00:40:14.309 patient, because of that increased risk of failure 00:40:14.309 --> 00:40:16.389 or stiffness, that's crucial information for 00:40:16.389 --> 00:40:18.750 both clinicians and patients to understand, isn't 00:40:18.750 --> 00:40:21.670 it? Indeed. And the evidence base is constantly 00:40:21.670 --> 00:40:24.150 evolving, which is why this area remains a topic 00:40:24.150 --> 00:40:26.349 of significant research and clinical discussion. 00:40:26.809 --> 00:40:28.789 It keeps changing. Okay, thinking about everything 00:40:28.789 --> 00:40:31.989 we've covered. The anatomical complexities, the 00:40:31.989 --> 00:40:34.250 difficulty in definitively diagnosing these tiers 00:40:34.250 --> 00:40:36.690 sometimes, the ongoing debate about the best 00:40:36.690 --> 00:40:38.670 way to fix certain types, especially for athletes 00:40:38.670 --> 00:40:40.809 trying to get back to peak performance, and the 00:40:40.809 --> 00:40:43.190 impact of age on outcomes and complications. 00:40:43.849 --> 00:40:45.710 Here's a provocative thought to leave you, our 00:40:45.710 --> 00:40:48.320 listeners, with. Given these persistent challenges, 00:40:48.460 --> 00:40:51.079 how might future advancements, maybe in areas 00:40:51.079 --> 00:40:53.579 like artificial intelligence, helping to analyze 00:40:53.579 --> 00:40:57.119 subtle patterns on MRI scans, or more sophisticated 00:40:57.119 --> 00:40:59.579 biomechanical modeling to understand forces on 00:40:59.579 --> 00:41:02.199 the labor in real time during movement, or even 00:41:02.199 --> 00:41:04.360 biological approaches to enhance laboral healing 00:41:04.360 --> 00:41:06.940 itself, how might these things fundamentally 00:41:06.940 --> 00:41:09.599 change how we diagnose and treat SLAP tiers in 00:41:09.599 --> 00:41:11.860 the future? Could we reach a point where we can 00:41:11.860 --> 00:41:14.500 much more accurately predict who needs what treatment 00:41:14.500 --> 00:41:16.519 and who is most likely to achieve their desired 00:41:16.519 --> 00:41:19.280 outcome? Or conversely, is the inherent variability 00:41:19.280 --> 00:41:21.880 in human anatomy, tissue quality, and individual 00:41:21.880 --> 00:41:24.360 healing potential simply something we will always 00:41:24.360 --> 00:41:26.619 have to navigate with clinical judgment and experience 00:41:26.619 --> 00:41:29.179 no matter how good the tech gets? Those are certainly 00:41:29.179 --> 00:41:31.619 the questions driving future research and innovation 00:41:31.619 --> 00:41:34.559 in orthopedic sports medicine. Big questions 00:41:34.559 --> 00:41:37.239 for the future. This has been the Deep Dive. 00:41:37.400 --> 00:41:39.840 We hope this detailed exploration has given you 00:41:39.840 --> 00:41:43.320 a clearer picture of SLAP lesions. If you found 00:41:43.320 --> 00:41:45.960 this insightful, please do consider reading and 00:41:45.960 --> 00:41:48.099 sharing this deep dive with colleagues or friends 00:41:48.099 --> 00:41:50.059 who might find it useful. Thank you for joining 00:41:50.059 --> 00:41:50.380 us.