Welcome to the Deep Dive, where we cut through
the information overload and give you the essential
insights from a stack of sources. Think of it
as getting the key knowledge without you having
to sift through all the academic journals yourself.
Our mission is to make you well -informed, quickly,
with just enough detail to make it stick. Today,
we are taking a deep dive into a shoulder injury
that's surprisingly common, particularly among
athletes who throw or do a lot of overhead work.
But it also presents, well, a real puzzle for
diagnosis and treatment. We're talking about
superior labrum, anterior and posterior tears,
or SLAP lesions. This isn't just some abstract
medical term, it's something that sidelines athletes
and causes persistent pain for many people. To
understand it properly, we've pulled insights
from peer -reviewed orthopedic literature, including
articles from the Journal of the American Academy
of Orthopedic Surgeons, JAAOS, and reliable foundational
resources like OrthoBullets. It's a complex corner
of orthopedics, isn't it? Filled with nuanced
anatomy and... evolving treatment approaches
and we're going to guide you through the most
important bits. I've always been fascinated by
SLAP tiers because they seem to be talked about
constantly in sports medicine but figuring out
what's really going on and how to best fix them.
Well it seems to be a source of ongoing debate.
Oh absolutely. They are a real challenge in clinical
practice. The symptoms can overlap with other
shoulder issues. You know imaging requires a
discerning eye and as the sources highlight deciding
on the optimal management strategy especially
for different patient profiles. files involves
navigating quite a few factors. There's no simple
formula, really, which is why understanding the
underlying anatomy and pathology is so critical.
OK, let's unpack this then, starting with the
absolute basics. We hear SLAP lesion. What exactly
is this tear, and where is it located in the
shoulder? Right. So at its most fundamental,
a SLAP lesion is an injury to the superior labrum
of the shoulder. The acronym SLAP stands for
superior labrum anterior and posterior. This
means the tear is specifically located in the
top, the superior portion of the ring of cartilage
surrounding the shoulder socket. And the crucial
characteristic defining this SLAP tear is that
this tear involves the superior labrum, and critically
it extends from the front, the anterior, to the
back, the posterior, encompassing the area where
the long head of the biceps tendon attaches to
the labrum. Ah, I see. So it's not just any tear
of that cartilage ring. It's a specific tear
in the upper part, right where the biceps hooks
in. Precisely. Yeah, exactly. To fully appreciate
this, let's maybe take a moment for a quick tour
of the shoulder anatomy, as described in the
sources. The shoulder is basically a ball and
socket joint. You have the ball, which is the
head of your humerus, your upper arm bone. Right.
And it fits into a rather shallow socket on your
shoulder blade called the glenoid. Now, because
that glenoid socket is relatively flat, the labrum
comes into play. And the labrum is sort of like
a bumper or a seal? Yes. Think of the labrum
as a rim or a bumper. That's a good way to put
it. It's a ring of tough fibrocartilaginous tissue
that attaches around the edge of the glenoid
socket. Its main job is really to deepen that
socket, making the shoulder joint inherently
more stable. It increases the contact area between
the humerus and the glenoid. It helps keep the
ball centered in the socket. Beyond deepening
the socket, the labrum also serves as an important
attachment point for some of the key ligaments
that provide stability to the shoulder joint.
And, as we just mentioned, it's the attachment
site for the long head of the biceps tendon.
Right, let's zero in on that biceps connection
then. It seems absolutely central to SLAP tears.
How does the long head of the biceps attach there?
Okay, the long head of the biceps tendon actually
originates just above the shoulder socket at
a point called the supraglenoid tubercle on the
scapula. It then travels through the shoulder
joint before blending with and attaching to the
superior portion of the labrum. According to
anatomical descriptions in the sources, the long
head of the biceps tendon commonly has a sort
of split attachment. Roughly 50 % of its fiber
is attached directly to the superior labrum.
And the other 50 % attached to that bony supraglinoid
tubercle. The tubercle itself is located about
six millimeters medial or towards the body's
midline. from the actual articular surface of
the glenoid. This point of attachment is generally
located posterior to the 12 o 'clock position
on the superior glenoid when you're looking at
it arthroscopically. And you mentioned anatomical
variations in how the biceps attaches. Does that
add another layer of complexity? It absolutely
does, yes. The way the biceps tendon attaches
to the superior labrum isn't identical in everyone.
There's this thing called the two -ahead classification
system. referenced in the sources, describes
some of these patterns. Type I is where the attachment
is completely posterior to that 12 o 'clock position
on the glenoid. Type II is predominantly posterior.
Type III has fibers attaching both anteriorly
and posteriorly. and type four is when the entire
attachment is anterior to the 12 o 'clock position.
The sources indicate that top eye and two attachments
are by far the most common, accounting for over
70 % of the anatomical variations observed. Understanding
these normal variations is important because,
well, they can influence how a tear presents
or how a surgeon views the anatomy during surgery.
Another relevant anatomical detail is that the
long head of the biceps tendon, It actually has
its porous blood supply. Precisely where it versus
through the shoulder joint. This limited blood
flow could potentially impact its ability to
heal after injury. Limited blood flow. That sounds
like a key piece of information. And what about
the labrum itself? Does its blood supply vary?
Yes, it does. The labrum receives its blood supply
not from the underlying bone, but from the surrounding
joint capsule and periosteal vessels. And critically,
the anterior superior portion of the labrum seems
to have the poorest blood supply compared to
other parts of the rim. Couple this with the
fact that the superior labrum attaches slightly
further medially on the glenoid compared to the
inferior labrum, making it a bit less firmly
supported at its base, you could say. And it
becomes clearer why this specific area where
the biceps tendon anchors can be considered something
of a weak link if prone to injury under certain
forces, resulting in a SLAP tear. So the very
anatomy of that superior labrum and biceps anchor
area kind of predisposes it to tearing. And speaking
of anatomy looking like tears, you mentioned
those tricky anatomical variants that can sometimes
fool even experienced eyes. That sounds like
a major diagnostic hurdle. It's a very significant
point, yes. particularly for surgeons looking
inside the joint. There are two main anatomical
variants in the superior labrum area that can
easily be mistaken for a tear on imaging or during
arthroscopy if you're not acutely aware of them.
One is called the sublaboral recess or sublaboral
foramen. This is a normal non -pathological separation
or space between the superior labrum and the
underlying glenoid bone. It's just how the anatomy
is configured in some people. It can sometimes
be associated with a thicker than usual middle
glenohumeral ligament, which is another ligament
in the shoulder. The key challenge is distinguishing
this normal space from a true tear, where the
labrum is detached and actually causing symptoms.
On an MRI arthrogram, dye might enter this normal
recess, which can be confusing. I can see that.
But the pattern is usually distinct from dye
entering a tear. It tends to be smoother. OK,
and the second variant? The second crucial variant
is the Buford complex. This is a specific anatomical
arrangement where the middle glenohumeral ligament
is very thick and cord -like, and it originates
directly from the superior labrum. When this
happens, there is a congenital absence, or a
bare area, of the antero -superior labrum. It
looks like a piece of the labrum is missing or
torn anteriorly. But it's not. But it's actually
a normal developmental variant present in a small
percentage of the population. And why is recognizing
the Buford complex so critical? What happens
if a surgeon mistakes it for a tear and tries
to fix that bare area? This is where the clinical
pitfall lies. It's really important. If a surgeon
doesn't recognize the Buford complex and mistakenly
repair that bare, antro -superior area of the
labrum to the glenoid, believing it's a tear,
they will significantly restrict the patient's
external rotation of the shoulder. Oh, wow. because
that thick cord -like ligament is meant to be
in that position, trying to anchor tissue there
that isn't supposed to be just restricts normal
shoulder movement. Recognizing these variants,
the sublaboral recess, and especially the Buford
complex, is absolutely paramount for accurate
diagnosis and avoiding unnecessary surgery that
can actually cause functional problems. That
really emphasizes how understanding the normal
variations is just as important as understanding
the pathology. It's not just a simple case of,
is there a tear or isn't there? Okay, so we know
what SLAP lesion is anatomically and some of
the quirks in that region. Who was most likely
to get one of these tears and what typically
causes them? Well, while SLAP lesions account
for a relatively small percentage of all shoulder
injuries, less than 5 % according to the sources.
Less than 5%. They are disproportionately seen
in specific groups. The classic patient is the
overhead or throwing athlete. Often in their
dominant arm think baseball pitchers, javelin
throwers, volleyball or tennis players, that
sort of thing. However, they can also occur in
older patients, particularly as a result of a
traumatic fall onto an outstretched arm. Are
there specific risk factors or certain movements
that are known to cause these tears? Yes, repetitive
overhead activities are the prime suspect in
athletes. The sheer volume and force of throwing
or soothing motions put immense stress on that
superior labrum and biceps anchor. Other common
mechanisms of injury include falling directly
onto an outstretched arm, especially if the arm
is slightly bent and the biceps muscle is tensed
at the time of impact. A sudden forceful pull
on the arm, like trying to catch a heavy object
unexpectedly, or rapid forceful movements of
the arm above shoulder level can also generate
enough force to tear the superior labrum. And
interestingly, a shoulder dislocation can sometimes
peel the labrum off the glenoid rim, occasionally
including the superior portion involved in a
SLAP tear. You mentioned a theory about throwers
specifically linking tightness to the injury.
Can you elaborate a bit on that biomechanics?
Absolutely. This is where some of the deeper
insight into the pathology comes from. There's
a well regarded theory that in throwing athletes
who often develop tightness in the posterior
capsule and the posterior inferior glenohumeral
ligament. Right, the back of the shoulder. Exactly.
Which is a key stabilizing structure at the back
and bottom of the shoulder. This tightness can
alter the mechanics of the throwing motion. As
the arm moves through the late cocking phase
and into acceleration, this posterior tightness
can cause the ball of the humerus to shift post
-rosuperiorly upwards and backwards relative
to the glenoid socket. This abnormal shift increases
the sheer force applied to the superior labrum,
effectively sort of grinding or peeling it away
from the bone, especially where the biceps tend
to detaches. Furthermore, the sources point out
that once a SLAP lesion is present, this detached
superior labrum and biceps anchor can then increase
the strain on the anterior band of the inferior
glenohumeral ligament. Which is the main stabilizer
at the front. Precisely, the primary anterior
stabilizer of the shoulder. This can lead to
a sort of vicious cycle where the SLAP tear contributes
to subtle instability, further disrupting normal
mechanics. That's fascinating. So the injury
itself can potentially worsen the underlying
problem or contribute to instability. It's not
just about the tear itself, but how the tear
changes the shoulders function. And you noted
that in older patients, it might not be from
trauma, but just wear and tear. Correct, yeah.
In individuals over the age of, say, 30 or 40,
it's not uncommon to see some degree of fraying
or degenerative changes in the superior labrum
on MRI or during arthroscopy. This could just
be a normal part of aging. and doesn't necessarily
cause symptoms or require treatment unless there
was a specific traumatic event superimposed on
these degenerative changes. Right. Differentiating
between a symptomatic tear and just age -related
fraying is another critical diagnostic step.
It's not always easy. And are SLAP tears usually
isolated injuries or do they often come with
other problems in the shoulder joint? They frequently
have company, yes. SLAP lesions are often associated
with other shoulder conditions, particularly
in throwing athletes. These can include things
like internal impingement. Or the cuff gets pinched.
Yeah, where the rotator cuff tendon gets pinched
in certain overhead positions. Also glenohumeral
internal rotation deficit, or GIRD, which is
that posterior tightness we discussed. Rotator
cuff tears are common too. Often partial thickness
tears on the articular or joint side. Subtle
shoulder instability and scapular dyskinesis
that's abnormal movement or positioning of the
shoulder blade during arm motion. Okay. Addressing
these associated conditions is often really important
for successful management, whether you go surgical
or non -operative. Okay. We understand the anatomy,
who gets them, and how they might happen. Now,
for the detective work, how do doctors actually
figure out if someone has a celipate tear? What
does the patient feel and what does the examination
involve? Right. Well, from the patient's perspective,
the symptoms of a cell A pay tear can be somewhat
inconsistent and often mimic other shoulder problems,
which, as we said, is part of the diagnostic
challenge. Common complaints include a deep aching
pain within the shoulder that's often difficult
to localize precisely. People struggle to point
exactly where it hurts. A key symptom is often
mechanical people describe hearing or feeling
popping, clicking, catching, or grinding sensations
in the shoulder with certain movements. Pain
is typically aggravated by specific positions,
especially those involving overhead activities
or when lifting heavy objects. Athletes, particularly
throwers, might notice a significant decrease
in their performance, maybe loss of velocity
or control, feeling weakness, or experiencing
what's sometimes called a dead arm sensation
after throwing. The dead arm, yeah. Some patients
also report a feeling of apprehension, or like
the shoulder might pop out. And studies suggest
apprehension tests are actually positive in a
high percentage, around 85 % of patients with
SLAP tears. 85%, that's quite high. It is. Reduced
range of motion or easy fatigue ability can also
occur. And it's worth noting that sometimes symptoms
might not fully manifest immediately after the
injury, but rather develop gradually over time.
So the symptoms are broad and can sound like
other things. How does a doctor approach trying
to pin down if it's actually a SLI peer? Well,
the diagnostic process begins, as with any injury
really, with a detailed medical history. The
doctor will ask about the onset of the pain,
whether there's a specific injury or if it came
on gradually. What activities make it worse?
especially work or sports, the exact location
and character of the pain, and any previous treatments
they might have tried. The patient's age and
activity level are also critical pieces of information.
Following the history, a thorough physical examination
is performed. This involves assessing the shoulder's
range of motion in different planes, evaluating
muscle strength, and testing the overall stability
of the joint. A key component of the physical
exam for suspected SLA key tears involves performing
what are called provocative tests. Provocative
tests. These are specific maneuvers where the
doctor moves the patient's arm into positions
designed to put stress on the superior labrum
and biceps anchor to see if they can reproduce
the patient's pain or mechanical symptoms. Are
these provocative tests definitive? Like, if
one test is positive, you know for sure it's
a SLA P tear. Ah, this is a critical point from
the sources and really highlights the diagnostic
difficulty. There is no single physical examination
test that is perfectly sensitive or specific
for diagnosing a SLAP lesion on its own. Right.
No silver bullet test. Exactly. A diagnosis is
based on the combination of the patient's history,
their reported symptoms, and the findings from
multiple provocative tests, along with of course
the imaging results. It's putting all the pieces
together. Can you walk us through a couple of
these provocative tests and maybe explain why
they might reproduce symptoms if a SLIP is present?
What's the thinking behind them? Certainly. The
sources list several. Some are general biceps
provocation tests like Speed's test or Jurgesson's
test, though these can be positive with other
biceps issues too, so they're not super specific.
More specific SLAP tests include the active compression
test, often known as O 'Brien's test. O 'Brien's
test, yeah, I've heard of that one. The crank
test, the dynamic labral shear test, and the
Kibler anterior slide test. There are quite a
few. Let's look at the O 'Brien's test as it's
commonly used. The patient flexes their arm forward
to 90 degrees, adducts it about 10, 15 degrees
across the body, and internally rotates it so
the thumb points down. Right, thumb down, arm
across. Exactly. The doctor then applies downward
resistance, and the patient resists. This position,
with the arm slightly across the body and internally
rotated, is thought to put a twisting or torsional
stress on the superior labrum and biceps anchor.
Then the arm is externally rotated, so the palm
is up, and the resistance is applied again. A
positive test is if the pain or clicking experience
with the thumb down position is reduced or eliminated
when the palm is up, particularly if the pain
is felt deep inside the shoulder. The idea is
that with the thumb down, the superior labrum
is being loaded and perhaps peeled away slightly,
while with the palm up, that stress is relieved.
I see. And the crank test, how does that one
work? For the crank test, the arm is abducted,
so lift it away from the body to about 120 degrees.
The doctor applies an axial load, basically pushing
the humerus head into the socket gently, and
then rotates the arm internally and externally.
This maneuver is designed to try and catch or
pinch a torn labral flap between the humerus
head and the glenoid. It's trying to reproduce
those catching or clicking mechanical symptoms.
The presence of pain or a click, especially during
external rotation with that axial load, can suggest
a superior label tear. Right. But again, it's
crucial to remember a positive result on any
single test isn't proof positive. It just raises
suspicion that needs to be confirmed by other
means like imaging. That makes sense. You're
essentially trying to manually stress that specific
area where the tear might be to see if you can
reproduce the patient's symptoms. Given that
physical tests aren't definitive, imaging must
play a really crucial role then. What do they
use and how good is it at actually seeing these
tears? You're right. Imaging is essential. Standard
x -rays are usually the first step, but they
primarily show bone, not soft tissues like the
labrum. So they'll likely be normal. Exactly.
X -rays in a patient with a cesolactare are typically
normal. They're mostly useful for ruling out
other potential causes of pain, like arthritis,
bone spurs, or maybe a fracture. Okay. To visualize
the labrum itself, Magnetic Resonance Imaging,
or MRI, is the primary tool. On a standard MRI,
a cell AP p -tear might appear as increased signal
a brighter area on certain sequences, particularly
T2 -weighted images between the superior labrum
and the glenoid bone, usually posterior to where
the biceps attaches. However, standard MRI sensitivity
for detaching a cell AP p -tears is only around
50%. 50%. That sounds pretty low, especially
for such a key diagnostic tool. It is quite low.
It means it misses about half of them, although
its specificity is higher, around 90%. So if
it sees something, it's likely real, but it misses
a lot. So how do they improve its accuracy? There
must be a better way. This is where an MRI arthrogram
becomes invaluable. This involves injecting a
contrast agent, basically a dye, directly into
the shoulder joint before the MRI scan is performed.
Ah, injecting dye into the joint first. Exactly.
The dye fills the joint space. If there's a tear
in the labrum... the dye will leak into that
tear, highlighting the defect and making it much
more visible on the scan. The sources are clear
that an MRI arthrogram significantly increases
the accuracy for diagnosing labral tears compared
to a standard MRI. It's really the gold standard
for imaging these. You can visually distinguish
between, say, a normal sublabor recess where
the dye might pool slightly in a smooth pattern
and a true tear, where the dye seeps irregularly
into the torn tissue or the defect. The presence
of a paralabral gangly insist is another important
imaging finding. These are fluid -filled sacs
that often form adjacent to a labral tear, particularly
in the spinoculnoid notch near the shoulder blade.
Assist near the tear. Yes. And their presence
on MRI is considered highly specific for an underlying
labral tear, even if the tear itself is subtle
or difficult to see directly on the scan. It's
a strong secondary sign. The diagnosis is really
a puzzle pieced together from the patient's story,
the physical exam findings, even if they're not
definitive individually, and then ideally, a
specific type of imaging, like an MRI arthrogram.
Once a tear is identified, the sources talk about
classification systems. Why bother classifying
these tears? What's the point? Classification
systems are used mainly to standardize the description
of the tear pattern. This helps in communication
among clinicians, surgeons, physios, and importantly,
it helps guide treatment decisions. Different
types of tears might be managed differently.
The most widely referenced system is the Snyder
classification, which uniquely describes four
main types based on the anatomical location and
the involvement of the biceps tendon anchor.
Could you briefly explain those Snyder types
for us? Type I to IV? Certainly. Let's run through
them. Type I. This is considered more of a degenerative
tear. It involves fraying of the superior labrum
and sometimes the biceps tendon itself, but the
key thing is the biceps anchor remains firmly
attached to the glenoid. These account for about
11 % of SLAP lesions. Just fraying anchors okay.
Got it. Type 2. This is the most common type,
particularly in throwing athletes, making up
around 41 % of cases. It involves fraying of
the superior labrum and a detachment of the biceps
tendon anchor from the superior glenoid. The
labrum and biceps anchor are essentially peeled
away from the bone. Okay, that's the detached
anchor one. Exactly. Type 3. This is described
as a bucket -handle tear of the superior labrum.
A flap of the labrum tears and can displace into
the joint, but critically, the biceps tendon
anchor remains intact and attached to the glenoid.
The biceps actually separates from the torn labral
flap. These are about 33 % of cases. So the labrum
tears, but the biceps anchor stays put. Correct.
And type 4. This is also a bucket -handle tear,
like type 3, but in this case, the tear extends
into the biceps tendon itself, and the biceps
tendon anchor is also detached and remains attached
to the torn labral flap. These are less common,
around 15%. Right, so the tear goes into the
biceps tendon too, and the anchor comes off with
it. Precisely. And there are more types added
later. I think you mentioned MAFIT. Yes, that's
right. The MAFIT classification and others expanded
the system to include tears extending into other
parts of the labrum, or associated with other
ligamentous injuries. For example, type V is
a type II tear that extends down and forward
into the antero -inferior labrum, similar to
a bankart lesion which you see in dislocations.
Type VI is a type II with an unstable labral
flap, and type VII involves extension into the
middle glenohumeral ligament. There are even
more types described, up to X, but... While these
extended classifications exist, the Snyder R5
are really the foundational ones clinicians often
refer back to. Given the complexity in those
variants we talked about, is classifying these
tears always straightforward even when the surgeon
is looking right at it during surgery? Unfortunately,
no. This is another challenge highlighted in
the sources. There's significant inter -observer
variability. Meaning different surgeons might
grade it differently. Exactly, and even intra
-observer variability, where the same surgeon
might classify the same care differently if they
looked at it again at different times. This variability
really underscores the subjective nature of assessing
these tears. Even with direct visualization during
arthroscopy. It reinforces that it's not just
a simple clear -cut diagnosis or classification.
There's judgment involved. Okay, so we've diagnosed
it. We've classified it maybe with some variability.
How do you treat a cell AP tear? Is surgery always
the answer or is there a non -operative approach
first? The good news is that surgery is not always
necessary. And the sources strongly recommend
starting with non -operative treatment in most
cases. This is considered the first line of management.
OK, so try physio first. What does non -operative
treatment typically involve? Non -operative management
includes several components. Firstly, rest or
a modification of activities, especially avoiding
the movements that cause pain that's particularly
important for athletes, obviously. Secondly,
a structured physical therapy program, or physio,
is crucial. This therapy focuses on regaining
full, pain -free range of motion, strengthening
the muscles around the shoulder, especially the
rotator cuff and the muscles that control the
shoulder blade. Addressing that scapular dyskinesis
you mentioned. Precisely. Addressing scapular
dyskinesis, and importantly, stretching out any
associated tightness like GIRD, that posterior
tightness. Thirdly, non -steroidal anti -inflammatory
medications, NSAIDIDES, can be used to help manage
pain and reduce inflammation. This non -operative
approach is typically pursued for a significant
period usually between three and six months to
really see if symptoms improve. Three to six
months, okay. Corticosteroid injections into
the shoulder joint can also be used often to
help calm inflammation and sometimes as a diagnostic
aid if the exact source of the pain is a bit
unclear. How effective is this non -operative
approach, especially for that high -demand overhead
athlete the pitcher may be, who wants to get
back to throwing at full speed? Ah, this is a
key distinction made in the sources and it's
quite important. While non -operative treatment
can be successful for some individuals, particularly
those with lower activity demands or maybe more
degenerative tiers, the data on high -level pitching
athletes is less encouraging. The number of pitchers
who successfully return to their prior level
of performance using only non -surgical methods
has been described in the literature as Unsatisfactory.
Unsatisfactory. That's quite blunt. It is. It's
a critical insight. It suggests that for this
specific, highly demanding population, non -operative
treatment, while a necessary first step, often
doesn't actually get them back to where they
need to be competitively. That makes sense, unfortunately,
for them. So if non -operative treatment fails,
or perhaps if the tear is severe or unstable
from the outset, surgery comes into consideration.
What does that involve? Surgical treatment for
SLAP lesions is typically performed arthroscopically
keyhole surgery using small incisions, a camera,
the arthroscope, and specialized miniature instruments.
The goal of surgery is to address the tear based
on its type, the patient's age, their activity
level, and the surgeon's assessment of stability
and tissue quality. This is also the area where,
particularly for type 2 tears, there is significant
ongoing discussion and, as the sources call it,
quite a bit of controversy. Right, you mentioned
controversy around type 2 tears. What's the debate
here? What are the options? Okay, the core debate
for type 2 tears, remember they're the most common
in throwers and involve the detached biceps anchor,
is whether to actually repair the torn labrum
and reattach the biceps anchor back to the bone.
The traditional approach. The traditional approach,
yes. Or, alternatively, whether to perform a
procedure on the biceps tendon itself, either
a tenotomy or a tenodesis, and essentially leave
the superior labrum alone, or perhaps just de
-bride it, trim it up. Okay, let's clarify those
biceps procedures again. What exactly are tenotomy
and tenodesis? Right. Biceps tenotomy is simply
cutting the long head of the biceps tendon near
its attachment inside the shoulder joint, allowing
it to retract down the arm. It essentially removes
the and pull on the superior labrum. Just cut
it loose. Pretty much. Biceps tendinesis also
involves cutting the tendon, but then the cut
end is reattached, usually with an anchor or
screw, to the humerus, the upper arm bone, lower
down, typically outside the shoulder joint itself.
Okay, cut and reattach it lower down. Exactly.
Tenodesis is generally preferred over tenotomy
in active patients because it helps maintain
biceps strength and the normal shape of the muscle,
preventing the potential cosmetic deformity called
a Popeye muscle bulge that can sometimes occur
with just a tenotomy. Right, the Popeye bulge.
So traditionally, type 2 tears, especially in
younger athletes, were repaired. Why the shift
towards considering tenodesis more often now?
This is really where the outcomes data is influencing
practice. While repairing the labrum and biceps
anchor seems intuitively correct, you know, restoring
the anatomy. Yeah, it sounds like the right thing
to do. It does. But recent investigations have
shown a notable disconnect. A high incidence
of SLAP repairs being performed, but often disappointing
return to play rates. particularly for pitchers.
Studies cited in the sources have shown that
return -to -play rates after SLAP repairs are
significantly lower for pitchers compared to
athletes in other overhead sports like tennis
or volleyball. Lower for pitchers specifically.
Interesting. Yes. And importantly, return -to
-play rates for throwers are actually similar
whether they undergo a SLAP repair or a biceps
tenodesis. So the repair doesn't seem to offer
an advantage for getting back to pitching. Specifically.
So similar outcomes for return to play, but maybe
other factors. Exactly. Furthermore, the sources
highlight a strong association between age and
the success of SLAP repair. Failures after SLAP
repair are specifically linked to patients over
the age of 36. Over 36. OK. This suggests that
perhaps tissue quality or healing potential might
be poorer in older patients, making the repair
less likely to hold reliably or possibly leading
to complications like stiffness, which we'll
talk about. Because of these findings, poorer
return to throwing after repair compared to non
-throwing sports, similar return to throwing
between repair and tenodesis, and higher failure
and stiffness rates in older patients after repair,
the general consensus among orthopedic surgeons.
As reflected in the literature, is increasingly
favoring bicep synotomy or tenodesis, especially
in patients over the age of 40. Right, so over
40 lean towards the biceps procedure. Generally,
yes. For younger, high -level overhead athletes,
the decision is still debated, it's more nuanced,
but the pendulum is certainly swinging towards
considering biceps procedures more frequently.
Even in this group, if return to high -level
throwing is the primary goal, simply due to the
less -than -ideal results seen with repair in
that specific population. That's a really significant
shift in thinking, isn't it? Moving away from
trying to restore the anatomy with repair towards
essentially just offloading the biceps tension
because the repair outcomes, particularly for
throwers or older patients, haven't been as successful
as everyone hoped. What about the other types
of tears, types 1, 3, and 4? Right, for type
I tears, which are just fraying with an intact
anchor, and maybe some type III or V tears involving
less than one -third of the biceps tendon without
significant symptoms after non -operative treatment,
simple arthroscopic debridement is often sufficient.
Just trimming the frayed bits. Exactly, just
trimming away the unstable frayed edges of the
labrum or biceps. For type 4 tears, where more
than one -third of the biceps tendon is involved,
causing severe symptoms that haven't responded
to non -operative care, the options are typically
debridement plus either labor repair or biceps
tendon imidinodesis. The choice here would again
depend heavily on the patient's age, activity
level, and the surgeon's preference, considering
all the same factors we just discussed for type
2. So treatment is highly individualized based
on tear type. age, activity goals, and this evolving
evidence. Once surgery is done, whichever route
is chosen, what does the road to recovery look
like? Rehabilitation must be absolutely critical.
Oh, rehabilitation is absolutely paramount to
the success of any surgical intervention for
a cesilite tear, whether it's a repair or a biceps
procedure. It's not optional, it's essential.
It's a structured multi -stage process that progresses
gradually to protect the healing issues while
carefully restoring motion and strength. Okay,
what's the initial phase like after the surgery?
Immediately after surgery, the shoulder is typically
immobilized in a sling. The duration varies depending
on the surgery's complexity and the surgeon's
protocol, but usually ranges from about two to
six weeks. The initial phase, typically the first
one to four weeks, focuses heavily on protection
and controlled motion. Patients are usually allowed
gentle passive range of motion, where the therapist
moves the arm, and maybe some active assisted
range of motion exercises, often in the scapular
plane, which is arm moving slightly forward from
the side, kind of a safe zone. Crucially, during
this phase, it is vital to avoid any extremes
of abduction and external rotation. Right. Don't
stretch it out too much. Exactly. And absolutely
no resisted biceps exercises, especially if the
biceps anchor was repaired, to protect that healing
site. You don't want to pull on it. Makes sense.
What happens as you move beyond that initial
protective phase, say after the first month or
so? Around weeks 4 -6, as healing progresses
and pain allows, the patient typically transitions
to active range of motion exercises, trying to
move the arm themselves under their own power.
They also usually start isometric strengthening
tensing muscles without actually moving the joint.
The mid -stage, generally from week 6 -12, involves
progressing to more functional exercises and
beginning light -resistant strengthening, really
focusing on the rotator cuff and those periscapular
muscles, the ones controlling the shoulder blade.
The goal is to build foundational strength and
control. Okay, building back the support system.
Precisely. The late stage, from 12 weeks onwards,
involves advancing strengthening exercises, restoring
full range of motion, and initiating sport -specific
training if the patient is an athlete. This might
involve progressive drills mimicking the movements
required for their sport, like starting a throwing
program. When can someone realistically expect
to return to full activity or sport after all
this? A typical return to full activity or sport
after SLIP surgery is often quoted around six
months. However, this timeline is highly variable.
It really depends on the specific type and severity
of the injury, the patient's individual healing
rate, their overall health, and critically, their
activity goals. Six months is just a ballpark
figure, them. Very much so. For throwing athletes,
an early interval throwing program might begin
around three, four months. But a full return
to competitive pitching can easily take six months
or even longer, sometimes nine months to a year,
to feel truly back to normal. The sources emphasize
that complete recovery can take several months,
particularly in more complicated cases. And diligently
following the surgeon's post -operative instructions
and the prescribed rehabilitation plan is absolutely
vital for optimizing the outcome. You simply
can't rush the biology of healing. That sounds
like a long and very dedicated process. What
are the potential roadblocks or complications
that can occur after SLAP surgery? What can go
wrong? Well, like any surgical procedure. There
are potential complications. For SLAP repair
specifically, the most common complication reported
in the sources is post -operative stiffness.
It occurs in a significant percentage of patients,
one source mentioned, around 78%. 78%. That's
a very high number for stiffness. Are there specific
factors that make someone more likely to experience
stiffness after a SLAP repair? Yes, the sources
identify significant risk factors for post -operative
stiffness after SLAP repair. A particularly strong
risk factor seems to be performing an incidental
SLAP repair in older patients, specifically those
over the age of 45, when doing surgery for a
different primary problem, such as a rotator
cuff repair. So finding a cell AP tear while
fixing something else and deciding to repair
it in an older patient is risky for stiffness.
Exactly. It reinforces the clinical trend away
from routinely repairing these lesions in older
patients and perhaps opting for a biceps procedure
instead, which tends to have less risk of stiffness.
And if someone does develop stiffness, how is
it treated? Can it be fixed? Early recognition
and intervention are key. Rehabilitation protocols
are designed to start controlled motion relatively
early, even in the protective phase. Things like
pendulum swings are often encouraged, sometimes
beginning as early as one week post -op, specifically
to help prevent stiffness setting in. If stiffness
develops and persists despite dedicated physio,
a secondary procedure called a capsular release
might be necessary. This involves arthroscopically
releasing the tightened tissues, the capsule,
around the joint to restore motion. Okay. Are
there other potential complications besides stiffness?
Yes, other potential complications include, though
less commonly, injury to the suprascapular nerve.
This is a nerve near the shoulder blade that
controls some of the rotator cuff muscles. This
could potentially happen if the glenoid bone
is over -drilled during the process of placing
anchors for a prey pair, as the nerve runs quite
close by. Careful technique is needed. Right.
And unfortunately, sometimes the SLAP repair
simply fails or the patient continues to experience
symptoms despite the surgery. What typically
causes a failed SLAP repair? Why might it not
work? Failures can be multifactorial. There isn't
always one single reason. Causes can include
the repair anchors pulling out of the bone, failure
of the labral tissue itself to heal back to the
bone properly, or perhaps the presence of associated
injuries. like articular cartilage damage that
weren't fully addressed initially or that progressed
over time. The sources again highlight the association
of failures with age, specifically noting that
failures are more common in patients over the
age of 36. Right, reinforcing that age factor
again. Exactly. Further supporting the rationale
for considering biceps tenodesis in this age
group. It's also really important to note that
the outcomes after surgical management of a failed
SLAP repair. So going back in to try and revise
the initial surgery are generally inferior to
the outcomes achieved after a successful primary
repair. So it's much better to get it right the
first time. Absolutely. It really emphasizes
the importance of selecting the right procedure
for the right patient the first time around.
So getting that initial treatment decision correct
based on all the factors, age, activity, tear
type, evidence, is really paramount for the best
chance of success. Putting it all together then,
what's the overall prognosis for someone who
undergoes treatment for a cell AP tear? What
can they expect? Well, the prognosis for a cell
AP after treatment is generally positive in terms
of reducing pain and improving shoulder strength
for the majority of patients, particularly those
with symptoms directly attributable to the tear
who undergo appropriate surgical intervention
after feeling a good course of non -operative
care. However, as we've discussed quite a bit,
the ability to return to a prior high level of
performance, especially for elite overhead throwers,
remains variable and can be unpredictable. It's
not guaranteed. Achieving a successful outcome
relies heavily on the correct diagnosis in the
first place, appropriate treatment selection
tailored to the individual, addressing any associated
shoulder pathologies concurrently, and critically,
the patient's commitment to that structured and
often lengthy post -operative rehabilitation
process. It really is a complex injury requiring
a comprehensive approach from everyone involved.
This has truly been a deep dive into the world
of SLAP lesions. We've covered the nuanced anatomy,
including those tricky variants like the Buford
complex, gone through the detective work of diagnosis
using history, physical exam, and specialized
imaging like MRI orthograms, and explored the
evolving and sometimes controversial landscape
of treatment decisions, particularly that shift
towards biceps procedures for type 2 pairs in
certain patient populations. Plus the challenges
of rehabilitation and potential complications
like that risk of stiffness. It's absolutely
clear that this is far from a simple injury,
and managing it effectively requires a deep understanding
of all these interconnected factors. That's a
very accurate summary, I think. The diagnostic
challenges, the importance of recognizing anatomical
variants, the controversy surrounding the optimal
management of type 2 care, especially in different
age groups and activity levels, and the critical
role of rehabilitation. Those are all key takeaways
from the literature we reviewed today. And understanding
why certain decisions are made, like opting for
a biceps tenodesis over a repair in an older
patient, because of that increased risk of failure
or stiffness, that's crucial information for
both clinicians and patients to understand, isn't
it? Indeed. And the evidence base is constantly
evolving, which is why this area remains a topic
of significant research and clinical discussion.
It keeps changing. Okay, thinking about everything
we've covered. The anatomical complexities, the
difficulty in definitively diagnosing these tiers
sometimes, the ongoing debate about the best
way to fix certain types, especially for athletes
trying to get back to peak performance, and the
impact of age on outcomes and complications.
Here's a provocative thought to leave you, our
listeners, with. Given these persistent challenges,
how might future advancements, maybe in areas
like artificial intelligence, helping to analyze
subtle patterns on MRI scans, or more sophisticated
biomechanical modeling to understand forces on
the labor in real time during movement, or even
biological approaches to enhance laboral healing
itself, how might these things fundamentally
change how we diagnose and treat SLAP tiers in
the future? Could we reach a point where we can
much more accurately predict who needs what treatment
and who is most likely to achieve their desired
outcome? Or conversely, is the inherent variability
in human anatomy, tissue quality, and individual
healing potential simply something we will always
have to navigate with clinical judgment and experience
no matter how good the tech gets? Those are certainly
the questions driving future research and innovation
in orthopedic sports medicine. Big questions
for the future. This has been the Deep Dive.
We hope this detailed exploration has given you
a clearer picture of SLAP lesions. If you found
this insightful, please do consider reading and
sharing this deep dive with colleagues or friends
who might find it useful. Thank you for joining
us.