mtomaino
09-12-2010, 03:37 PM
This is increasingly controversial. Among shoulder experts around the world, the indications for repairing SLAP lesions as opposed to either releasing the biceps tendon or performing a tenodesis, are being narrowed. Why?----because in some patients stiffness may develop and pain may persist. The observation that some high profile athletes, like John Elway, extended their careers by undergoing a biceps release (even though he had long head biceps degeneration, not a SLAP lesion) calls into question the need to fix all SLAP tears. Below is a "white paper" of sorts which I have prepared on the subject.
In 1985 Andrews reported on the treatment of superior labral tears in overhead athletes by debridement, but it was not until Snyder’s classification in 1990, that the term SLAP (superior labrum anterior and posterior) lesion became popular, and the notion of repair was introduced. The notion that all SLAP tears should be repaired, however, should be rejected, since not all superior labral tears reflect a traumatic disruption of the attachment nor is restoration of a normal attachment always critical to restoration of normal shoulder mechanics. In that regard, additions to the original 4 types of SLAP lesions, described by Maffet and colleagues, reflect tear extensions that may contribute to instability. Though the depressor function of the biceps and its superior attachment may contribute to shoulder stability in biomechanical testing, a SLAP tear may not necessarily result in clinically relevant instability.
Both traction and compression mechanisms may cause SLAP tears. Traction may be sustained in throwers from an eccentric contraction of the biceps or via a peel back mechanism accompanying abduction and external rotation. Alternatively, an inferior or forward pull may cause a tear—from an external load or simply due to excessive capsular strain during internal rotation when posterior capsular contracture exists. In the throwing/overhead athlete a tight posterior capsule leads to a glenohumeral internal rotation deficit and posterosuperior shift of glenohumeral contact. The peel back mechanism, which has been implicated in the etiology of SLAP tears in the throwing athlete, necessitates restoration of shoulder kinematics if SLAP repair is undertaken, otherwise pathomechanics will lead to recurrence. Compression injury may result from a fall onto an outstretched arm or a direct blow to the shoulder. Symptoms may be difficult to differentiate from the anterosuperior shoulder pain typically seen with rotator cuff impingement or partial tears of the rotator cuff, unless catching, locking, popping or grinding is reported. Although the use of MR imaging with contrast may improve the diagnostic success of preoperative tests, arthroscopic evaluation remains the gold standard.
In summary, despite our appreciation of different types of SLAP tears, arriving at an appropriate treatment strategy (F) is more elusive, and requires not merely identification and classification of the SLAP lesion, but also consideration of Etiology (A), whether instability is present (B), the status of the biceps tendon itself (C), functional expectation and need for early motion (D), and the age of the patient (E).
A. Etiology. When electing treatment of a SLAP lesion—Type 2 tears in particular—the most important consideration is whether there have been prodromal symptoms, as characteristically occurs in overhead athletes and throwers. If a more acute traumatic episode leads to a SLAP tear, one might be inclined, arguably, to restore anatomy with repair. However, absent a compelling reason to do so—a concern about contributing to instability in the absence of repair (7), as in the case of a thrower with heightened glenohumeral translation and forces, for example, one might reasonably consider the alternative of tenotomy or tenodesis (8). Burkhart has revealed the likelihood of pathomechanics and a tight posterior capsule in throwers, which can accentuate the normal peel back mechanism by which the superior labrum can avulse during late cocking part of the throw (9). If glenohumeral internal rotation deficit is not corrected either before SLAP repair or at the same time, poor outcome is likely.
B. Clinical evidence of instability. Though Rodosky (6) and others have found that the long head of the biceps contributes to stability, clinical evidence of instability following tenotomy and tenodesis is lacking unless more classic anterior inferior ligamentous disruption is noted as well. Thus, as long as a significant sulcus sign or drive through sign are not noted at the time of arthroscopy, concern that instability may result if a SLAP lesion is not repaired is probably not warranted.
C. Status of the biceps tendon. Walch et al have shown that the biceps tendon can be a significant pain mediator in patients with irreparable rotator cuff tears, and that tenotomy can effectively improve function by providing pain relief (6). So too has Boileau shown that tenodesis can result in excellent outcome as compared to SLAP repair (8). Thus, if the long head is unstable, associated with concomitant subscapularis pathology or thickened or torn, one should not hesitate to consider tenodesis or tentomy. A successfully repaired SLAP lesion does nor equate to a pain free shoulder. As an alternative to arthroscopic tenodesis, subpectoral tenodesis, through a small incision in the medial aspect of the upper arm, ensures that the extraarticular biceps is not a source of pain within the bicipital groove.
D. Need for early motion. SLAP repairs must be protected in a sling for 4 weeks and postoperative motion needs to be restricted to allow healing. Our protocol restricts external rotation to 40 degrees and forward elevation to 140 degrees for 4 weeks. Stiffness is a risk. When early motion is required, after lysis of adhesions for adhesive capsulitis for example , SLAP repair is ill-advised. In point of fact—certain diagnoses are rarely associated with SLAP lesions that require repair. However, it is well known that Impingement and SLAP tears can co-exist. In this light, it is important to appropriately consider the alternatives to repair in cases for which a “SLAP tear” may not be the primary problem.
E. Age. Age is admittedly an arbitrary guideline for recommending for or against repair. In my experience, the potential for postoperative stiffness after SLAP repair increases after age 40. In this light Boileau’s favorable results of tenodesis are attractive—obviating the need for limitation of postoperative motion (8).
F. Treatment. Type 1 tears can simply be debrided. However, if the labral fraying is reflective of a greater problem of tendonopathy, and concern exists that the biceps tendon may be a pain mediator, then tenotomy or tenodesis may be warranted. For Type 2 tears in throwers, repair may indeed be indicated, but posterior capsular contracture must be corrected. If patients are not responsive to the sleeper stretch, then posterior release is advisable. In nonthrowers who are young and active repair can be considered, but Boileau’s report should be given consideration. Tenodesis—and it should follow, tenotomy—may provide a reasonable outcome without the potential complications of SLAP repair. In patients older than 50, it’s my practice to not repair type 2 SLAP tears. There is no valid reason to do so, and depending on the patient’s preference regarding the appearance of the biceps muscle, tenotomy or tenodesis will be performed.
1. Andrews JR, Carson W Jr, McLeod W. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985; 13: 337-341.
2. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990; 6: 274-279
3. Maffet MW, Gartsman GM, Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med. 1995 Jan-Feb;23(1):93-8
4. Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009 Oct;17(10):627-37
5. Katz LM, Hsu S, Miller SL, Richmond JC, Ketia E, Kohli N, Curtis AS. Poor outcomes after SLAP repair: descriptive analysis and prognosis. Arthroscopy. 2009 Aug;25(8):849-55
6. Szabó I, Boileau P, Walch G. The proximal biceps as a pain generator and results of tenotomySports Med Arthrosc. 2008 Sep;16(3):180-6.
7. Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med. 1994 Jan-Feb;22(1):121-30
8. Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R. Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med. 2009 May;37(5):929-936.
9. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy. 2003 Apr;19(4):404-20.
10. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers.Arthroscopy. 2003 May-Jun;19(5):531-9.
In 1985 Andrews reported on the treatment of superior labral tears in overhead athletes by debridement, but it was not until Snyder’s classification in 1990, that the term SLAP (superior labrum anterior and posterior) lesion became popular, and the notion of repair was introduced. The notion that all SLAP tears should be repaired, however, should be rejected, since not all superior labral tears reflect a traumatic disruption of the attachment nor is restoration of a normal attachment always critical to restoration of normal shoulder mechanics. In that regard, additions to the original 4 types of SLAP lesions, described by Maffet and colleagues, reflect tear extensions that may contribute to instability. Though the depressor function of the biceps and its superior attachment may contribute to shoulder stability in biomechanical testing, a SLAP tear may not necessarily result in clinically relevant instability.
Both traction and compression mechanisms may cause SLAP tears. Traction may be sustained in throwers from an eccentric contraction of the biceps or via a peel back mechanism accompanying abduction and external rotation. Alternatively, an inferior or forward pull may cause a tear—from an external load or simply due to excessive capsular strain during internal rotation when posterior capsular contracture exists. In the throwing/overhead athlete a tight posterior capsule leads to a glenohumeral internal rotation deficit and posterosuperior shift of glenohumeral contact. The peel back mechanism, which has been implicated in the etiology of SLAP tears in the throwing athlete, necessitates restoration of shoulder kinematics if SLAP repair is undertaken, otherwise pathomechanics will lead to recurrence. Compression injury may result from a fall onto an outstretched arm or a direct blow to the shoulder. Symptoms may be difficult to differentiate from the anterosuperior shoulder pain typically seen with rotator cuff impingement or partial tears of the rotator cuff, unless catching, locking, popping or grinding is reported. Although the use of MR imaging with contrast may improve the diagnostic success of preoperative tests, arthroscopic evaluation remains the gold standard.
In summary, despite our appreciation of different types of SLAP tears, arriving at an appropriate treatment strategy (F) is more elusive, and requires not merely identification and classification of the SLAP lesion, but also consideration of Etiology (A), whether instability is present (B), the status of the biceps tendon itself (C), functional expectation and need for early motion (D), and the age of the patient (E).
A. Etiology. When electing treatment of a SLAP lesion—Type 2 tears in particular—the most important consideration is whether there have been prodromal symptoms, as characteristically occurs in overhead athletes and throwers. If a more acute traumatic episode leads to a SLAP tear, one might be inclined, arguably, to restore anatomy with repair. However, absent a compelling reason to do so—a concern about contributing to instability in the absence of repair (7), as in the case of a thrower with heightened glenohumeral translation and forces, for example, one might reasonably consider the alternative of tenotomy or tenodesis (8). Burkhart has revealed the likelihood of pathomechanics and a tight posterior capsule in throwers, which can accentuate the normal peel back mechanism by which the superior labrum can avulse during late cocking part of the throw (9). If glenohumeral internal rotation deficit is not corrected either before SLAP repair or at the same time, poor outcome is likely.
B. Clinical evidence of instability. Though Rodosky (6) and others have found that the long head of the biceps contributes to stability, clinical evidence of instability following tenotomy and tenodesis is lacking unless more classic anterior inferior ligamentous disruption is noted as well. Thus, as long as a significant sulcus sign or drive through sign are not noted at the time of arthroscopy, concern that instability may result if a SLAP lesion is not repaired is probably not warranted.
C. Status of the biceps tendon. Walch et al have shown that the biceps tendon can be a significant pain mediator in patients with irreparable rotator cuff tears, and that tenotomy can effectively improve function by providing pain relief (6). So too has Boileau shown that tenodesis can result in excellent outcome as compared to SLAP repair (8). Thus, if the long head is unstable, associated with concomitant subscapularis pathology or thickened or torn, one should not hesitate to consider tenodesis or tentomy. A successfully repaired SLAP lesion does nor equate to a pain free shoulder. As an alternative to arthroscopic tenodesis, subpectoral tenodesis, through a small incision in the medial aspect of the upper arm, ensures that the extraarticular biceps is not a source of pain within the bicipital groove.
D. Need for early motion. SLAP repairs must be protected in a sling for 4 weeks and postoperative motion needs to be restricted to allow healing. Our protocol restricts external rotation to 40 degrees and forward elevation to 140 degrees for 4 weeks. Stiffness is a risk. When early motion is required, after lysis of adhesions for adhesive capsulitis for example , SLAP repair is ill-advised. In point of fact—certain diagnoses are rarely associated with SLAP lesions that require repair. However, it is well known that Impingement and SLAP tears can co-exist. In this light, it is important to appropriately consider the alternatives to repair in cases for which a “SLAP tear” may not be the primary problem.
E. Age. Age is admittedly an arbitrary guideline for recommending for or against repair. In my experience, the potential for postoperative stiffness after SLAP repair increases after age 40. In this light Boileau’s favorable results of tenodesis are attractive—obviating the need for limitation of postoperative motion (8).
F. Treatment. Type 1 tears can simply be debrided. However, if the labral fraying is reflective of a greater problem of tendonopathy, and concern exists that the biceps tendon may be a pain mediator, then tenotomy or tenodesis may be warranted. For Type 2 tears in throwers, repair may indeed be indicated, but posterior capsular contracture must be corrected. If patients are not responsive to the sleeper stretch, then posterior release is advisable. In nonthrowers who are young and active repair can be considered, but Boileau’s report should be given consideration. Tenodesis—and it should follow, tenotomy—may provide a reasonable outcome without the potential complications of SLAP repair. In patients older than 50, it’s my practice to not repair type 2 SLAP tears. There is no valid reason to do so, and depending on the patient’s preference regarding the appearance of the biceps muscle, tenotomy or tenodesis will be performed.
1. Andrews JR, Carson W Jr, McLeod W. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985; 13: 337-341.
2. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990; 6: 274-279
3. Maffet MW, Gartsman GM, Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med. 1995 Jan-Feb;23(1):93-8
4. Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009 Oct;17(10):627-37
5. Katz LM, Hsu S, Miller SL, Richmond JC, Ketia E, Kohli N, Curtis AS. Poor outcomes after SLAP repair: descriptive analysis and prognosis. Arthroscopy. 2009 Aug;25(8):849-55
6. Szabó I, Boileau P, Walch G. The proximal biceps as a pain generator and results of tenotomySports Med Arthrosc. 2008 Sep;16(3):180-6.
7. Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med. 1994 Jan-Feb;22(1):121-30
8. Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R. Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med. 2009 May;37(5):929-936.
9. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy. 2003 Apr;19(4):404-20.
10. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers.Arthroscopy. 2003 May-Jun;19(5):531-9.