summary A SLAP lesion (Superior Labrum from Anterior to Posterior tear) generally occurs as result of overuse injury to the shoulder in overhead athletes or traumatic falls in older patients and can result in deep shoulder pain and biceps tendonitis. Diagnosis generally requires MRI studies to assess the superior labrum and the integrity of the biceps tendon. Treatment may be nonoperative or operative depending on patient age, activity levels, severity of symptoms and associated instability. Epidemiology Incidence uncommon injuries, account for less than 5% of all shoulder injuries Demographics dominant shoulder of overhead and throwing athletes Risk factors glenohumeral internal rotation deficit Etiology Pathophysiology mechanisms of injury repetitive overhead activities (often seen in throwing athletes) fall on outstretched arm with tensed biceps traction on the arm pathoanatomy in throwers may be due to tightness of the posterior-IGHL which shifts the glenohumeral contact point posterosuperiorly and increases the shear force on the superior labrum SLAP lesion increases the strain on the anterior band of the IGHL and thus compromises stability of shoulder Associated conditions internal impingement GIRD rotator cuff tears (usually articular sided) instability (may be subtle) scapular dyskinesis Anatomy Anatomy of glenohumeral joint Variant anatomic anatomy variable anatomic relationships extremely common in the glenohumeral joint recognition of these critical but often challenging Biceps anatomy long head of biceps tendon most commonly has 50% fibers attaching to labrum and 50% to supraglenoid tubercle tubercle located over 6mm medial to glenoid surface biceps tendon attachment on glenoid (Tuoheti classification) Type I - completely posterior Type II - predominantly posterior Type I and II together comprise >70% Type III - anterior + posterior (25%) Type IV - anterior (5%) most common pattern of biceps tendon attachment to the superior labrum is posterior to the 12 o'clock position blood supply poorest tendon blood supply while traversing through joint function contributes to torsional and horizontal stability during late-cocking phase of throwing Glenoid labrum function chock block to subluxation composition composed of fibrocartilaginous tissue blood supply from suprascapular, circumflex scapular, posterior humeral circumflex arteries labrum receives blood from capsule and periosteal vessels and not from underlying bone anterior-superior labrum has poorest blood supply stability superior labrum attaches further (medial) from glenoid rim than rest of labrum anchors biceps tendon and is weak link that leads to SLAP lesion anatomic variants sublabral recess/foramen can be confused with a tear on MRI sublabral recess/foramen with thickened MGHL meniscoid appearance (1%) Buford complex cordlike MGHL with associated bare area of the anterosuperior labrum repair of Buford complex to glenoid will result is significant loss of external rotation superior attachment of MGHL on glenoid Classification SLAP Classification Type Description I Labral and biceps fraying, anchor intact (11% of cases) II Labral fraying with detached biceps tendon anchor (41% of cases) III Bucket handle tear, intact biceps tendon anchor (33% of cases) (Biceps separates from bucket handle tear) IV Bucket handle tear with detached biceps tendon anchor (15% of cases) (Biceps remains attached to bucket handle tear) V Type II + anteroinferior labral extension (Bankart lesion) VI Type II + unstable flap VII Type II + MGHL injury VIII Type II + posterior extension IX Circumferential X Type II + posteroinferior extension (reverse Bankart) Snyder Classification: Original classification which includes Types I-IV Maffet sub-classification: Includes the original I-IV and added Types V-VII Significant inter-and intra-observer varaibility when designating classification for SLAP tears Presentation History feeling "pop" sensation in shoulder during overhead activity or traumtic event Symptoms location vague deep shoulder pain timing often a lag between the time of injury and the onset of symptoms mechanical symptoms of popping and clicking weakness, easy fatigue, and decrease athletic performance Physical exam inspection evaluate scapular position and muscle atrophy palpation bicipital groove tenderness motion pop may be reproduced during overhead range of motion particular attention to internal rotation and total rotational arc of motion always compare to contralateral side neurovascular atrophy of supra- and/or infraspinatus due to suprascapular neuropathy provocative tests there is no one specific test for SLAP lesions biceps provocation tests Speed's test Yergason's test Kim biceps load test SLAP lesion tests active compression test (O'Brien's test) crank test arm placed in full abduction and humerus loaded and rotated dynamic labral shear test Kibler anterior slide test apprehension positive in 85% of patients Imaging Radiographs findings often normal MRI +/- arthrogram indications high suspicion for labral tear findings T2 signal intensity between the superior labrum, lateral to glenoid rim, and posterior to the biceps sensitivity ~50% and specificity ~90% which increases with arthrogram may see an associated paralabral ganglion cyst, which is highly specific for labral tear usually in the spinoglenoid notch Treatment Nonoperative rest from sports followed by physical therapy and NSAIDs indications first line of treatment address GIRD if present rehab focusing on scapular dyskinesia and rotator cuff strengthening for all patients Operative arthroscopic debridement indications Types I, III, and IV tears involving <1/3rd of the biceps tendon, causing severe symptoms that have failed nonoperative management arthroscopic debridement with repair of the labrum/biceps versus debridement with biceps tenotomy/tenodesis indications highly controversial Type 2 tears traditionally repaired in overhead athletes return to play rates after SLAP repairs are significantly lower for pitchers compared to non-pitchers general consensus bodes for tenotomy/tenodesis among those over 40 years of age arthroscopic debridement with repair or debridement of the labrum with biceps tenotomy/tenodesis indications Type IV tears with >1/3rd of the biceps tendon involved, causing severe symptoms that have failed nonoperative management Techniques Arthroscopic debridement versus stabilization of the labrum and biceps tendon versus tenotomy/tenodesis approach standard arthroscopic approach to the shoulder soft tissue look for erythema and tearing under labrum to differentiate from normal recess "peel back" test shows "peel back" of the labrum with 90° of external rotation and abduction debride loose flaps of labrum/biceps decompress any cysts SLAP repair utilize accessory or percutaneous portals as necessary for anchor placement near glenoid rim sutures placed depending on tear anatomy traditionally, sutures placed anterior to biceps anchor place patient at increased risk of stiffness post-operatively biceps tenotomy/tenodesis tenotomize biceps near attachment to labrum with arthroscopic scissors or shaver device tenodesis may be done all-arthroscopically or through mini-open incision variety of tenodesis devices used for biceps fixation into proximal humerus rehabilitation week 1-4 passive and active assisted flexion in the scapular plane avoid extremes of abduction and external rotation, and resisted biceps exercises week 4-6 progress to active ROM, isometrics week 6-12 functional exercise and light strengthening week 12+ advance strength and ROM, sport-specifics typical return to sport around 6 months Complications Stiffness incidence most common complication following SLAP repair, around 78% of all patients risk factors incidental SLAP lesions repaired in older patients (>45 years) having arthroscopic rotator cuff repair treatment early passive and active assisted range of motion (pendulum) exercises begun 1 week following repair if stiffness does not resolve with physical therapy, capsular release is indicated Suprascapular nerve injury overdrilling the glenoid can injure the suprascapular nerve Failed SLAP repair and persistent symptoms many causes including articular cartilage injuries, hardware failure and anchor pullout failures associated with age >36 years biceps tenodesis better option in this age group Prognosis Return to Play variable and unpredictable rates of return among elite-level throwers