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

Abstract

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

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

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

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

Fig. (1)

Right shoulder viewed from the posterior portal in the lateral decubitus position showing a peel-back lesion.

Fig. (2)

Right shoulder with the patient in the lateral decubitus position showing a Type II SLAP lesion as viewed from the posterior portal with probe coming in from the anterior portal. The biceps anchor attachment has been disrupted.

Fig. (3)

Right shoulder with the patient in the lateral decubitus position, view from the anterior portal. The initial suture anchor for SLAP repair has been placed between the 10 o’clock and 11 o’clock position on the glenoid through the port of Wilmington.

Fig. (4)

Right shoulder with the patient in the lateral decubitus position as viewed from an anterior portal. A 12 o’clock suture will be passed by shuttling a PDS suture using a spinal needle via the Neviaser portal.

Fig. (5)

Right shoulder (lateral decubitus position) as viewed from the posterior portal with SLAP repair and biceps tenotomy completed. The biceps can be left in the tenotomized state, or a tenodesis may be performed with the surgeon’s preferred technique.

Fig. (6)

Right shoulder (lateral decubitus position) as viewed from the posterior portal with SLAP repair completed.

Fig. (7)

Right shoulder with patient in the lateral decubitus position as viewed from the posterior portal. The labrum and biceps anchor have been stripped from the superior glenoid consistent with a Type II SLAP lesion.

Fig. (8)

Left shoulder with the patient in the lateral decubitus position, view from the posterior portal. The arm is abducted and externally rotated, showing the posterior superior labrum separating from the superior glenoid as seen with a peel-back lesion.