Superior labrum anterior posterior lesions of the shoulder: Operative techniques of management

Since the advent of shoulder arthroscopy, pathology of the superior glenoid labrum and biceps anchor has been increasingly recognized as a source of shoulder pain and disability. Additional biomechanical testing has substantiated the role of the superior labrum and biceps anchor in glenohumeral stability. The diagnosis of superior labral injury such as the superior labrum anterior posterior (SLAP) lesion remains difficult, as the history, clinical examination, and radiographic evaluation can only raise suspicion. The ultimate diagnosis of the SLAP lesion can only be made with a well-directed diagnostic glenohumeral arthroscopy. The treatment of SLAP lesions depends on the type of SLAP lesion encountered at arthroscopy. This includes debridement of most type I and III lesions, and repair of type II and many type IV SLAP lesions. In this report, we will present our basic approach towards evaluation and treatment of SLAP lesions at the Southern California Orthopedic Institute.     

SLAP tears of the glenoid labrum in contact athletes.

OBJECTIVE: To describe the distribution and clinical presentation of labral injuries in rugby players and the time taken for them to return to sports. DESIGN: Retrospective cohort study. SETTING: Busy shoulder practice in the North West of England, treating a large number of professional athletes. PATIENTS: A review of 51 shoulder arthroscopies performed on professional rugby players over a 35 month period. All patients diagnosed with a SLAP lesion at arthroscopy were identified. Eighteen patients had a documented SLAP tear; this group represented our study population. INTERVENTIONS: Arthroscopic debridement and/or stabilization was carried out for all labral injuries using Panaloc anchors and No. 2 PDS via a 2 portal technique. MAIN OUTCOME MEASUREMENTS: Classification of injury, Satisfaction, Time to return to play. RESULTS: The incidence of SLAP tears in our study population was 35%. There were 11 isolated SLAP tears (61%), 3 SLAP tears associated with a Bankart lesion (17%), 2 SLAP tears associated with a posterior labral lesion (11%), and 2 SLAP tears associated with an anterior and posterior labral injuries (11%). Of the 18 SLAP tears, 14 (78%) were type 2, 3 (17%) were type 3, and 1 (5%) was type 4. None of the patients with a SLAP tear presented with symptoms of instability. MR Arthrogram had a 76% sensitivity for detecting SLAP tears. By 6 months postsurgery, 89% of patients were satisfied. Patients with isolated SLAP tears were the quickest to return to sports, at an average of 2.6 months postsurgery. CONCLUSIONS: SLAP tears are a common injury in rugby players. These can often be diagnosed with MR arthrography. Arthroscopic repair is associated with excellent results and early return to sports.     

Arthroscopic repair of isolated type II superior labrum anterior–posterior lesion

The effectiveness of arthroscopic repair of type II superior labrum anterior-posterior lesion (SLAP) was unclear as previous studies examined this treatment with patients of combined types of SLAP lesions. To address this research gap, we evaluated the clinical and functional outcomes of arthroscopic repair for 16 patients (mean=24.2, SD=6.5) with clinical evidence of isolated type II SLAP lesion. After having arthroscopic stabilizations with Bioknotless suture anchors (Mitek), the patients were offered post-operative rehabilitation programs (e.g., physiotherapy) for 6 months. The symptoms of SLAP lesion and the functions of the shoulder were assessed pre-operatively and 28-month post-operatively by O'Brien test, Speed test, Yergason test, and University of California at Los Angeles rating for pain and function of the shoulder. Wilcoxon Signed Ranks test and McNemar test were employed to analyze the difference between assessment in pre-operation and post-operation phases. The result showed that patients' shoulder functions improved (UCLA Shoulder Score), and symptoms of SLAP lesion reduced (O'Brien test, Speed test, and Yergason test) significantly (P<0.05). Time for returning to play with pre-injury level was in average 9.4 months (range 4-24), and no complication or recurrence was detected. We concluded that arthroscopic repair is an effective operation of type II SLAP lesion with good clinical and functional outcomes; however, athletes with high demand of overhead throwing activities are likely to take longer duration of rehabilitation to attain full recovery.     

MR arthrographic findings of SLAP lesion type V

PURPOSE: The purpose of this study was to determine the findings of MR arthrography of the shoulder and to assess the role of MR arthrography in the diagnosis of superior labrum anterior to posterior (SLAP) lesion type V. METHODS AND MATERIALS: Two radiologists retrospectively reviewed fat-suppressed T1-weighted MR arthrography images of six patients who were diagnosed with SLAP lesion type V by arthroscopy. Each imaging plane, including the transverse, oblique coronal, oblique sagittal, and oblique transverse in abductor external rotation (ABER) position were evaluated for the following three findings: tear of the superior labrum at biceps tendon insertion, Bankart lesion, and continuity of the two former findings. RESULTS: Tear of the superior labrum was shown in all patients on oblique coronal images. Bankart lesion was noted in five patients on the transverse images and in four on the oblique sagittal images. On the oblique transverse images in ABER position, Bankart lesion was shown in all patients. The continuity of the two former findings was noted in three patients on the ABER positioned images. Therefore, three patients could be diagnosed as having SLAP lesion type V by MR arthrography in our series. CONCLUSION: It is difficult to detect all three findings of SLAP lesion type V in one imaging plane, however, a combination of multi-directional images may increase the feasibility of MR arthrography in diagnosing SLAP lesion type V.     

Influence of SLAP lesions on chondral lesions of the glenohumeral joint

From 2004 to 2008 we evaluated 431 SLAP lesions during 3,395 shoulder arthroscopies and compared two groups of patients, one with SLAP lesion as group I and one without SLAP lesions as group II. Exclusion of type I SLAP lesions, rotator cuff tears and history of dislocation of the shoulder in both groups left 182 cases in group I, and additionally, exclusion of all-type SLAP lesions left 251 patients in group II. In group I, SLAP lesion-associated chondral lesions were present in 20% at the humerus (4% group II, p = 0.005), 18% at the glenoid (5% in group II, p = 0.05) and 14% glenohumeral (3% group II, p = 0.04). We observed a pattern of typical localization of SLAP-associated chondral lesions at the humerus underneath the biceps tendon (78%) and at the anterior half of the glenoid (63%) in group I in contrast to the central region of the humerus (82%) and the central region at the glenoid (55%) in group II. The association of SLAP and chondral lesions was not influenced by the presence of trauma or age of the patients. SLAP lesions seem to be a risk factor for subsequent early onset of osteoarthritis either caused by a bicipital chondral print or glenohumeral instability or a combination of both.     

Intrinsic risk factors for the development of patellar tendinitis in an athletic population. A two-year prospective study

Retrospective studies have suggested various factors that might cause a disposition to develop patellar tendinitis, but no prospective data exist to determine any relationships. The purpose of this study was to determine the intrinsic risk factors for the development of patellar tendinitis in an athletic population. Before the study, 138 male and female students of physical education were evaluated for anthropometric variables, leg alignment characteristics, and muscle tightness and strength parameters. During the 2-year study, 19 of the 138 students developed patellar tendinitis. In all cases the diagnosis was confirmed by the presence of a hypoechogenic nodular lesion in the proximal region of the patellar tendon. Univariate and stepwise discriminant function analyses were performed comparing the various measurements. These analyses revealed that the only significant determining factor was muscular flexibility, with the patellar tendinitis patients being less flexible in the quadriceps and hamstring muscles (P < 0.05). The results of this study demonstrate that lower flexibility of the quadriceps and hamstring muscles may contribute to the development of patellar tendinitis in an athletic population. Therefore, the prevention of this condition in athletes should be focused on screening for and treating poor quadriceps and hamstring muscle flexibility.     

Trends in the diagnosis of SLAP lesions in the US military

Purpose

Shoulder pathology, particularly SLAP (superior labrum anterior-posterior) lesions, is prevalent in overhead athletes and physically active individuals. The aim of this study is to quantify the burden of SLAP lesions in the military and establish risk factors for diagnosis.

Methods

A retrospective analysis of all service members diagnosed with a SLAP lesion (International Classification of Disease, Ninth Revision code 840.70) in the Defense Medical Epidemiological Database between 2002 and 2009 was performed. Available epidemiological risk factors including age, sex, race, military rank, and branch of service were evaluated using multivariate Poisson regression analysis, and cumulative and subgroup incidence rates were calculated.

Results

During the study period, approximately 23,632 SLAP lesions were diagnosed among a population at risk of 11,082,738, resulting in an adjusted incidence rate of 2.13 per 1,000 person-years. The adjusted annual incidence rate for SLAP lesions increased from 0.31 cases per 1,000 person-years in 2002 to 1.88 cases per 1,000 person-years in 2009, with an average annual increase of 21.2 % (95 % CI 20.7 %, 22.0 %, p < 0.0001) during the study period. Age, sex, race, branch of military service, and military rank were independent risk factors associated with the incidence rate of SLAP lesion (p < 0.01). Male service members were over twofold more likely (IRR, 2.12; 95 % CI 2.01, 2.23) to sustain a SLAP lesion when compared with females. Increasing age category was associated with a statistically significant increase in the incidence rate for SLAP lesions in the present study (p < 0.001). After controlling for the other variables, those individuals of white race, enlisted ranks, or Marine Corps service experienced the highest incidence rates for SLAP.

Conclusion

This is the first study to establish the epidemiology of SLAP lesions within an active military cohort in the American population. Sex, age, race, military rank, and branch of military service were all independently associated with the incidence rate of SLAP lesions in this physically active population at high risk for shoulder injury.

Level of evidence

II.

     

Superior labral anterior posterior (SLAP) lesions of the glenoid labrum: reliability and accuracy of MR arthrography for diagnosis

PURPOSE: To determine the reliability and accuracy of magnetic resonance (MR) arthrography for the diagnosis of superior labral anterior posterior (SLAP) tears. MATERIALS AND METHODS: The MR arthrograms in 80 patients who underwent arthroscopy and MR arthrography during a 54-month period were retrospectively reviewed. MR arthrograms were independently scored by three observers for the presence and type of SLAP lesion. Type I SLAP lesions were regarded as negative as they most often are not clinically relevant. Interobserver agreement for detection of SLAP lesions was calculated by using kappa coefficients. The differences in areas under the receiver operating characteristic (ROC) curves were assessed with a univariate z score test. RESULTS: At arthroscopy, there were 25 SLAP tears: type II (n = 22), type III (n = 2), and type IV (n = 1). Sensitivity, specificity, and accuracy of each reader were 92%, 84%, and 86%; 92%, 82%, and 85%; and 84%, 69%, and 74%, respectively. Interobserver agreement for SLAP tears was substantial (kappa = 0.77) to moderate (kappa = 0.52, kappa = 0.44). The areas under the ROC curves for each reader were 0.94, 0.93, and 0.83, which were not significantly different. CONCLUSION: MR arthrography of the shoulder is reliable and accurate for detection of SLAP tears.     

MR-arthrography in superior instability of the shoulder: correlation with arthroscopy

Purpose

This study was undertaken to evaluate magnetic resonance (MR) arthrography in the detection and classification of lesions that may cause superior instability.

Materials and methods

Forty-two consecutive patients with clinical signs of chronic superior instability of the shoulder underwent MR arthrography followed by arthroscopic surgery. For each patient we retrospectively reviewed the MR arthrography and surgical findings.

Results

We detected 31 superior labral anterior posterior (SLAP) lesions, all confirmed on arthroscopy with three cases of underestimation: in the detection of SLAP lesions, the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MR arthrography were 100%; in the evaluation of the type of SLAP lesion, sensitivity was 100%, specificity was 78.5%, accuracy was 92.8%, PPV was 71.7% and NPV was 100%. All cases of capsular laxity (13/42) and biceps tendon lesions (3/42) were confirmed on arthroscopy with sensitivity, specificity, accuracy, PPV and NPV of 100%. Eleven cuff lesions were detected on MR arthrography, 10 of which confirmed at arthroscopy: sensitivity was 100%, specificity was 96.8%, accuracy was 97.6%, PPV was 90.9% and NPV was 100%. Associated lesions were found in 38/42 patients.

Conclusions

Superior instability is frequently associated with different anatomical variants or pathological conditions, such as SLAP lesions. The role of MR arthrography is to describe the key features of lesions affecting the superior portion of the shoulder, including location, morphology, extent, and associated injuries and leanatomical variants and to correlate these features with clinical symptoms.     

The relationship of superior labralanteroposterior (SLAP) lesions and pseudolaxity to shoulder injuries in the overhead athlete

Understanding the effect of superior labral lesions on the function of the shoulder is essential to successfullytreating the overhead athlete. Recognizing the pseudolaxity owing to superior labral anteroposterior (SLAP) lesions and the pathological "peel-back" sign is critical in evaluating the injured shoulder in general and repairing the SLAP lesion in particular. The mechanical characteristics of suture anchors are more favorable than tacks in resisting the pathological forces responsible for the peel-back mechanism. The higher success rate of arthroscopic suture anchor repair of SLAP lesions in comparison with open capsulolabral reconstruction suggests that SLAP lesions are the usual cause of the "dead arm" syndrome. In our experience, arthroscopic repair of SLAP lesions can return the overhead athlete to their preoperative level of function in the vast majority of cases (87% return to preoperative level for two or more seasons).     

Increased glenohumeral translation and biceps load after SLAP lesions with potential influence on glenohumeral chondral lesions: a biomechanical study on human cadavers

Purpose  

The aim of the study was to evaluate the stabilizing function of the long head of biceps tendon (LHB) and its tension, both without and with the presence of SLAP lesion to analyze a potentially occurring humeral chondral print of LHB with consecutive glenohumeral chondral lesions in SLAP lesions.     

肩关节损伤MRI与关节镜的对比分析

目的探讨常规MRI对肩关节损伤的诊断价值。方法回顾性分析因肩关节损伤行常规MRI和关节镜检查的55例病人资料,MRI观察指标包括肩袖、盂唇形态及信号,有否肩峰下撞击及骨性损伤。以肩关节镜为诊断金标准,统计MRI对不同类型肩关节损伤的诊断结果,并分别计算MRI的诊断敏感度、特异度和准确度。采用Kappa检验分析MRI与肩关节镜诊断结果的一致性。结果肩关节损伤的MRI征象中分别有25%部分肩袖撕裂、13.3%Bankart’s损伤、20%盂唇上部前后方向(SLAP)损伤和11.6%肩峰下撞击漏诊。MRI诊断损伤性病变的特异度及肩袖全层撕裂(100%)、骨性损伤(100%)、肩峰下撞击(88%)和Bankart’s损伤(87%)的敏感度较高,诊断SLAP损伤(75%)和肩袖部分撕裂(75%)的敏感度较低;诊断肩袖全层撕裂(100%)和骨性损伤(100%)的准确度最高,其次是Bankart’s损伤(96%),诊断SLAP损伤(89%)的准确度较低。MRI和关节镜诊断肩袖全层撕裂、骨性损伤的κ值为1,结果完全一致,诊断Bankart’s损伤的κ值为0.904,一致性较好,诊断肩袖部分撕裂、SLAP损伤和肩峰下撞击的κ值虽稍低,但均0.75,一致性也较好,P均0.05。结论 MRI是有效诊断肩关节损伤的影像方法,但对SLAP损伤和肩袖部分撕裂的诊断准确度有待提高。     

Role of MRI in the study of the Achilles tendon and patellar tendon

The possibilities of MRI and radiography with mammogram to diagnose mechanical tendinitis have been prospectively evaluated in thirty sportsmen. Sixteen had Achilles tendon lesion, fourteen had patellar ligament lesion. Each patient included in the study was programmed for radiography with mammogram and MRI of the pathologic tendon and the controlateral tendon. These examinations were separately interpreted by two reviewers who had no knowledge of pain location. The number of tendinitis diagnosis based on X-ray and MRI was approximatively the same. But the microtearings were more often diagnosed on MRI data than on X-ray data (10/1). Eight patients underwent an operation. The surgery findings always confirmed the MRI diagnoses. MRI seems to be the examination of choice to evaluate the tendon injuries and particularly microtearings before surgery.     

SLAP lesions: a treatment algorithm

Tears of the superior labrum involving the biceps anchor are a common entity, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature particularly for young athletes. However, the results in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance. The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates as compared to younger patients. In this population, tenotomy or tenodesis of the biceps tendon is a viable alternative to SLAP repairs in order to improve clinical outcomes. The present article introduces a treatment algorithm for SLAP lesions based upon the recent literature as well as the authors’ clinical experience. The type of lesion, age of patient, concomitant lesions, and functional requirements, as well as sport activity level of the patient, need to be considered. Moreover, normal variations and degenerative changes in the SLAP complex have to be distinguished from “true” SLAP lesions in order to improve results and avoid overtreatment. The suggestion for a treatment algorithm includes: type I: conservative treatment or arthroscopic debridement, type II: SLAP repair or biceps tenotomy/tenodesis, type III: resection of the instable bucket-handle tear, type IV: SLAP repair (biceps tenotomy/tenodesis if >50 % of biceps tendon is affected), type V: Bankart repair and SLAP repair, type VI: resection of the flap and SLAP repair, and type VII: refixation of the anterosuperior labrum and SLAP repair.     

Superior labrum anterior-posterior lesions: diagnosis with MR arthrography of the shoulder

PURPOSE: To determine the accuracy of magnetic resonance (MR) arthrography in the diagnosis of superior labrum anterior-posterior (SLAP) lesions of the shoulder. MATERIALS AND METHODS: From January 1995 to June 1998, MR arthrography of the shoulder was performed in 159 patients with a history of chronic shoulder pain or instability. Fifty-two patients underwent arthroscopy or open surgery 12 days to 5 months after MR arthrography. Diagnostic criteria for SLAP lesion included marked fraying of the articular aspect of the labrum, biceps anchor avulsion, inferiorly displaced bucket handle fragment, and extension of the tear into the biceps tendon fibers. Surgical findings were correlated with those from MR arthrography. RESULTS: SLAP injuries were diagnosed at surgery in 19 of the 52 patients (37%). Six of the 19 lesions (32%) were classified as type I, nine (47%) as type II, one (5%) as type III, and three (16%) as type IV. MR arthrography had a sensitivity of 89% (17 of 19 patients), a specificity of 91% (30 of 33 patients), and an accuracy of 90% (47 of 52 patients). The MR arthrographic classification showed correlation with the arthroscopic or surgical classification in 13 of 17 patients (76%) in whom SLAP lesions were diagnosed at MR arthrography. CONCLUSION: MR arthrography is a useful and accurate technique in the diagnosis of SLAP lesions of the shoulder. MR arthrography provides pertinent preoperative information with regard to the exact location of tears and grade of involvement of the biceps tendon.     

Shoulder injuries in overhead athletes. The "dead arm" revisited

The following statements summarize this article: Three distinct categories of Type 2 SLAP lesions exist: (1) anterior, (2) posterior, and (3) combined anteroposterior. Posterior Type 2 SLAP lesions have distinct clinical and anatomic features that distinguish them from anterior Type 2 SLAP lesions. Posterior and combined Type 2 SLAP lesions can be disabling to overhead-throwing athletes because of posterosuperior instability and anteroinferior pseudolaxity. The Jobe relocation test is positive with posterosuperior pain in patients with posterior or combined anterior-posterior Type 2 SLAP lesions and is negative in patients with anterior Type 2 SLAP lesions. Rotator cuff tears are frequently associated with posterior or combined anterior-posterior SLAP lesions, are lesion-location specific, and typically begin from inside the joint as undersurface tears. Repair of posterior SLAP lesions can return overhead-throwing athletes to full overhead athletic functioning. The peel-back mechanism is a likely cause of posterior Type 2 SLAP lesions. To securely repair the posterosuperior labrum to resist torsional peel-back, sulure anchors must be placed posterior to the biceps at the corner of the glenoid. The repair must be protected against external rotation past 0 degree for 3 weeks to avoid undue premature torsional stresses on the repair from the peel-back mechanism. A tight posteroinferior capsule predisposes to Type 2 SLAP lesions in overhead athletes. Shoulders at risk for the dead arm syndrome have a marked loss of internal rotation caused by contracture of the posteroinferior capsule such that less than a 180 degrees arc of rotation is achieved with the arm abducted 90 degrees (the 180 degrees rule). Type 2 SLAP lesions that cause the dead arm syndrome in overhead-throwing athletes are most likely acceleration injuries that occur in late cocking rather than deceleration injuries in follow-through. Rehabilitation of athletes with the dead arm syndrome must include the entire kinetic chain. The root cause of the dead arm syndrome is the Type 2 SLAP lesion.     

SLAP lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization

Superior labral anterior posterior (SLAP) tears are an abnormality of the superior labrum usually centered on the attachment of the long head of the biceps tendon. Tears are commonly caused by repetitive overhead motion or fall on an outstretched arm. SLAP lesions can lead to shoulder pain and instability. Clinical diagnosis is difficult thus imaging plays a key diagnostic role. The normal anatomic variability of the capsulolabral complex can make SLAP lesions a diagnostic challenge. Concurrent shoulder injuries are often present including rotator cuff tears, cystic changes or marrow edema in the humeral head, capsular laxity, Hill-Sachs or Bankart lesion. The relevant anatomy, capsulolabral anatomic variants, primary and secondary findings of SLAP tears including MR arthrography findings, types of SLAP lesions and a practical approach to labral lesions are reviewed.     

Outcome of the isolated SLAP lesions and analysis of the results according to the injury mechanisms

Superior labral anterior posterior (SLAP) lesions of the shoulder arise from various causes and have some controversies in their treatment. The purpose of this study is to evaluate the outcomes of arthroscopic SLAP repair and the relationship between injury mechanisms and outcomes. We evaluated the clinical results of 24 patients (mean 33 months follow-up) who had an arthroscopic isolated SLAP (type II: 21, type III: 1, type IV: 2 patients) repair with suture anchors. These labral tears were arthroscopically repaired with 1–4 anchors (mean 1.8). All patients were evaluated with University of California, Los Angeles (UCLA) and Visual Analogue Scale (VAS) scores. There were the following injury mechanisms: compression-type, 10; traction-type, 9; combined or other-type, 5 patients. We also compared the clinical results according to the injury mechanisms. Preoperatively, the mean of UCLA and VAS scores were 22.7 and 6.4 points, respectively. At an average of 33 months postoperatively, the mean of UCLA and VAS scores were 29.9 and 2.1 points, respectively. There was statistical improvement in the subjective scores from the pre- to post-operation. UCLA and VAS scores of the pre- and post-operation were not statistically different according to the injury mechanisms. Arthroscopic repair is effective in the treatment of isolated SLAP lesion and injury mechanisms do not affect the clinical outcomes.