Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / SLAP Tears

Transcript

SLAP Tears · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

0:00
Welcome to the Deep Dive, where we cut through
0:01
the information overload and give you the essential
0:04
insights from a stack of sources. Think of it
0:07
as getting the key knowledge without you having
0:08
to sift through all the academic journals yourself.
0:11
Our mission is to make you well -informed, quickly,
0:14
with just enough detail to make it stick. Today,
0:16
we are taking a deep dive into a shoulder injury
0:19
that's surprisingly common, particularly among
0:21
athletes who throw or do a lot of overhead work.
0:24
But it also presents, well, a real puzzle for
0:27
diagnosis and treatment. We're talking about
0:29
superior labrum, anterior and posterior tears,
0:33
or SLAP lesions. This isn't just some abstract
0:36
medical term, it's something that sidelines athletes
0:38
and causes persistent pain for many people. To
0:41
understand it properly, we've pulled insights
0:43
from peer -reviewed orthopedic literature, including
0:45
articles from the Journal of the American Academy
0:47
of Orthopedic Surgeons, JAAOS, and reliable foundational
0:51
resources like OrthoBullets. It's a complex corner
0:54
of orthopedics, isn't it? Filled with nuanced
0:56
anatomy and... evolving treatment approaches
0:59
and we're going to guide you through the most
1:01
important bits. I've always been fascinated by
1:04
SLAP tiers because they seem to be talked about
1:06
constantly in sports medicine but figuring out
1:09
what's really going on and how to best fix them.
1:11
Well it seems to be a source of ongoing debate.
1:14
Oh absolutely. They are a real challenge in clinical
1:17
practice. The symptoms can overlap with other
1:19
shoulder issues. You know imaging requires a
1:22
discerning eye and as the sources highlight deciding
1:24
on the optimal management strategy especially
1:26
for different patient profiles. files involves
1:29
navigating quite a few factors. There's no simple
1:31
formula, really, which is why understanding the
1:33
underlying anatomy and pathology is so critical.
1:36
OK, let's unpack this then, starting with the
1:38
absolute basics. We hear SLAP lesion. What exactly
1:43
is this tear, and where is it located in the
1:45
shoulder? Right. So at its most fundamental,
1:48
a SLAP lesion is an injury to the superior labrum
1:51
of the shoulder. The acronym SLAP stands for
1:55
superior labrum anterior and posterior. This
1:59
means the tear is specifically located in the
2:01
top, the superior portion of the ring of cartilage
2:04
surrounding the shoulder socket. And the crucial
2:06
characteristic defining this SLAP tear is that
2:09
this tear involves the superior labrum, and critically
2:11
it extends from the front, the anterior, to the
2:14
back, the posterior, encompassing the area where
2:17
the long head of the biceps tendon attaches to
2:19
the labrum. Ah, I see. So it's not just any tear
2:22
of that cartilage ring. It's a specific tear
2:24
in the upper part, right where the biceps hooks
2:26
in. Precisely. Yeah, exactly. To fully appreciate
2:29
this, let's maybe take a moment for a quick tour
2:31
of the shoulder anatomy, as described in the
2:33
sources. The shoulder is basically a ball and
2:36
socket joint. You have the ball, which is the
2:39
head of your humerus, your upper arm bone. Right.
2:41
And it fits into a rather shallow socket on your
2:43
shoulder blade called the glenoid. Now, because
2:46
that glenoid socket is relatively flat, the labrum
2:50
comes into play. And the labrum is sort of like
2:52
a bumper or a seal? Yes. Think of the labrum
2:55
as a rim or a bumper. That's a good way to put
2:58
it. It's a ring of tough fibrocartilaginous tissue
3:01
that attaches around the edge of the glenoid
3:03
socket. Its main job is really to deepen that
3:06
socket, making the shoulder joint inherently
3:09
more stable. It increases the contact area between
3:12
the humerus and the glenoid. It helps keep the
3:14
ball centered in the socket. Beyond deepening
3:17
the socket, the labrum also serves as an important
3:19
attachment point for some of the key ligaments
3:21
that provide stability to the shoulder joint.
3:23
And, as we just mentioned, it's the attachment
3:26
site for the long head of the biceps tendon.
3:28
Right, let's zero in on that biceps connection
3:30
then. It seems absolutely central to SLAP tears.
3:34
How does the long head of the biceps attach there?
3:36
Okay, the long head of the biceps tendon actually
3:39
originates just above the shoulder socket at
3:42
a point called the supraglenoid tubercle on the
3:44
scapula. It then travels through the shoulder
3:47
joint before blending with and attaching to the
3:50
superior portion of the labrum. According to
3:53
anatomical descriptions in the sources, the long
3:56
head of the biceps tendon commonly has a sort
3:58
of split attachment. Roughly 50 % of its fiber
4:01
is attached directly to the superior labrum.
4:04
And the other 50 % attached to that bony supraglinoid
4:07
tubercle. The tubercle itself is located about
4:10
six millimeters medial or towards the body's
4:13
midline. from the actual articular surface of
4:16
the glenoid. This point of attachment is generally
4:19
located posterior to the 12 o 'clock position
4:22
on the superior glenoid when you're looking at
4:25
it arthroscopically. And you mentioned anatomical
4:27
variations in how the biceps attaches. Does that
4:30
add another layer of complexity? It absolutely
4:32
does, yes. The way the biceps tendon attaches
4:35
to the superior labrum isn't identical in everyone.
4:38
There's this thing called the two -ahead classification
4:40
system. referenced in the sources, describes
4:43
some of these patterns. Type I is where the attachment
4:45
is completely posterior to that 12 o 'clock position
4:48
on the glenoid. Type II is predominantly posterior.
4:51
Type III has fibers attaching both anteriorly
4:53
and posteriorly. and type four is when the entire
4:56
attachment is anterior to the 12 o 'clock position.
4:59
The sources indicate that top eye and two attachments
5:01
are by far the most common, accounting for over
5:04
70 % of the anatomical variations observed. Understanding
5:07
these normal variations is important because,
5:09
well, they can influence how a tear presents
5:11
or how a surgeon views the anatomy during surgery.
5:15
Another relevant anatomical detail is that the
5:18
long head of the biceps tendon, It actually has
5:21
its porous blood supply. Precisely where it versus
5:24
through the shoulder joint. This limited blood
5:27
flow could potentially impact its ability to
5:30
heal after injury. Limited blood flow. That sounds
5:33
like a key piece of information. And what about
5:35
the labrum itself? Does its blood supply vary?
5:37
Yes, it does. The labrum receives its blood supply
5:40
not from the underlying bone, but from the surrounding
5:43
joint capsule and periosteal vessels. And critically,
5:47
the anterior superior portion of the labrum seems
5:49
to have the poorest blood supply compared to
5:52
other parts of the rim. Couple this with the
5:53
fact that the superior labrum attaches slightly
5:55
further medially on the glenoid compared to the
5:58
inferior labrum, making it a bit less firmly
6:00
supported at its base, you could say. And it
6:03
becomes clearer why this specific area where
6:06
the biceps tendon anchors can be considered something
6:08
of a weak link if prone to injury under certain
6:12
forces, resulting in a SLAP tear. So the very
6:15
anatomy of that superior labrum and biceps anchor
6:18
area kind of predisposes it to tearing. And speaking
6:22
of anatomy looking like tears, you mentioned
6:25
those tricky anatomical variants that can sometimes
6:28
fool even experienced eyes. That sounds like
6:30
a major diagnostic hurdle. It's a very significant
6:33
point, yes. particularly for surgeons looking
6:36
inside the joint. There are two main anatomical
6:38
variants in the superior labrum area that can
6:40
easily be mistaken for a tear on imaging or during
6:44
arthroscopy if you're not acutely aware of them.
6:46
One is called the sublaboral recess or sublaboral
6:49
foramen. This is a normal non -pathological separation
6:53
or space between the superior labrum and the
6:56
underlying glenoid bone. It's just how the anatomy
6:59
is configured in some people. It can sometimes
7:02
be associated with a thicker than usual middle
7:04
glenohumeral ligament, which is another ligament
7:06
in the shoulder. The key challenge is distinguishing
7:09
this normal space from a true tear, where the
7:12
labrum is detached and actually causing symptoms.
7:15
On an MRI arthrogram, dye might enter this normal
7:18
recess, which can be confusing. I can see that.
7:20
But the pattern is usually distinct from dye
7:22
entering a tear. It tends to be smoother. OK,
7:25
and the second variant? The second crucial variant
7:27
is the Buford complex. This is a specific anatomical
7:31
arrangement where the middle glenohumeral ligament
7:33
is very thick and cord -like, and it originates
7:36
directly from the superior labrum. When this
7:38
happens, there is a congenital absence, or a
7:41
bare area, of the antero -superior labrum. It
7:44
looks like a piece of the labrum is missing or
7:46
torn anteriorly. But it's not. But it's actually
7:49
a normal developmental variant present in a small
7:52
percentage of the population. And why is recognizing
7:54
the Buford complex so critical? What happens
7:57
if a surgeon mistakes it for a tear and tries
7:59
to fix that bare area? This is where the clinical
8:03
pitfall lies. It's really important. If a surgeon
8:06
doesn't recognize the Buford complex and mistakenly
8:09
repair that bare, antro -superior area of the
8:12
labrum to the glenoid, believing it's a tear,
8:14
they will significantly restrict the patient's
8:17
external rotation of the shoulder. Oh, wow. because
8:19
that thick cord -like ligament is meant to be
8:22
in that position, trying to anchor tissue there
8:24
that isn't supposed to be just restricts normal
8:26
shoulder movement. Recognizing these variants,
8:29
the sublaboral recess, and especially the Buford
8:31
complex, is absolutely paramount for accurate
8:34
diagnosis and avoiding unnecessary surgery that
8:37
can actually cause functional problems. That
8:39
really emphasizes how understanding the normal
8:42
variations is just as important as understanding
8:44
the pathology. It's not just a simple case of,
8:46
is there a tear or isn't there? Okay, so we know
8:50
what SLAP lesion is anatomically and some of
8:53
the quirks in that region. Who was most likely
8:55
to get one of these tears and what typically
8:58
causes them? Well, while SLAP lesions account
9:01
for a relatively small percentage of all shoulder
9:03
injuries, less than 5 % according to the sources.
9:06
Less than 5%. They are disproportionately seen
9:09
in specific groups. The classic patient is the
9:12
overhead or throwing athlete. Often in their
9:15
dominant arm think baseball pitchers, javelin
9:17
throwers, volleyball or tennis players, that
9:20
sort of thing. However, they can also occur in
9:23
older patients, particularly as a result of a
9:25
traumatic fall onto an outstretched arm. Are
9:28
there specific risk factors or certain movements
9:30
that are known to cause these tears? Yes, repetitive
9:33
overhead activities are the prime suspect in
9:36
athletes. The sheer volume and force of throwing
9:39
or soothing motions put immense stress on that
9:42
superior labrum and biceps anchor. Other common
9:45
mechanisms of injury include falling directly
9:47
onto an outstretched arm, especially if the arm
9:50
is slightly bent and the biceps muscle is tensed
9:52
at the time of impact. A sudden forceful pull
9:55
on the arm, like trying to catch a heavy object
9:58
unexpectedly, or rapid forceful movements of
10:01
the arm above shoulder level can also generate
10:03
enough force to tear the superior labrum. And
10:06
interestingly, a shoulder dislocation can sometimes
10:09
peel the labrum off the glenoid rim, occasionally
10:12
including the superior portion involved in a
10:15
SLAP tear. You mentioned a theory about throwers
10:18
specifically linking tightness to the injury.
10:21
Can you elaborate a bit on that biomechanics?
10:23
Absolutely. This is where some of the deeper
10:25
insight into the pathology comes from. There's
10:28
a well regarded theory that in throwing athletes
10:30
who often develop tightness in the posterior
10:32
capsule and the posterior inferior glenohumeral
10:35
ligament. Right, the back of the shoulder. Exactly.
10:37
Which is a key stabilizing structure at the back
10:40
and bottom of the shoulder. This tightness can
10:42
alter the mechanics of the throwing motion. As
10:45
the arm moves through the late cocking phase
10:47
and into acceleration, this posterior tightness
10:50
can cause the ball of the humerus to shift post
10:53
-rosuperiorly upwards and backwards relative
10:56
to the glenoid socket. This abnormal shift increases
10:59
the sheer force applied to the superior labrum,
11:02
effectively sort of grinding or peeling it away
11:04
from the bone, especially where the biceps tend
11:06
to detaches. Furthermore, the sources point out
11:09
that once a SLAP lesion is present, this detached
11:13
superior labrum and biceps anchor can then increase
11:16
the strain on the anterior band of the inferior
11:19
glenohumeral ligament. Which is the main stabilizer
11:21
at the front. Precisely, the primary anterior
11:23
stabilizer of the shoulder. This can lead to
11:25
a sort of vicious cycle where the SLAP tear contributes
11:28
to subtle instability, further disrupting normal
11:30
mechanics. That's fascinating. So the injury
11:33
itself can potentially worsen the underlying
11:35
problem or contribute to instability. It's not
11:38
just about the tear itself, but how the tear
11:40
changes the shoulders function. And you noted
11:42
that in older patients, it might not be from
11:44
trauma, but just wear and tear. Correct, yeah.
11:47
In individuals over the age of, say, 30 or 40,
11:51
it's not uncommon to see some degree of fraying
11:53
or degenerative changes in the superior labrum
11:56
on MRI or during arthroscopy. This could just
11:59
be a normal part of aging. and doesn't necessarily
12:02
cause symptoms or require treatment unless there
12:05
was a specific traumatic event superimposed on
12:08
these degenerative changes. Right. Differentiating
12:10
between a symptomatic tear and just age -related
12:13
fraying is another critical diagnostic step.
12:15
It's not always easy. And are SLAP tears usually
12:18
isolated injuries or do they often come with
12:20
other problems in the shoulder joint? They frequently
12:22
have company, yes. SLAP lesions are often associated
12:25
with other shoulder conditions, particularly
12:27
in throwing athletes. These can include things
12:29
like internal impingement. Or the cuff gets pinched.
12:31
Yeah, where the rotator cuff tendon gets pinched
12:34
in certain overhead positions. Also glenohumeral
12:37
internal rotation deficit, or GIRD, which is
12:40
that posterior tightness we discussed. Rotator
12:42
cuff tears are common too. Often partial thickness
12:45
tears on the articular or joint side. Subtle
12:48
shoulder instability and scapular dyskinesis
12:50
that's abnormal movement or positioning of the
12:52
shoulder blade during arm motion. Okay. Addressing
12:55
these associated conditions is often really important
12:58
for successful management, whether you go surgical
13:00
or non -operative. Okay. We understand the anatomy,
13:03
who gets them, and how they might happen. Now,
13:06
for the detective work, how do doctors actually
13:08
figure out if someone has a celipate tear? What
13:11
does the patient feel and what does the examination
13:14
involve? Right. Well, from the patient's perspective,
13:17
the symptoms of a cell A pay tear can be somewhat
13:19
inconsistent and often mimic other shoulder problems,
13:22
which, as we said, is part of the diagnostic
13:24
challenge. Common complaints include a deep aching
13:27
pain within the shoulder that's often difficult
13:29
to localize precisely. People struggle to point
13:31
exactly where it hurts. A key symptom is often
13:34
mechanical people describe hearing or feeling
13:37
popping, clicking, catching, or grinding sensations
13:40
in the shoulder with certain movements. Pain
13:43
is typically aggravated by specific positions,
13:46
especially those involving overhead activities
13:48
or when lifting heavy objects. Athletes, particularly
13:52
throwers, might notice a significant decrease
13:54
in their performance, maybe loss of velocity
13:56
or control, feeling weakness, or experiencing
13:59
what's sometimes called a dead arm sensation
14:01
after throwing. The dead arm, yeah. Some patients
14:04
also report a feeling of apprehension, or like
14:06
the shoulder might pop out. And studies suggest
14:09
apprehension tests are actually positive in a
14:11
high percentage, around 85 % of patients with
14:15
SLAP tears. 85%, that's quite high. It is. Reduced
14:19
range of motion or easy fatigue ability can also
14:21
occur. And it's worth noting that sometimes symptoms
14:24
might not fully manifest immediately after the
14:26
injury, but rather develop gradually over time.
14:29
So the symptoms are broad and can sound like
14:31
other things. How does a doctor approach trying
14:33
to pin down if it's actually a SLI peer? Well,
14:36
the diagnostic process begins, as with any injury
14:39
really, with a detailed medical history. The
14:42
doctor will ask about the onset of the pain,
14:44
whether there's a specific injury or if it came
14:46
on gradually. What activities make it worse?
14:49
especially work or sports, the exact location
14:52
and character of the pain, and any previous treatments
14:55
they might have tried. The patient's age and
14:58
activity level are also critical pieces of information.
15:02
Following the history, a thorough physical examination
15:05
is performed. This involves assessing the shoulder's
15:08
range of motion in different planes, evaluating
15:10
muscle strength, and testing the overall stability
15:13
of the joint. A key component of the physical
15:16
exam for suspected SLA key tears involves performing
15:19
what are called provocative tests. Provocative
15:21
tests. These are specific maneuvers where the
15:23
doctor moves the patient's arm into positions
15:26
designed to put stress on the superior labrum
15:28
and biceps anchor to see if they can reproduce
15:30
the patient's pain or mechanical symptoms. Are
15:32
these provocative tests definitive? Like, if
15:34
one test is positive, you know for sure it's
15:36
a SLA P tear. Ah, this is a critical point from
15:40
the sources and really highlights the diagnostic
15:43
difficulty. There is no single physical examination
15:47
test that is perfectly sensitive or specific
15:50
for diagnosing a SLAP lesion on its own. Right.
15:54
No silver bullet test. Exactly. A diagnosis is
15:58
based on the combination of the patient's history,
16:01
their reported symptoms, and the findings from
16:03
multiple provocative tests, along with of course
16:06
the imaging results. It's putting all the pieces
16:08
together. Can you walk us through a couple of
16:10
these provocative tests and maybe explain why
16:13
they might reproduce symptoms if a SLIP is present?
16:16
What's the thinking behind them? Certainly. The
16:19
sources list several. Some are general biceps
16:21
provocation tests like Speed's test or Jurgesson's
16:24
test, though these can be positive with other
16:26
biceps issues too, so they're not super specific.
16:28
More specific SLAP tests include the active compression
16:31
test, often known as O 'Brien's test. O 'Brien's
16:34
test, yeah, I've heard of that one. The crank
16:35
test, the dynamic labral shear test, and the
16:37
Kibler anterior slide test. There are quite a
16:39
few. Let's look at the O 'Brien's test as it's
16:41
commonly used. The patient flexes their arm forward
16:44
to 90 degrees, adducts it about 10, 15 degrees
16:47
across the body, and internally rotates it so
16:50
the thumb points down. Right, thumb down, arm
16:53
across. Exactly. The doctor then applies downward
16:56
resistance, and the patient resists. This position,
17:00
with the arm slightly across the body and internally
17:02
rotated, is thought to put a twisting or torsional
17:05
stress on the superior labrum and biceps anchor.
17:08
Then the arm is externally rotated, so the palm
17:11
is up, and the resistance is applied again. A
17:14
positive test is if the pain or clicking experience
17:16
with the thumb down position is reduced or eliminated
17:19
when the palm is up, particularly if the pain
17:21
is felt deep inside the shoulder. The idea is
17:24
that with the thumb down, the superior labrum
17:26
is being loaded and perhaps peeled away slightly,
17:29
while with the palm up, that stress is relieved.
17:31
I see. And the crank test, how does that one
17:33
work? For the crank test, the arm is abducted,
17:35
so lift it away from the body to about 120 degrees.
17:38
The doctor applies an axial load, basically pushing
17:41
the humerus head into the socket gently, and
17:43
then rotates the arm internally and externally.
17:46
This maneuver is designed to try and catch or
17:48
pinch a torn labral flap between the humerus
17:51
head and the glenoid. It's trying to reproduce
17:54
those catching or clicking mechanical symptoms.
17:57
The presence of pain or a click, especially during
18:00
external rotation with that axial load, can suggest
18:02
a superior label tear. Right. But again, it's
18:06
crucial to remember a positive result on any
18:08
single test isn't proof positive. It just raises
18:11
suspicion that needs to be confirmed by other
18:13
means like imaging. That makes sense. You're
18:16
essentially trying to manually stress that specific
18:19
area where the tear might be to see if you can
18:21
reproduce the patient's symptoms. Given that
18:24
physical tests aren't definitive, imaging must
18:27
play a really crucial role then. What do they
18:29
use and how good is it at actually seeing these
18:32
tears? You're right. Imaging is essential. Standard
18:35
x -rays are usually the first step, but they
18:37
primarily show bone, not soft tissues like the
18:40
labrum. So they'll likely be normal. Exactly.
18:42
X -rays in a patient with a cesolactare are typically
18:45
normal. They're mostly useful for ruling out
18:47
other potential causes of pain, like arthritis,
18:50
bone spurs, or maybe a fracture. Okay. To visualize
18:54
the labrum itself, Magnetic Resonance Imaging,
18:57
or MRI, is the primary tool. On a standard MRI,
19:00
a cell AP p -tear might appear as increased signal
19:03
a brighter area on certain sequences, particularly
19:07
T2 -weighted images between the superior labrum
19:09
and the glenoid bone, usually posterior to where
19:12
the biceps attaches. However, standard MRI sensitivity
19:15
for detaching a cell AP p -tears is only around
19:18
50%. 50%. That sounds pretty low, especially
19:21
for such a key diagnostic tool. It is quite low.
19:23
It means it misses about half of them, although
19:25
its specificity is higher, around 90%. So if
19:28
it sees something, it's likely real, but it misses
19:30
a lot. So how do they improve its accuracy? There
19:32
must be a better way. This is where an MRI arthrogram
19:35
becomes invaluable. This involves injecting a
19:37
contrast agent, basically a dye, directly into
19:40
the shoulder joint before the MRI scan is performed.
19:42
Ah, injecting dye into the joint first. Exactly.
19:45
The dye fills the joint space. If there's a tear
19:48
in the labrum... the dye will leak into that
19:50
tear, highlighting the defect and making it much
19:52
more visible on the scan. The sources are clear
19:55
that an MRI arthrogram significantly increases
19:58
the accuracy for diagnosing labral tears compared
20:01
to a standard MRI. It's really the gold standard
20:04
for imaging these. You can visually distinguish
20:06
between, say, a normal sublabor recess where
20:09
the dye might pool slightly in a smooth pattern
20:11
and a true tear, where the dye seeps irregularly
20:14
into the torn tissue or the defect. The presence
20:17
of a paralabral gangly insist is another important
20:20
imaging finding. These are fluid -filled sacs
20:22
that often form adjacent to a labral tear, particularly
20:25
in the spinoculnoid notch near the shoulder blade.
20:28
Assist near the tear. Yes. And their presence
20:31
on MRI is considered highly specific for an underlying
20:33
labral tear, even if the tear itself is subtle
20:36
or difficult to see directly on the scan. It's
20:39
a strong secondary sign. The diagnosis is really
20:43
a puzzle pieced together from the patient's story,
20:45
the physical exam findings, even if they're not
20:48
definitive individually, and then ideally, a
20:51
specific type of imaging, like an MRI arthrogram.
20:54
Once a tear is identified, the sources talk about
20:56
classification systems. Why bother classifying
21:00
these tears? What's the point? Classification
21:02
systems are used mainly to standardize the description
21:05
of the tear pattern. This helps in communication
21:07
among clinicians, surgeons, physios, and importantly,
21:11
it helps guide treatment decisions. Different
21:13
types of tears might be managed differently.
21:15
The most widely referenced system is the Snyder
21:17
classification, which uniquely describes four
21:20
main types based on the anatomical location and
21:22
the involvement of the biceps tendon anchor.
21:25
Could you briefly explain those Snyder types
21:27
for us? Type I to IV? Certainly. Let's run through
21:30
them. Type I. This is considered more of a degenerative
21:32
tear. It involves fraying of the superior labrum
21:35
and sometimes the biceps tendon itself, but the
21:37
key thing is the biceps anchor remains firmly
21:39
attached to the glenoid. These account for about
21:42
11 % of SLAP lesions. Just fraying anchors okay.
21:45
Got it. Type 2. This is the most common type,
21:49
particularly in throwing athletes, making up
21:51
around 41 % of cases. It involves fraying of
21:54
the superior labrum and a detachment of the biceps
21:57
tendon anchor from the superior glenoid. The
22:00
labrum and biceps anchor are essentially peeled
22:02
away from the bone. Okay, that's the detached
22:04
anchor one. Exactly. Type 3. This is described
22:06
as a bucket -handle tear of the superior labrum.
22:09
A flap of the labrum tears and can displace into
22:11
the joint, but critically, the biceps tendon
22:14
anchor remains intact and attached to the glenoid.
22:17
The biceps actually separates from the torn labral
22:19
flap. These are about 33 % of cases. So the labrum
22:22
tears, but the biceps anchor stays put. Correct.
22:25
And type 4. This is also a bucket -handle tear,
22:28
like type 3, but in this case, the tear extends
22:30
into the biceps tendon itself, and the biceps
22:33
tendon anchor is also detached and remains attached
22:35
to the torn labral flap. These are less common,
22:38
around 15%. Right, so the tear goes into the
22:40
biceps tendon too, and the anchor comes off with
22:42
it. Precisely. And there are more types added
22:44
later. I think you mentioned MAFIT. Yes, that's
22:46
right. The MAFIT classification and others expanded
22:49
the system to include tears extending into other
22:51
parts of the labrum, or associated with other
22:54
ligamentous injuries. For example, type V is
22:57
a type II tear that extends down and forward
23:00
into the antero -inferior labrum, similar to
23:03
a bankart lesion which you see in dislocations.
23:06
Type VI is a type II with an unstable labral
23:10
flap, and type VII involves extension into the
23:13
middle glenohumeral ligament. There are even
23:16
more types described, up to X, but... While these
23:20
extended classifications exist, the Snyder R5
23:23
are really the foundational ones clinicians often
23:26
refer back to. Given the complexity in those
23:28
variants we talked about, is classifying these
23:30
tears always straightforward even when the surgeon
23:33
is looking right at it during surgery? Unfortunately,
23:35
no. This is another challenge highlighted in
23:37
the sources. There's significant inter -observer
23:40
variability. Meaning different surgeons might
23:42
grade it differently. Exactly, and even intra
23:44
-observer variability, where the same surgeon
23:46
might classify the same care differently if they
23:49
looked at it again at different times. This variability
23:51
really underscores the subjective nature of assessing
23:54
these tears. Even with direct visualization during
23:57
arthroscopy. It reinforces that it's not just
24:00
a simple clear -cut diagnosis or classification.
24:04
There's judgment involved. Okay, so we've diagnosed
24:07
it. We've classified it maybe with some variability.
24:10
How do you treat a cell AP tear? Is surgery always
24:15
the answer or is there a non -operative approach
24:17
first? The good news is that surgery is not always
24:20
necessary. And the sources strongly recommend
24:22
starting with non -operative treatment in most
24:24
cases. This is considered the first line of management.
24:27
OK, so try physio first. What does non -operative
24:29
treatment typically involve? Non -operative management
24:32
includes several components. Firstly, rest or
24:35
a modification of activities, especially avoiding
24:37
the movements that cause pain that's particularly
24:39
important for athletes, obviously. Secondly,
24:41
a structured physical therapy program, or physio,
24:44
is crucial. This therapy focuses on regaining
24:47
full, pain -free range of motion, strengthening
24:50
the muscles around the shoulder, especially the
24:52
rotator cuff and the muscles that control the
24:54
shoulder blade. Addressing that scapular dyskinesis
24:56
you mentioned. Precisely. Addressing scapular
24:59
dyskinesis, and importantly, stretching out any
25:01
associated tightness like GIRD, that posterior
25:05
tightness. Thirdly, non -steroidal anti -inflammatory
25:09
medications, NSAIDIDES, can be used to help manage
25:12
pain and reduce inflammation. This non -operative
25:16
approach is typically pursued for a significant
25:18
period usually between three and six months to
25:21
really see if symptoms improve. Three to six
25:22
months, okay. Corticosteroid injections into
25:25
the shoulder joint can also be used often to
25:27
help calm inflammation and sometimes as a diagnostic
25:30
aid if the exact source of the pain is a bit
25:32
unclear. How effective is this non -operative
25:35
approach, especially for that high -demand overhead
25:37
athlete the pitcher may be, who wants to get
25:39
back to throwing at full speed? Ah, this is a
25:42
key distinction made in the sources and it's
25:43
quite important. While non -operative treatment
25:46
can be successful for some individuals, particularly
25:49
those with lower activity demands or maybe more
25:51
degenerative tiers, the data on high -level pitching
25:54
athletes is less encouraging. The number of pitchers
25:56
who successfully return to their prior level
25:58
of performance using only non -surgical methods
26:01
has been described in the literature as Unsatisfactory.
26:05
Unsatisfactory. That's quite blunt. It is. It's
26:08
a critical insight. It suggests that for this
26:10
specific, highly demanding population, non -operative
26:14
treatment, while a necessary first step, often
26:17
doesn't actually get them back to where they
26:18
need to be competitively. That makes sense, unfortunately,
26:21
for them. So if non -operative treatment fails,
26:24
or perhaps if the tear is severe or unstable
26:27
from the outset, surgery comes into consideration.
26:29
What does that involve? Surgical treatment for
26:32
SLAP lesions is typically performed arthroscopically
26:35
keyhole surgery using small incisions, a camera,
26:38
the arthroscope, and specialized miniature instruments.
26:41
The goal of surgery is to address the tear based
26:43
on its type, the patient's age, their activity
26:46
level, and the surgeon's assessment of stability
26:48
and tissue quality. This is also the area where,
26:51
particularly for type 2 tears, there is significant
26:54
ongoing discussion and, as the sources call it,
26:57
quite a bit of controversy. Right, you mentioned
26:59
controversy around type 2 tears. What's the debate
27:02
here? What are the options? Okay, the core debate
27:05
for type 2 tears, remember they're the most common
27:07
in throwers and involve the detached biceps anchor,
27:11
is whether to actually repair the torn labrum
27:13
and reattach the biceps anchor back to the bone.
27:16
The traditional approach. The traditional approach,
27:18
yes. Or, alternatively, whether to perform a
27:22
procedure on the biceps tendon itself, either
27:25
a tenotomy or a tenodesis, and essentially leave
27:28
the superior labrum alone, or perhaps just de
27:31
-bride it, trim it up. Okay, let's clarify those
27:33
biceps procedures again. What exactly are tenotomy
27:36
and tenodesis? Right. Biceps tenotomy is simply
27:39
cutting the long head of the biceps tendon near
27:41
its attachment inside the shoulder joint, allowing
27:43
it to retract down the arm. It essentially removes
27:46
the and pull on the superior labrum. Just cut
27:48
it loose. Pretty much. Biceps tendinesis also
27:51
involves cutting the tendon, but then the cut
27:53
end is reattached, usually with an anchor or
27:55
screw, to the humerus, the upper arm bone, lower
27:58
down, typically outside the shoulder joint itself.
28:01
Okay, cut and reattach it lower down. Exactly.
28:04
Tenodesis is generally preferred over tenotomy
28:06
in active patients because it helps maintain
28:09
biceps strength and the normal shape of the muscle,
28:13
preventing the potential cosmetic deformity called
28:14
a Popeye muscle bulge that can sometimes occur
28:17
with just a tenotomy. Right, the Popeye bulge.
28:20
So traditionally, type 2 tears, especially in
28:23
younger athletes, were repaired. Why the shift
28:26
towards considering tenodesis more often now?
28:29
This is really where the outcomes data is influencing
28:31
practice. While repairing the labrum and biceps
28:34
anchor seems intuitively correct, you know, restoring
28:37
the anatomy. Yeah, it sounds like the right thing
28:39
to do. It does. But recent investigations have
28:42
shown a notable disconnect. A high incidence
28:45
of SLAP repairs being performed, but often disappointing
28:48
return to play rates. particularly for pitchers.
28:52
Studies cited in the sources have shown that
28:53
return -to -play rates after SLAP repairs are
28:56
significantly lower for pitchers compared to
28:58
athletes in other overhead sports like tennis
29:01
or volleyball. Lower for pitchers specifically.
29:03
Interesting. Yes. And importantly, return -to
29:06
-play rates for throwers are actually similar
29:08
whether they undergo a SLAP repair or a biceps
29:12
tenodesis. So the repair doesn't seem to offer
29:14
an advantage for getting back to pitching. Specifically.
29:18
So similar outcomes for return to play, but maybe
29:20
other factors. Exactly. Furthermore, the sources
29:23
highlight a strong association between age and
29:26
the success of SLAP repair. Failures after SLAP
29:29
repair are specifically linked to patients over
29:31
the age of 36. Over 36. OK. This suggests that
29:35
perhaps tissue quality or healing potential might
29:38
be poorer in older patients, making the repair
29:40
less likely to hold reliably or possibly leading
29:43
to complications like stiffness, which we'll
29:45
talk about. Because of these findings, poorer
29:47
return to throwing after repair compared to non
29:50
-throwing sports, similar return to throwing
29:52
between repair and tenodesis, and higher failure
29:54
and stiffness rates in older patients after repair,
29:57
the general consensus among orthopedic surgeons.
30:00
As reflected in the literature, is increasingly
30:02
favoring bicep synotomy or tenodesis, especially
30:05
in patients over the age of 40. Right, so over
30:07
40 lean towards the biceps procedure. Generally,
30:10
yes. For younger, high -level overhead athletes,
30:14
the decision is still debated, it's more nuanced,
30:16
but the pendulum is certainly swinging towards
30:18
considering biceps procedures more frequently.
30:21
Even in this group, if return to high -level
30:24
throwing is the primary goal, simply due to the
30:26
less -than -ideal results seen with repair in
30:29
that specific population. That's a really significant
30:32
shift in thinking, isn't it? Moving away from
30:35
trying to restore the anatomy with repair towards
30:38
essentially just offloading the biceps tension
30:41
because the repair outcomes, particularly for
30:43
throwers or older patients, haven't been as successful
30:45
as everyone hoped. What about the other types
30:48
of tears, types 1, 3, and 4? Right, for type
30:50
I tears, which are just fraying with an intact
30:53
anchor, and maybe some type III or V tears involving
30:55
less than one -third of the biceps tendon without
30:58
significant symptoms after non -operative treatment,
31:00
simple arthroscopic debridement is often sufficient.
31:03
Just trimming the frayed bits. Exactly, just
31:05
trimming away the unstable frayed edges of the
31:07
labrum or biceps. For type 4 tears, where more
31:11
than one -third of the biceps tendon is involved,
31:13
causing severe symptoms that haven't responded
31:15
to non -operative care, the options are typically
31:18
debridement plus either labor repair or biceps
31:21
tendon imidinodesis. The choice here would again
31:24
depend heavily on the patient's age, activity
31:26
level, and the surgeon's preference, considering
31:28
all the same factors we just discussed for type
31:30
2. So treatment is highly individualized based
31:33
on tear type. age, activity goals, and this evolving
31:37
evidence. Once surgery is done, whichever route
31:40
is chosen, what does the road to recovery look
31:42
like? Rehabilitation must be absolutely critical.
31:46
Oh, rehabilitation is absolutely paramount to
31:48
the success of any surgical intervention for
31:50
a cesilite tear, whether it's a repair or a biceps
31:53
procedure. It's not optional, it's essential.
31:55
It's a structured multi -stage process that progresses
31:58
gradually to protect the healing issues while
32:01
carefully restoring motion and strength. Okay,
32:03
what's the initial phase like after the surgery?
32:05
Immediately after surgery, the shoulder is typically
32:08
immobilized in a sling. The duration varies depending
32:11
on the surgery's complexity and the surgeon's
32:13
protocol, but usually ranges from about two to
32:16
six weeks. The initial phase, typically the first
32:19
one to four weeks, focuses heavily on protection
32:22
and controlled motion. Patients are usually allowed
32:24
gentle passive range of motion, where the therapist
32:27
moves the arm, and maybe some active assisted
32:30
range of motion exercises, often in the scapular
32:32
plane, which is arm moving slightly forward from
32:35
the side, kind of a safe zone. Crucially, during
32:37
this phase, it is vital to avoid any extremes
32:40
of abduction and external rotation. Right. Don't
32:43
stretch it out too much. Exactly. And absolutely
32:45
no resisted biceps exercises, especially if the
32:48
biceps anchor was repaired, to protect that healing
32:50
site. You don't want to pull on it. Makes sense.
32:53
What happens as you move beyond that initial
32:55
protective phase, say after the first month or
32:57
so? Around weeks 4 -6, as healing progresses
33:01
and pain allows, the patient typically transitions
33:04
to active range of motion exercises, trying to
33:07
move the arm themselves under their own power.
33:09
They also usually start isometric strengthening
33:12
tensing muscles without actually moving the joint.
33:14
The mid -stage, generally from week 6 -12, involves
33:17
progressing to more functional exercises and
33:19
beginning light -resistant strengthening, really
33:22
focusing on the rotator cuff and those periscapular
33:24
muscles, the ones controlling the shoulder blade.
33:27
The goal is to build foundational strength and
33:29
control. Okay, building back the support system.
33:32
Precisely. The late stage, from 12 weeks onwards,
33:35
involves advancing strengthening exercises, restoring
33:37
full range of motion, and initiating sport -specific
33:40
training if the patient is an athlete. This might
33:43
involve progressive drills mimicking the movements
33:45
required for their sport, like starting a throwing
33:47
program. When can someone realistically expect
33:50
to return to full activity or sport after all
33:53
this? A typical return to full activity or sport
33:56
after SLIP surgery is often quoted around six
33:58
months. However, this timeline is highly variable.
34:02
It really depends on the specific type and severity
34:04
of the injury, the patient's individual healing
34:07
rate, their overall health, and critically, their
34:10
activity goals. Six months is just a ballpark
34:12
figure, them. Very much so. For throwing athletes,
34:15
an early interval throwing program might begin
34:17
around three, four months. But a full return
34:20
to competitive pitching can easily take six months
34:22
or even longer, sometimes nine months to a year,
34:25
to feel truly back to normal. The sources emphasize
34:28
that complete recovery can take several months,
34:31
particularly in more complicated cases. And diligently
34:34
following the surgeon's post -operative instructions
34:36
and the prescribed rehabilitation plan is absolutely
34:39
vital for optimizing the outcome. You simply
34:41
can't rush the biology of healing. That sounds
34:43
like a long and very dedicated process. What
34:46
are the potential roadblocks or complications
34:48
that can occur after SLAP surgery? What can go
34:51
wrong? Well, like any surgical procedure. There
34:54
are potential complications. For SLAP repair
34:57
specifically, the most common complication reported
34:59
in the sources is post -operative stiffness.
35:03
It occurs in a significant percentage of patients,
35:05
one source mentioned, around 78%. 78%. That's
35:10
a very high number for stiffness. Are there specific
35:13
factors that make someone more likely to experience
35:15
stiffness after a SLAP repair? Yes, the sources
35:20
identify significant risk factors for post -operative
35:22
stiffness after SLAP repair. A particularly strong
35:26
risk factor seems to be performing an incidental
35:29
SLAP repair in older patients, specifically those
35:32
over the age of 45, when doing surgery for a
35:35
different primary problem, such as a rotator
35:37
cuff repair. So finding a cell AP tear while
35:40
fixing something else and deciding to repair
35:42
it in an older patient is risky for stiffness.
35:45
Exactly. It reinforces the clinical trend away
35:47
from routinely repairing these lesions in older
35:49
patients and perhaps opting for a biceps procedure
35:51
instead, which tends to have less risk of stiffness.
35:54
And if someone does develop stiffness, how is
35:56
it treated? Can it be fixed? Early recognition
35:58
and intervention are key. Rehabilitation protocols
36:02
are designed to start controlled motion relatively
36:04
early, even in the protective phase. Things like
36:07
pendulum swings are often encouraged, sometimes
36:09
beginning as early as one week post -op, specifically
36:12
to help prevent stiffness setting in. If stiffness
36:15
develops and persists despite dedicated physio,
36:19
a secondary procedure called a capsular release
36:21
might be necessary. This involves arthroscopically
36:24
releasing the tightened tissues, the capsule,
36:27
around the joint to restore motion. Okay. Are
36:30
there other potential complications besides stiffness?
36:33
Yes, other potential complications include, though
36:36
less commonly, injury to the suprascapular nerve.
36:39
This is a nerve near the shoulder blade that
36:41
controls some of the rotator cuff muscles. This
36:44
could potentially happen if the glenoid bone
36:45
is over -drilled during the process of placing
36:48
anchors for a prey pair, as the nerve runs quite
36:50
close by. Careful technique is needed. Right.
36:53
And unfortunately, sometimes the SLAP repair
36:56
simply fails or the patient continues to experience
36:58
symptoms despite the surgery. What typically
37:00
causes a failed SLAP repair? Why might it not
37:03
work? Failures can be multifactorial. There isn't
37:06
always one single reason. Causes can include
37:09
the repair anchors pulling out of the bone, failure
37:12
of the labral tissue itself to heal back to the
37:14
bone properly, or perhaps the presence of associated
37:17
injuries. like articular cartilage damage that
37:20
weren't fully addressed initially or that progressed
37:23
over time. The sources again highlight the association
37:26
of failures with age, specifically noting that
37:29
failures are more common in patients over the
37:31
age of 36. Right, reinforcing that age factor
37:33
again. Exactly. Further supporting the rationale
37:36
for considering biceps tenodesis in this age
37:39
group. It's also really important to note that
37:41
the outcomes after surgical management of a failed
37:44
SLAP repair. So going back in to try and revise
37:48
the initial surgery are generally inferior to
37:50
the outcomes achieved after a successful primary
37:53
repair. So it's much better to get it right the
37:54
first time. Absolutely. It really emphasizes
37:57
the importance of selecting the right procedure
37:58
for the right patient the first time around.
38:01
So getting that initial treatment decision correct
38:03
based on all the factors, age, activity, tear
38:07
type, evidence, is really paramount for the best
38:10
chance of success. Putting it all together then,
38:13
what's the overall prognosis for someone who
38:16
undergoes treatment for a cell AP tear? What
38:18
can they expect? Well, the prognosis for a cell
38:21
AP after treatment is generally positive in terms
38:23
of reducing pain and improving shoulder strength
38:25
for the majority of patients, particularly those
38:27
with symptoms directly attributable to the tear
38:29
who undergo appropriate surgical intervention
38:31
after feeling a good course of non -operative
38:33
care. However, as we've discussed quite a bit,
38:37
the ability to return to a prior high level of
38:39
performance, especially for elite overhead throwers,
38:42
remains variable and can be unpredictable. It's
38:44
not guaranteed. Achieving a successful outcome
38:47
relies heavily on the correct diagnosis in the
38:49
first place, appropriate treatment selection
38:51
tailored to the individual, addressing any associated
38:54
shoulder pathologies concurrently, and critically,
38:57
the patient's commitment to that structured and
38:59
often lengthy post -operative rehabilitation
39:02
process. It really is a complex injury requiring
39:05
a comprehensive approach from everyone involved.
39:08
This has truly been a deep dive into the world
39:10
of SLAP lesions. We've covered the nuanced anatomy,
39:14
including those tricky variants like the Buford
39:16
complex, gone through the detective work of diagnosis
39:18
using history, physical exam, and specialized
39:21
imaging like MRI orthograms, and explored the
39:24
evolving and sometimes controversial landscape
39:26
of treatment decisions, particularly that shift
39:28
towards biceps procedures for type 2 pairs in
39:31
certain patient populations. Plus the challenges
39:34
of rehabilitation and potential complications
39:36
like that risk of stiffness. It's absolutely
39:39
clear that this is far from a simple injury,
39:42
and managing it effectively requires a deep understanding
39:44
of all these interconnected factors. That's a
39:47
very accurate summary, I think. The diagnostic
39:49
challenges, the importance of recognizing anatomical
39:52
variants, the controversy surrounding the optimal
39:55
management of type 2 care, especially in different
39:58
age groups and activity levels, and the critical
40:00
role of rehabilitation. Those are all key takeaways
40:03
from the literature we reviewed today. And understanding
40:06
why certain decisions are made, like opting for
40:09
a biceps tenodesis over a repair in an older
40:12
patient, because of that increased risk of failure
40:14
or stiffness, that's crucial information for
40:16
both clinicians and patients to understand, isn't
40:18
it? Indeed. And the evidence base is constantly
40:21
evolving, which is why this area remains a topic
40:24
of significant research and clinical discussion.
40:26
It keeps changing. Okay, thinking about everything
40:28
we've covered. The anatomical complexities, the
40:31
difficulty in definitively diagnosing these tiers
40:34
sometimes, the ongoing debate about the best
40:36
way to fix certain types, especially for athletes
40:38
trying to get back to peak performance, and the
40:40
impact of age on outcomes and complications.
40:43
Here's a provocative thought to leave you, our
40:45
listeners, with. Given these persistent challenges,
40:48
how might future advancements, maybe in areas
40:51
like artificial intelligence, helping to analyze
40:53
subtle patterns on MRI scans, or more sophisticated
40:57
biomechanical modeling to understand forces on
40:59
the labor in real time during movement, or even
41:02
biological approaches to enhance laboral healing
41:04
itself, how might these things fundamentally
41:06
change how we diagnose and treat SLAP tiers in
41:09
the future? Could we reach a point where we can
41:11
much more accurately predict who needs what treatment
41:14
and who is most likely to achieve their desired
41:16
outcome? Or conversely, is the inherent variability
41:19
in human anatomy, tissue quality, and individual
41:21
healing potential simply something we will always
41:24
have to navigate with clinical judgment and experience
41:26
no matter how good the tech gets? Those are certainly
41:29
the questions driving future research and innovation
41:31
in orthopedic sports medicine. Big questions
41:34
for the future. This has been the Deep Dive.
41:37
We hope this detailed exploration has given you
41:39
a clearer picture of SLAP lesions. If you found
41:43
this insightful, please do consider reading and
41:45
sharing this deep dive with colleagues or friends
41:48
who might find it useful. Thank you for joining
41:50
us.