Diagnosis and Management of Superior Labral (SLAP) Tears of the Shoulder

 Diagnosis and Management of Superior Labral (SLAP) Tears of the Shoulder

                                                       Dr. KS Dhillon

Anatomy of the labrum and its normal variants

The labrum is a fibrous structure that is attached around the edge of the glenoid and it serves to increase the contact surface area between the glenoid and the humeral head at the shoulder joint. It consists mainly of fibrous cartilage, although some studies have shown that it is composed of dense fibrous collagen tissue [1].

The superior and anterosuperior portions of the labrum are loosely attached to the glenoid. The macro-anatomy of these portions of the labrum is similar to that of the meniscus of the knee. The inferior labrum is more rounded and is more tightly attached to the glenoid rim.

The inferior portion of the labrum is fixed firmly by inelastic fibrous tissue to the glenoid rim and the superior portion is attached by loose connective fibers [1]. 

The labrum serves as the attachment site for the long head of the biceps tendon, and the superior, middle, and inferior glenohumeral ligaments are continuous with the labrum [2].

The blood supply for the labrum comes from a network of vessels originating from the suprascapular artery, the circumflex scapular branch of the subscapular artery, and the posterior circumflex humeral artery. The vascular penetration of the labrum is more at the periphery close to the capsular attachment [1]. The vascular penetration is less in the central zone. The anterosuperior portion of the labrum is less vascular than the rest of the labrum. The vascularity diminishes with age [3].

Free nerve endings are present in the fibrocartilaginous tissue of the labrum [4]. 

The cross‐sectional shape of the superior labrum is normally triangular with a sharp edge pointing towards the center of the joint and its appearance is similar to the knee meniscus [1]. In some individuals, the free edge of the labrum is more prominent and may extend into the center of the joint. This type of labrum is termed as “meniscoid‐type” superior labrum and it must not be considered pathological. 

In some individuals, there is a minimal recess or anterior sublabral hole that is normal and it must not be confused with a SLAP lesion [5]. 

A third normal anatomical variation of the glenoid labrum is known as the Buford complex. It is a cord‐like middle glenohumeral ligament that blends with the anterior superior labrum with the absence of part of the anterior superior labrum on the glenoid [6].

 

Pathogenesis of SLAP Lesions

Several injury mechanisms are responsible for SLAP lesions. These lesions can result from a single traumatic event or be due to repetitive micro traumatic injuries. Traumatic events include falling on an outstretched arm, falling onto the shoulder, bracing oneself during a motor vehicle accident, direct blows, and forceful traction injuries of the upper extremity [7].

Repetitive overhead activity, such as that seen in throwing a baseball, is another common mechanism of injury that produces SLAP lesions [8].

There is a strong correlation between SLAP lesions and glenohumeral instability [9].

Classification of SLAP Lesions

Snyder et al [10] in 1990 described four types of SLAP lesions based on a retrospective review of 700 shoulder arthroscopies. The 4 types of SLAP lesions include:

Type                                  Description                                               %

   I                  Labral and biceps fraying, anchor intact                  11%

   II           Labral fraying with detached biceps tendon anchor          41%

III  Bucket handle tear with intact biceps tendon anchor where             33%

      the biceps separates from bucket handle tear

IV  Bucket handle tear with detached biceps tendon anchor which        15%

     remains attached to bucket handle tear

Over the years, this classification has been expanded to include six more types. These include: 

Type                                    Description

                                                      

V        Type II + anteroinferior labral extension (Bankart lesion)

VI        Type II + unstable flap

VII        Type II + middle glenohumeral ligament injury

VIII     Type II + posterior extension

 

IX     Circumferential

   

 X     Type II + posteroinferior extension (reverse Bankart)

The Snyder classification is still the most recognized and widely used classification.

Clinical diagnosis

Making a clinical diagnosis of a SLAP lesion can be difficult due to several reasons. The history and physical findings can often be ambiguous. There are several pathologies in the shoulder that can coexist with SLAP lesions making the diagnosis more difficult. 

History

Symptoms from SLAP lesions can be acute or insidious depending on the mechanism of injury. Individuals involved in overhead throwing are most likely to present with an insidious history. They complain of reduced ability to throw and to carry out overhead movements. Acute symptoms result from acute trauma following a fall on an outstretched limb and injury due to traction.

The most common complaint in patients with a SLAP lesion is pain [11]. The patient can present with pain deep in the shoulder or with discomfort radiating to the front of the shoulder.

The nature of the pain is usually exacerbated by activities such as pushing, lifting heavy objects, and carrying out overhead activities. Patients with Type III or IV SLAP lesions complain of mechanical symptoms including sensation of giving way especially when they perform overhead activities. They can also complain of weakness of the limb.

Examination

Clinical examination of patients with SLAP lesions is usually unequivocal and clinical diagnosis is extremely challenging. There are several provocative tests to diagnose SLAP lesions but these tests lack sensitivity or specificity. These include: 

• Active compression test (O'Brien's test)
• Speed test 
• Anterior slide test 
• Crank test 
• Yergason test

Hegedus et al. [12] and Parentis et al. [13] showed that no single test had sufficient sensitivity and specificity to make a consistent diagnosis of SLAP lesion. The active compression test had the highest sensitivity (67%) but the specificity was only 37% [14]. The Yergason test had the highest specificity (95) but the sensitivity was low at 12% [12].

Co-existing shoulder pathology further clouds the clinical picture in patients with SLAP lesions. A study by Kim et al [13] found that 88% of patients with SLAP lesions had coexisting shoulder pathology. 

In patients with SLAP lesions, the active range of motions of the shoulder joint is usually normal but pain may be elicited in the position of internal impingement i.e on external rotation of the abducted and externally rotated shoulder [16]. The O’Brien test is probably the most commonly utilized test for the diagnosis of SLAP lesions [17]. To perform this test, the shoulder is flexed to 90°, adducted 15°, fully internal rotated, and the forearm is pronated. The patient is asked to flex the shoulder against resistance. The test is positive if the patient experiences deep or anterior shoulder pain.

Arnander & Tennant [17] suggested that a combination of O’Brien’s test and Kim’s biceps load test II gave the best likelihood of making a diagnosis of a SLAP lesion. 

The biceps load test II is carried out by placing the shoulder in 120 degrees of abduction, maximal external rotation with the forearm in supination. The patient is then instructed to perform a biceps contraction against resistance. Deep pain in the shoulder during this contraction is indicative of a SLAP lesion. 

Mayo Shear test which is also known as the modified O’Driscoll test or the modified dynamic labral shear test is useful to detect a labral click that is indicative of an unstable SLAP lesion. This test is carried out with the patient standing with his elbow flexed 90 degrees and shoulder abducted above 120 degrees. The examiner then applies further external rotation until resistance is felt. The examiner then applies a shear force through the shoulder joint by maintaining external rotation and horizontal abduction and lowering the arm from 120 to 60 degrees abduction. Reproduction of pain and/or a painful click or catch in the joint along the posterior joint line between 120 and 90 degrees of abduction denotes a positive test [18].

Diagnostic imaging

MRI-arthrography has been reported to have a 96% sensitivity and 85% specificity in the diagnosis of SLAP lesions [19-21]. Unfortunately, these imaging studies are poor in differentiating normal age-related abnormalities from truly unstable symptomatic labral lesions. MRI findings cannot be taken in isolation when determining indications for surgery.

The anatomic variability of the superior labrum makes it difficult to determine whether the anatomic abnormality is truly symptomatic. Hence, the radiological report must be carefully correlated with the patient’s history and physical examination. Even diagnostic arthroscopy among experienced shoulder surgeons gives mixed results in terms of inter-observer and intra-observer reliability with substantial interobserver and intraobserver variability [22-24].

Treatment options

Conservative treatment

The conservative management of SLAP lesions involves 3 basic principles [2]: 

1. Reducing inflammation with the use of NSAIDs, cryotherapy, and/or steroid injections. 

2. Postural correction through scapular retraction exercises, posture bracing and taping, and biofeedback exercises. 

3. Rotator cuff rehabilitation and proprioceptive neuromuscular rehabilitation exercises to return to normal function while monitoring the scapular position.

Fedoriw et al. [25] in a retrospective review of 119 consecutive baseball players showed that about two-thirds of SLAP patients responded to rehabilitation focused on postural correction and balancing exercises.  

Hip range of motion, abductor strength, and core exercises are emphasized and corrected in throwing athletes [2]. 

Edwards et al [26] showed that 10 of 15 overhead throwers with a SLAP lesion treated conservatively were able to return to play at the same level or better.

There are, however, some patients who do not get better with conservative management. These patients would then require surgery.

Surgical treatment

The role of surgery in the treatment of SLAP tears remains shrouded in controversy. There are no clear guidelines and no randomized control studies for surgical treatment of SLAP lesions. It is important to note that not all SLAP lesions seen during arthroscopy require repair/surgery. Meticulous patient selection becomes very important. Factors to take into consideration before embarking on surgery include the patient's age, occupation, levels of activity, expectations, workers’ compensation status, and co-existing shoulder pathology. 

Type I

Type I SLAP lesion is usually an incidental finding at arthroscopy of the shoulder. Such lesions are usually asymptomatic.  They are due to age-related degeneration which results in fraying of the superior labrum. Such lesions need no specific treatment. These lesions are usually not seen on MRI of the shoulder.

The shoulder pain in patients with type I lesions is usually due to coexisting pathology such as subacromial impingement or rotator cuff pathology.

During arthroscopy, if the labrum is found to be extensively frayed

debridement back to healthy labral tissue is recommended [27,28].

Type II

This is the most common and clinically important subtype of SLAP lesion. In patients with shoulder symptoms in whom the clinical examination is suggestive of SLAP lesion and arthroscopy of the shoulder reveals no other pathology, treatment of the SLAB lesion is recommended.

There are several techniques to treat type II lesions and these are also a source of much controversy.

The most common method of repairing these lesions is suture anchors. Some surgeons use biodegradable tacks. 

The number of anchors and suturing techniques i.e simple, dual simple, or horizontal mattress, is again controversial and a subject of debate [29]. 

There have been several studies which showed good outcome following primary repair for SLAP II lesions [28,30,31].

Although there are several studies which show good outcome with primary repair there are other studies which show poorer outcome with increasing age. 

Denard et al [32], carried out a study to evaluate the outcome of surgical treatment of SLAB II lesions and they found a trend of poor outcomes with increasing age. 

Provencher et al [33] carried out a large prospective study of patients with SLAP II lesions who were treated with a repair. They also found an increased rate of failure of SLAP repairs in patients above the age of 36 years. 

Boileau et al [34]  were the first to study the differences in clinical outcome between primary repairs versus biceps tenodesis for SLAP lesions. They found that 60% of patients who had a repair were not satisfied or were disappointed with the outcome while 87% of patients who had a tenodesis were satisfied with the outcome and had a higher rate of return to sports. Forty percent of the patients who had a repair required revision surgery due to persistent pain and inability to participate in sports [34]. In this study average age in the two groups differed. The average age in the repair group was 37 years and in the tenodesis group, the average age was 52 years.

There is now a tendency to treat patients with isolated type II lesions who are above the age of 36 years with low sporting demand and poor tissue quality by biceps tenodesis. In patients below the age of 36 years who are active in sports and have good tissue quality repair of the lesion is recommended. After the repair, if symptoms persist biceps tenodesis can still be performed with good and predictable outcomes [29].

There still exists controversy regarding surgical strategies in the treatment of patients with type II lesions. 

A recent study by Schroder et al. [35] showed that SLAP repair or biceps tenodesis had no significant clinical benefit over sham surgery. They carried out a double-blind, sham-controlled trial in 118 patients with an average age of 40 years. They randomly assigned patients to either labral

repair (n=40), biceps tenodesis (n=39), or sham surgery (n=39), if at arthroscopy they found an isolated SLAP II lesion. They found that there were no significant differences in the clinical outcome between the 3 groups at 2 years follow up. The authors were of the opinion that there is a possibility of overtreatment of SLAP lesions and that there is a need to narrow indications for surgery in the treatment of SLAP lesions.

Type III

Type III SLAP lesions are treated by resection of the unstable bucket handle lesion and debridement back to stable rim just like for bucket handle meniscus tears in the knee. During the resection, it is very important to make sure that the middle glenohumeral ligament (MGHL) is not destabilized because damage to the MGHL can cause significant anterior instability of the joint [29]. 

Type III lesions involving the Buford complex, however, are treated as type II SLAP lesions [7]. 

Type IV

Treatment of type IV lesions depends on several factors including the age of the patient, quality of labral tissue, and extent of bicep tendon involvement. In patients with less than 30% of biceps tendon involvement, the labrum and the pathological biceps tendon is debrided and resected. In young patients with more than 30% of biceps tendon involvement, biceps tenodesis and labral repair are carried out. In older patients and in patients with poor quality labral tissue labral debridement is carried out with either biceps tenotomy or tenodesis [29].

Type V to X

There is a more significant injury to the labrum in patients with type V to X SLAP lesions. The labral injury is often associated with shoulder instability. Treatment of these lesions includes the treatment of labral-tendon complex injury, MGHL injury, and injury to other parts of the labrum [29].

SLAP and co-existing pathology

Isolated SLAP lesions with no co-existing pathology are uncommon. Co-existing intra-articular and extra-articular pathology is common in patients with SLAP lesions. A study by Kim et al [15] showed that 88% of patients with SLAP lesions have co-existing pathology. Hence, there is a need for the surgeons to be aware that for resolution of the patient’s symptoms the co-existing pathology has to be adequately managed [29].

SLAP tear with rotator cuff pathology

In patients with rotator cuff pathology and concomitant SLAP lesions, it can be difficult to clinically determine which pathology is causing the symptoms. If both structures are the cause of symptoms then repair of both can be carried out with good clinical outcome, restoration of motion, and a high degree of patient satisfaction [36].

A randomized controlled clinical trial by Franceschi et al [37] showed that in patients over the age of 50 years with rotator cuff pathology and SLAP II lesions there is no advantage in repairing the SLAP lesion because a rotator cuff repair and a biceps tenotomy produced significantly better outcome compared to a SLAP and rotator cuff repair.

Another study by Abbot et al [38] showed that in patients above the age of 45 years with SLAP II lesion and rotator cuff tear, rotator cuff repair with debridement of the SLAP lesion provided greater patient satisfaction and better functional outcome in terms of pain relief and range of motion as compared to rotator cuff and type II SLAP repair. 

Complications of surgical treatment

There are several complications that have been reported following SLAP lesion surgery. These include residual pain, shoulder stiffness, nerve injury, persistent symptoms, failure of repair, adhesive capsulitis, chondral injury, infection, post-infection arthrosis, chondrolysis, and non-return to previous activity level [34,39,40,41]. The risk factors for these unsatisfactory results remain unknown.

Complications occur in about 21% of the patients [42]. The most common is the presence of residual pain, followed by adhesive capsulitis [42]. 

Overdrilling the glenoid can cause injury to the suprascapular nerve.

Conclusion

SlAP lesion diagnosis and management remains controversial. A proper detailed history and a good physical examination are more valuable than imaging in the diagnosis of these lesions. 

Conservative non-operative management which focuses on scapular rebalancing is usually effective in managing these patients. 

Surgery to repair SLAP lesions is needed if the history and physical examination show instability. If there is no instability a tenotomy or tenodesis should be sufficient. Sometimes both procedures may be needed.

In patients with an unstable bucket-handle lesion, the bucket handle is resected and debridement is carried out to stable rim. 

In patients with SLAP lesions coexisting pathology is common and this has to be dealt with to achieve resolution of symptoms.

In overhead throwing athletes, such as baseball players, aggressive rehabilitation is required. Surgery, if performed, in these athletes, should be as minimal as possible to improve their chances of both returning to sport and preinjury activity level [2].

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