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    Arthroscopic Repair of a Suspected Type II SLAP Tear

    A 16-year-old high school athlete who plays football and baseball presents with pain while throwing but no specific history of injury. Six months of physical therapy has provided no relief. When an MRI arthrogram reveals a superior labral tear, the patient agrees to shoulder arthroscopy with labral repair.

    Author

    Christopher M. Aland, MD

    Disclosures

    Dr. Aland does not have any disclosures relevant to this article.

    Introduction

    Although uncommon, superior labral pathology (SLAP tears) can be disabling in overhead athletes. Patients notice pain at maximal external rotation and at the start of the deceleration phase (ball release) of throwing or throwing-equivalent motions, such as a tennis serve or a volleyball spike. Athletes may also note a drop-off in velocity. Patients occasionally have a history of an injury, usually a fall on an outstretched arm, but there is frequently only a history of repetitive throwing-type activity.

    When the arm is in the maximally rotated, late-cocking phase of the throwing motion, the labrum is felt to peel back from the superior glenoid, creating the basis for pathology. [1] This pathology may be associated with a partial-thickness posterior-superior undersurface rotator cuff tear, which has been termed “internal impingement” of the shoulder.

    Although the injury was originally described by Andrews in 1985, [2] the term “SLAP” was not coined until 1990 with the publication of Snyder’s classification of injury. [3] The 4 original groups of SLAP tears described by Snyder have been expanded to 10 groups, with subclass groupings for many of these groups. [4] The groups are based on the location of the pathology and associated intraarticular findings.

    The athlete will usually give a consistent history of pain during the throwing motion; however, the physical examination is often varied and inconsistent. This is largely based on the injury pattern and associated pathology. [5] Even diagnostic imaging can be inconsistent, with MRI arthrogram being the gold standard of diagnosis.

    Conservative management is often definitive, as most injuries will improve without repair. However, surgical treatment, in the form of arthroscopic repair of the labrum back to bone, followed by physical therapy is sometimes required to return an athlete to competition.

    Case Presentation

    A 16-year-old high school athlete who plays football and baseball presented with a chief complaint of pain while throwing. There was no specific history of injury, but he did note he often slid headfirst. He denied any episode of instability or dead arm complaints. He had participated in physical therapy for more than 6 months without improvement.

    Physical Examination

    • No deformity or atrophy at his shoulder.
    • Normal strength in all groups
    • No tenderness in the acromioclavicular joint
    • Positive O’Brien test: shoulder at 90 degrees elevation, 30 degrees horizontal adduction
    • Pain with loading arm at internal rotation, forearm pronated; pain improved with external rotation
    • Positive biceps load test
    • Positive labral shear test
    • Negative relocation test

    Differential Diagnosis

    • SLAP tear
    • Bankhart lesion (injury to inferior glenohumeral ligament)
    • Humleral avulsion of the glenohumeral ligament
    • Posterior labral tear
    • Microinstabiltiy
    • Internal impingement

    Imaging

    • Plain X-rays negative
    • MRI arthrogram positive for superior labral tear with extension to 3 o’clock anteriorly (Figures 1-2)

    Figures 1-2. Coronal and axial images showing superior and anterior labral separation.

    Diagnosis

    • Superior labral tear; suspected Type II tear

    Treatment

    The author recommended shoulder arthroscopy with labral repair. After discussion with his parents, the patient agreed to undergo the procedure.

    • The patient was placed in the beach chair position.   
    • A standard posterior portal and anterior and anterolateral portals were used, determined by localizing with a spinal needle.
    • A diagnostic arthroscopy was performed, which confirmed a type II labral tear (detachment of superior labrum from superior glenoid tubercle). A drive-through sign was noted. (Figures 3-6).
    • No associated pathology was identified. The labrum was detached posteriorly from the 11 o’clock position anteriorly to the 2 o’clock position.
    • The glenoid rim was debrided and freshened.
    • 2.4 mm suture tacks were placed at the 12 o’clock and 1 o’clock positions (Figure 7).
    • A suture lasso was used to pass the sutures, which were then secured with arthroscopic sliding, locking knots (Figures 8-9).
    • The labrum repair was firm, and the drive-through sign was eliminated (Figure 10).

    Figure 3. Initial view from the posterior portal, showing anterior labral irregularity,

    Figure 4. Probe elevating the labrum from the anterior superior glenoid.

    Figure 5. Another view of the probe elevating the labrum from the anterior superior glenoid.

    Figure 6. Close-up showing elevation with no glenoid attachment.

    Figure 7. Initial suture anchor in place at the 12 o’clock position, with the suture lasso showing the position of the first pass

    Figure 8. Simple stitch after retrieval.

    Figure 9. After securing with sliding, locking knot (Nicky’s knot).

    Figure 10. After second anchor and knot at 1 o’clock.

    Postoperative Course

    • A padded sling with an abduction pillow was used. The patient was encouraged to keep his hand forward.
    • Elbow and scapular range of motion (ROM) were initiated immediately.
    • At 4 weeks after surgery, passive and active assisted ROM and isometric exercises were allowed.
    • At 8 weeks after surgery, progressive resistance exercises were initiated.
    • Plyometrics and sport-specific rehabilitation were started at 12 weeks after surgery.
    • The patient returned to full football and baseball activities at 6 months after surgery.

    Discussion

    Shoulder pain in overhead athletes can be caused by numerous injuries. Pain may be vague and frequently mimicking impingement; however, the history is often consistent. Even in the absence of defined injury, pain with the throwing motion – specifically at ball release – is the typical complaint.

    Although many normal variants that can mimic SLAP pathology, such as meniscal-type labrum, sublabral hole, and Buford complex, true SLAP tears are uncommon, even in athletic populations. Careful history, physical exam, and diagnostic imaging are important.

    However, the diagnosis may not be confirmed until the time of surgery, when the labrum can be directly examined and manipulated. It is important to note that true instability and detachment should be present for a SLAP tear to be diagnosed. A meniscoid or floppy labrum with a more medial attachment is a normal variant and is not pathologic.

    Type II tears are most commonly seen in overhead athletes, but the spectrum of pathology that exists through the 10 classifications and subgroups requires the surgeon to be ready to repair labrum, capsule, and rotator cuff as needed. An excellent review of tear patterns and classification is found in the article by Wilk et al. [5] Preoperative preparation should ensure the availability of a full range of implants and equipment. Suture anchor repair, either requiring knot-tying or knotless, is the gold standard.

    Strict compliance with postoperative restrictions, a progressive physical therapy program, and patience with return to play guidelines are key elements to successful treatment. Yocum et al reported 96% good to excellent results in elite (collegiate or professional) athletes, with a return to play of 80% in those without rotator cuff pathology. [6]

    Unrestricted return to play at 6 months is usually possible, and is predicated on healing and sport-specific conditioning.

    Author Information

    Christopher M. Aland, MD, is an orthopaedic surgeon with The Rothman Institute in Philadelphia, Pennsylvania. He specializes in sports medicine.

    Sports Medicine Section Editor, Rothman Institute Grand Rounds

    Fotios P. Tjoumakaris, MD

    References

    1. Burkhart SS, Morgan CD. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repairs and rehabilitation.  Arthroscopy. 1998; 14 (6): 637-40
    2. Andrews JR, Carson WG, Jr., McLeod WD.  Glenoid labrum tears related to the long head of the biceps.  Am J Sports Med.  1985; 13 (5): 337-41.
    3. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Firedman MJ.  SLAP lesions of the shoulder. Arthroscopy. 1990; 6(4): 274-9.
    4. Powell SE, Nord KD, Ryu RK. The Diagnosis, classification, and treatment of SLAP lesions. Oper Tech Sports Med. 2004; 12: 99-110.
    5. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR.  The recognition and treatment of superior labral lesions in the overhead athlete.  Int J Sports Phys Ther. Oct 2013; 8(5):  579-600.
    6. Neri BR, ElAttrache NS, Owlsley KC, Mohr K, Yocum LA. Outcome of TypeII  superior labral anterior posterior repairs in elite overhead athletes.  Am J Sports Med. 2011; 39 (1):114-20.