Shoulder and Elbow

My Approach to Superior Labral Pathology

The Problem

Injury to the superior glenoid labrum and biceps anchor is an important cause of shoulder pain in overhead athletes and active individuals. Accurate diagnosis is often challenging, and management of these injuries remains controversial. “Superior labrum anterior-posterior” – or SLAP – tears represent a variety of injuries originally classified into four types (Figure 1). Type I injuries involve fraying of the superior labrum with an intact biceps anchor. Type I injuries represent a degenerative process and are rarely the primary source of a patient’s symptoms. In type II tears, which are the most common, representing 55% of SLAP’s in our series, the superior labrum and biceps anchor are detached from the superior glenoid. Type III SLAP tears represent a tear of the inner portion of a meniscoid superior labrum without extension into the biceps tendon. Type IV lesions are similar to type III, but the tear does extend into the biceps tendon. Types III and IV are the least common, representing only 9% and 10% of tears, respectively, in our series.

Figure 1.

Classification of SLAP Tears. SLAP tears are classified into types I-IV as shown in the illustrations and representative arthroscopic photographs. Type I lesions consist of degenerative fraying of the superior labrum. Type II injuries involve separation of the biceps anchor from the supraglenoid tubercle. Type III and IV injuries consist of bucket-handle tears of a meniscoid superior labrum, with extension into the biceps tendon in type IV tears.

Clinical Presentation

Events leading to clinically significant superior labral injury, which are more common in males than females, typically involve either a traumatic injury or repetitive overhead activity.

Traumatic SLAP tears are thought to result from either a traction mechanism, such as a sudden pull on the arm, or a compression mechanism, such as a fall onto the outstretched arm. Pain is the most common presenting symptom, however, the location of the pain is variable and may be located posteriorly, anterosuperiorly, or in the bicipital groove region. Pain is typically exacerbated by overhead activity and roughly 50% of patients admit to experiencing mechanical symptoms such as catching or grinding.

A second type of presentation is seen in patients participating in repetitive overhead activities – classically the overhead or throwing athlete. These athletes experience a decline in performance associated with activity-related shoulder pain. Throwers may experience “dead arm syndrome”, which is characterized by pain with attempted throwing as well as a decline in throwing velocity.

Diagnostic Workup

Classic physical exam findings

No physical exam maneuver is highly sensitive and specific for superior labral pathology. Nonetheless, a variety of tests are advocated in the setting of a suspected SLAP tear and may increase the examiner’s confidence in the diagnosis when combined with appropriate history and imaging findings. We prefer Speed’s test, the compression-rotation test, and O’Brien’s test.

In Speed’s test, which also elicits pain in patients with long head of the biceps tendon pathology, the arm is placed in 90 degrees of forward elevation at the shoulder, with the elbow fully extended and the forearm fully supinated. The patient is asked to maintain this position as the examiner applies downward pressure distally. We prefer to also perform this test with the forearm fully pronated. Shoulder pain in the supinated position, more so than the pronated position, constitutes a positive test.

The compression-rotation test, similar to the McMurray test in the knee, is designed to elicit mechanical symptoms associated with an unstable tear. In this maneuver, with the patient in the supine position, the examiner abducts the shoulder to about 90 degrees, then applies an axial load to the glenohumeral joint while rotating the humerus in an attempt to trap loose labrum in the joint. A painful clunk supports the diagnosis of an unstable superior labral injury.

Finally, O’Brien’s test is performed with the shoulder flexed to 90 degrees, adducted 10 degrees, and internally rotated such that the thumb points downward. The patient is instructed to resist downward pressure applied by the examiner. The shoulder is then externally rotated and the stress is applied again. Pain elicited in internal rotation that is improved or eliminated in external rotation constitutes a positive result.

We consider positive findings on one or more of the above provocative tests, in the setting of an appropriate history, to constitute a “suspicious physical examination”.

Imaging findings

Magnetic resonance imaging (MRI) is the preferred imaging modality for superior labral pathology. The addition of intra-articular contrast, while not essential, is considered the most reliable technique. Nonetheless, diagnosis by MRI remains challenging and requires a thorough understanding of normal superior labral anatomy.

Coronal oblique images are best for evaluating the superior labrum, which normally appears as a dark triangle at the superior glenoid margin. In the majority of individuals, the inner border of the superior labrum does not attach directly to the glenoid articular cartilage, but instead consists of a free “meniscoid” inner border with a sublabral recess (Figure 2, see A). This sublabral recess is often visible, particularly with MR arthrogram, as a thin line of high signal intensity deep to the labrum along the smooth contour of the glenoid extending superiorly and medially (Figure 2, see B). To the inexperienced evaluator, signal in the sublabral recess may be mistaken for a SLAP tear. In contrast to the narrow, smooth, superomedially-directed signal of the normal sublabral recess, a true slap tear is marked by wide or irregular signal and will often project laterally away from the glenoid (Figure 2, see C). Signal that completely transects the labrum is suggestive of a type III or IV injury (Figure 2, see D).

Figure 2.

In MRI Findings in the majority of individuals, the superior labrum is �meniscoid�, resulting in a potential space between the deep surface of the labrum and the glenoid cartilage (sublabral recess) (A). In these patients, a thin smooth rim of contrast can often be seen tracking along the sublabral recess on MR arthrogram (B). In contrast, a type II SLAP tear is characterized by wide irregular contrast signal under the biceps anchor, often with signal extending laterally (C). In type III and IV lesions, signal is often seen transecting the entire superior labrum (D).

Another important region of relevant variable anatomy is the anterosuperior quadrant of the labrum adjacent to the biceps anchor. In the majority of shoulders, the anterior superior labrum is attached to the anterior superior glenoid. Some individuals, however, have normal variants that may be confused with injury to the superior labrum. A normal separation between the anterior superior quadrant of the labrum and the glenoid, called a “sublabral foramen”, is seen in 12% of patients. In a smaller percentage (1.5% in our series), the superior labrum is completely absent and a cord-like middle glenohumeral ligament attaches directly to the superior labrum at the level of the biceps anchor. This less common configuration is known as a “Buford Complex”. Care must be taken to avoid mistaking these normal variants for pathologic labral disruptions, as misguided fixation of the anterior superior labrum or middle glenohumeral ligament to the glenoid in these individuals will likely result in restricted motion and poor clinical outcomes.

Finally, cysts superomedial to the glenoid near the spinoglenoid notch are often seen in the setting of superior or posterior labral tears and may raise the examiner’s suspicion for such injuries.

Considering the variable anatomy in this region, it comes as no surprise that there is a tendency for inaccurate MRI interpretation, particularly by the inexperienced evaluator. The astute surgeon must understand normal anatomy and common anatomic variants, as well as abnormalities suggestive of true pathology in order to accurately interpret MRI findings with regard to the superior labrum. Only then can MRI be a useful adjunct in the diagnostic work-up in combination with the history, physical exam, and arthroscopic findings.

Final thoughts on diagnosis of SLAP tears

In spite of the above history, physical exam, and imaging clues, diagnosis of symptomatic superior labral pathology remains difficult at times. Coexisting pathology, such as biceps tendinopathy, rotator cuff disease, or anterior instability, is often present and may cloud the history and physical exam findings. In addition, evidence of superior labral pathology seen on MRI or at the time of arthroscopy may represent an incidental finding as opposed to the true cause of the patient’s symptoms. With this in mind, surgical decision-making in these cases is rarely straightforward. The flow chart (Figure 3) represents our treatment algorithm and may serve as a guide in complex clinical scenarios.

Figure 3.

SLAP Repair versus Biceps Tenodesis Algorithm. The decision whether to perform a SLAP repair or biceps tenodesis depends on a variety of factors, including the integrity of the biceps tendon, presence of associated pathology, as well as patient age and activity level. This algorithm may serve as a useful guide when faced with this decision. (RCT � Rotator cuff tear, MRI � magnetic resonance imaging) This figure was published in: �Surgical Techniques of the Shoulder, Elbow, and Knee in Sports Medicine, 2nd Edition�, Cole BJ. and Sekiya JK., page 281, Figure 26-3: Algorithm for management of superior labral anterior-posterior (SLAP) lesion. MRI, Magnetic resonance imaging; RCT, rotator cuff tear., Copyright Elsevier Limited (2013).

Non–Operative Management

A trial of rest, anti-inflammatory medication, and physical therapy is recommended, particularly in equivocal cases; conservative management is unlikely to result in satisfactory resolution of pain in patients with truly symptomatic SLAP tears, in our experience.

Indications for Surgery

Arthroscopic evaluation is indicated in patients with appropriate history (trauma or overhead athlete), “suspicious physical exam”, and MRI findings suggestive of superior labral injury, who have failed a course of non-operative management. In cases warranting surgical intervention, type I and III lesions are treated with debridement. Type IV tears are treated with debridement of the torn portion and, if a large portion of the biceps tendon is involved or if the remaining tendon appears degenerative, a biceps tenodesis is performed as well. If, in a type III or IV injury, the biceps anchor is unstable, it is repaired using the technique described below for a type II SLAP tear.

For cases in which a repairable type II injury is present, the decision whether to perform a SLAP repair or biceps tenodesis depends on patient specific factors and should be made on a case-by-case basis. Figure 3 outlines our general treatment algorithm when faced with this decision. Both anatomic repair and biceps tenodesis can result in favorable outcomes when performed well and in the appropriate patient. In the technique described below, we describe our preferred technique for repair of type II SLAP tears.

Surgical Technique

Necessary Equipment/Instrumentation

We perform superior labral repairs using standard arthroscopy equipment including a 30 degree arthroscope, arthroscopic shaver and curette, double loaded suture anchor with high strength suture, and a Spectrum (ConMed/Linvatec Inc, Largo, FL) medium-sized crescent hook loaded with a Shuttle Relay Suture Passer (ConMed/Linvatec).

Patient Set–Up

The patient is positioned in the lateral decubitus position on a beanbag with the operative shoulder leaning about 20 degrees posteriorly. Following examination under anesthesia to assess range of motion and stability, the operative arm is held in 10-12 pounds of traction at 70 degrees of abduction and 10-20 degrees of forward flexion. The operative table is turned 45 degrees such that the head of the bed is accessible to the surgeon standing posteriorly.

Diagnostic Exam

We begin every shoulder arthroscopy with a standardized 15-point arthroscopic exam of the glenohumeral joint, viewing from both posterior and anterior portals. At the beginning of this exam, the biceps tendon is grasped and pulled into the joint for close inspection. The superior labrum is inspected and palpated to assess for stability using an arthroscopic probe or grasper. Diagnosis of type I, III, and IV tears is usually straightforward, but confirmation of type II lesions may require thoughtful examination. Several arthroscopic findings may help confirm diagnosis of type II SLAP tear, including the following:

Biceps anchor can be displaced from the underlying glenoid = 5mm

Exposed bone seen on the superior glenoid beneath the superior labrum and biceps anchor (as opposed to smooth articular cartilage)

Surrounding synovitis, labral fraying, or hypervascularity present adjacent to the biceps anchor

Variants including the sublabral recess, sublabral foramen, cord-like middle glenohumeral ligament, and Buford complex must be recognized as normal and not inappropriately “repaired”.

Preparation

Three portals are used for our standard “Single Anchor Double Suture” repair technique. Viewing from the posterior portal, the anterior superior portal (ASP) is created next using an outside-in technique. Precise placement of this portal is critical both to avoid injury to the rotator cuff and permit safe anchor placement in the supraglenoid tubercle. A spinal needle is introduced 1 cm off the anterior lateral corner of the acromion and directed to pass through the superior portion of the rotator interval. The needle should pass slightly anterior to the supraspinatus tendon and enter the joint just posterior to the biceps tendon. Using the spinal needle, ensure that the angle of approach to the superior glenoid will be adequate for suture anchor placement at the center of the biceps insertion. A small incision is made through skin. Then a rigid 6 mm clear cannula with a taper tipped obturator is inserted through the rotator interval in the path determined with the spinal needle. The anterior mid-glenoid portal is created in a similar fashion and a second cannula is introduced for suture shuttling.

Any remaining frayed edges of the superior labrum are gently debrided with a shaver. The superior glenoid below the detached superior labrum and biceps anchor is then debrided using a shaver and/or curette. The bony surface is lightly decorticated to create a good surface for healing. At this point, any associated cysts may be decompressed as well, taking care not to stray more than 1.5 cm medially from the edge of the glenoid in order to avoid injury to the infraspinatus branch of the suprascapular nerve.

Repair

A drill guide or punch for a double loaded suture anchor is inserted through the ASP cannula and placed precisely in the center of the biceps insertion on the supraglenoid tubercle slightly medial to the articular margin, taking care to aim toward the center of the glenoid in the sagittal plane and angle 45 degrees medially relative to the glenoid face (Figure 4, see A). Use caution when preparing this anchor insertion site, as the drill guide or punch can easily skive posteromedially (risking injury to the suprascapular nerve) or laterally onto the glenoid surface. Directing the instrument as above also ensures that the path for the anchor is surrounded by bone on all sides, resulting in solid anchor fixation. The anchor is then inserted along the same trajectory as the drill or punch and fully seated down to the mark on the insertion instrument, with the suture eyelet oriented parallel to the glenoid face.

Figure 4.

Single Anchor Double Suture Repair Technique. A drill or punch for a double loaded suture anchor is carefully introduced through the ASP into the center of the biceps insertion (A). Following anchor placement with the suture eyelet parallel to the glenoid, the two lateral suture tails are retrieved out the AMGP and stored outside the cannula (B). After shuttling the two lateral sutures together through the base of the biceps, knots are tied away from the articular surface posterior and anterior to the tendon through the ASP (C). Arthroscopic image of the final construct (D).

Next, the two suture tails exiting the lateral side of the eyelet are retrieved out the AMGP and stored outside the cannula until tying at the end of the repair (Figure 4, see B). The two medial suture tails are then retrieved out the AMGP for subsequent shuttling. Through the ASP, we then use a Spectrum (ConMed/Linvatec) medium-sized crescent hook to pass a Shuttle Relay Suture Passer (ConMed/Linvatec) from superomedial to inferolateral across the biceps anchor, exiting deep to the superior labrum at the center of the biceps insertion. The suture passer is retrieved out the AMGP and used to shuttle both medial suture tails through the biceps anchor/superior labrum and out the ASP.

The repair is completed by tying one suture pair posterior to the biceps and one anterior to the biceps. To accomplish this, one medial suture tail is first retrieved into the AMGP using a crochet hook. Now, with one remaining medial suture in the ASP, its partner is retrieved from the AMGP into the ASP. The medial suture (now exiting through the superior labrum) is shortened and used as the post and a sliding locking SMC knot is tied followed by three alternating half-hitches (Figure 4, see C). The knot is secured posterior to the biceps tendon and well off the articular surface on the capsular side of the repair to avoid damage to the articular cartilage. Next, the second suture pair is retrieved into the ASP anterior to the biceps tendon and tied in similar fashion, completing the repair (Figure 5, see D).

Figure 5.

Examples of several SLAP repair complications leading to revision. Fixation only posterior to the biceps anchor (A) or extending too far anteriorly to involve the anterior superior quadrant and, in this case, a normal cord-like middle glenohumeral ligament (B), will compromise clinical outcomes. Suture anchors must be inserted with care to avoid proud anchors (C) and poor fixation in the bone, which may lead to anchor pull-out, and can occur with either non-metal (D) or metal (E) anchors. Failure of non-metal anchors can be diagnosed by MRI prior to revision surgery (F).

Pearls and Pitfalls of Technique

Pearls

  • Accurate diagnosis of symptomatic SLAP tears can be difficult. In the setting of an appropriate history, “suspicious physical exam”, and positive MRI findings the diagnosis can be made with some confidence, but must be confirmed at the time of arthroscopy.

  • Careful placement of the ASP is critical, as it determines the angle of approach for the anchor placed at the center of the biceps insertion. This portal is placed in the anterior portion rotator interval after determining its location and trajectory with a spinal needle.

  • The Single Anchor Double Suture repair technique described here results in a stable construct with excellent restoration of contact area between the biceps/superior labrum complex and the superior glenoid.

Pitfalls

  • Failure to correctly differentiate a normal sublabral recess from a true superior labral tear on MRI may lead to misguided surgery.

  • Failure to recognize normal anatomical variants in the anterior superior quadrant (sublabral foramen, cord-like middle glenohumeral ligament, Buford complex) may lead to unnecessary “repair” and overconstraint of the glenohumeral joint.

  • Failure to diagnose and address concomitant pathology (i.e. rotator cuff tear, instability, biceps tendinopathy, spinoglenoid cyst) may lead to persistent disability following treatment of the superior labral injury.

Potential Complications

Complications may result from either technical errors or judgment errors (Figure 5). Technical errors include poor anchor or suture placement resulting in local tissue damage, loss of fixation, non-anatomic repair, or suprascapular nerve injury. Judgment errors include fixation of normal anatomical variants resulting in overconstraint of the glenohumeral joint. Spinoglenoid cysts must also be recognized on pre-operative imaging and decompressed to avoid nerve compression. Finally, fixation of type II SLAP tears in physiologically older individuals has also been associated with poor outcomes and this remains an area of controversy.

Post–operative Rehabilitation

Patients are initially made non-weight bearing and are immobilized using an UltraSling 4 in 15 degrees of external rotation and slight abduction (DJ Orthopedics, Carlsbad, CA). We believe that immobilization in external rotation reduces the risk of internal rotation contracture often seen with conventional sling immobilization. Patients are encouraged to remove the sling to perform pendulum exercises, as well as hand, wrist, and elbow range of motion exercises several times per day beginning immediately post-operatively. Physical therapy begins at 4 weeks with a focus on range of motion. Light strengthening begins at 6-8 weeks and progresses gradually to full activity at an average of 4 months post-operatively when full strength and normal motion is attained. Throwing is started at 4-5 months post-operation.

Outcomes/Evidence in the Literature

Andrews, JR, Carson, WG, McLeod, WD. "Glenoid labrum tears related to the long head of the biceps". Am J Sports Med. vol. 13. 1985. pp. 337-41.

(First description of superior labral tears found on arthroscopic examination in 73 baseball pitchers.)

Snyder, SJ, Karzel, RP, Del Pizzo, W, Ferkel, RD, Friedman, MJ. "SLAP lesions of the shoulder". Arthroscopy. vol. 6. 1990. pp. 274-9.

(Original classification of SLAP tears into types I-IV, with proposed traumatic mechanism of injury.)

Snyder, SJ, Banas, MP, Karzel, RP. "An analysis of 140 injuries to the superior glenoid labrum". J Shoulder Elbow Surg. vol. 4. 1995. pp. 243-8.

(Of 140 SLAP tears found in over 2300 shoulder arthroscopies, 55% were type II, 21% were type I, 10% were type IV, 9% were type III, and 5% were complex. Only 28% were isolated SLAP tears. More often than not, the SLAP tear was found in conjunction with a rotator cuff tear (40%) or Bankart (22%).)

Smith, DK, Chopp, TM, Aufdemorte, TB, Witkowski, EG, Jones, RC. "Sublabral recess of the superior glenoid labrum: study of cadavers with conventional nonenhanced MR imaging, MR arthrography, anatomic dissection, and limited histologic examination". Radiology. vol. 201. 1996. pp. 251-6.

(Cadaveric study of 26 shoulders examining MRI appearance, gross appearance at dissection, and histologic appearance of the superior labrum. Authors documented the presence of a superior labral recess in 73%. On histologic sectioning, they found no evidence of traumatic origin. Thus the sublabral recess represents a normal anatomic finding at the superior labrum and is present in the majority of shoulders.)

Williams, MM, Snyder, SJ, Buford, D. "The Buford complex--the "cord-like" middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant". Arthroscopy. vol. 10. 1994. pp. 241-7.

(A series of 200 consecutive shoulder arthroscopy videos were inspected for anterior superior glenolabral anatomical variants at the time of arthroscopy. A sublabral foramen was present in 12%, a cordlike middle glenohumeral ligament in 9%, and a Buford complex in 1.5%.)

Sung-Jae, Kim, Sung-Hwan, Kim, Su-Keon, Lee, Jae-Hoo, Lee, Yong-Min, Chun. "Footprint Contact Restoration Between the Biceps-Labrum Complex and the Glenoid Rim in SLAP Repair: A Comparative Cadaveric Study Using Pressure-Sensitive Film". Arthroscopy. vol. 29. 2013. pp. 1005-11.

(This cadaveric study compared three SLAP repair configurations and demonstrated that a repair performed with a one double-loaded suture anchor with two simple stitches placed in a V-shaped configuration (similar to the single anchor double suture technique described above) resulted in good restoration of contact area and pressure between the biceps anchor and supraglenoid tubercle.)

Gorantla, K, Gill, C, Wright, RW. "The outcome of type II SLAP repair: a systematic review". Arthroscopy. vol. 26. 2010. pp. 537-45.

(Systematic review of 12 level III and IV studies evaluating outcomes of SLAP repair using a variety of surgical techniques at minimum 2 year follow-up. Good to excellent results were seen in 40-94% of patients. Lower return-to-play rates were observed in throwing athletes in several studies. Authors concluded that arthroscopic SLAP repair results in overall excellent results for individuals not involved in throwing or overhead sports. In overhead athletes, results have been less predictable.)

Provencher, MT, McCormick, F, Dewing, C, McIntire, S, Solomon, D. "A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure". Am J Sports Med. vol. 41. 2013. pp. 880-6.

(Prospective cohort of military patients followed for a mean of 40 months after repair of type II SLAP tears. While shoulder scores improved significantly from pre-op to final follow-up, a total of 37% of patients met criteria for clinical failure. Of these, 28% underwent further surgery, most often with biceps tenodesis. Older age was the best predictor of clinical failure. Mean patient age in failed repairs was 39.2 years, compared with 29.7 years in those with successful outcomes.)

Boileau, P, Parratte, S, Chuinard, C, Roussanne, Y, Shia, D, Bicknell, R. "Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion". Am J Sports Med. vol. 37. 2009. pp. 929-36.

(This retrospective study evaluated 25 patients treated for isolated type II SLAP tears with either SLAP repair (n=10, mean age 37 years) or arthroscopic biceps tenodesis (n = 25, mean age 52 years). The majority of patients participated in overhead sports pre-operatively. Among patients treated with SLAP repair, only 40% were satisfied compared with 93% of patients treated with tenodesis. Although this is an imperfect retrospective study, it suggests that biceps tenodesis may be an acceptable alternative to SLAP repair in some cases.)

Denard, PJ, Lädermann, A, Burkhart, SS. "Long term outcome after arthroscopic repair of type II SLAP lesions: results according to age and workers’ compensation status". Arthroscopy. vol. 28. 2012. pp. 451-7.

(Retrospective review of 55 patients followed for an average of 77 months following arthroscopic type II SLAP repair. Overall good to excellent results were observed in 87% of patients at final follow-up, with a higher percentage of good to excellent results in patients under 40 years old (97%) compared with those over 40 (81%). Overall 91% of patients were satisfied.)

Summary

Superior labral tears are often a diagnostic challenge and treatment remains controversial, particularly in older patients. Knowledge of classic patient history, physical exam findings, associated pathology, and normal as well as pathologic anatomical findings on MRI and at the time of arthroscopy will help the surgeon make appropriate diagnostic and management decisions for each individual patient. Finally, in our experience, the above simple and mechanically sound repair technique performed with careful attention to detail results in favorable outcomes in properly selected patients.

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