Superior Glenoid Labrum Lesions: (SLAP) : Wheeless' Textbook of Orthopaedics

- See: proximal biceps tendonopathy

- Discussion:
- refers to a detachment lesion of the superior aspect of glenoid labrum, which serves as the insertion of long head of biceps;
- relatively common injury in throwing atheletes, but may most commonly occur in patients who have fallen or who have received a blow on the shoulder;
- references:
- Kinetics of baseball pitching with implications about injury mechanisms.
- A Cadaveric Model of the Throwing Shoulder: A Possible Etiology of Superior Labrum Anterior-to-Posterior Lesions.
- Failure of biceps superior labral complex: A biomechanical investigation comparing late cocking and early deceleration positions of throwing.
- The role of long head of biceps muscle and superior glenoid labrum in anterior stability of the shoulder.
- Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation.
- varient anatomy:
- in 50% of patients, biceps predominately attaches to supraglenoid tubercle where as in other half biceps predominately attaches to superior labrum;
- slight detachment of the superior posterior labrum may be normal in older aults;
- Buford complex: (see shoulder capsule)
- anatomical variant: MGHL ligament appears cord-like and will often be frayed and is often associated w/ a physiologic antero-superior sublabral hole;
- glenoid labrum opposite of the MGHL will often be absent;
- attempts to close down this sub-labral hole w/ a absorable tack anchor may precipitate frozen shoulder;
- in most cases a SLAP lesion will show infammatory changes around the biceps tendon origin;
- arthroscopic findings: (true slap vs normal findings)
- glenoid chondromalacia in the area of detachment, with corresponding fraying on the underside of the detached labrum and glenoid;
- anterior cannula may be used to hold labrum against the glenoid while the shoulder is externally rotated;
- normal variants will pop free with external rotation, while tears can be held inplace;
- references:
- Buford complex: "cord like" middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant.
- Relationship between the tendon of the long head of biceps brachii and the glenoidal labrum in humans.
- Normal variations of the glenohumeral ligament complex: an anatomic study for arthroscopic bankart repair.
- Anatomical Variants in the Anterosuperior Aspect of the Glenoid Labrum.
- Repair of SLAP Lesions Associated With a Buford Complex: A Novel Surgical Technique
- associated conditions:
- rotator cuff pathology is present in 40%;
- anterior instability:
- ref: Risk of motion loss with combined Bankart and SLAP repairs.
- spinoglenoid cysts
- Treatment of Labral Tears with Associated Spinoglenoid Cysts without Cyst Decompression

- Radiographic Findings:
- references:
- Injuries of the superior portion of the glenoid labrum involving the insertion of the biceps tendon: MR imaging findings in nine cases.
- Labral injuries: accuracy of detection with unenhanced MR imaging of the shoulder.

- Clinical Findings:
- pain w/ overhead activity which may mimic impingement syndrome (see throwing shoulder)
- mechanicals symptoms;
- active compression test:
- ref: The active compression test: a new and effective test for dx labral tears and AC joint abnormality. Am J Sports Med. 1998 Sep-Oct;26( 5):610-3.
- references:
- The Resisted Supination External Rotation Test. A New Test for the Diagnosis of Superior Labral Anterior Posterior Lesions.
- The SLAP lesion: a cause of failure after distal clavicle resection
- A clinical test for superior glenoid labral or 'SLAP' lesions.
- Clinical Presentation and Follow-up of Isolated SLAP Lesions of the Shoulder (SS-04)

- Classification and Treatment:
- labrum is assessed, including stability ofthe biceps labral attachment, as well as bicepstendon;
- SLAPtears will show more than 5 mm of exposed superior glenoidbone and often a peel back sign;
    - peel back sign:
           - look for positive "peel-back"sign to confirm the diagnosis of a SLAP tear;
- peel back sign is demonstrated with abductionand external rotation;
- type I:
- fraying and degeneration of the superior labrum, normal biceps (no detachment);
- most common type of SLAP tear (75% of SLAP tears);
- often associated with rotator cuff tears;
- these are treated w/ debridement;
- type II:
- detachment of superior labrum and biceps insertion from the supra-glenoid tuberlce;
- when traction is applied to the biceps, the labrum arches away from the glenoid;
- typically the superior and middle glenohumeral ligaments are unstable;
- may resemble a normal variant (Buford complex);
- 3 subtypes: based on detachment of labrum involved anterior aspect of labrum alone, the posterior aspect alone, or both aspects;
- posterior labram tears may be caused by impingement of cuff against the labrum with the arm in the abducted and externally rotated position;
- as noted by Kim TK et al. type-II lesions in patients older than 40 years of age were associated with a supraspinatus tear where as
in patients younger than 40 years were associated with participation in overhead sports and a Bankart lesion;
- treatment involves anatomic arthroscopic repair;
            - age:
                   - The effect of age on the outcomes of arthroscopic repair of type II superior labral anterior and posterior lesions.
- Arthroscopic treatment of concomitant (SLAP) lesions and rotator cuff tears in patients over the age of 45 years.
- No advantages in repairing a type II (SLAP) lesion when associated with RC repair in patients over age 50: RCT.
- references:
- Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases.
- Biomechanical assessment of Type II (SLAP) + anterior shoulder capsular laxity as seen in throwers: a cadaveric study.
- Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears.
- Ganglion cysts of shoulder: arthroscopic decompression and fixation of associated type II SLAP lesions.
                   - Shoulder injuries in overhead athletes. The "dead arm" revisited.
                   - Differences in the ultimate strength of the biceps anchor and the generation of type II SLAP lesions in a cadaveric model.
- Treatment of Labral Tears with Associated Spinoglenoid Cysts without Cyst Decompression
- Outcomes After Arthroscopic Repair of Type-II SLAP Lesions
- A biomechanical comparison of 2 anchor configurations for repair of SLAP lesions subjected to a peel-back mechanism of failure.
- Quantifying the extent of a type II SLAP lesion required to cause peel-back of the glenoid labrum--a cadaveric study.
- Long-term outcome after arthroscopic repair of type II SLAP lesions: results according to age and workers' compensation status.
- Arthroscopic Biceps Tenodesis Compared With Repair of Isolated Type II SLAP Lesions in Patients Older Than 35 Years
- Return to Play After Type II Superior Labral Anterior-Posterior Lesion Repairs in Athletes: A Systematic Review
- type III:
- bucket handle type tear;
- biceps anchor is intact;
- type IV
- vertical tear (bucket-handle tear) of the superior labrum, which extends into biceps (intrasubstance tear);
- may be treated w/ biceps tenodesis if more than 50% of the tendon is involved;

- Surgical Options:
- Biceps Tenodesis:
            - ref: Postoperative Restoration of Upper Extremity Motion and Neuromuscular Control During the Overhand Pitch

- Arthroscopic Repair Technique: - see: shoulder arthroscopy:
- anterior portal
- anterior portal needs to be positioned along superior aspect of the rotator interval anteriorly and slightly superior to the biceps tendon;
- second portal is made just above the subscapularis;
      - anterolateral portal:
           - portal is made immediately lateral to the anterior border of the supraspinatus tendon, which allows a more perpendicular approach to the glenoid;
      - transtendon portal:
- Percutaneous SLAP Lesion Repair Technique Is an Effective Alternative to Portal of Wilmington
- Injury to the Suprascapular Nerve During SLAP Repair: Is a Rotator Interval Portal Safer Than an Anterosuperior Portal?
- labral exposure:
              - consider passing a heavy suture under the labrum and bringing both ends of the suture out of the end of the canula;
- tension is kept constant by applying a clamp over the sutures at the end of the canula.
- this will keep the labram out of the way while drilling and suture passage is completed.
- once the labrum is ready to be secured, tension on the stay suture is released;
- anchor position:
- goal is insertion within the superior glenoid tubercle;
- consider hand tamping the drill bit instead of power drilling, so that the drill bit will not skive;
- posterior fixation:
- A biomechanical comparison of two anchor configurations for repair of type II SLAP lesions subjected to a peel-back mechanism of failure.
- arthroscopic knots: