SLAP Lesions

James R. Lebolt, D.O.

Spectrum Health Medical Group
Grand Rapids, MI
“SLAP” Definition

“Injury of the superior labrum that begins

posteriorly and extends anteriorly,
stopping before or at the the mid-glenoid
notch and including the ‘anchor’ of the
biceps tendon to the labrum.”

- Snyder, et al., Arthroscopy, 1990

History

◦ First to describe – AJSM, 1985

◦ Glenoid labral tears near biceps tendon
origin noted in 73 throwing athletes
(60% anterosuperior)
SLAP Mechanism
 5 PEARLS
 Identify normal versus pathologic
anatomy.
 Only treat symptomatic labral tears.
 Proper bone preparation and
anchor placement.
 Stay organized.
 Appropriate therapy is “more
important than the surgical
procedure”.
 5 PEARLS
 Identify normal versus pathologic
anatomy.
 Only treat symptomatic labral tears.
 Proper bone preparation and
anchor placement.
 Stay organized.
 Appropriate therapy is “more
important than the surgical
procedure”.
 The original Snyder classification
of SLAP lesions.
 Type I has degenerative superior
labrum tearing but attached
biceps (A).
 Type II has detachment of the
superior labrum/biceps tendon
complex from the superior glenoid
(B)
 Type III has a bucket handle tear
of a meniscoid superior labrum
but attached biceps (C).
 Type IV has tearing of the
superior labrum up into the biceps
tendon (D).

 From Snyder SJ, Karzel RP, Del Pizzo W, et al: SLAP lesions of the shoulder. Arthroscopy
6:274-279, 1990.)
Identify the lesion
Normal Variants

 Incidence in shoulder arthroscopies:

◦ Sublabral foramen: 12.0%
 73% in MR and cadaveric studies
◦ Buford complex: 1.5-5%
 Do not stabilize normal structures.
 Normal variants may become pathologic lesions!
◦ Bents and Skeet showed that 83% of patients with a
Buford complex had an associated SLAP lesion.
Normal Variant
Normal Variant- Buford Complex
 Cordlike middle
glenohumeral ligament
attaching to the base of
the biceps anchor

 Absence of labral tissue

on the anterior superior
glenoid

 Fixation leads to
diminished external
rotation
 5 PEARLS
 Identify normal versus pathologic
anatomy.
 Only treat symptomatic labral tears.
 Proper bone preparation and
anchor placement.
 Stay organized.
 Appropriate therapy is “more
important than the surgical
procedure”.
 SLAP - Diagnosis

 Difficult and challenging

 Overlap of symptoms with other shoulder
disorders
◦ Rotator Cuff, GH instability
 Definitive diagnosis only with arthroscopy
SLAP Symptoms
 Pain isolated in overhead activity
 Clicking
 Loss of velocity
 Loss of control
 Uneasiness in the shoulder (loss of
confidence)
PE of Shoulder - Special Tests
 Impingement sign
 Impingement test
 Hawkins sign
 “Empty-the-can” test
 Drop arm test
 Abduction sign
 Jerk test
 Posterior stress test
 Push-pull test
 Lift-off sign
 Load and shift test
 Cross-arm adduction sign
 Yergason’s test
 Feagin test
 Biceps load test I & II
 Jahnke test
 Ludington’s test
 DeAquin’s test
 Lippmann’s test
 Heuter’s sign
 Norwood stress test
 Anterior release test
 Apprehension test
 Fulcrum test
 Fulcrum maneuver
 Crank test
 Anterior&posterior drawer test
 Relocation test
 Apprehension suppression test
 Posterior impingement sign
 Compression-rotation test
 Active compression test
 Clunk test
 Biceps tension test/Speed’s test
 Napolean’s sign
 Whipple test
 Anterior slide test/Kibler’s test
 Fukuda test
 SLAP test of Field
 Protzman test
 Dugas’ test
 Sulcus sign
 O'Brien‘s Test

 Abduction/compression
◦ Compressing tuberosity against anterior
labrum
 Mimori’s Test
 Mimori et al.
AJSM, 1999.
 arm ABD to 90° to
100°; ER shoulder,
and put forearm in
max pronation and
then max supination
 pain in
pronation>pain in
supination
SLAP Imaging
 Difficult area to image
◦ Contrast/no contrast?
◦ ABER views
 If it shows up on MRI usually large
tear
◦ Need to probe and roll the shoulder back
in the OR to find
 If you can’t see, still could be there
 Symptomatic SLAP tear
 Don’t lose focus
◦ more significant pathology commonly seen in
older patients = rotator cuff tears, subacromial
impingement and arthritis
 Occasionally, the older athlete will have a
symptomatic SLAP lesion, extremely rare
over age 40.
 Debride asymptomatic Type II SLAP lesions
and regard the rotator cuff pathology as the
cause of symptoms.
 Repair may lead to loss of motion and worsening of the
patient’s preoperative symptoms
Conclusion: debridement better than repair with combined RTC
over age 45.
Conclusions: There are no advantages in repairing a
type II SLAP lesion when associated with a rotator cuff
tear in patients over 50 years of age.
Conclusion: In patients with rotator cuff and labral lesions,
arthroscopic treatment of both lesions yields good clinical
outcomes, restoration of motion, and a high degree of
patient satisfaction.

*average age of SLAP repairs in study was 49 (range 31-65)

 When should we operate?

“If you want a reason to operate on a pitcher, get an MRI”

Dr. James Andrews

◦ Cuff tear >50% thickness

◦ Large tear with mechanical symptoms
◦ Failed conservative treatment
 4-6 weeks rest, followed by Interval Throwing
Program
 Scapular Stabilizers
 5 PEARLS
 Identify normal versus pathologic
anatomy.
 Only treat symptomatic labral tears.
 Proper bone preparation and
anchor placement.
 Stay organized.
 Appropriate therapy is “more
important than the surgical
procedure”.
SLAP Surgical Treatment
Place portals
Prepare Glenoid
 5 PEARLS
 Identify normal versus pathologic
anatomy.
 Only treat symptomatic labral tears.
 Proper bone preparation and
anchor placement.
 Stay organized.
 Appropriate therapy is “more
important than the surgical
procedure”.
 Stay organized

 One anchor at a time

 Suture is tied using a low profile, sliding,
locking knot through the anterior
disposable cannula.
 Most medial strand as the post
◦ the knot will lie away from the surface of the
glenoid
◦ knots that remain on the articular surface of
the glenoid can often cause an audible
“squeeking”
Place Anchors
Final SLAP Repair

Biceps anchor

Posterior Superior
Labrum
Glenoid
 5 PEARLS
 Identify normal versus pathologic
anatomy.
 Only treat symptomatic labral tears.
 Proper bone preparation and
anchor placement.
 Stay organized.
 Appropriate therapy is “more
important than the surgical
procedure”.
 Inappropriate/delayed therapy
◦ disrupt the repair
◦ allow the patient to lose significant external
rotation

 First 4 weeks
◦ simple sling is worn during the day
◦ immobilizer is used for sleeping
◦ weeks 1-2 passive and AAROM, weeks 3-4
light external/internal rotation tubing

 Should see full motion by week 8

 Therapy
 If satisfactory stability and strength have been
achieved by 4 months:
◦ interval throwing program in throwers
◦ others = endurance training and restricted sport
activities (light swimming, half golf swings).
 Criteria for return to sport
◦ full functional ROM, satisfactory shoulder stability, and
no pain or tenderness.
 Rarely allow return to competition in throwing
athletes before 7 months, while most high-level
athletes require about a year for return, and up to
18 months to maximize function.
Outcomes less reliable in throwers baseball players with athletes
perception that they return to 84.1% of preinjury level with mean
return to play at 11.7 months
Thank you