Authors’ Disclosure Statement: Dr. Romeo reports that he receives royalties from Arthrex and Elsevier; is a consultant for Arthrex; receives research support from Arthrex, Smith & Nephew, Össur, MioMed Orthopaedics, DJO Global, ConMed Linvatec, and Athletico; is on the editorial board of Orthopedics Today, Journal of Shoulder and Elbow Surgery, Techniques in Shoulder and Elbow Surgery, Operative Techniques in Sports Medicine, Sports Health, and Orthopedics; and receives publisher support from Elsevier and Orthopedics Today. The other authors report no actual or potential conflict of interest in relation to this article.
Type I lesions typically are described as fraying at the inner margin of the labrum and are common in throwers, even asymptomatic throwers. Type II lesions, separations of the biceps and labrum from the superior glenoid (≥5 mm of excursion), are the most commonly occurring and treated variant in throwing athletes.20-22 Intraoperative evaluation for a peel-back lesion (placing the arm in abduction with external rotation), rather than for a sulcus of 1 mm to 2 mm, may confirm a type II SLAP tear.20,23,24 It is often important to consider the direction of tear propagation as well. Type III lesions include those with an intact BLC (but with a bucket-handle tear of the superior labral complex and an intact biceps tendon), whereas type IV lesions involve additional extension of the tear into the biceps tendon.18,19The classification systems are well defined. Nevertheless, management of SLAP lesions remains controversial.
Options for Surgical Treatment
SLAP Tear Repair—Outcomes
The incidence of SLAP tear repairs has increased dramatically in recent years.6,25 There are various SLAP tear repair methods, but the most common consists of repairing the labrum and biceps anchor. Management of type II SLAP lesions remains controversial. Several prospective studies have found overall improvement after SLAP tear repair.26-31 Other series have reported less encouraging outcomes, including dissatisfaction with persistent pain and inability to return to throwing.28,32 A 2010 systematic review found that the percentage of patients who returned to their preinjury level of play was only 64%, and outcomes for overhead throwing athletes were even worse—only 22% to 60% of these patients returned to their previous level.33 The right surgery for SLAP tears in this population continues to be an area of uncertainty for many surgeons.
Failed SLAP tear repairs (poor outcomes) have become common in overhead throwing athletes. The reasons for these failed repairs are unclear, but several possible explanations have been offered. One is that labral repair may result in permanent alterations in pitching biomechanics, which may lead to an inability to regain velocity and command.3 Another is that the athlete’s shoulder may remain unstable even after repair.10Hardware complications are a significant concern in this high-level population. Suture anchor pullout or iatrogenic cartilage damage may occur during instrumentation or as a result of suture anchor reactive changes. In addition, there are several reports of glenoid osteochondrolysis (Figure 2) caused by prominent hardware or prominent knots.34-39
Intra-articular hardware concerns aside, lack of healing is another reason for failed SLAP tear repairs, as the vascular supply to the superior labrum is scarce near the biceps attachment, where shear forces are high.38,40,41 The intra-articular portion of the biceps tendon, as well as the portion within the bicipital groove, contains sensory fibers, which may become the source of persistent pain and inflammation after SLAP tear repair.24,42,43
Several studies have reported this phenomenon (Figure 3), leading some authors to perform primary biceps tenodesis in an attempt to avoid revision surgery.42,44-47
Stiffness after SLAP tear repair is a significant problem, with most patients taking up to 6 months to regain full motion.26,48 Overtensioning of the labrum and the glenohumeral ligaments may be the cause, and the solution may be to place anchors posterior (vs anterior) to the biceps insertion. In a large prospective military study, mean forward flexion and external rotation were reduced at final follow-up.31 These outcomes are less acceptable to overhead throwing athletes, who rely on motion for high-end throwing activities.
Primary Biceps Tenodesis—Outcomes
A 2015 database study found a 1.7-fold increase in biceps tenodesis over the preceding 5 years.49 However, relatively few procedures included in the study were performed in patients age younger than 30 years. For many older non-overhead throwers with type II tears, SLAP tear repair has become less popular as a treatment option.32 There is a dearth of knowledge about the outcomes of subpectoral biceps tenodesis as a primary treatment for biceps tendonitis and an associated SLAP tear. Although type I tears historically have been treated with débridement, débridement is seldom used for concomitant biceps tendonitis. It should be coupled with careful clinical examination.
In recent years, biceps tenodesis has been proposed as an alternative to repair for SLAP tears, particularly in older patients.24,44 For obvious reasons, however, there has been some trepidation about performing biceps tenodesis in throwing athletes. Some authors have proposed biceps tenodesis as primary treatment for isolated SLAP tears. Boileau and colleagues44 compared the outcomes of treatment of isolated type II SLAP lesions in 25 consecutive patients. For 10 patients, repair involved suture anchors; for the other 15, arthroscopic biceps tenodesis was performed with an absorbable interference screw. Six of the 10 suture anchor patients were disappointed with their outcome (persistent pain or inability to return to sport), whereas 14 of the 15 biceps tenodesis patients were satisfied. The authors concluded that arthroscopic biceps tenodesis is an effective alternative to repair for type II SLAP lesions, though their study was not isolated to overhead athletes (tenodesis group mean age, 52 years).
In a 2014 series of cases, Ek and colleagues50 reported good outcomes of SLAP tear repair and biceps tenodesis. Again, though, tenodesis was used in older patients, and repair in younger, more active patients, with no high-level athletes in either group. There was no difference in return to sport between groups. In a study of patients who underwent primary biceps tenodesis, Gupta and colleagues51 found 80% excellent outcomes (improved shoulder outcome scores) in select SLAP tear patients, including 8 athletes, 88% of whom were overhead athletes. Gottschalk and colleagues52 reported on differences in prospectively collected outcome data (age, sex, SLAP lesion type II or IV) for primary biceps tenodesis in a series of 33 patients. Twenty-six of the 29 patients who completed follow-up returned to their previous level of activity. These studies suggest that primary biceps tenodesis may be an alternative with lower failure rates in the treatment of SLAP tears in middle-aged patients, and in overhead athletes, though additional specific studies are needed to focus on overhead athletes on a larger scale.
