SLAP lesion

Introduction

• Superior Labral Anterior to Posterior lesion
• Usually following fall on out stretched hand or repetitive overhead activities
• Young male
• Pathophysiology is thought to be tightness of the posterior IGHL which shifts the glenohumeral contact point postero-superioly and increases the shear force on the superior labrum
• Antero-superior labrum recieves poorest blood supply
• May be associated with
  • Instability
  • Internal impingement
  • Rotator cuff tears
• SLAP lesion increases the strain on the anterior part of the IGHL and compromises stability of shoulder

Anatomy

• There is a normal variant consisting of a sublabral foramen below the anterosuperior labrum present in approximatley 12% of patients undergoing arthroscopy. Seventy five percent of these variants are associated with a cord-like middle glenohumeral ligament (MGHL) (~9% of patients undergoing arthroscopy) .
• The Buford complex consists of a cord-like MGHL that inserts on the superior labrum at the base of the biceps tendon and crosses the subscapularis tendon to insert on the humerus. There is no anterior-superior labral tissue present between this attachment and the midglenoid notch .

Pathogenesis

Describe the biologic basis of the disorder or the mechanism of injury

Natural History

Describe the natural history,epidemiology and prognosis

Classification

• G I : Degenerative fraying
• G II : Detached superior labrum + biceps anchor
• G III : Bucket handle superior labrum + intact biceps
• G IV : Bucket handle superior labrum + biceps anchor
• G V : SLAP extends to anterior labrum
• G VI : SLAP extends as superior flap tear
• G VII : SLAP extends to MGHL
• G VIII : SLAP extends to posterior labrum
• G IX : SLAP extends circumferentially

Patient History and Physical Findings

History:

• Presents with deep shoulder pain, popping and clicking
• May develop secondary ganglion cyst, which can cause suprascapular nerve pressure

Physical Findings:

• Dynamic labral shear: Patient supine. Begin with shoulder in adduction, neutral rotation. Abduct the shoulder while axial loading. Positive exam with painful click or shift at roughly 90 degrees abduction.
• Positive O'Brien's test
• Positive Crank test
• Positive Speed's test
• Positive Yerguson's test
• Bicipital groove tenderness

Imaging and Diagnostic Studies

Radiography:

• For associated lesions
• MRI
  • Can be diagnostic
  • Sensitivity and specificity increases with arthrogram
  • Shows associated ganglion cyst
• Definitive diagnosis with arthroscopy

Differential Diagnosis

Treatment

Nonoperative treatment:

• NSAIDs
• Activity modification
• Physiotherapy and muscle strengthening

Operative treatment:

• Debridement and tenotomy +/- tenodesis
  • High-level basesball pitchers
  • Low demand patients and those over the age of 40 or 50 are best treated with debridement and tenotomy +/- tenodesis. There is minimal functional difference between tenotomy and tenodesis.
    • Consider tenodesis for:
      • laborers who frequently uses a screwdriver
      • patients concerned about cosmesis of biceps contour
      • body builders
• SLAP repair
  • Consider SLAP repair for:
    • Young athlete with healthy biceps tendon and a clean SLAP tear

Pearls and Pitfalls

• For repair candidates, consider the following guideline:
  • G I : Debridement
  • G II : Stabilization
  • G III : Debridement
  • G IV : Stabilization ± biceps tenodesis
  • G V : Stabilization
  • G VI : Debridement
  • G VII : Stabilization
  • G VIII : Stabilization
  • G IX : Stabilization

Tips and problems to avoid

Postoperative Care

Include immediate postoperative care and rehabilitation

Outcome

Include functional and prosthetic survivorship data as applicable

Complications

Include overview of complications

References