This document discusses repair versus biceps tenodesis for SLAP tears. It provides a brief history of SLAP tears, reviews anatomy and biomechanics, mechanisms of injury, clinical tests for diagnosis, classification systems, and results of studies on surgical management. For treatment decision making, it suggests considering factors like history of injury, age, symptoms, clinical exam findings, and presence of other shoulder pathology to determine whether SLAP repair or biceps tenodesis is most appropriate in a given case. The author's experience shows slightly better outcomes with SLAP repair compared to conversion to tenodesis for failed repairs.

1. SLAP Tears
Repair Vs Biceps Tenodesis
Bijay Singh
Consultant Orthopaedic Surgeon
Medway Foundation NHS Trust

2. Overview
History
Anatomy
Signs & Symptoms
Diagnostics
Results
Management Algorithm

5. History
• 1985
– First Described by Andrews et al
• 1990
– Snynder & Karzel classified

6. SLAP Tears• 1983
–James Andrews at the AOSSM Meeting
–73 base ball pitchers & other throwing
athletes
–Hypothesis:
• Biceps tendon is subjected to large forces during
throwing
• Most tears – near the antero-superior portion near
origin of biceps tendon
• Biceps tendon lifts the labrum off the glenoid

7. Methods & Results
• 120 arthroscopy – 73 throwing
athletes
–35 pitchers
– (22 prof, 9 college, 4 high school)
–Football, Softball, Tennis, Volleyball
• Symptoms
–95% pain whilst throwing
–47% Popping or catching during throwing
• Signs

8. • 60% - Anterosuperior
• 23% - Antero & Postero Superior
• 83% - tearing of glenoid labrum in
some portion of antero superior region
in the area of the biceps tendon /
labrum complex
• 45% partial supraspinatus tendon tear

9. Onyekwelu et al: The rising Incidence of SLAP
repairs JSES, 2012, 21, 728-31
• Surgical cases: 55%
• Ambulatory cases: 135%
• SLAP Repair: 464%

10. Current Literature
• No Level I or II publications
related to treatment of SLAP
tears

11. Anatomy
• Superior Labrum
–Triangular structure coposed of
fibrous & fibrocartilagenous tissue
• LHB
–Supra-glenoid tubercle – 60%
–Superior labrum – 40%
• Significant variation

12. Anatomical Variants
• Sublabral Foramen
–3 – 12% incidence
–Labrum detached from the glenoid in
front of the biceps between 9 – 12 o’clock
for left & 12 – 3 o’clock for right
• Buford complex
–1.5 – 2%
–Absence of antero superior labrum
–Cord like MGHL attaching to biceps
tendon

13. Anatomical Variants

14. Relevant Biomechanics• Not fully understood
• Provides transational & rotational
stability
• LHB Tenotomy
–Increased proximal migration by 16%
• Cadaveric Model
–SLAP causes increased translation &
ER

15. Pathophysiology

16. Mechanism of Injury• Andrews et al
–Deceleration traction injury from pull of
biceps
• Burkhart et al
–Contracture of posterior shoulder capsule
• Grossman et al
–Postero-superior humeral head migration
• Another:

17. • Repetitive throwing places shoulder
at extremes of motion
• Complex series of of co-coordinated
motions to efficiently transfer large
forces & high amounts or energy
from legs, back & trunk
• Altered range of motion
• Eccentric contractions

18. GIRD
– Deficit in IR of at least 20
compared to the contra-lateral side

19. Diagnosis• Injury
–Traction
–Compression of shoulder
–Repetitive over head athletic use
• Pain
–Poorly located
–Located globally

20. • Duration of symptoms
• Anterior shoulder pain in dominant
arm
• Clicking or Popping during throwing
• Night pain
• Weakness
• Instability

21. Tests
• O'Brien Active Compression
• Speed
• Dynamic Labral Shear (Mayo Shear)
• Biceps Load II (Kim)
• Resisted Supination External Rotation (Labral Tension)
• Upper Cut
• Kibler Anterior Slide
• Compression Rotation

22. O'Brien's test
• shoulder at 90 of flexion, 10 of
horizontal adduction, and
maximum internal rotation with
the elbow in full extension
• downward force at the wrist
• patient resists the down- ward
force
• pain as ‘‘on top of the shoulder’’
(acromioclavicular joint) or
‘‘inside the shoulder’’ (SLAP
lesion)

23. Speed Test
• Patient Sitting
• elbow extended and
the forearm in full
Supination
• Resisted active
flexion from 0 to 60

24. Dynamic Labral Shear Test
(O’Driscoll)
• Sitting or Supine
• arm at side and elbow flexed 90
• ER & Abd 90
• Pain
– deep and/or posterior
– 90 to 120 abduction
What I describe as Jobe’sWhat I describe as Jobe’s
Maneuver for painManeuver for pain

25. Biceps Load II Test – Kim II
• Shoulder 120 abduction,
elbow 90 flexion, and
forearm in Supination
• Apprehension position
• Flex his or her elbow while
the examiner resists this
movement
• Positive test by pain

26. • Upper Cut
– Elbow flexed 90, forearm supinated, patient making a fist
– Bringing the hand up quickly – boxing upper cut

27. Sleeper Stretch for
Posterior Capsular
Contracture

28. Accuracy of Clinical Tests
Jones & Galluch et al

29. Results
Should be wary about relying on these tests whenShould be wary about relying on these tests when
assessing these indviduals with shoulder dysfunctionassessing these indviduals with shoulder dysfunction
- they may have more than one pathology- they may have more than one pathology

30. Clinical Utility of Traditiional & New Tests in Diagnosis of
Biceps Tendon Injuries & SLAP Lesions
Kibler et al , AJSM, 37(9), 1840 – 1847)
• 325 consecutive patients
• 101 patients underwent surgery
• 8 tests
–Yergasons, Speed, Bear Hug, Belly Press,
O’briens, Anterior Slide
–Upper Cut & Modified Labral Shear

33. Meta-analysis of clinical testing for SLAP Tears;
Meserve et al, AJSM, 37(11), 2252
• Active compression, crank, and Speed tests are
more accurate for detecting labral tears than is the
anterior slide test.
• Sensitivity and Specificity values ranged from low to
high.
• Active compression test is the most sensitive and
Speed test the most specific.
• Bicep load, passive compression, and Kim tests may
be good alternatives, but more research is warranted

34. Investigations
&
Classification

35. Imaging
• No specific radiographic findings
pathognomonic for SLAP lesion

36. • MR Arthrogram gold standard
– 90% accuracy
– Coronal Oblique Sequences
– ABER position
– High incidence of false positive MRI

37. Arthroscopic Classification

38. Agreement in Classification
• Wolf et al – AJSM, 39(12), 2588 –
2594
–16 shoulder surgeons
–Clinical variables in diagnosing &
treating
–50 arthroscopic videos of superior
labrum
–Three different occasions

39. Results
• Job / Sports, Age & Physical examination most
important factor in treating
• 1st
& 3rd
viewings – 28.5% different class
• With clinical info – 71.5% different
• Inter-surgeon agreement was moderate
without clinical info & fair with clinical info

40. Clinical Results

41. A Prospective Analysis of 179 type 2 SLAP repairs
Provencher et al: AJSM, Vol 20 (10)
• 179/225 patients over 4 year period - Military Personnel
– Age: 31.6 (18 – 45)
– Male: Female 80%:20%
– Follow up: 40.4 (26 – 62)
– Traumatic: Atraumatic 47%:53%
• ASES, WOSI, SANE significantly improved
• Flexion & Abduction – significant improvement
• ER, ABER, ABIR – no difference

42. Failure
• ASES<70, Revision Surgery, Medical Board, Unable to return to
duty
• 66/179 = 38%
–16 = Medical Board = medical discharge
–50 = Revision Surgery (28%)
• Tenodesis = 42
• Tenotomy = 4
• Debridement = 4
• Logistic Regression

43. Long Term Results after SLAP Repair – 5 yr follow up of 107
patients
Schroder et al: Arthroscopy, 2012, 28(11), 1601-07
• Prospective Cohort Study
• 1998 – 2002,
• 171 patiens – 64 excluded
• 43.8 yrs (20 – 68)
• 71 male vs 36 females
• Duration of Symptoms – 52 months

44. • 97 followed up for 5 years (4 – 8 yrs)
• Modified Rowe, Pain, Stability, Function
& Muscle Strength, ROM
• 88.1% - Good to excellent in >40
• 88.3% - Good to excellent in <40
• 14 complications – not age related

45. Results of Arthroscopic Superior Labral
Repairs:
Kim SH et al, JBJS, 84(A), 981-5
• 34 arthroscopic repairs
• 32/34 had satisfactory UCLA score
• 31 regained pre-injury shoulder
function
• Overhead activity sports persons
had significantly lower scores (97 vs
90)

46. Outcome of Type II SLAP Repair – prospective
analysis:
Friel et al, JSES, 2010, 19, 859-67• 48 patients
• Age: 33 +/- 12 (16 – 59)
• Athlete: 27 (overhead 11)
• Traumatic / Atraumatic: 24
• Associated procedures: 22
• 3.4 yrs follow up ( 2 – 5.7 yrs)
• Arthroscopic SLAP repairs provides
significant improvement in shoulder
function

47. Results
• SST, ASES, SF12 & VAS all
significantly better
• Non athletes showed larger
improvement in scores &
movements
• 54% (7) returned to previous
level sport

48. SLAP Repair in presence of Cuff Tear in patients over 50
years age:
Franceschi et al , AJSM, 2008, 36(2), p 247 - 253
• 63 patients > 50 with cuff tear
– 31 had SLAP repair
– 32 had biceps tenotomy
• Average 2.9 yrs follow up
• Results:
– UCLA Score significantly better in tenotomy
– Movements also better in tenotomy
• Now routinely perform tenotomy

49. Boileau et al: AJSM 37(5), 929 - 936
25 patients with isolated SLAP tears
10 pts (men) had SLAP repair (37)
15 pts (9+6) had tenodesis (52)
9/10 & 11/15 collegiate or
professional

50. 6/10 disappointed / dissatisfied
1/15 disappointed / dissatisfied
87% returned to sports in tenodesis
20% returned to sports in repair
4 tenodesis later returned

51. Non Operative Treatment for SLAP tears:
Edwards et al, AJSM, 2010, 38(7), 1456-61
• 371 patients with suspected SLAP
• Diagnosis:
– O'Brien's Test
– Tender on Groove
– MRI / MRA
• 50 replied back – 39 included
• 67% better / improved
• 20 had surgery, 19 non op
• All successful treatment returned to sports

52. Outcome of SLAP Repair – Systematic Review,
Gorantla et al, Arthroscopy, 2010, 26(4), 537-45
• Isolated Type II SLAP repair with 2 yr
FU
• No level I or II studies
• 12 full studies met inclusion criteria
• 2 prospective
• 40 – 94% good to excellent

53. Gorantla et al
• Excellent results for individuals not
involved in throwing or overhead
sports
• Much less predictable in throwing &
overhead athlete
• 64% overhead athlete returned to
sports

54. Controversies
• Snyder et al
–40% had not healed at second arthroscopy
–Treated with debridement alone
• Gorantla et al
–64% overhead athletes returned to pre-injury
level
• Boileau et al
–80% vs 40% = tenodesis vs repair
–87% vs 20% = return to previous sports

56. My Experience
SLAP ASAD ACJ
Cuff
Repair
NHS 21 7 2 3
PP 24 4 1 1
Total 45 11 3 4

57. NHS PP Total
2008-09 4 0 4
2010 9 4 13
2011 7 8 15
2012 1 12 13
2013 0 0 0
Total 21 24 45

58. Complications / Issues
9/45 = 20%
Stiffness - 1 patient - resolved
Redo - 2 patient (fall)
Tenodesis - 2 (1 awaiting)
ASAD - 3
Ongoing unexplained pain - 2

59. Decision Making?
History
Injury
Repetitive throwing / heavy overhead work
Age
Symptoms:
Location of pain - anterior suggest LHB
Clicking / locking on throwing position
Instability
Signs
Helpful but not necessarily definitive

60. Obvious Biceps PathologyObvious Biceps Pathology
(Tear / Type IV)(Tear / Type IV)
TenodesisTenodesis
Full thickness RCT /Full thickness RCT /
Degenerate labrumDegenerate labrum
TenodesisTenodesis
H/o Trauma + MRI +H/o Trauma + MRI +
Clinical SuspicionClinical Suspicion
RepairRepair
SLAPSLAP
Other SymptomaticOther Symptomatic
Surgical pathologySurgical pathology
Debride Labrum &Debride Labrum &
Address Other pathologyAddress Other pathology
Age <40Age <40
Repair SLAPRepair SLAP TenodesisTenodesis
YesYes
YesYes
YesYes
YesYes
YesYes
NoNo
NoNo
NoNo
NoNo
NoNo
Snyder et al: JSES, 2011, 82-Snyder et al: JSES, 2011, 82-
8888