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Superior Glenoid Labrum Lesions: (SLAP)

- 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 of the biceps labral attachment, as well as biceps tendon;
- SLAP tears will show more than 5 mm of exposed superior glenoid bone 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 abduction and 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:

- Complications:
suprascapular nerve injury:
Iatrogenic Suprascapular Nerve Injury After Repair of Type II SLAP Lesion
      - Medial perforation of the glenoid neck following SLAP repair places the suprascapular nerve at risk: a cadaveric study
Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction.

- References:
Clinical Presentation and Follow-up of Isolated SLAP Lesions of the Shoulder (SS-04)

An analysis of 140 injuries to the superior glenoid labrum.

SLAP lesions of the shoulder.

Arthroscopic repair of combined Bankart and superior labral detachment anterior and posterior lesions: a  technique and preliminary results.

Arthroscopic fixation of superior labral lesions using a bioabsorbable implant. a preliminary report.

Case report: arthroscopic repair of a type IV SLAP lesion--the red-on-white lesion as a component of anterior instability.

Clinical evaluation and treatment of spinoglenoid notch ganglion cysts

Arthroscopy Effectively Treats Ganglion Cysts of the Shoulder.