SLAP Repair

There are generally three categories of patients who are diagnosed with SLAP tears and this categorization as well as tear anatomy is what guides treatment.

The first category of patients that are also the optimal candidates for SLAP repairs are younger patients with isolated traumatic injuries to the labrum who have failed conservative treatment.  These patients achieve excellent outcomes with anatomically restoring the torn labrum to its position.

The second category of SLAP tears occurs in throwing or overhead athletes (such as pitchers and volleyball players) who sustain repetitive microtrauma to the superior labrum.  These overhead athletes frequently have chronic adaptive changes that occur in the shoulder (that allow them to throw a ball at high velocity or hit overhead with force) that lead to the shoulder losing internal rotation (called “GIRD” for Glenohumeral Internal Rotation Deficit).   The presence of GIRD can be a normal finding in many overhead athletes but in some can be a risk factor for the humeral head translating or sliding up and rubbing on the labrum when the arm is overhead as during pitching(1).  When these patients have failed conservative treatment, they may be good candidates for SLAP repair with or without treatment of the biceps tendon with a procedure called a tenodesis.   The decision to repair a SLAP tear in a competitive overhead throwing athlete should not be taken lightly as the return to play levels are not as encouraging in this population, especially with pitchers(2).  Adding a biceps tenodesis to the surgery in this group may improve return to play rates but still is a topic of active investigation.

The third category of patients with SLAP tears are those with degenerative-type lesions or those associated with other pathology.  These tears are by far the most common, and frequently occur in slightly older patients who have coexistent problems, such as disease in the rotator cuff. In this patient group, chronic rubbing of the humeral head on the labrum, which may be secondary to an injury affecting the rotator cuff, causes the tear in the superior labrum.  If there is injury to these surrounding tissues, which becomes especially common in patients above the age of 36, SLAP repair should rarely be performed due to poorer outcomes(3).  In fact, overly aggressive repair of these tears in this population can lead to pain and stiffness and may lead to further revision shoulder surgery in this population (called the “failed SLAP”)(4).

If you have a symptomatic SLAP tear, are above the age of 40 years of age, and especially if you have other concomitant pathology in the shoulder, including glenohumeral osteoarthritis or rotator cuff tendinopathy or tearing, chances are debridement of the SLAP alone or debridement of the SLAP with biceps tenodesis is the right option.  This cohort of patients has a better outcome compared with SLAP repair(5).

In the younger age cohort, biceps tenodesis is generally only utilized for patients that have failed prior SLAP repair or have tears that propagate substantially into the biceps tendon (called a type IV lesion).

Surgery for SLAP repair is performed as a same day procedure where a sling is placed and worn for six weeks to let the tissues heal.  During this time, gentle exercises are initiated with a therapist.  The sling is discontinued at six weeks followed by gradual return to full activities, including overhead ones.  In throwing athletes, a core strengthening program and early throwing regimen is initiated at 4 months, with full velocity mound pitching resuming around 8 months after surgery pending the athlete’s progress.