Skip to main content

SLAP lesions: a treatment algorithm

Knee Surgery, Sports Traumatology, Arthroscopy volume 24, pages 447–455 (2016)Cite this article

Abstract

Tears of the superior labrum involving the biceps anchor are a common entity, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature particularly for young athletes. However, the results in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance. The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates as compared to younger patients. In this population, tenotomy or tenodesis of the biceps tendon is a viable alternative to SLAP repairs in order to improve clinical outcomes. The present article introduces a treatment algorithm for SLAP lesions based upon the recent literature as well as the authors’ clinical experience. The type of lesion, age of patient, concomitant lesions, and functional requirements, as well as sport activity level of the patient, need to be considered. Moreover, normal variations and degenerative changes in the SLAP complex have to be distinguished from “true” SLAP lesions in order to improve results and avoid overtreatment. The suggestion for a treatment algorithm includes: type I: conservative treatment or arthroscopic debridement, type II: SLAP repair or biceps tenotomy/tenodesis, type III: resection of the instable bucket-handle tear, type IV: SLAP repair (biceps tenotomy/tenodesis if >50 % of biceps tendon is affected), type V: Bankart repair and SLAP repair, type VI: resection of the flap and SLAP repair, and type VII: refixation of the anterosuperior labrum and SLAP repair.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9

References

  1. Alpert JM, Wuerz TH, O’Donnell TF, Carroll KM, Brucker NN, Gill TJ (2010) The effect of age on the outcomes of arthroscopic repair of type II superior labral anterior and posterior lesions. Am J Sports Med 38:2299–2303

    Article  PubMed  Google Scholar 

  2. Andrews JR, Carson WG Jr, McLeod WD (1985) Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 13:337–341

    Article  CAS  PubMed  Google Scholar 

  3. Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R (2009) Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med 37:929–936

    Article  PubMed  Google Scholar 

  4. Brockmeier SF, Voos JE, Williams RJ III, Altchek DW, Cordasco FA, Allen AA (2009) Outcomes after arthroscopic repair of type-II SLAP lesions. J Bone Joint Surg Am 91:1595–1603

    PubMed Central  Article  PubMed  Google Scholar 

  5. Burkhart SS, Morgan CD (1998) The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 14:637–640

    Article  CAS  PubMed  Google Scholar 

  6. Chalmers PN, Monson B, Frank RM, Mascarenhas R, Nicholson GP, Bach BR Jr, Verma NN, Cole BJ, Romeo AA (2015) Combined SLAP repair and biceps tenodesis for superior labral anterior-posterior tears. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3774-6

    PubMed  Google Scholar 

  7. Chan KK, Muldoon KA, Yeh L, Boutin R, Pedowitz R, Skaf A, Trudell DJ, Resnick D (1999) Superior labral anteroposterior lesions: MR arthrography with arm traction. AJR Am J Roentgenol 173:1117–1122

    Article  CAS  PubMed  Google Scholar 

  8. Connor PM, Banks DM, Tyson AB, Coumas JS, D’Alessandro DF (2003) Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. Am J Sports Med 31:724–727

    PubMed  Google Scholar 

  9. Cordasco FA, Steinmann S, Flatow EL, Bigliani LU (1993) Arthroscopic treatment of glenoid labral tears. Am J Sports Med 21:425–430

    Article  CAS  PubMed  Google Scholar 

  10. De Carli A, Mossa L, Larciprete M, Ferretti M, Argento G, Ferretti A (2012) The gymnast’s shoulder MRI and clinical findings. J Sports Med Phys Fitness 52:71–79

    PubMed  Google Scholar 

  11. Denard PJ, Ladermann A, Burkhart SS (2012) Long-term outcome after arthroscopic repair of type II SLAP lesions: results according to age and workers’ compensation status. Arthroscopy 28:451–457

    Article  PubMed  Google Scholar 

  12. Dodson CC, Altchek DW (2009) SLAP lesions: an update on recognition and treatment. J Orthop Sports Phys Ther 39:71–80

    Article  PubMed  Google Scholar 

  13. Ebinger N, Magosch P, Lichtenberg S, Habermeyer P (2008) A new SLAP test: the supine flexion resistance test. Arthroscopy 24:500–505

    Article  PubMed  Google Scholar 

  14. Ek ET, Shi LL, Tompson JD, Freehill MT, Warner JJ (2014) Surgical treatment of isolated type II superior labrum anterior-posterior (SLAP) lesions: repair versus biceps tenodesis. J Shoulder Elbow Surg 23:1059–1065

    Article  PubMed  Google Scholar 

  15. Erickson J, Lavery K, Monica J, Gatt C, Dhawan A (2015) Surgical treatment of symptomatic superior labrum anterior-posterior tears in patients older than 40 years: a systematic review. Am J Sports Med 43:1274–1282

    Article  PubMed  Google Scholar 

  16. Franceschi F, Longo UG, Ruzzini L, Rizzello G, Maffulli N, Denaro V (2008) No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50: a randomized controlled trial. Am J Sports Med 36:247–253

    Article  PubMed  Google Scholar 

  17. Fu FH, Harner CD, Klein AH (1991) Shoulder impingement syndrome. A critical review. Clin Orthop Relat Res 269:162–173

    PubMed  Google Scholar 

  18. Gartsman GM, Hammerman SM (2000) Superior labrum, anterior and posterior lesions. When and how to treat them. Clin Sports Med 19:115–124

    Article  CAS  PubMed  Google Scholar 

  19. Guanche CA, Jones DC (2003) Clinical testing for tears of the glenoid labrum. Arthroscopy 19:517–523

    Article  PubMed  Google Scholar 

  20. Harris JD, Frank JM, Jordan MA, Bush-Joseph CA, Romeo AA, Gupta AK, Abrams GD, McCormick FM, Bach BR Jr (2013) Return to sport following shoulder surgery in the elite pitcher: a systematic review. Sports Health 5:367–376

    PubMed Central  Article  PubMed  Google Scholar 

  21. Holtby R, Razmjou H (2004) Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy 20:231–236

    Article  PubMed  Google Scholar 

  22. Huang H, Zheng X, Li P, Shen H (2013) Arthroscopic reconstruction of shoulder’s labrum with extensive tears. Int J Surg 11:876–881

    Article  PubMed  Google Scholar 

  23. Huri G, Hyun YS, Garbis NG, McFarland EG (2014) Treatment of superior labrum anterior posterior lesions: a literature review. Acta Orthop Traumatol Turc 48:290–297

    Article  PubMed  Google Scholar 

  24. Ide J, Maeda S, Takagi K (2005) Sports activity after arthroscopic superior labral repair using suture anchors in overhead-throwing athletes. Am J Sports Med 33:507–514

    Article  PubMed  Google Scholar 

  25. Imhoff AB, Agneskirchner JD, Konig U, Temme C, Ottl G, McFarland EG (2000) Superior labrum pathology in the athlete. Orthopade 29(10):917–927

    Article  CAS  Google Scholar 

  26. Jee WH, McCauley TR, Katz LD, Matheny JM, Ruwe PA, Daigneault JP (2001) Superior labral anterior posterior (SLAP) lesions of the glenoid labrum: reliability and accuracy of MR arthrography for diagnosis. Radiology 218:127–132

    Article  CAS  PubMed  Google Scholar 

  27. Jobe FW, Giangarra CE, Kvitne RS, Glousman RE (1991) Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med 19:428–434

    Article  CAS  PubMed  Google Scholar 

  28. Kartus J, Kartus C, Brownlow H, Burrow G, Perko M (2004) Repair of type-2 SLAP lesions using Corkscrew anchors. A preliminary report of the clinical results. Knee Surg Sports Traumatol Arthrosc 12:229–234

    Article  PubMed  Google Scholar 

  29. Kibler WB, Sciascia A (2015) Current practice for the surgical treatment of SLAP lesions: a systematic review. Arthroscopy S0749-8063(15):00752-00755. doi:10.1016/j.arthro.2015.08.041

    Google Scholar 

  30. Kibler WB, Sciascia AD, Hester P, Dome D, Jacobs C (2009) Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med 37:1840–1847

    Article  PubMed  Google Scholar 

  31. Kim DS, Yi CH, Yoon YS (2011) Arthroscopic repair for combined Bankart and superior labral anterior posterior lesions: a comparative study between primary and recurrent anterior dislocation in the shoulder. Int Orthop 35:1187–1195

    PubMed Central  Article  PubMed  Google Scholar 

  32. Lorbach O, Trennheuser C, Anagnostakos K (2014) Diagnostics and therapy of isolated proximal biceps lesions. Obere Extremität 9:10–16. doi:10.1007/s11678-013-0243-z

    Article  Google Scholar 

  33. Maffet MW, Gartsman GM, Moseley B (1995) Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med 23:93–98

    Article  CAS  PubMed  Google Scholar 

  34. McCormick F, Nwachukwu BU, Solomon D, Dewing C, Golijanin P, Gross DJ, Provencher MT (2014) The efficacy of biceps tenodesis in the treatment of failed superior labral anterior posterior repairs. Am J Sports Med 42:820–825

    Article  PubMed  Google Scholar 

  35. Modarresi S, Motamedi D, Jude CM (2011) Superior labral anteroposterior lesions of the shoulder: part 2, mechanisms and classification. AJR Am J Roentgenol 197:604–611

    Article  PubMed  Google Scholar 

  36. Neri BR, ElAttrache NS, Owsley KC, Mohr K, Yocum LA (2011) Outcome of type II superior labral anterior posterior repairs in elite overhead athletes: effect of concomitant partial-thickness rotator cuff tears. Am J Sports Med 39:114–120

    Article  PubMed  Google Scholar 

  37. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB (2011) Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction. Am J Sports Med 39:1883–1888

    Article  PubMed  Google Scholar 

  38. Nord KD, Masterson JP, Mauck BM (2004) Superior labrum anterior posterior (SLAP) repair using the Neviaser portal. Arthroscopy 20(Suppl 2):129–133

    Article  PubMed  Google Scholar 

  39. O’Brien SJ, Allen AA, Coleman SH, Drakos MC (2002) The trans-rotator cuff approach to SLAP lesions: technical aspects for repair and a clinical follow-up of 31 patients at a minimum of 2 years. Arthroscopy 18:372–377

    Article  PubMed  Google Scholar 

  40. Onyekwelu I, Khatib O, Zuckerman JD, Rokito AS, Kwon YW (2012) The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs. J Shoulder Elbow Surg 21:728–731

    Article  PubMed  Google Scholar 

  41. Pandya NK, Colton A, Webner D, Sennett B, Huffman GR (2008) Physical examination and magnetic resonance imaging in the diagnosis of superior labrum anterior-posterior lesions of the shoulder: a sensitivity analysis. Arthroscopy 24:311–317

    Article  PubMed  Google Scholar 

  42. Patterson BM, Creighton RA, Spang JT, Roberson JR, Kamath GV (2014) Surgical trends in the treatment of superior labrum anterior and posterior lesions of the shoulder: analysis of data from the american board of orthopaedic surgery certification examination database. Am J Sports Med 42:1904–1910

    Article  PubMed  Google Scholar 

  43. Provencher MT, McCormick F, Dewing C, McIntire S, Solomon D (2013) A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med 41:880–886

    Article  PubMed  Google Scholar 

  44. Rames RD, Karzel RP (1993) Injuries to the glenoid labrum, including slap lesions. Orthop Clin North Am 24:45–53

    CAS  PubMed  Google Scholar 

  45. Rao AG, Kim TK, Chronopoulos E, McFarland EG (2003) Anatomical variants in the anterosuperior aspect of the glenoid labrum: a statistical analysis of seventy-three cases. Bone Joint Surg Am 85-A:653–659

    Google Scholar 

  46. Snyder SJ, Karzel RP, Del PW, Ferkel RD, Friedman MJ (1990) SLAP lesions of the shoulder. Arthroscopy 6:274–279

    Article  CAS  PubMed  Google Scholar 

  47. Snyder SJ, Banas MP, Karzel RP (1995) An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 4:243–248

    Article  CAS  PubMed  Google Scholar 

  48. Trantalis JN, Sohmer S, More KD, Nelson AA, Wong B, Dyke CH, Thornton GM, Boorman RS, Lo IK (2015) Arthroscopic repair of type II SLAP lesions: clinical and anatomic follow-up. Int J Shoulder Surg 9:74–80

    PubMed Central  Article  PubMed  Google Scholar 

  49. Vangsness CT Jr, Jorgenson SS, Watson T, Johnson DL (1994) The origin of the long head of the biceps from the scapula and glenoid labrum. An anatomical study of 100 shoulders. J Bone Joint Surg Br 76:951–954

    PubMed  Google Scholar 

  50. Virk MS, Tilton AK, Cole BJ (2015) Biceps tenodesis and superior labrum anterior to posterior (SLAP) tears. Am J Orthop 44:491–494

    PubMed  Google Scholar 

  51. Walch G, Boileau P, Noel E, Donell ST (1992) Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg 1:238–245

    Article  CAS  PubMed  Google Scholar 

  52. Waterman BR, Arroyo W, Heida K, Burks R, Pallis M (2015) SLAP repairs with combined procedures have lower failure rate than isolated repairs in a military population: surgical outcomes with minimum 2-year follow-up. Orthop J Sports Med 3:2325967115599154

    PubMed Central  PubMed  Google Scholar 

  53. Weber SC (2010) Surgical management of the failed SLAP repair. Sports Med Arthrosc 18:162–166

    Article  PubMed  Google Scholar 

  54. Williams MM, Snyder SJ, Buford D Jr (1994) The Buford complex—the “cord-like” middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant. Arthroscopy 10:241–247

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Affiliations

  1. Department of Orthopedic Surgery, Saarland University, Kirrberger Str., 66421, Homburg/Saar, Germany

    Matthias Brockmeyer, Dieter M. Kohn & Olaf Lorbach

  2. Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA

    Marc Tompkins

  3. TRIA Orthopaedic Center, Minneapolis, MN, USA

    Marc Tompkins

Authors
  1. Matthias Brockmeyer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marc Tompkins
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dieter M. Kohn
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Olaf Lorbach
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Olaf Lorbach.

Ethics declarations

Conflict of interest

The authors report no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Brockmeyer, M., Tompkins, M., Kohn, D.M. et al. SLAP lesions: a treatment algorithm. Knee Surg Sports Traumatol Arthrosc 24, 447–455 (2016). https://doi.org/10.1007/s00167-015-3966-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-015-3966-0

Keywords

  • SLAP lesion
  • Shoulder
  • Superior labrum
  • Biceps tendon
  • Treatment algorithm