Current Practice for the Diagnosis of a SLAP Lesion: Systematic Review and Physician Survey

Glenoid Labral Injuries Are More Common Posteriorly Than Superiorly and Are Combined Across Multiple Areas of the Glenoid

Purpose

To categorize arthroscopically observed labral injuries to include location on the glenoid and frequency of the injuries in each location.

Methods

Patients undergoing arthroscopic labral surgery between January 2018 and June 2020 were reviewed. Inclusion criteria for labral injury were consistently applied and included history, clinical examination and imaging findings, and failure of rehabilitation. Exclusion criteria included arthritis, adhesive capsulitis, and previous surgery. Injury locations were categorized into superior, anterior, and/or posterior areas on the glenoid and as isolated in one area or combined in more than one area. Injury patterns also were evaluated. Interrater and intrarater agreement was assessed between 2 raters for injury location and tear pattern for 22 randomly assigned cases.

Results

In total, 167 cases met the inclusion criteria. Injuries were found in all areas. Combined injuries were found almost twice as often as isolated injuries (63.5% vs 37.5%). Isolated posterior injuries had the greatest frequency of all specific injury types (26.3%). Isolated superior injuries (SLAP 2-4) had a frequency of 7.2%. Tear patterns included peel back, separation/split, insubstance injury, peripheral rim flattening, and extension into the posterior inferior glenohumeral ligament. Interrater was excellent for all tear locations (intraclass correlation coefficient ≥0.85) whereas intrarater agreement was good to excellent (intraclass correlation coefficient ≥0.63).

Conclusions

Labral injuries that are associated with clinical symptoms can occur as isolated or combined types in the superior, anterior, and posterior glenoid areas and can display multiple injury patterns. Combined types of injuries are almost twice as common as those that are isolated in one area. Posterior injuries, isolated or combined, are frequent but superior injuries are less common

Level of Evidence

Level IV, therapeutic case series.

[Research progress on the relationship between shoulder instability and superior labrum anterior posterior lesion]

OBJECTIVE

To summarize the relationship between shoulder instability and superior labrum anterior posterior (SLAP) lesion.

METHODS

The characteristics of shoulder instability and SLAP lesion were analyzed, and the relationship between them in pathogenesis, clinical symptoms, and biomechanics was discussed by referring to relevant domestic and foreign literature.

RESULTS

Shoulder instability and SLAP lesion can occur both spontaneously and respectively. SLAP lesion destroys the superior labrum integrity and the long head of biceps tendon (LHBT) insertion, causing excessive humeral head displacement against glenoid, and leading to shoulder instability. While chronic repetitive or acute high-energy traumatic shoulder instability can in turn aggravate SLAP lesion, resulting in expansion and increased degree of the original lesion.

CONCLUSION

SLAP lesion destroys mechanisms of shoulder stability, while shoulder instability causes tears of the upper labrum and the LHBT, showing a connection between shoulder instability and SLAP lesion. However, the existing evidence can only demonstrate that shoulder instability and SLAP lesion induce and promote the development of each other, instead of a necessary and sufficient condition. Therefore, the specific causal relationship between the two remains unknown and needs to be further studied.

Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis

Superior labrum anterior-posterior (SLAP) lesions are common in overhead athletes. Though some patients have asymptomatic lesions, many tears cause pain and diminished athletic performance. Accurate diagnosis of SLAP lesions can be challenging as the sensitivity and specificity of both the physical exam and advanced imaging is questionable. Management is also difficult, as treatment can be life-altering or career-ending for many athletes. If first-line nonoperative treatment fails, surgical options may be considered. The optimal surgical management of SLAP lesions in athletes is debated. Historically, return to play (RTP) rates among athletes who have undergone arthroscopic SLAP repair have been unsatisfactory, prompting clinicians to seek alternate surgical options. Biceps tenodesis (BT) has been postulated to eliminate biceps tendon-related pain in the shoulder and is increasingly used as a primary procedure for SLAP lesions. The purpose of this text is to review the current literature on the surgical management of SLAP lesions in athletes with an emphasis on the role of BT.

Not All SLAPs Are Created Equal: A Comparison of Patients with Planned and Incidental SLAP Repair Procedures

Background

Epidemiological studies have shown a progressive increase in the rate of superior labrum anterior-posterior (SLAP) repair surgery after the year 2000. However, it is not clear whether this is due to increased recognition of isolated SLAP tears or increased SLAP repair performed secondarily during arthroscopy for other purposes.

Hypothesis/Purpose

We hypothesized that both isolated SLAP repair and secondary SLAP repair increased with time and that patient age influenced the pathway to SLAP diagnosis and surgery—such that younger patients were more likely to have isolated SLAP repair surgery after being diagnosed in clinic.

Study Design

Descriptive epidemiology study.

Methods

Data were obtained from the MarketScan database from 2003 to 2013. CPT and ICD-9 codes were used to identify SLAP surgery patients and concomitant procedures. The timing of SLAP diagnosis relative to surgery was used to determine whether the injury was recognized preoperatively.

Results

64,497 SLAP surgery patients were included. Preoperative SLAP diagnosis increased from 17.1% in 2003 to 44.6% in 2013. Patients diagnosed preoperatively were younger and had fewer concomitant procedures. Increasing age and concomitant rotator cuff tear (RCT) repair corresponded to lower odds of preoperative SLAP diagnosis.

Discussion

Younger patients were more likely to have their SLAP tear diagnosed prior to surgery. Those diagnosed before surgery had fewer simultaneous procedures during their operations, suggesting that SLAP repair was more likely the primary operation. From 2003 to 2013, SLAP tears were increasingly recognized in the preoperative setting.

Surgical management of type II superior labrum anterior posterior (SLAP) lesions: a review of outcomes and prognostic indicators

A Type II SLAP (superior labrum anterior posterior) lesion is a tear of the superior glenoid labrum with involvement of the long head of the biceps tendon insertion. In patients that do not improve with conservative treatment, there is a great deal of variability in the surgical management of these injuries that includes arthroscopic SLAP repair, arthroscopic SLAP repair with biceps tenodesis, biceps tenodesis alone and biceps tenotomy. Each surgical technique has specific effects on a patient's postoperative course and functional recovery. Rehabilitation strategies may be best formulated on an individual basis with an open line of communication between the operating surgeon and the physical therapist. Despite an increased incidence in treatment, there is currently no consensus on the optimal surgical procedure or treatment algorithm for Type II SLAP injuries. However, in middle-aged or older patients (>35) with Type II SLAP tears, either arthroscopic suprapectoral or mini-open subpectoral biceps tenodesis is recommended due to the higher failure rates observed with arthroscopic SLAP repair in this patient group. Although more patients present with a 'Popeye' sign after biceps tenotomy, long-term functional outcome is similar between biceps tenodesis compared to tenotomy. However, more patients will experience biceps fatigue or cramping after the tenotomy procedure. Biceps tenodesis is preferred in younger, more active patients, while tenotomy is preferred in the middle-aged or older and lower demand patients. The aim of this paper is to provide a brief description of the different surgical techniques employed to address Type II SLAP lesions (arthroscopic repair, biceps tenodesis, and biceps tenotomy) and provide a review of available literature regarding outcomes and prognostic factors associated with each technique.

Diagnostic utility of the Active Compression Test for the superior labrum anterior posterior tear: A systematic review

BACKGROUND

The Active Compression Test has been proposed to have high diagnostic accuracy for superior labrum anterior to posterior tears. The aim of this systematic review was to compile the available evidence for this test and evaluate its diagnostic accuracy.

METHODS

The databases PubMed, Embase, Cochrane, CINAHL, and SCOPUS were searched for case control, diagnostic studies that evaluated the Active Compression Test between 1999 (date of test introduction) and February 2018. Two independent review authors screened the search results, assessed the risk of bias using QUADAS-2, and extracted the data.

RESULTS

Eighteen studies (pooled sample = 3091) were included in this review. Twelve out of 18 studies either had high or unclear risk of bias (66.6%). Results from the pooled analysis of all 18 studies provided that the Active Compression Test is more sensitive (71.5: 95% CI = 68.8, 74.0) than specific (51.9: 95% CI = 50.7, 53.1) and only marginally influenced posttest probability from a pretest probability of 31.7-40.72% with a positive finding and a pretest probability of 31.7-20.33% with a negative finding.

DISCUSSION

The Active Compression Test has both limited screening and confirmation ability; therefore, we do not advocate for its use in clinical decision making.

Diagnosis and Treatment of Injuries to the Biceps and Superior Labral Complex in Overhead Athletes

PURPOSE OF REVIEW

This review discusses the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex.

RECENT FINDINGS

A focused patient history, numerous physical examination maneuvers, and appropriate advanced imaging studies must be utilized to reach an accurate diagnosis. Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion. Despite the operative treatment challenges that SLAP tears present, with new techniques and proper patient selection, overhead athletes with injuries to the biceps and superior labrum complex can return to sport at a high level.

Comprehensive Examination of the Athlete's Shoulder

Context:

Shoulder pain and dysfunction are common, with patients presenting complaints to both primary and orthopaedic physicians. History and physical examination remain essential to creating a differential diagnosis, even as noninvasive imaging has improved.

Evidence Acquisition:

Literature was obtained through keyword searches based on the pathology in question (eg, rotator cuff) and the keywords physical examination using PubMed from January 1, 1980, through September 20, 2017. Additional evidence was obtained through screening references from articles identified through the PubMed searches.

Study Design:

Clinical review.

Level of Evidence:

Level 3.

Results:

A total of 7817 articles were screened for relevance. Several physical examination maneuvers have been described for each specific pathology. The Neer sign has a 75% sensitivity for subacromial impingement (SAI), while the Hawkins-Kennedy test has an 80% sensitivity. The painful arc test has an 80% specificity for SAI. The apprehension test has a hazard ratio of 2.96 for anterior shoulder instability. The Jobe test has a sensitivity of 52.6% and a specificity of 82.4% for full-thickness supraspinatus tears, confirmed on arthroscopy. The lag sign is highly sensitive and specific for combined full-thickness supraspinatus and infraspinatus tears at 97% and 93%, respectively. The Speed test has a sensitivity of 54% and specificity of 81% for biceps pathology. The anterior slide test and O’Brien active compression test have been described for superior labrum anterior posterior tears with inconsistent reliability. The cross-body adduction test has a sensitivity of 77% and a specificity of 79% for acromioclavicular joint pathology.

Conclusion:

Several physical examination maneuvers can isolate specific pathology of the shoulder, with widely ranging sensitivity and specificity.

MRI to Arthroscopy Correlations in SLAP Lesions and Long Head Biceps Pathology

Superior labral anterior and posterior lesions and long head biceps injury are 2 common sources of shoulder pain. The presenting complaints and physical examination findings for these etiologies are often nonspecific, making diagnosis challenging. Further complicating their diagnoses, these 2 pathologies often cooccur together or with other shoulder pathologies such as subacromial bursitis, rotator cuff tear, and shoulder instability. However, with advancement in magnetic resonance imaging and shoulder arthroscopy techniques the ability to diagnose and treat these pathologies has vastly improved over the past 30 years. This review provides a case-based description of the correlation between magnetic resonance imaging and arthroscopic findings in common superior labral anterior and posterior and long head biceps injury, accompanied with current management strategies.

A Modification of the Active Compression Test for the Shoulder Biceps-Labrum Complex

The active compression test (O'Brien Sign) is widely used by physicians to aid in the diagnosis of biceps-labrum complex disease. This maneuver has been particularly criticized in the literature, however, with regard to interobserver reliability. Criticisms may in fact stem from inaccurate and inconsistent practice of the examination maneuver, stemming from both patient- and physician-related errors. In this Technical Note, we introduce an easy modification to the O'Brien Sign that limits such errors and improves test uniformity.

Progression of function and pain relief as indicators for returning to sports after arthroscopic isolated type II SLAP repair-a prospective study

Background

One of the currently used surgical techniques in isolated type II SLAP lesions is arthroscopic SLAP repair. Postoperatively, patients tend to suffer from a prolonged period of pain and are restricted in their sports activities for at least 6 months. The aim of this study was to prospectively evaluate the clinical outcome as well as the postoperative course of pain after arthroscopic type II SLAP repair.

Methods

Outcome measures were assessed using the Individual Relative Constant Score (CS_indiv), the American Shoulder and Elbow Surgeons (ASES) Score, the Visual Analogue Scale (VAS), and the Short Form 36 (SF-36). Data were collected preoperatively, as well as at 3, 6, 12 and >24 months postoperatively.

Results

Eleven patients with an average age of 31.8 years (range: 22.8-49.8 years) underwent arthroscopic repair of isolated type II SLAP lesions. Mean follow-up time was 41.9 months (range: 36.1–48.4 months). 6 months after surgery, there was a statistically significant improvement of function according to the CS_indiv (p = 0.004), the ASES Score (p = 0.006), and the SF-36 subscale “physical functioning” (p = 0.014) and a statistically significant decrease of pain according to the VAS (p = 0.007) and the SF-36 subscale “bodily pain” (p = 0.022) compared to preoperative levels.

Conclusions

Arthroscopic repair of isolated type II SLAP lesions with suture anchors leads to a satisfactory functional outcome and return to pre-injury sports levels, with delayed, but significant pain relief observed 6 months after surgery. Thus, a return to sports should not be allowed earlier than 6 months after surgery, when patients have reached pain-free function and recovered strength.

Trial registration

Researchregistry1761 (UIN).

Research Pearls: The Significance of Statistics and Perils of Pooling

A series of articles on statistics are intended for an audience of clinicians, as well as statisticians and authors. Statistical significance is different than clinical significance. Understanding of clinical outcomes, value, quality, or generalizability requires critical analysis of medical research literature to ensure that statistical analyses have been properly applied and interpreted.

Clinical Assessment of the Dynamic Labral Shear Test for Superior Labrum Anterior and Posterior Lesions

BACKGROUND

Diagnosing superior labrum anterior and posterior (SLAP) lesions through physical examination remains challenging. The dynamic labral shear test (DLST) has been shown to have likelihood ratios (LRs) of 31.6 and 1.1 for diagnosing SLAP lesions.

PURPOSE

To determine the clinical utility of the DLST for diagnosing SLAP lesions.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

This prospective, consecutive case series included 774 patients who underwent diagnostic arthroscopy and a preoperative DLST between 2007 and 2013. Patients were divided into 3 groups: 610 control patients with no SLAP lesion but with other abnormalities, 9 patients with isolated SLAP lesion (ISL), and 155 patients with concomitant SLAP lesion (CSL), who had a SLAP lesion and another shoulder abnormality. We determined sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), odds ratio (OR), and diagnostic accuracy (DA) of the DLST with and without other tests.

RESULTS

The DLST was positive for 242 of 610 controls (40%), 7 of 9 patients (78%) in the ISL group, and 88 of 155 patients (57%) in the CSL group. In the ISL group, the DLST had a sensitivity of 78%, specificity of 51%, PPV of 2%, NPV of 100%, OR of 3.58, and DA of 51%. In comparison, the ORs were 1.09 for the active compression test, 1.30 for the lift-off test, and 1.53 for the relocation test, which were not significantly different from each other. For diagnosing a SLAP lesion existing in a joint with other associated injury, the DLST had a sensitivity of 57%, specificity of 52%, PPV of 23%, NPV of 83%, OR of 1.4, and DA of 53%. Combining all 4 tests did not improve the OR for detecting ISLs or CSLs.

CONCLUSION

The DLST is sensitive but not specific for detecting ISLs. With an OR of 3.58, the DLST is useful for diagnosing ISLs. However, in patients who have CSLs, the DLST is not as useful for diagnosing SLAP lesions.

Making the Right Treatment Decision Requires Consideration of Utility and Reconsideration of Value

To achieve a good clinical outcome, arthroscopic and related surgeons must choose the proper treatment, and the basis of this choice is accurate diagnosis. Generally, our clinical focus is on outcome, but outcome is achieved after the fact. While this seems obvious, arthroscopic and related surgeons-and our patients who participate in shared decision making-evaluate the utility, or usefulness, of potential treatments based on desired and expected benefits versus potential risks. Today, cost is frequently considered as a determinant of value in medicine and may be applied to the decision analysis, but if an individual patient perceives health to be priceless, cost becomes irrelevant. In the end, an individual patient's satisfaction is determined on a case-by-case basis. Proper choice of treatment cannot be formulaic.

Value on the Front End: Making the Effective Diagnosis for Optimal Treatment

Much effort is being made to quantitate and improve the outcomes associated with medical treatment. These outcomes are defined as how the patient did after an intervention and may be termed "value on the back end" of the treatment process. The diagnosis guides the content and timing of the treatment, and may be considered the "value on the front end" that optimizes the treatment process. The diagnosis can be defined as "that body of information, collected through the process of evaluating the patient's health problem, that determines the content and timing of the treatment of the health problem." An Institute of Medicine monograph has documented "troubling" deficiencies in the diagnostic process and has suggested guidelines to establish a comprehensive and effective diagnosis, which should include anatomic and patient-derived factors, have multidisciplinary input, have implications for treatment content and timing, and relate to outcomes. The monograph establishes a linear relationship and direct linkage between the diagnosis and treatment. There is much evidence in orthopaedics that these deficiencies exist and often limit the implementation of the most beneficial treatments. Efforts should be made to improve the effectiveness of the diagnostic process to optimize the entire treatment process. The 5 A's framework can be used as a template for the accumulation of information that can guide the treatment process.

Editorial Commentary: On Kibler & Sciascia: What Did the Five Fingers Say to the Face? SLAP. A Systematic Review Wake-Up Call to Improve SLAP Repair Guidelines

Both the quality and quantity of reporting in the SLAP repair literature, especially the surgical indications and technical intraoperative characteristics, leaves significant room for improvement. In their systematic review, Kibler and Sciascia identify this considerable underlying imprecision. Based on the current literature, no consensus exists for establishing any criteria for a successful SLAP repair--surgical indications, characteristics (type, location, number of anchors), completeness of repair, or rehabilitation.

Current Practice for the Surgical Treatment of SLAP Lesions: A Systematic Review

PURPOSE

To analyze current literature reporting surgical treatment of SLAP lesions to examine the consistency of reported surgical details (surgical indications, surgical technique, and postoperative rehabilitation) that are deemed important for best treatment outcomes and to try to establish a consensus regarding treatment.

METHODS

A systematic review of papers reporting surgical treatment of a SLAP lesion was performed. Each paper was analyzed for the description of (1) the arthroscopic indications for surgery; (2) surgical aspects including type, location, and number of anchors and sutures; (3) description of criteria for determination of completeness of the repair; and (4) postoperative rehabilitation details. These findings were also analyzed to determine whether a consensus could be developed regarding surgical treatment.

RESULTS

Twenty-six papers were included, with 12 focused on isolated SLAP repair and 14 focused on combined SLAP repair with other lesions; 54% did not report indications for surgery. Reporting of the anchor/suture details was not consistent, with 35% reporting some variation of 12:00 placement but 31% not reporting the position of placement; 89% of papers did not report the criteria for determining completeness of the repair; 85% reported general postoperative rehabilitation guidelines, but only 4% reported in-depth details.

CONCLUSIONS

This review demonstrated a wide variability in the reported surgical aspects and that a relatively high percentage of papers did not report many of the details. This lack of precision and consistency makes analysis of individual papers and comparison between papers and their outcomes difficult and does not allow a consensus regarding current practice to be developed. These findings may be some of the factors responsible for the variability in treatment outcomes and suggest that efforts could be directed toward consistency in documenting and reporting surgical indications, surgical techniques, surgical endpoints, and efficacious rehabilitation programs.

LEVEL OF EVIDENCE

Level IV, systematic review of level III-IV studies.

The Expectation Game: Patient Comprehension Is a Determinant of Outcome

Patient comprehension of orthopaedic procedures is low and their expectations for successful outcomes are often unrealistic. Surgeons need to understand this and guide patients toward sensible expectations.

Editorial Commentary: Lesions of the Superior Labrum From Anterior to Posterior (SLAP) Are a Slap in the Face to the Traditional Trinity of History, Examination, and Imaging

Superior labrum from anterior to posterior (SLAP) lesions are a slap in the face to the revered trinity of history, physical examination, and imaging. SLAP lesions are difficult to diagnose, and arthroscopy is not only the gold standard, but the current method on which expert arthroscopic shoulder subspecialists rely.