Return to play after treatment of superior labral tears in professional baseball players

Preventive interventions for throwing injuries in baseball players: a scoping review

BACKGROUND

Shoulder and elbow pain are the common complaints associated with throwing injuries in baseball players. Prospective studies evaluating the effectiveness of stretching in increasing posterior shoulder flexibility or strengthening the external rotator muscles as preventive strategies for throwing injuries in baseball players have been published. However, there are limited reviews highlighting the role of preventive interventions for throwing injuries in baseball players. Therefore, this scoping review aimed to summarize the existing literature on preventive interventions for throwing injuries in baseball players.

METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Scopus databases on 3 March 2023. Two independent reviewers screened the studies based on the eligibility criteria. We extracted existing literature on preventive interventions and effectiveness for throwing injuries in baseball players, and participants' characteristics and results were extracted from the studies. This scoping review was performed in accordance with the Extended Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for Scoping Reviews.

RESULTS

The initial database search yielded 1170 articles, four of which met the eligibility criteria. Of the included studies, two were randomized controlled trials, and the remaining two were prospective cohort studies. Eligible studies targeted youth-to high school-level players and focused on preventive programs for throwing injuries that manifest in the upper extremities of baseball players. The outcome measure most commonly used to quantify the effectiveness of prevention programs was the incidence of shoulder and elbow injuries, although the definitions vary among studies. The prevention program included sleeper stretching, shoulder external rotation strengthening exercises, and comprehensive prevention programs (focusing on improving the elbow, shoulder, and hip range of motion; rotator cuff and periscapular muscle strength; posture; and lower extremity balance). Each prevention program was reported to have the potential to reduce the incidence of throwing injuries in baseball players, and two studies suggested that high compliance with the program led to a lower injury risk.

CONCLUSION

This scoping review confirmed the presence of studies that examined preventive interventions for throwing injuries in baseball players. Preventive interventions that may reduce throwing injuries in baseball players include sleeper stretching, shoulder external rotation strengthening exercises, and comprehensive prevention programs. However, the characteristics of participants (eg, age, sports level, and position) and the definition of injury varied among previous studies. Injury profiles and prevention strategies may differ according to age, sport level, and position of players, and more studies are needed to prove this issue.

A 6-week randomized-controlled field study: effect of isokinetic eccentric resistance training on strength, flexibility and muscle structure of the shoulder external rotators in male junior handball players

Background: Team handball involves a tremendous amount of shoulder motion with high forces during repeated extended external range of motion. This causes shoulder complaints and overuse injuries. While eccentric training for the lower extremity shows preventive effects by improving strength, range of motion and fascicle length, there is a research gap for the shoulder joint and for advanced tissue characterization using diffusion tensor imaging. Objectives: To investigate the effects of 6-week eccentric isokinetic resistance training on strength, flexibility, and fiber architecture characteristics of the external rotators compared to an active control group in junior male handball players. Methods: 15 subjects were randomly assigned to the eccentric training group and 14 subjects to the active control group (conventional preventive training). Primary outcome measures were eccentric and concentric isokinetic strength of the external rotators, range of motion, and muscle fascicle length and fascicle volume. Results: The intervention group, showed significant changes in eccentric strength (+15%). The supraspinatus and infraspinatus muscles showed significant increases in fascicle length (+13% and +8%), and in fractional anisotropy (+9% and +6%), which were significantly different from the control group. Conclusion: Eccentric isokinetic training has a significant effect on the function and macroscopic structure of the shoulder external rotators in male junior handball players. While strength parameters and muscle structure improved, range of motion did not change. This research helps understanding the physiology of muscle and the role of eccentric training on shoulder function and muscle structure. Furthermore, DTI was found to be a promising tool for advanced tissue characterization, and the in vivo derived data can also serve as model input variables and as a possibility to extend existing ex-vivo muscle models. Future research is needed for functional and structural changes following convenient eccentric field exercises.

Criteria, Timing, and Factors Associated With Return to Competitive Sport After Rotator Cuff Surgery

Rotator cuff pathology in competitive athletes is common and may produce chronic symptoms and joint disability, impairing sports participation and leading to premature retirement. Athletes are a high-functioning patient population with unique characteristics. Decision-making for return to sport is a complex and multifactorial process. Literature is sparse and does not provide precise guidelines to assist physicians to make the right decision. This review aimed to highlight factors affecting outcome, timing, and criteria for return to competitive sport after rotator cuff surgery to help physicians to clearly counsel athletes and make high-quality decisions for return to sport.

Return to Sport at Preinjury Level is Common After Surgical Treatment of SLAP Lesions: A Systematic Review and a Meta-analysis

BACKGROUND

Patients undergoing surgery for Superior-Labrum-anterior-to-posterior (SLAP) lesions are often worried about their return to sport performance. This systematic review determined the rate of return to sport and return to sport at the previous level (RTSP) after surgery for SLAP lesion.

MATERIALS AND METHODS

The PRISMA guidelines were followed. Meta-analysis of data through forest plot projections was conducted. Studies were divided and analyzed according to the type of interventions (isolated slap repair or SLAP repair with rotator cuff debridement and biceps tenodesis).

RESULTS

The mean overall rate of return to sport after the procedures was 90.6% and the mean overall rate of return to sport at the previous level after the procedures was 71.7%. RTSP rates of the whole population were 71% (95% CI: 60%-80%), 66% (95% CI: 49%-79%), and 78% (95% CI: 67%-87%) for isolated SLAP repair, SLAP repair with the rotator cuff debridement and biceps tenodesis, respectively. A lack of subgroup analysis for the specific performance demand or type of lesion related to the surgical technique used might induce a high risk of bias.

DISCUSSION

Return to sports at the previous level after surgically treated superior labrum anterior to posterior lesion is possible and highly frequent, with the highest rates of RTSP in patients treated with biceps tenodesis. More studies and better-designed trials are needed to enrich the evidence on indications of SLAP surgical treatment in relation to specific sports-level demand.

LEVEL OF EVIDENCE

Level-IV.

Rehabilitation of the painful shoulder

Managing the painful shoulder in overhead athletes can be difficult because of a lack of time-loss injuries in overhead sports and focusing primarily on either pathoanatomic causes or movement impairments. Although managing the painful shoulder can be challenging, the combination of identifying pathoanatomic causes with movement impairments can provide a more focused rehabilitation approach directed at the causes of shoulder pain. Understanding the potential influence of scapular positioning as well as mobility and/or strength impairments on shoulder pain can help clinicians develop more directed rehabilitation programs. Furthermore, sports-specific methods such as long toss or the use of weighted balls for achieving physiological or performance-based gains have limited empirical evidence regarding their clinical and performance-based benefits, which may impede the rehabilitation process. Applying a comprehensive evaluation approach prior to and throughout the treatment process can assist clinicians with selecting the most appropriate treatment based on patient need. Reconsidering traditional treatments based on existing evidence may help refine the treatment process for overhead athletes with shoulder pain.

Effects of repetitive baseball throwing on hip muscle strength and trunk and pelvic motions at the shoulder's maximum external rotation position during the late cocking phase and ball release

[Purpose] This study aimed to investigate the changes in the trunk and pelvic lateral tilt angles at the shoulder's maximum external rotation during the late cocking phase (MER) and ball release (BR) and hip muscle strength during repetitive throwing. [Participants and Methods] In this study, 12 male baseball players participated. During the throwing, which was filmed using a high-speed video camera, the trunk and pelvic lateral tilt angles toward the nonthrowing side were measured at the MER and BR. Hip muscle strength during abduction, adduction, and external internal rotations were measured on the throwing and nonthrowing sides. Repetitive throwing was performed for nine innings, with 15 pitches per inning. Throwing motion was compared during innings 1, 7, 8, and 9. Hip muscle strength was measured before and after repetitive throwing. [Results] Compared with the trunk lateral tilt angle toward the nonthrowing side at BR in inning 1, the angle in innings 8 and 9 increased. The strength of hip abduction, adduction, and external and internal rotations on the throwing and nonthrowing sides decreased after repetitive throwing. [Conclusion] Hip muscle strength decreases after 135 pitches, and throwing >120 pitches changes the trunk lateral tilt angle at BR.

Intraobserver and Interobserver Reliability of the Snyder and Expanded SLAP Classification System: A Video Study

Background

Superior labral anterior and posterior (SLAP) tears are a common finding in overhead athletes. The original classification system produced by Snyder in 1990 contained 4 types of SLAP tears and was later expanded to 10 types. The classification has been challenging because of inconsistencies between surgeons making diagnoses and treatments based on the diagnosis. Furthermore, patient factors-such as age and sports played-affect the treatment algorithms, even across similarly classified SLAP tears.

Purpose

To (1) assess the interobserver and intraobserver reliability of the Snyder and expanded SLAP (ESLAP) classification systems and (2) determine the consistency of treatment for a given SLAP tear depending on different clinical scenarios.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

A total of 20 arthroscopic surgical videos and magnetic resonance imaging scans of patients with SLAP tears were sent to 20 orthopaedic sports medicine surgeons at various stages of training. Surgeons were asked to identify the type of SLAP tear using the Snyder and ESLAP classifications. Surgeons were then asked to determine the treatment for a SLAP tear using 4 clinical scenarios: (1) in the throwing arm of an 18-year-old pitcher; (2) in the dominant arm of an 18-year-old overhead athlete; (3) a 35-year-old overhead athlete; (4) or a 50-year-old overhead athlete. Responses were recorded, and the cases were shuffled and sent back 6 weeks after the initial responses. Results were then analyzed using the Fleiss kappa coefficient (κ) to determine interobserver and intraobserver degrees of agreement.

Results

There was moderate intraobserver reliability in both the Snyder and ESLAP classifications (κ = 0.52) and fair interobserver reliability for both classification systems (Snyder, κ = 0.31; ESLAP, κ = 0.30; P < .0001) among all surgeons. Additionally, there was only fair agreement (κ = 0.30; P < .0001) for the treatment modalities chosen by the reviewers for each case.

Conclusion

This study demonstrated that SLAP tears remain a challenging problem for orthopaedic surgeons in diagnostics and treatment plans. Therefore, care should be taken in the preoperative discussion with the patient to consider all the possible treatment options because this may affect the postoperative recovery period and patient expectations.

Effects of Repetitive Pitching on Trunk Muscle Endurance and Thoracic and Shoulder Kinematics

Background

Baseball players are aware of the potential of shoulder problems due to repetitive throwing. However, few studies have examined how pitching repeatedly affects the thoracic spine and shoulder.

Purpose

This study aimed to determine the effects of pitching repeatedly on the endurance of trunk muscles and kinematics of the thoracic spine and shoulder.

Study design

Cohort study.

Methods

Trunk muscle endurance was assessed in flexion, extension, and lateral flexion positions in 12 healthy amateur baseball players. The positions of stride foot contact (SFC) during the early cocking phase and maximal shoulder external rotation (MER) during the late cocking phase were used to compute the thoracic and shoulder kinematics in degrees. Participants were then asked to throw 135 fastballs (~9 innings with 15 throws per inning). Throwing motions were monitored throughout the first, seventh, eighth, and nine innings, whereas trunk muscular endurance was assessed before and after the repetitive throwing activity. Ball speed during pitching was measured using a radar gun. All outcome measures were statistically compared to examine differences over time.

Results

The trunk muscle endurance declined after the throwing task. In the eighth inning, compared with the first inning, the thoracic rotation angle at the SFC increased toward the throwing side. In contrast, the shoulder horizontal adduction angle at MER decreased in the seventh and ninth innings.

Conclusion

With repeated pitching, trunk muscle endurance gradually declines, and repetitive throwing significantly altered kinematics of the thoracic rotation at SFC and shoulder horizontal plane at MER.

Level of Evidence

2a.

Surgical Treatment of Superior Labral/Biceps Pathology in the Overhead Thrower

Symptomatic superior labral anterior and posterior (SLAP) tears have become an increasingly common diagnosis, particularly within the competitive overhead athlete population. Type II SLAP tears are the most encountered variant in overhead throwing athletes. Given the high incidence of false positives on advanced imaging, corroborating the history and physical examination with imaging is paramount to accurately establish a SLAP lesion diagnosis. Previous studies have reported conflicting success rates with conservative management, but the number of pitching athletes able to return to prior level of performance with nonsurgical management strategies has been unsatisfactory. Although there has historically been a notable disconnect between the incidence of SLAP tears in the literature and the number of SLAP repairs in recent investigations, high-grade or unstable tears may be candidates for débridement, labral repair, biceps tenodesis, or less frequently, biceps tenotomy. Biceps tenodesis has been increasingly used for the management of these lesions, with recent studies reporting high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes in carefully selected athletes.

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

Return to Play After Shoulder Arthroscopy in Major League Baseball Pitchers vs Position Players

Background

Recovery from shoulder arthroscopy may vary between professional pitchers and position players in Major League Baseball (MLB). The time that it takes to return to play (RTP) and the level of skills to be regained after surgery are important factors for an athlete to consider when making career decisions.

Purpose

To identify MLB players who had arthroscopic shoulder surgery and observe their rates of RTP to MLB and the minor league, as well as to compare pre- and postinjury performance statistics and career metrics.

Study Design

Descriptive epidemiology study.

Methods

Public records (press releases, http://www.prosportstransactions.com, http://www.baseball-reference.com) were searched and analyzed to determine the number of days from shoulder arthroscopy to RTP and pre- and postinjury statistics for pitchers and position players in the MLB and minor league from 1998 to 2018. To meet inclusion criteria, a player must have undergone shoulder arthroscopy after having played at least 1 game in the MLB and had no identifiable concomitant injuries.

Results

Of 134 players, 89 (66.4%) returned to MLB. Fifty-four of 89 pitchers (60.7%) and 35 of 45 position players (77.8%) returned to MLB (P = .048). Forty-nine of 54 pitchers (90.7%) and 23 of 35 position players (65.7%) who returned to MLB returned to the minor league first. The mean time to RTP was 469.6 days (range, 100-1079 days) for pitchers and 301.6 days (range, 94-1488) for position players (P = .002). The WAR statistic (wins above replacement) for the pitchers decreased significantly (P = .004) after shoulder arthroscopy.

Conclusion

MLB position players returned to play at higher rates and more quickly than did pitchers. The WAR statistic declined in pitchers during the first season of RTP. Players undergoing arthroscopic shoulder surgery should be aware of these possible outcomes in time to RTP and postoperative performance.

Return to Play After Shoulder Surgery in Professional Baseball Players: A Systematic Review and Meta-analysis

Background

The current literature lacks an updated review examining return to play (RTP) and return to prior performance (RTPP) after shoulder surgery in professional baseball players.

Purpose

To summarize the RTP rate, RTPP rate, and baseball-specific performance metrics among professional baseball players who underwent shoulder surgery.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search was performed utilizing the PubMed, MEDLINE, and CINAHL databases and according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were English-language studies reporting on postoperative RTP and/or RTPP in professional baseball players who underwent shoulder surgery between 1976 and 2016. RTP rates, RTPP rates, and baseball-specific performance metrics were extracted from qualifying studies. A total of 2034 articles were identified after the initial search. Meta-analysis was performed where applicable, yielding weighted averages of RTP and RTPP rates and comparisons between pitchers and nonpitchers for each type of surgery. Baseball-specific performance metrics were reported as a narrative summary.

Results

Overall, 26 studies featuring 1228 professional baseball players were included. Patient-level outcome data were available for 529 players. Surgical interventions included rotator cuff debridement (n = 197), rotator cuff repair (RCR; n = 43), superior labrum from anterior to posterior repair (n = 124), labral repair (n = 103), latissimus dorsi/teres major (LD/TM) repair (n = 21), biceps tenodesis (n = 17), coracoclavicular ligament reconstruction (n = 15), anterior capsular repair (n = 5), and scapulothoracic bursectomy (n = 4). Rotator cuff debridement was the most common surgical procedure, while scapulothoracic bursectomy was the least common (37.2% and 0.8% of interventions, respectively). Meta-analysis revealed that the RTP rate was highest for LD/TM repair (84.5%) and lowest for RCR (53.5%), while the RTPP rate was highest for LD/TM repair (100.0%) and lowest for RCR (27.9%). RTP and RTPP rates were generally higher for position players than for pitchers. Nonvolume performance metrics were unaffected by shoulder surgery, while volume statistics decreased or remained similar.

Conclusion

RTP and RTPP rates among professional baseball players were modest after most types of shoulder surgery. Among surgical procedures commonly performed on professional baseball players, RTP and RTPP rates were highest for LD/TM repair and lowest for RCR.

High Rate of Return to Sporting Activity Among Overhead Athletes With Subpectoral Biceps Tenodesis for Type II SLAP Tear

PURPOSE

To evaluate the functional and athletic outcomes after primary subpectoral biceps tenodesis for type II SLAP tear in overhead athletes.

METHODS

All competitive elite athletes with type II SLAP tears undergoing biceps tenodesis by a single surgeon were isolated between 2007 and 2015. Exclusion criteria were applied to individuals not involved in overhead athletics, clinical follow-up <24 months, adjacent rotator cuff or labral repair, concomitant SLAP repair, and/or previous arthroscopic shoulder surgery. Patient-reported outcome measures included visual analog scale (VAS), Kerlan Jobe Orthopaedic Clinic shoulder score, and Single Assessment Numerical Assessment. Clinical and sporting outcomes were recorded using a sports-specific questionnaire.

RESULTS

Of 22 identified patients, 16 competitive overhead athletes (72.7%; 11 men, 5 women) with a mean age of 21.0 years were available at mean 4.5-year follow-up. Baseball or softball comprised the majority of patients (n = 9; 56.3%), followed by gymnastics (n = 2), swimming (n = 2), and other sports (n = 3). At mean 4.1 months postoperatively, 13 patients (81.3%) returned to previous level of athletic activity, whereas 2 patients (12.5%) failed to return to sporting activity and 1 (6.3%) returned at a lower level of competition. VAS pain significantly decreased from an average of 4.4 preoperatively to 1.7 postoperatively (P = .002), and mean Single Assessment Numerical Assessment scores also demonstrated significant improvement (55.4-76.7; P = .008). Final mean Kerlan Jobe Orthopaedic Clinic score was 74.0 (standard deviation 25.9), including 2 patients with suboptimal outcomes due to persistent pain. There were no significant differences in mean forward flexion or rotation in either the adducted or throwing position (P > .05), although small, significant decreases in postoperative active abduction were noted (165° vs 155°; P = .003).

CONCLUSIONS

In the current series of competitive overhead athletes, 81% of patients returned to previous level of play at an average of 4.1 months postoperatively after subpectoral biceps tenodesis for symptomatic SLAP tear. Athletes reliably experienced significant decreased activity-related pain with athletic function.

LEVEL OF EVIDENCE

IV, case series.

Upper-Extremity Injuries Have the Poorest Return to Play and Most Time Lost in Professional Baseball: A Systematic Review of Injuries in Major League Baseball

PURPOSE

To summarize the incidence of injuries occurring in professional baseball and compare player outcomes reported in the literature.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines across 3 databases (PubMed, MEDLINE, Embase). Inclusion criteria were studies of injury incidences and/or injury outcomes on active Major League Baseball (MLB) athletes and studies published in the English language. Exclusion criteria were non-MLB players, case series and case report studies with a cohort of ≤3 players, and/or review articles.

RESULTS

A total of 477 articles were identified from the initial search of 3 databases, with 105 studies meeting inclusion criteria. Among these articles, the most common injuries studied were elbow (38%), shoulder (14%), hip/groin (11%), hand/wrist (7%), head/face (7%), knee (7%), spine (5%), and foot/ankle (3%). Injuries with the greatest incidence included hand/wrist (150.3 per year), hamstring (7.8-73.5 per year), ulnar collateral ligament (UCL) tears (0.23-26.8 per year), gastrocnemius strains (24.2 per year), and concussions (3.6-20.5 per year). Lowest rates of return to play were seen following shoulder labral tears (40%-72.5%), rotator cuff tears (33.3%-87%), and UCL tears (51%-87.9%). The injuries leading to most time away from sport included elbow UCL tears (average 90.3 days treated nonoperatively to 622.8 days following revision reconstruction), shoulder labral tears (average 315-492 days), and anterior cruciate ligament (ACL) tears (average 156.2-417.5 days). Following ACL tears, rotator cuff tears, shoulder labral tears, and hip femoroacetabular impingement requiring arthroscopy, athletes had a significantly lower workloads compared with before injury upon return to play.

CONCLUSIONS

Most published investigations focus on elbow injuries of the UCL, with variable return to play and mixed performance following surgery. UCL tears, shoulder labral tears, and ACL tears result in the most missed time. Upper-extremity injury such as shoulder labral tears, rotator cuff tears, and UCL tears had the poorest return to play rates. Workload was most affected following ACL reconstruction, rotator cuff repair, shoulder labral repair, and hip arthroscopy for femoroacetabular impingement.

LEVEL OF EVIDENCE

IV, systematic review of level II-IV studies.

SLAP Tears: Treatment Algorithm

SLAP lesions can be significant pain generators in the shoulder. These injuries are the most common shoulder injury in overhead athletes, as repetitive overhead motion is the most common etiology of SLAP lesions. These lesions present a diagnostic and treatment challenge to patients and physicians. Factors to consider when discussing treatment options for SLAP lesions include age, type of sports activity, level of sports participation, and degree of symptoms. Nonoperative management is the first-line treatment for most young, active patients without history of trauma, mechanical symptoms, and/or demand for overhead activities. These conservative measures include rest, avoidance of aggravating factors, injections, and physical therapy focusing on correcting scapular dyskinesis, restoring range of motion and strength, and evaluating the biomechanical throwing motion. It has been reported that 40% of professional baseball players can successfully return to play after rehabilitation alone. Alternatively, operative treatment is reserved for failure of nonoperative treatment and those with persistent symptoms that prevent individuals from participating in sports activities or activities of daily living. The two most common operative treatment options include arthroscopic repair versus biceps tenodesis. Arthroscopic repair can be considered in younger athletes (<30 years old) and elite athletes who are involved in overhead sports (baseball, tennis, volleyball) and consists of repairing the labral anchor back to the superior glenoid rim with knotless anchor repair techniques. Alternatively, biceps tenodesis is the first-line treatment option for failed SLAP repairs, and as an index procedure, traditionally has been reserved for middle-aged individuals (>30 years old), patients receiving workers' compensation, nonoverhead athletes, or in those with concomitant rotator cuff tears. However, due to a relatively high failure rate of SLAP repairs, biceps tenodesis as an index procedure is gaining more popularity, as emerging evidence suggests encouraging functional outcomes and return-to-sport rates even in younger athletes.

Biceps Tenodesis cannot be used as primary treatment option in baseball pitchers with intact rotator cuff muscles

Background Surgeons remain hesitant to perform biceps tenodesis in athletes with type II superior labrum anterior-to-posterior tears due to the lack of reported clinical outcomes for individual overhead throwing sports and associated concerns that this may predispose the joint to instability. This study aimed to assess the effect of biceps tenodesis on shoulder stability for major overhead throwing sports to aid sport-specific surgical decision-making for athletes with type II superior labrum anterior-to-posterior tears.

METHODS

This is a combined modelling and experimental study. Motion data and external forces were measured from 13 participants performing five overhead throwing motions. These data served as input into a musculoskeletal shoulder model that quantifies shoulder stability and muscle loading.

FINDINGS

The loading of the long head of the biceps brachii decreases significantly following biceps tenodesis in three overhead throwing motions (p = 0.02). The loss in joint stability following biceps tenodesis is compensated by a non-significant increase in rotator cuff muscle force which maintains shoulder stability across all overhead throwing motions, except baseball pitching (p = 0.01). The presence of a full-thickness supraspinatus tear post biceps tenodesis further decreases shoulder stability in four of the five overhead throwing motions (p = 0.01).

INTERPRETATION

The study findings demonstrate that an increase in rotator cuff muscle force maintains joint stability for all overhead throwing motions post biceps tenodesis, except baseball pitching. As the presence of a full-thickness tear of the supraspinatus significantly reduces joint stability, biceps tenodesis may be used as a primary treatment in overhead throwing athletes with intact rotator cuff muscles, except baseball pitchers.

LEVEL OF EVIDENCE

Controlled Laboratory Study; Level of Evidence 3.

Return to sports after arthroscopic bankart repair on the dominant shoulder in overhead athletes

BACKGROUND

Arthroscopic Bankart repair (ABR) yields good results in young athletes with anterior shoulder instability. However, the treatment for overhead athletes is challenging because recovery of range of motion is necessary for return to play and repeated shoulder motion may lead to recurrent instability. The aim of this study was to investigate the clinical outcomes and return to sports after ABR on the dominant shoulder in overhead athletes.

METHODS

This study included 24 competitive level overhead athletes who underwent ABR on their dominant shoulders. The mean age at surgery was 17.6 years, and the mean follow-up was 39.7 months. The range of bilateral shoulder motion, the Rowe score, the Japanese Shoulder Society Shoulder Instability Score (JSS-SIS), and the Japanese Shoulder Society Shoulder Sports Score (JSS-SSS) were evaluated before the surgery and at the final visit. Recurrent instability, the final level of return to sports, and the duration before returning to sports were confirmed, as well as the pre-, intra- and postoperative factors, which prohibited complete return to play.

RESULTS

There were no cases of recurrent instability. The Rowe score, JSS-SIS, JSS-SSS, and the range of flexion, abduction, internal rotation significantly improved postoperatively. Fifteen athletes (62.5%) returned to the same or superior levels without any complaint in their shoulders. The mean duration needed for a complete return was 13.3 months. The postoperative external rotation deficit in abduction was larger in the athletes who returned incompletely than those who returned completely, 7.8° and 2.3°, respectively.

CONCLUSIONS

ABR is a reliable surgery for preventing recurrent instability in overhead athletes, however the rate of a complete return to preinjury level was low and a long duration was needed for complete return to play. The postoperative external rotation may be necessary for a complete return to overhead sports.

LEVEL OF EVIDENCE

Level IV: Retrospective Case Series.

SLAP Repair Versus Biceps Tenodesis in Patients Younger Than 40 Years: A Cost-Effectiveness Analysis

BACKGROUND

The surgical management of type II superior labrum anterior and posterior (SLAP) tears in patients younger than 40 years is controversial, but growing evidence suggests comparable outcomes between primary SLAP repair and primary biceps tenodesis, with lower rates of reoperations after primary biceps tenodesis. Given the relatively similar patient-reported outcomes, cost-effectiveness analyses of direct and indirect costs associated with the two procedures propound a valuable comparative technique.

HYPOTHESIS

In this value-based comparison of SLAP repair versus biceps tenodesis, we hypothesized that biceps tenodesis would be more cost-effective than SLAP repair in patients younger than 40 years.

STUDY DESIGN

Economic and decision analysis; Level of evidence, 4.

METHODS

A 1-month Markov cycle was simulated to reflect 10 years of health outcomes. Health states were selected based on outcomes that are especially important in assessing indirect costs for a younger, active patient population: return-to-sport rates, which demonstrate a return to baseline function, and reoperation rates. Transition state probabilities were obtained through an index systematic review and meta-analysis comparing labral repair and biceps tenodesis for the treatment of type II SLAP lesions in patients younger than 40 years. Health state utility and cost values were obtained from accepted values denoted in existing literature.

RESULTS

Both primary SLAP repair and primary biceps tenodesis yielded an average expected 8.1 quality-adjusted life years over the 10-year period. The average cost (in 2021 US$) was $16,619 for biceps tenodesis and $19,388 for SLAP repair.

CONCLUSION

In a younger patient population, SLAP repair and biceps tenodesis had comparable quality-adjusted life years and utility in the treatment of type II SLAP tears; however, SLAP repair cost $19,388, while biceps tenodesis cost $16,619, reflecting a 14% cost savings with biceps tenodesis. These findings can be extrapolated to further establish the role for these procedures in treating SLAP tears.

Moderate Return to Play and Previous Performance After SLAP Repairs in Competitive Overhead Athletes: A Systematic Review

PURPOSE

To perform a systematic review of return to play (RTP) and return to previous level of performance (RPP) in competitive overhead athletes after SLAP repair to identify factors associated with failure to RTP.

METHODS

Systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Review was registered with PROSPERO International prospective register of systematic reviews (CRD42020215488). Inclusion criteria were literature reporting RTP or RPP following SLAP repair in overhead athletes were run in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Categories for data collection for each full article included (1) article information; (2) patient demographics; (3) surgical techniques; (4) level of competition; (5) rotator cuff treatment; (6) player position; (7) patient-reported outcome measures; and (8) RTP and RPP rates. The Methodological Index for Non-randomized Studies checklist was used to evaluate quality of all included studies.

RESULTS

Eight studies with 333 subjects were identified. Overall RTP and RPP rates were 50% to 83.6% and 35.3% to 64%, respectively. Patients with surgically treated rotator cuff pathology had lower RTP (12.5%-64.7%) rates compared with those without (80.0%-83.6%). Professional athletes had similar RTP rates (62.5%-81.5%) compared with high-school (75.0%-90.0%) and college athletes (12.5%-83.3%). However, professional athletes demonstrated the lowest relative range of reported RPP rates (27.7%-55.6%). Pitchers had lower RTP (62.5%-80.0%) and RPP (52.0%-58.9%) compared with position players (91.3% RTP, 76.3%-78.2% RPP).

CONCLUSIONS

Studies reviewed reported moderate RTP and RPP rates following SLAP repairs in competitive overhead athletes. Those with associated rotator cuff tear requiring treatment, and baseball pitchers were less likely to RTP and RPP. Professional athletes had similar RTP to an amateur; however, they were less likely to RPP.

LEVEL OF EVIDENCE

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

Analysis of common shoulder injuries in collegiate baseball players

OBJECTIVES

Baseball players are highly susceptible to shoulder injuries due to repetitive overhead throwing. The purpose of this study was to investigate men's collegiate baseball shoulder injury rates and associated risk factors.

METHODS

Using the NCAA Injury Surveillance Program (ISP) database, shoulder injury data for men's baseball players was analyzed from 2009-2010 through 2013-2014. Only the most common shoulder injuries were examined, including acromioclavicular (AC) sprain, anterior dislocation, biceps tear, biceps tendinitis, SLAP (superior labrum from anterior to posterior) tear, non-SLAP labral tear, rotator cuff tear, rotator cuff tendinitis, and shoulder impingement. Statistical analysis was performed using proportion ratios (PR). Statistical significance was initially defined as p < 0.05; a post-hoc Bonferroni adjustment was applied using a p < 0.005 threshold balancing the likelihood of false positive and false negative findings.

RESULTS

Overall, 138 shoulder injuries were identified of which 51.4% occurred during practice. Rotator cuff pathology represented 45.6% of all injuries, with rotator cuff tears significantly more likely to be season-ending injuries (PR 2.5, 95% CI 1.2-5.6, p = 0.019). Pitching or throwing was the mechanism of injury in 100% of players with rotator cuff tendonitis, 87.5% of SLAP tears, 70% of players with biceps tendinitis, and 67% of players with rotator cuff tears. Biceps tendinitis (PR 3.9, 95% CI 1.2-12.5, p = 0.024) and SLAP tears (PR 6.4, 95% CI 1.6-25.0, p = 0.008) were significantly more likely to be chronic. SLAP tears were significantly more likely to be recurrent (PR 5.5, 95% CI = 1.5-20.4, p = 0.010). Being a freshman or sophomore was significantly associated with a lower proportion of biceps tendinitis (PR = 0.2, 95% CI = 0.04-0.8, p = 0.028). All anterior shoulder dislocations occurred while running the bases or sliding, and AC sprains were significantly associated with contact (PR 20.6, 95% CI = 2.5-168.7, p = 0.0048).

CONCLUSIONS

Repetitive overhead throwing in college baseball is a common cause of overuse shoulder injuries. These athletes are especially susceptible to rotator cuff pathology, which is significantly more likely to cause season-ending injuries. While we have to interpret these results in light of both adjusted and unadjusted p-values, this information signifies the importance of shoulder injury prevention strategies by physicians and trainers taking care of collegiate baseball players.

Initial kinematic chain injuries increase hazard of subsequent arm injuries in professional baseball pitchers

BACKGROUND

Currently, there are few studies that have evaluated the relationship between a lower extremity or trunk injury (kinematic chain) and subsequent arm injury. The purpose of this study was (1) to investigate the relationship between initial kinematic chain (lower extremity or trunk) injury and subsequent arm injury; and (2) to investigate the relationship between initial shoulder or elbow injury and subsequent arm injury.

METHODS

A 7-year prospective injury risk study was conducted with Minor League Baseball pitchers. Pitches, pitching appearances, athlete exposures (AEs), and arm injuries (≥1-day time loss) were documented throughout the season. Cox survival analyses with 95% confidence intervals (95% CIs) were performed. Confounders controlled for included age, body mass index, arm dominance, pitching role, previous arm injury, number of pitching appearances, and seasonal pitch load.

RESULTS

A total of 297 pitchers participated (total player days = 85,270). Arm injury incidence was 11.4 arm injuries/10,000 AEs, and kinematic chain incidence was 5.2 injuries/10,000 AEs. Pitchers who sustained a kinematic chain injury demonstrated a greater hazard (2.6 [95% CI: 1.2, 5.6], P = .019) of sustaining an arm injury. Pitchers who sustained an initial shoulder injury demonstrated a greater hazard (9.3 [95% CI: 1.1, 83], P = .047) of sustaining a subsequent shoulder or elbow injury compared with pitchers who sustained an initial elbow injury.

CONCLUSIONS

Pitchers who sustained an initial lower extremity or trunk injury demonstrated an increased subsequent arm injury hazard compared with pitchers who did not. Pitchers who sustained an initial shoulder injury demonstrated a greater hazard of sustaining a subsequent arm injury compared with pitchers who sustained an initial elbow injury. However, this secondary analysis should be interpreted with caution. Clinicians should monitor risk with workload accumulation, which may be related to pitching compensatory strategies in a fatigued state. Pitchers who sustain a shoulder injury should be evaluated and perform both shoulder and elbow rehabilitation strategies before return to sport.

Risk factors and prevention strategies for shoulder injuries in overhead sports: an updated systematic review

PURPOSE

The aim of this systematic review was to update the knowledge on risk factors and prevention strategies for shoulder injuries in overhead sports with special emphasis on methodological quality.

METHODS

All methodological procedures were performed in line with a previous systematic review by Asker et al. (2018). The literature search was conducted in the PubMed, Google Scholar, Cochrane, and SPORT-Discuss databases. Due to the risk of bias assessment, only studies with at least an acceptable methodological quality were included. A best-evidence synthesis was performed to clarify the evidence and direction of the risk factors and prevention strategies.

RESULTS

A total of nine studies were included in the data extraction process. One study had a high and eight studies had an acceptable methodological quality. Seven cohort studies investigated risk factors and two randomised controlled trails evaluated prevention strategies. Moderate evidence was found for two non-modifiable (playing position, gender) and three modifiable factors (shoulder rotational strength, scapular dyskinesia, shoulder prevention programme) that were associated with the shoulder injury risk. All further risk factors had moderate and no association with risk (shoulder rotational ROM, joint position sense) or limited (history of shoulder/elbow pain, age, training experience, training volume, school grade, playing level), and conflicting evidence (setting).

CONCLUSIONS

There is moderate evidence for two non-modifiable (playing position, gender) and three modifiable factors (shoulder rotational strength, scapular dyskinesia, shoulder prevention programme) being associated with the shoulder injury risk in overhead sports.

Is early trunk rotation really hazardous for shoulder biomechanics in baseball throwing?

BACKGROUND AND HYPOTHESIS

Early trunk rotation (ETR), which is a unique kinematics of the trunk that occurs during baseball throwing, is thought to be related to shoulder injuries. Pelvic rotation is a confounder when studying the effects of trunk rotation on shoulder biomechanics. The purpose of this study was to understand the "pure" effects of trunk rotation on shoulder biomechanics, with pelvic rotation under control. Our hypotheses were as follows: (1) throwers with ETR have a different shoulder kinematics pattern compared with throwers without ETR; (2) throwers with ETR have a lower ball speed performance than do throwers without ETR; and (3) throwers with ETR have a greater value of shoulder forces and moments, which may increase risks of shoulder injury, than do throwers without ETR.

METHODS

Fifty-seven elite throwers were enrolled and divided into 2 groups (non-ETR and ETR) using an outdoor motion analysis. Several kinematics and kinetics parameters of the shoulder were analyzed and compared between the 2 groups.

RESULTS

Ball velocity was faster in the non-ETR group (127 km/h) compared with the ETR group (120 km/h). The shoulders of throwers in the ETR group showed pathokinematics of "horizontal adduction lag" and "dropped elbow." The increases in maximal posterior force, inferior force, horizontal abduction moment, and vertical adduction moment were 9.2%, 13.6%, 21.3%, and 24.3%, respectively, in the shoulders of throwers in the ETR group. These results indicate that ETR may be hazardous for the throwing shoulder. With lower ball velocity and higher shoulder joint loading, ETR is not a proper pitching pattern for kinetic energy transfer.

CONCLUSION

Improper pitching mechanics among baseball throwers, such as ETR, may result in higher shoulder joint loading and increased risk of shoulder injuries. When treating throwers with shoulder injuries, it is important not only to address shoulder anatomy and pathology but also to understand the possible pathomechanics and pathogenesis of the shoulder caused by ETR. Furthermore, special training programs focusing on trunk flexibility and core muscle strengthening should be implemented to prevent ETR and decrease the risk of shoulder injuries. Motion analysis is useful for the screening and early detection of improper pitching mechanics in throwers.

Return to play following nonsurgical management of superior labrum anterior-posterior tears: a systematic review

BACKGROUND

Superior labrum anterior-posterior (SLAP) tears are common shoulder injuries, especially in overhead athletes. Often, initial management of these injuries is nonsurgical with focused rehabilitation. The purpose of this review was to evaluate the outcomes of nonsurgical management of SLAP tears in athletes.

METHODS

A systematic review was performed for articles published before March 2021 using key search terms pertaining to clinical studies evaluating the nonsurgical treatment of SLAP tears in adult patients published in English-language literature. Abstracts and manuscripts were independently reviewed by 2 co-authors to determine eligibility. Return-to-play rate and return-to-prior-athletic-performance rate were determined by combining results across studies.

RESULTS

Five articles met the inclusion criteria. There were 244 total athletes (162 elite or higher-level athletes). The mean ages ranged from 20.3 to 38.0 years. Type II SLAP tears were most common; baseball, softball, and weightlifting were the most common sports involved. The return-to-play rate was 53.7% in all athletes and 52.5% in elite or higher-level athletes. In athletes who were able to complete their nonoperative rehabilitation program, the return-to-play rate was 78% in all athletes and 76.6% in elite or higher-level athletes. The overall rate of return to prior performance was 42.6%, which increased to 72% for those athletes who were able to complete their rehabilitation. Patients who discontinued the rehabilitation protocol in favor of surgery had an average of 8 physical therapy sessions compared with 20 sessions for patients with successful nonoperative treatment. The timing of return to play was generally less than 6 months in studies that reported it. Patient-reported outcomes, including the American Shoulder and Elbow Surgeons score and visual analog scale, all improved significantly after nonsurgical treatment. Factors associated with failure of nonsurgical management included older age, participation in overhead sports (especially baseball pitchers), traumatic injury, positive compression rotation test, concomitant rotator cuff injury, longer baseball career, longer symptomatic period, and the presence of a Bennett spur.

CONCLUSIONS

Overall, nonoperative treatment of SLAP tears in athletes can be successful, especially in the subset of patients who are able to complete their rehabilitation program before attempting a return to play. Although nonoperative treatment should be considered the first line of treatment for most SLAP tears, there are some factors that may be associated with failure of conservative treatment; therefore, further high level, prospective studies would be beneficial to identify those athletes most likely to respond favorably to nonoperative treatment.

SLAP Repair Versus Subpectoral Biceps Tenodesis for Isolated SLAP Type 2 Lesions in Overhead Athletes Younger Than 35 Years: Comparison of Minimum 2-Year Outcomes

Background:

It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis.

Purpose:

To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported.

Results:

Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; P = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; P = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery.

Conclusion:

Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis.

Disabled Throwing Shoulder: 2021 Update: Part 2-Pathomechanics and Treatment

The purpose of this paper is to provide updated information for sports healthcare specialists regarding the disabled throwing shoulder (DTS). A panel of experts, recognized for their experience and expertise in this field, was assembled to address and provide updated information on several topics that have been identified as key areas in creating the DTS spectrum. Each panel member submitted a concise presentation on one of the topics within these areas, each of which were then edited and sent back to the group for their comments and consensus agreement in each area. Part two presents the following consensus conclusions and summary findings regarding pathomechanics and treatment, including (1) internal impingement results from a combination of scapular protraction and humeral head translation; (2) the clinically significant labral injury that represents pathoanatomy can occur at any position around the glenoid, with posterior injuries most common; (3) meticulous history and physical examination, with a thorough kinetic chain assessment, is necessary to comprehensively identify all the factors in the DTS and clinically significant labral injury; (4) surgical treatment should be carefully performed, with specific indications and techniques incorporating low profile implants posterior to the biceps that avoid capsular constraint; (5) rehabilitation should correct all kinetic chain deficits while also developing high-functioning, throwing-specific motor patterns and proper distribution of loads and forces across all joints during throwing; and (6) injury risk modification must focus on individualized athlete workload to avoid overuse. LEVEL OF EVIDENCE: V, expert opinion.

Thoracic Outlet Syndrome in Major League Baseball Pitchers: Return to Sport and Performance Metrics After Rib Resection

Background:

Thoracic outlet syndrome (TOS) is a rare injury that affects Major League Baseball (MLB) pitchers and is often corrected with surgical resection of the first rib. There are limited return-to-play (RTP) data for this surgery in MLB pitchers.

Hypothesis:

It was hypothesized that MLB pitchers who undergo first rib resection for TOS will show (1) a high rate of RTP, (2) no difference in postoperative career length compared with controls, (3) no difference in pre- and postoperative performance, and (4) no difference in postoperative performance compared with controls.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective cohort study evaluated MLB pitchers with neurogenic or vascular TOS who underwent rib resection surgery between January 1, 2001, and December 31, 2019. Players were identified through public injury reports from press releases, the MLB website, MLB team injury reports, and blogs. A demographics- and performance-matched control group was generated for comparison. Each player in the control group was given an index year that corresponded to the surgery year of the case group. Performance data included innings pitched (IP), games played (GP), earned run average (ERA), complete GP, shutouts, saves, hits, runs, home runs (HR), walks, strikeouts (K), walks plus hits per IP (WHIP), and earned runs (ER).

Results:

We identified 26 MLB pitchers who underwent rib resection for neurogenic or vascular TOS; 21 players (81%) had a successful RTP. Pitchers were 30 ± 3.6 years old at the time of surgery and had played 6.2 ± 3.5 seasons before undergoing surgery. Average postoperative career length was 3.1 ± 2.0 seasons, with an average time from surgery to RTP being 10 ± 4.7 months. Pitchers who RTP showed no significant differences in performance metrics compared with controls. Players pitch 0.94 (P < .05) more IP/GP in the season directly following RTP compared with the season before surgical intervention.

Conclusion:

MLB pitchers undergoing rib resection for TOS demonstrated (1) high RTP rates following rib resection, (2) no difference in postoperative career length compared with controls, (3) improvement in postoperative performance, and (4) no difference in postoperative performance compared with controls.

Performance Metrics and Economics of SLAP Repairs in Major League Baseball Pitchers

Background

Superior labrum anterior-posterior tears (SLAP) can be a career-altering injury for Major League Baseball (MLB) pitchers. Surgery and postoperative rehabilitation keep pitchers on the injured list (IL) for extended time, which results in a significant cost to a team. To date, no analyses have focused on the financial cost of SLAP repairs in MLB pitchers.

Methods

A retrospective review of MLB pitchers with SLAP repair from 2004 to 2019 was conducted utilizing IL and financial contract data from the MLB website. Cost of injury was calculated from salary of the player. Performance metrics including earned run average, walks + hits per innings pitched, and innings pitched (IP) were averaged for one and all seasons played before and after injury. Return to play and return to prior performance rates were calculated and reported.

Results

Of the 55 players identified, 22 players (40%) returned to play and 18 of these 22 players (82%) returned to prior performance. Annual cost increased over the study period (R² = 0.288) averaging $3.5 million, and a stable average of 172 days was spent on the IL (R² = 0.001). Performance was negligible except IP (106.95 vs. 50.85; P < .01) for 1 season before and after injury. For all seasons, earned run average and walks + hits per innings pitched significantly increased (4.13 vs. 5.19; P = .030, and 1.36 vs. 1.53; P = .033, respectively), while IP downtrended without significance (P = .058).

Conclusion

SLAP repairs in MLB pitchers have significant financial impact and time spent on the IL, which surprisingly has not changed over time. It is encouraging to know return-to-play pitchers return without profound decline in performance level following SLAP repair.

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.

The Thrower's Shoulder

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The thrower's shoulder has been a subject of great interest for many decades. Different theories have been proposed to clarify the pathophysiology, clinical presentation, and treatment options for this condition. In this review article, we summarize the relevant anatomy and pathophysiology and how these translate into signs, symptoms, and imaging findings. Also, a historical review of the treatment methodologies in the setting of an evolving concept is presented.

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The initial event in the cascade is thickening and contracture of the posteroinferior capsule resulting from repetitive tensile forces during the deceleration phase of throwing. This is known as "the essential lesion" and is clinically perceived as glenohumeral internal rotation deficit (GIRD), and a Bennett lesion may be found on radiographs.

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Change in the glenohumeral contact point leads to a series of adaptations that are beneficial for the mechanics of throwing, specifically in achieving the so-called "slot," which will maximize throwing performance.

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The complexity of the throwing shoulder is the result of an interplay of the different elements described in the cascade, as well as other factors such as pectoralis minor tightness and scapular dyskinesis. However, it is still unclear which event is the tipping point that breaks the balance between these adaptations and triggers the shift from an asymptomatic shoulder to a painful disabled joint that can jeopardize the career of a throwing athlete. Consequences are rotator cuff impingement and tear, labral injury, and scapular dyskinesis, which are seen both clinically and radiographically.

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A thorough understanding of the pathologic cascade is paramount for professionals who care for throwing athletes. The successful treatment of this condition depends on correct identification of the point in the cascade that is disturbed. The typical injuries described in the throwing shoulder rarely occur in isolation; thus, an overlap of symptoms and clinical findings is common.

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The rationale for treatment is based on the pathophysiologic biomechanics and should involve stretching, scapular stabilization, and core and lower-body strengthening, as well as correction of throwing mechanics, integrating the entire kinetic chain. When nonoperative treatment is unsuccessful, surgical options should be tailored for the specific changes within the pathologic cascade that are causing a dysfunctional throwing shoulder.

Management of proximal biceps tendon pathology

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

Anterior Shoulder Instability in Throwers and Overhead Athletes: Long-term Outcomes in a Geographic Cohort

BACKGROUND

Athletes of all sports often have shoulder instability, most commonly as anterior shoulder instability (ASI). For overhead athletes (OHAs) and those participating in throwing sports, clinical and surgical decision making can be difficult owing to a lack of long-term outcome studies in this population of athletes.

PURPOSE/HYPOTHESIS

To report presentation characteristics, pathology, treatment strategies, and outcomes of ASI in OHAs and throwers in a geographic cohort. We hypothesized that OHAs and throwers would have similar presenting characteristics, management strategies, and clinical outcomes but lower rates of return to play (RTP) when compared with non-OHAs (NOHAs) and nonthrowers, respectively.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

An established geographic medical record system was used to identify OHAs diagnosed with ASI in the dominant shoulder. An overall 57 OHAs with ASI were matched 1:2 with 114 NOHAs with ASI. Of the OHAs, 40 were throwers. Sports considered overhead were volleyball, swimming, racquet sports, baseball, and softball, while baseball and softball composed the thrower subgroup. Records were reviewed for patient characteristics, type of sport, imaging findings, treatment strategies, and surgical details. Patients were contacted to collect Western Ontario Shoulder Instability index (WOSI) scores and RTP data. Statistical analysis compared throwers with nonthrowers and OHAs with NOHAs.

RESULTS

Four patients, 3 NOHAs and 1 thrower, were lost to follow-up at 6 months. Clinical follow-up for the remaining 167 patients (98%) was 11.9 ± 7.2 years (mean ± SD). Of the 171 patients included, an overall 41 (36%) NOHAs, 29 (51%) OHAs, and 22 (55%) throwers were able to be contacted for WOSI scores and RTP data. OHAs were more likely to initially present with subluxations (56%; P = .030). NOHAs were more likely to have dislocations (80%; P = .018). The number of instability events at presentation was similar. OHAs were more likely to undergo initial operative management. Differences in rates of recurrent instability were not significant after initial nonoperative management (NOHAs, 37.1% vs OHAs, 28.6% [P = .331] and throwers, 21.2% [P = .094]) and surgery (NOHAs, 20.5% vs OHAs, 13.0% [P = .516] and throwers, 9.1% [P = .662]). Rates of revision surgery were similar (NOHAs, 18.0% vs OHAs, 8.7% [P = .464] and throwers, 18.2% [P > .999]). RTP rates were 80.5% in NOHAs, as compared with 71.4% in OHAs (P = .381) and 63.6% in throwers (P = .143). Median WOSI scores were 40 for NOHAs, as compared with 28 in OHAs (P = .425) and 28 in throwers (P = .615).

CONCLUSION

In a 1:2 matched comparison of general population athletes, throwers and OHAs were more likely to have more subtle instability, as evidenced by higher rates of subluxations rather than frank dislocations, when compared with NOHAs. Despite differences in presentation and the unique sport demands of OHAs, rates of recurrent instability and revision surgery were similar across groups. Similar outcomes in terms of RTP, level of RTP, and WOSI scores were achieved for OHAs and NOHAs, but these results must be interpreted with caution given the limited sample size.

Management of common upper extremity injuries in throwing athletes: a critical review of current outcomes

Given the rising incidence and prevalence of shoulder injuries in throwing athletes, this review aims to evaluate management options and outcomes of common shoulder injuries in overhead throwers. Laxity of the glenohumeral joint is often adaptive for overhead athletes to achieve the velocity necessary to compete in the professional ranks. Surgical repair of the stabilizers of the humeral head-specifically the labrum and rotator cuff-often causes inflammation, scarring, and overtensioning of the glenohumeral joint which lead to poor postoperative performance. Thus, nonsurgical management should be exhausted in this population before considering surgical intervention.

Imaging of Patients Suspected of SLAP Tear: A Cost-Effectiveness Study

Background: Superior labral anterior-to-posterior (SLAP) tears are a common shoulder pathology. While MRI is the imaging gold standard for diagnosis of this pathology, the cost-effectiveness of the common MRI strategies is unclear. Objective: The primary objective of our study was to determine the cost-effectiveness of the common MRI-based strategies used for the diagnosis of SLAP tears. Methods: We created decision analytic models from the U.S. health care system perspective over a two-year time horizon for a hypothetical patient population of 25-year-olds with a previous diagnosis of SLAP tear. We used the decision models to compare the differences in incremental cost-effectiveness of the common MRI strategies and resulting treatment applied for this patient type, which included combinations of 1.5T and 3T imaging and unenhanced MRI and MR arthrogram protocols. Input data on cost, probability, and utility estimates were obtained through a comprehensive literature search. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2017 U.S. dollars. Results: When all imaging strategies were considered, the unenhanced 3T MRI based imaging strategy was the preferred and dominant option over 3T MR arthrography (MRA) and 1.5T imaging (MRI/MRA). When the model was run without 3T imaging as an option, 1.5T MRA was the favored option. Probabilistic sensitivity analyses confirmed the same preferred imaging strategy results. Conclusion: An unenhanced 3T MRI based strategy is the most cost-effective imaging option for patients with suspected SLAP tear. When 3T imaging is not available, 1.5T MRA is more cost-effective than 1.5T imaging. The main driver of these results is the fact that 3T MRI and 1.5T MRA are the most specific tests in these respective scenarios which results in fewer false positives and prevents unnecessary surgeries leading to decreased costs. Clinical Impact: Our cost-effectiveness model findings complement prior diagnostic accuracy work, helping produce a more comprehensive approach to define imaging utility for the SLAP patient population for radiologists, clinicians, and patients who have access to various types of MRI options.

Repair versus biceps tenodesis for the slap tears: A systematic review

PURPOSE

The ideal treatment algorithm is still controversial for Superior Labral Anterior-Posterior (SLAP) tears. In this systematic review, we aimed to clarify and ascertain which treatment modality is effective and more usable in which conditions.

METHODS

In this systematic review, we used the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines established for systematic reviews and meta-analysis. "SLAP or Superior Labral Anterior-Posterior" and "biceps tenodesis" search terms were used in The Cochrane Library database and Pubmed from their inception to the 30th of September 2020. A total of 2326 titles were screened and 2069 articles were removed because of their ineligibility. Full texts of 14 studies were screened and finally, six were suitable for the present systematic review. Demographic details and study characteristics, patient satisfaction, functional outcomes, return to preinjury sports level, reoperation, stiffness, sling time and rehabilitation protocols were reviewed and compared between SLAP repair and biceps tenodesis groups.

RESULTS

A total of 2326 titles were screened and six studies were detected eligible. Results of 287 patients (SLAP repair: 160, Biceps Tenodesis: 127) were reviewed in included six studies. Biceps tenodesis was showed as more satisfied technique in four of the studies but the statistical comparing results of two groups were not significantly different in each study. Different functional scoring systems used in the studies were not statistically significantly different between the groups. The percentage of return to sport and preinjury level is higher in biceps tenodesis in the five studies. The total reoperation rate for SLAP repair was 19/160 (12%) and biceps tenodesis was 7/127 (6%).

CONCLUSION

The biceps tenodesis has a higher return to preinjury sports level, higher patient satisfaction and lower reoperation rates but functional scores are similar between SLAP repair groups in patients with SLAP tear.

The Relationship between Kinesiophobia and Return to Sport after Shoulder Surgery for Recurrent Anterior Instability

Purpose  To evaluate the relationship between kinesiophobia and patient's return to sport after shoulder stabilization surgery. The hypothesis was that kinesiophobia represents an independent factor correlated to the difference between preinjury and postoperative level of sport.

Methods  This study retrospectively evaluated 66 patients (mean age: 35.5, standard deviation [SD] = 9.9 years) and at a mean follow-up of 61.1 (SD = 37.5) months after arthroscopic Bankart's repair or open Bristow–Latarjet procedure. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK); return to the preinjury sport was assessed by the difference between baseline and postoperative degree of shoulder involvement in sport (D-DOSIS) scale. The Western Ontario Shoulder Instability index (WOSI) was used to evaluate participants' perceptions of shoulder function.

Results  TSK showed correlation with D-DOSIS ( ρ  = 0.505, p <  0.001) and the WOSI score ( ρ  = 0.589, p  < 0.001). There was significant difference in TSK and WOSI scores between participants who had and had not returned to their previous level of sport participation ( p  = 0.006, and 0.0001, respectively).

Conclusion  This study demonstrated that kinesiophobia is correlated to the return to sport after shoulder stabilization surgery.

Level of Evidence  Level IV, retrospective case series.

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.

SLAP tears and return to sport and work: current concepts

Superior labrum, anterior and posterior (SLAP) lesions are common and identified in up to 26% of shoulder arthroscopies, with the greatest risk factor appearing to be overhead sporting activities. Symptomatic patients are treated with physical therapy and activity modification. However, after the failure of non-operative measures or when activity modification is precluded by athletic demands, SLAP tears have been managed with debridement, repair, biceps tenodesis or biceps tenotomy. Recently, there have been noticeable trends in the operative management of SLAP lesions with older patients receiving biceps tenodesis and younger patients undergoing SLAP repair, largely with suture anchors. For overhead athletes, particularly baseball players, SLAP lesions remain a difficult pathology to manage secondary to concomitant pathologies and unpredictable rates of return to play. As a consequence, the most appropriate surgical option in elite throwers is controversial. The objective of this current concepts review is to discuss the anatomy, mechanism of injury, presentation, diagnosis and treatment options of SLAP lesions and to present current literature on outcomes affecting return to sport and work.

Reported Technical Aspects of Type II SLAP Lesion Repairs in Athletes

Purpose

To systematically review the available literature to further describe and report the available data on SLAP repair techniques and the association with outcomes.

Methods

A systematic review of literature was performed on manuscripts describing type II SLAP repairs in athletes. Selection criteria included studies reporting exclusively type II SLAP tears without concomitant pathology, minimum 2-year postoperative follow-up, use of anchor fixation, and return to previous level of play data available. We extracted patient outcome as well as surgical construct details from each article. Average outcomes and return to play rates were calculated and substratified further by athlete type. Return to play rates were compared by repair constructs with the Student t test.

Results

Initial search resulted in 107 articles. After exclusion criteria were applied, 17 articles were included in the final analysis. Overall, 84% of patients had good-to-excellent results. Of all athletes, 66% returned to previous level of play. There was significant variation in reported technique in terms of anchor number, location, material, suture type, and knotless versus knotted constructs. No significant difference was reported in outcomes in comparison of suture type (P-value .96) or knotted versus knotless constructs (P-value .91). Given the significant variability in reporting, no statistical analysis was felt able to be performed on anchor location and number.

Conclusions

Repair of type II SLAP tears in athletes is a difficult problem to treat with overall low return to play despite a high rate of “good” outcomes when assessed by outcome measures. Significant variability exists in surgical technique, as well as reporting of surgical technique, potentially limiting the ability to define the best or most effective technique for SLAP repair.

Level of Evidence

IV, systematic review of level III and level IV studies.

Biceps Tenodesis for Superior Labrum Anterior-Posterior Tear in the Overhead Athlete: A Systematic Review

BACKGROUND

Superior labrum anterior-posterior (SLAP) lesion is a common shoulder injury, particularly in overhead athletes. While surgical management has traditionally consisted of SLAP repair, high rates of revision and complications have led to alternative techniques, such as biceps tenodesis (BT). While BT is commonly reserved for older nonoverhead athletes, indications for its use have expanded in recent years.

PURPOSE

To determine functional outcomes and return-to-sport rates among overhead athletes after BT for SLAP tear.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was performed for any articles published before July 2019. The search phrase "labral tear" was used to capture maximum results, followed by keyword inclusion of "SLAP tear" and "biceps tenodesis." Inclusion criteria included outcome studies of BT for isolated SLAP tear in athletes participating in any overhead sports, not limited to throwing alone. Abstracts and manuscripts were independently reviewed to determine eligibility. When clearly delineated, outcome variables from multiple studies were combined.

RESULTS

After full review, 8 articles met inclusion criteria (99 athletes; mean age, 19.8-47 years), with baseball and softball players the most common among them (n = 62). Type II SLAP tear was the most common diagnosis, and 0% to 44% of athletes had a failed previous SLAP repair before undergoing BT. Only 1 study included patients with concomitant rotator cuff repair. Open subpectoral BT was most commonly used, and complication rates ranged from 0% to 14%, with wound erythema, traumatic biceps tendon rupture, brachial plexus neurapraxia, and adhesive capsulitis being reported. Combined reported postoperative functional scores were as follows: American Shoulder and Elbow Surgeons, 81.7 to 97; 12-Item Short Form Health Survey physical, 50 to 54; visual analog scale for pain, 0.8-1.5; Kerlan Jobe Orthopaedic Clinic, 66 to 79; and satisfaction, 80% to 87%. The overall return-to-sports rate for overhead athletes was 70% (60 of 86). For studies that clearly delineated outcomes based on level of play/athlete, the combined return-to-sports rate was 69% (11 of 16) for recreational overhead athletes, 80% (4 of 5) for competitive/collegiate athletes, and 60% (18 of 30) for professionals.

CONCLUSION

BT in the overhead athlete offers encouraging functional outcomes and return-to-sports rates, particularly in the recreational athlete. It can be successfully performed as an index operation rather than SLAP repair, as well as in a younger patient population. Careful consideration should be given to elite overhead athletes, particularly pitchers, who tend to experience poorer outcomes.

Return to Play After Biceps Tenodesis and Transfer in a Young, Athletic Population

The goal of this study was to investigate the level of play that can be expected in a young, athletic population after biceps tenodesis and transfer. The authors hypothesized that both return to play rates and clinical improvement would be high after biceps tenodesis and transfer among young athletes. They conducted a retrospective review of patients who underwent biceps tenodesis and transfer procedures with a minimum follow-up of 24 months. Eligible patients were contacted for consent and asked to complete a questionnaire on patient-reported, shoulder-specific outcome measure scores, level of postoperative play, and other relevant information. The study included 41 patients with a mean age of 21.3 years. Patients reported a mean Kerlan-Jobe Orthopaedic Clinic (KJOC) score of 71.7, Disabilities of the Arm, Shoulder and Hand (DASH)-Sports score of 21.3, Single Assessment Numeric Evaluation (SANE) score of 79.4, and Numeric Rating Scale (NRS) pain score of 1.8. Scores for all patient-reported outcome measures were statistically better (P<.05) for patients who underwent biceps transfer (n=24) compared with biceps tenodesis (n=17). Of the participants, 26 (63%) played a primary overhead throwing sport. Most of the patients (95%) returned to play, and of those who returned to play, 67% returned to their preoperative level or higher. Although biceps tenodesis and transfer procedures have been designated primarily for older patients with biceps-labral complex injuries, the high return to play rates and outcome scores of patients in this case series show that biceps tenodesis and transfer can provide effective surgical treatment for a younger athletic population with biceps-labral complex injuries. [Orthopedics. 2021;44(1):e13-e18.].

[Injuries of the biceps-labrum complex : Principles, pathologies and treatment concepts]

BACKGROUND

The biceps-labrum complex is prone to acute lesions and degenerative changes due to its anatomical structure and the high load it has to endure. Pathological changes of these structures are common pain generators and can significantly impair shoulder function. Anatomically, the biceps-labrum complex can be divided into three zones: inside, junction and bicipital tunnel.

DIAGNOSTIC PROCEDURE

Despite the focused physical examination and advancements in imaging techniques, the exact localization of pathologies remains challenging. Arthroscopy can be used to accurately diagnose inside and junctional pathologies but extra-articular changes in the region of the bicipital tunnel can only be partially visualized.

TREATMENT

In cases of unsuccessful conservative treatment and correct indications, a high level of patient satisfaction can be surgically achieved. In young patients an anatomical reconstruction of inside lesions or tenodesis of the long head of the biceps tendon is performed; however, even tenotomy is a valuable option and can achieve equally satisfactory results. Unaddressed pathological changes of the bicipital tunnel can lead to persistence of pain. In clinical procedures performing tenodesis, both the different techniques and the implants used have been found to show similar results. This article describes the anatomical principles, pathological changes, the focused clinical instrumental diagnostics and discusses the different treatment philosophies as well as the outcome according to the recent literature.

THE SUCCESS OF RETURN TO SPORT AFTER SUPERIOR LABRUM ANTERIOR TO POSTERIOR (SLAP) TEARS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Reviews on superior labral anterior to posterior (SLAP) injuries have been reported in the literature. However, current reviews have not focused on the success of athletes return to their previous level of sport or athletic performance.

Hypothesis/Purpose

Systematically review return to sport (RTS) and return to sport at previous level (RTSP) proportions after SLAP injury while reporting any additional performance metrics and outcome measures.

Study Design

Systematic Review & Meta-Analysis.

Methods

A computer assisted literature search of MEDLINE, CINAHL, Embase and SportDiscus databases utilizing keywords related to RTS post-surgery for SLAP tear was implemented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized for study methodology. Quality assessment utilized the MINORS scale.

Results

Twenty-two studies (617 athletes) qualified for analysis. Based on limited evidence from level 3b to 4 studies, athletes RTS post intervention for SLAP injury occurred at a rate of 93% (95% CI:87 to 98%) and overall RTSP rate was 72% (95% CI:60 to 83%). The mean time to RTS post intervention was reported in 59% of studies at 6.9 ± 2.9 months. Patient reported outcome measures (PROM's) were reported in 86% of studies. There was limited reporting of performance statistics, rehabilitation guidelines, return to sport criteria, and information regarding SLAP diagnosis in the available studies. None of the included studies reported post-surgical athletic performance or career longevity.

Conclusions

Limited evidence suggests that less than three in four athletes return to their previous level of sport participation after SLAP injury intervention. Treatment success for an athlete with SLAP injury remains relatively unknown as only 59% of included studies clearly delineate RTS from RTSP and neither athletic performance nor career longevity were reported in any included studies. Future studies of higher quality are required for this determination.

Level of Evidence

Level 1a.

Management of Failed SLAP Repair: A Systematic Review

BACKGROUND

Superior labrum anterior to posterior (SLAP) tears are a very common shoulder injury. The success rate of SLAP repair, particularly in the throwing athlete, has been variable in the literature.

QUESTIONS/PURPOSES

The purpose of this systematic review was to evaluate the reported post-operative outcomes of management techniques for failed SLAP repair.

METHODS

The electronic databases MEDLINE, Embase, and PubMed were searched for relevant studies, and pertinent data was abstracted. Only studies reporting outcomes of management techniques for failed SLAP repairs were included.

RESULTS

A total of 10 studies (levels III to IV) evaluating 176 patients were included in this systematic review. Most subjects were male (86.6%), with a mean age at surgery of 36.3 years (range, 17 to 67 years). The most commonly reported reason for failed SLAP repair was persistent post-operative mechanical symptoms after index SLAP repair. Common techniques used in the management of failed SLAP repair include biceps tenodesis and revision SLAP repair. Return to activity was significantly higher after biceps tenodesis than after arthroscopic revision SLAP repair. However, compared to primary SLAP repair, biceps tenodesis demonstrated no statistically significant differences in return to work rates. Complications reported in one case were resolved post-operatively, and there was no reported revision failure or reoperation after revision surgery.

CONCLUSION

The most common reason for failed SLAP repair is persistent post-operative mechanical symptoms. Revision surgery for failed SLAP repair has a high success rate. The rate of return to activity after biceps tenodesis was significantly higher than the rate after revision SLAP repair. Large high-quality randomized trials are required to provide definitive evidence to support the optimal treatment for failed SLAP repair.