Surgeons demystify labral pathology in overhead athletes
Since superior labrum lesions were first described in 1985 and the term “SLAP” lesion was coined in 1990, surgeons began to fixate on that region as a pain generator, especially in the overhead athlete population.
In the wake of the burgeoning interest in superior labrum anterior-posterior (SLAP) lesions and the surrounding region, the SLAP repair emerged as the preeminent surgical treatment. And early on, surgeons were “SLAP-aholics,” according to Anthony A. Romeo, MD, Chief Medical Editor of Healio | Orthopedics Today.
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“Every shoulder that had any change in the labrum, [surgeons] fixed it and said [they] did the best [they] could,” Romeo told Healio | Orthopedics Today. “If the athlete did not get back, that is their fault — not [the surgeon]. The truth is that medical device companies initially developed simple methods to fix the labrum, and the superior labrum was the easiest area to access and treat. The technology drove the decisions, not the understanding of the clinical deficit from the labral changes.”
However, Christopher S. Ahmad, MD, head team physician of the New York Yankees, said the widespread overemphasis on SLAP repair diminished when surgeons learned more about the biomechanics of the throwing athlete’s shoulder.
“The adaptive changes of [an athlete’s] shoulder that allows them to have extreme external rotation and throw with high velocity requires some contact in the back area of the shoulder that we call internal impingement,” Ahmad said. “That repetitive contact results in changes to the superior labrum, particularly posterior to the biceps, and also to the undersurface of the rotator cuff. When we say adaptive, it is beneficial.”
According to Peter N. Chalmers, MD, associate professor in the department of orthopedic surgery at the University of Utah, this realization signaled to the orthopedic community that not every labral injury needed to be repaired.
“In most throwers, we understand the SLAP tear to be an incidental finding to what is really bothering them,” Chalmers said.
Biceps tenodesis
Another key ideological shift occurred in 2009, when Pascal Boileau, MD, and colleagues from France published data that showed biceps tenodesis was an effective alternative to SLAP repair for the treatment of a SLAP lesion in overhead athletes, primarily tennis players, especially those older than 40 years. Boileau and colleagues found pain relief was better and return to sports was more reliable with a biceps tenodesis than surgical fixation of the superior labrum.
“The biceps tenodesis is performed when there is instability of the biceps tendon itself, a condition we call a medial subluxation,” Michael Q. Freehill, MD, orthopedic surgeon at Summit Orthopedics, told Healio | Orthopedics Today. “Oftentimes, that is associated with a concomitant tear of the subscapularis tendon.”
He added, “There could be an injury to the supporting ligaments that we call the pulley, [in which] the biceps is no longer supported and it subluxes out of the groove. Multifocal lesions, including a SLAP tear and tearing of the biceps tendon throughout its course, whether intra-articular or inflamed and damaged as it passes into the groove, are the primary reasons for a biceps tenodesis traditionally in my hands.”
Romeo said the indication for a biceps tenodesis combined with treating a pathologic SLAP lesion is when athletes have SLAP symptoms and pathology in addition to biceps tendon symptoms and pathology.
“That is based on clinical exam and MRI, which should be confirmed intraoperatively. You will see some fraying of the biceps because it has become slightly more unstable,” Romeo said. “When you can objectively define that both areas have pathology, that is probably the ideal situation.”
SLAP failure
Surgeons have also been utilizing SLAP repairs less frequently in large part due to high failure rates, according to John M. Tokish, MD, professor of orthopedics at the Mayo Clinic College of Medicine.
“Sometimes, it is a little bit of a diagnosis of exclusion,” Tokish told Healio | Orthopedics Today. “If the SLAP repair has failed, why has it failed? It could be because you are too tight, so you might be stiff. It could be because you have a prominent anchor or you have a little bit of that cartilage deficit, in which case you may not have motion problems, but you still have pain. You could have a clicking sensation.”
Ahmad added the knots placed in the shoulder for SLAP repair can cause chondral damage. The chondral damage can result in pain in the shoulder of an overhead athlete.
In addition, Chalmers suggested that a SLAP tear in some patients may also signal the beginning of a longer-term degenerative process.
“There is at least one paper to show that there is an association between SLAP tears and the later development of osteoarthritis, and we recently published a paper that supports this,” Chalmers said. “We looked at the influence of the SLAP tear upon the stability of the shoulder and showed that when you have a SLAP tear, it compromises the suction cup function of the labrum. And that loss results in micro instability that the likely consequence of which is abnormal loading of the cartilage and then, in the long run, the development of osteoarthritis.”
Revision
If a SLAP repair fails, it is inadvisable to perform another SLAP repair in the revision setting, according to Romeo.
“There has been no study that has supported revision SLAP repair as the primary goal of revision surgery on superior labral lesions in the last 10 to 15 years,” Romeo said. “In the beginning, that is all we could do. And the argument was maybe the surgery before did not get it quite right. Maybe it did not heal correctly or maybe there is some other way I can make an adjustment. But today, most surgeons would feel if you fail the SLAP lesion, a biceps tenodesis combined with debridement of the labral pathology is a good procedure.”
Freehill said the inability to perform a revision SLAP repair is due to the anatomical realities of the revision setting.
“If you are doing a SLAP repair, particularly in an overhead athlete, you have one good chance to make that surgery yield a positive outcome,” Freehill said. “You have limited real estate available for suture anchor fixation with a recurrent tear. Oftentimes, the tissue that is remaining is not adequate to stabilize that area any further. The methodology is to relieve the tension off the superior labrum. The best way to do that is to tenotomize the biceps and tenodese or transplant it to prevent recurrent symptomatology.”
Return to performance
Another key hurdle for surgeons trying to return overhead athletes to play is the idea of return to performance, which is defined differently than the standard return to play.
“If we do an operation such as a SLAP repair and the MRI scan shows that it is healed, but they still are not able to get back to throwing and they are not able to get back to their prior level of performance, we consider that a failure,” Ahmad told Healio | Orthopedics Today.
Freehill said it is also important to consider durability when assessing an athlete’s return to play.
“We have to be careful in how we define return to play,” Freehill said. “Is it returned to play at the same level? Is it returned to play at MLB level, but they pitch for three games and then they retired because their shoulder just was not the same? The data in MLB used to be if you got back to playing, even if it was an inning, you got back to playing in the major leagues. When we define success and survivorship following these repairs, does it yield a true durable return to play opportunity at a parallel level of preinjury performance?”
Combined procedures
Sometimes there are circumstances when combining SLAP repair with biceps tenodesis may be beneficial for an overhead athlete, according to Ahmad.
“If there is a suggestion of instability, then combining the tenodesis when properly indicated with a SLAP repair using current state of the art techniques can enhance shoulder stability,” Ahmad said. “For me, if there is shoulder instability with anterior or posterior labral tearing extending into the SLAP region, and we can enhance stability by repairing the SLAP, we will do that in combination with the biceps tenodesis. However, for the high-level thrower, such as pitcher, the stabilization must avoid loss of external rotation.”
Tokish said a combined SLAP repair and biceps tenodesis may also be performed in athletes who have a type 4 SLAP tear or bucket handle SLAP tear that “rips up into the biceps.”
“If you have an unstable superior labrum that is combined with biceps pathology, if you just cut the biceps, you have not fixed the superior labor pathology,” Tokish said. “If you just fix the SLAP, you have not addressed that distal pathology in the biceps.”
Future research
To identify the ideal treatment for labral pathologies in overhead athletes, Freehill said research will have to be done differently.
“We have some confounding and conflicting information because we are relying on case series or case reports as opposed to a comparative randomized study looking at a cohort of overhead athletes, each treated with either a SLAP repair or biceps tenodesis,” Freehill said. “That is the only true way we are going to discern whether or not one is much more effective than the other.”
In addition, Tokish said there is still a large blind spot in the literature on the role of the biceps in the throwing shoulder and whether it should be cut or repaired, especially among elite athletes.
“I do not think it matters in the high school athlete or the recreational athlete, but in the elite pitcher, which is what everybody wants to be treated as, is there truly a difference?” Tokish said.
There are also gaps in the literature on how effective it is to use the biceps as a potential augmentation tool in rotator cuff repair, according to Tokish. However, he said as those techniques become more prominent, surgeons may try to save the biceps more often.
“I think we are going to see the pendulum swing toward saving and salvaging the biceps in the gray area when you go in and you do not see obvious pathology,” Tokish said.
According to Romeo, the ability to monitor an overhead athlete’s biceps in motion has proved to be one of the most elusive areas of research, with difficulties in capturing fast movements with videotaping and biomechanical testing. However, he said the technology is getting better.
“You take a 20-camera system and videos and advanced computer analytics, and we are getting closer and closer to getting the right answer,” Romeo said. “You see more researchers doing marker-less video monitoring. So, all of that is going to play a role.”
Steps forward
Although many questions remain, Ahmad said the treatment of labral pathology continues to be a subject of interest.
“I have had the privilege of reviewing some of our baseball winter meetings and what the agenda has been over the span of 30 years because it has been obtained by the Yankees athletic trainer. Internal impingement, the baseball throwing shoulder and SLAP lesions have consistently been on that agenda for updates,” Ahmad said. “That is a testament that it is one of the most evolving areas of medicine. It is in our interest together to stay on top of this problem and keep up to date with what the changes are and how to best manage these patients.”
Tokish said the potential to expand upon the growth of the potential role of the biceps tendon could make wide-ranging impacts in the orthopedic world.
“We have gone from a time where it was save it all the time to then some people have gone to cut it all the time,” Tokish said. “Now we start recognizing the role of the biceps as a potential autograft source that can be used as a graft in lots of areas.”
He added, “I am glad that people are searching for new ways to employ this and new ways to use it because it is hard to beat the tendon quality, and it is free. When we start talking about costs of health care, especially when we get outside the U.S., if you have an option of real tenosites and real possibilities of using this as a tendon graft in the setting of places where cost is a big concern, this gives us a nice natural option.”
- References:
- Andrews JR, et al. Am J Sports Med. 1985;doi:10.1177/036354658501300508.
- Ishikawa H, et al. J Shoulder Elbow Surg. 2023;doi:10.1016/j.jse.2022.12.002.
- Boileau P, et al. Am J Sports Med. 2009;doi:10.1177/0363546508330127.
- Hurley ET, et al. J ISAKOS. 2024;doi:10.1016/j.jisako.2023.09.007.
- Lacheta L, et al. Orthop J Sports Med. 2022;doi:10.1177/23259671221105239.
- Snyder SJ, et al. Arthroscopy. 1990;doi:10.1016/0749-8063(90)90056-j.
- For more information:
- Christopher S. Ahmad, MD, of the New York Yankees, can be reached at csa4@cumc.columbia.edu.
- Peter N. Chalmers, MD, of the University of Utah, can be reached at p.n.chalmers@gmail.com.
- Michael Q. Freehill, MD, of Summit Orthopedics, can be reached at mqfreehill@gmail.com.
- Anthony A. Romeo, MD, of Healio | Orthopedics Today, can be reached at orthopedics@healio.com.
- John M. Tokish, MD, of the Mayo Clinic, can be reached at tokish.john@mayo.edu.
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