1. SLAP Lesions and Internal Impingement Chris Lehman M.D. Gabriel Soto M.D. Stephen Gunther M.D. William Coleman M.D.

2. Special Thanks to Ted Gallardo 1998 San Diego Arthroscopy Symposium

3. Overview Definition Relevant anatomy Classification scheme Clinical presentation Diagnostic imaging Pathophysiology Treatment

4. Definition S.L.A.P. = Superior Labrum Anterior Posterior Varying degrees of fraying and displacement of the shoulder labrum and biceps anchor Differentiated from Bankart lesion by location and biceps involvement Begins posterior to biceps tendon and stops at or above midglenoid notch

5. Anatomic Shoulder Stabilizers Lack of bony constraints to glenohumeral joint make soft tissues crucial to joint stability Both static and dynamic factors play role Static stabilizers include: –Articular congruity –Glenoid labrum –Negative intra-articular pressure –Joint capsule / ligaments

7. Anatomic Shoulder Stabilizers Dynamic forces increase in importance if static structures weaken or fail Dynamic factors include –Rotator cuff –Biceps (long head) –Rhomboids / Trapezius / Levator scapulae / Serratus Anterior –Joint proprioreception Vangsness, Arthroscopy 1995

8. Biceps Labral Complex Limits external rotation of shoulder when abducted and externally rotated Cadaveric studies have demonstrated that isolated superior labral lesions do not increase instability Instability develops when superior labral lesion is combined with destabilized biceps origin Pagnani, JBJS 1995

9. Biceps Labral Complex Study of 105 cadaveric shoulders noted that 50% of biceps origin was on superior glenoid labrum and 50% was on supraglenoid tubercle 4 types of labral origins were described Vangsness, JBJS 1994

10. Glenoid Labrum Composed of fibrocartilaginous tissue distinct from the adjacent hyaline articular cartilage Superior labrum is more meniscal in nature Blood supply is via suprascapular, circumflex scapular and posterior circumflex humeral arteries Vascularity is decreased in ant./antsup./sup. labrum Contains mechanoreceptors and free nerve endings

11. Bankart Lesion Traumatic avulsion of anterior/inferior labrum Cadaver studies have shown that 4 o’clock region is weakest part of labrum

12. Type I SLAP Lesion

13. Type II SLAP Lesion

14. Type II SLAP Lesion Variants Morgan, Arthroscopy 1998

15. Type III SLAP Lesion

16. Type IV SLAP Lesion

17. SLAP Lesions Superior Labrum Anterior to Posterior Tear I.Labral Fraying (21%) II.Labral Avulsion (55%) III.Bucket Handle Tear (9%) I.Bucket Handle Tear into Biceps Tendon (10%) Snyder, JSES 1995

18. “Complex” SLAP Lesions V. Type II + Bankart VI. Type II + Unstable radial or flap tears VII.Type II + Extension into MGHL Maffet, AJSM 1995

19. Normal Variants Sublabral foramen – Detachment of the anteriorsuperior labrum from the glenoid margin

20. Normal Variants Buford Complex – Absence of the anteriorsuperior labrum in association with a thick MGHL (1.5%)

21. Mechanism By History Fall on outstretched arm/ direct blow (31%) Lifting heavy object (16%-22%) Associated w/ overhead sports (12%-25%) Insidious onset (3%-14%) Snyder, JSES 1995 Handelberg, Arthroscopy1998

22. Symptoms Pain especially with overhead activities Mechanical symptoms of catching, locking, popping or grinding Pain when lying on shoulder, decreased shoulder ROM or upper extremity weakness Complaints not well correlated with pathology

23. Physical Exam Bicipital groove tenderness – Versus opposite side Speed’s test – Bicipital pain with resisted forward elevation and supination Obrien’s sign – Bicipital pain with resisted ER when arm is Adducted, IR and flexed 90

24. Physical Exam Jobe’s Relocation test – Apprehension relieved by posterior force on humeral head Compression-Rotation test – Grinding humeral head into glenoid at 90 abduction / flexion

25. Diagnostic Imaging Plain films usually normal CT Arthrography MRI 41-98% sens / 85-90% specific MR Arthrography 89% sens / 91% specific Bencardino, Radiology 2000

26. Normal Variations

27. MR Arthrography Type I SLAP

28. MR Arthrography Type II SLAP

29. MR Arthrography Type III SLAP

31. MR Arthrography Type IV SLAP

32. Specific MR Signs of SLAP Lesions Posterior high signal intensity (48% sens / 94% spec) Tuite, Radiology 2000

33. Specific MR Signs of SLAP Lesions Laterally curved area of high signal (65% sens / 84% spec) Tuite, Radiology 2000

34. Specific MR Signs of SLAP Lesions Two high signal lines (Double oreo sign) (17% sens / 94% spec) Tuite, Radiology 2000

35. Associated Injuries RTC Tear 40% of all SLAP lesions Assoc. labral pathology 22% ant. Labral tear Anterior glenohumeral instability, Drive –thru sign seen w/ lesions which resolves w/ repair Morgan Posterior humeral chondral injury and Hill-sachs lesions

36. Associated Injuries Cont. Acromial-clavicular joint arthritis Paralabral ganglion cysts Similar mechanism to meniscal cyst Often w/ impingement on suprascapular nerve, branch to infraspinatus May require open decompression of nerve/cyst Documented to resolve w/ arthroscopic Rx Chochole, Arthroscopy 1997

38. Mechanisms of Injury Impaction Eccentric load on biceps tendon Instability Peel-back mechanism

39. Impaction Mechanism Fall or direct blow to shoulder Impaction of humeral head onto superior labrum, trapping and tearing labrum against underlying glenoid Most common for non- competitive athletes Snyder, JSES 1995 Handelberg, Arthroscopy1998

40. Traction Mechanism Pain w/ lifting heavy object Eccentric load on biceps leading to traction failure Acute and Chronic modes Chronic mechanism may occur during deceleration phase of throwing in overhead sports Andrews, Am J Sports Med 1985

42. Subluxation Mechanism Role of subluxation: Slap lesions often assoc. w/ DRIVE THRU sign Biceps restraint to external rotation and anterior translation in ABD/ ER position Inferior gleno-humeral ligament strain increased 102- 120% with creation of SLAP lesion Rodosky, Am J Sports Med 1994

43. Subluxation Mechanism Role of subluxation: Biceps load to failure tested on 16 cadaver shoulders With stable joint 2/8 occurred at labrum With inferior subluxation 7/8 occurred at labrum Bey, JSES 1998

45. Peel-back Mechanism Produces posterior slap lesion Assoc w/ posterior dominant biceps insertion into labrum Occurs in extremes of ABD/ER in late cocking phase of throwing Burkhart, Arthroscopy 1998

46. Peel-back Mechanism Cont.: Generates torsional force to post/sup labrum causing it to rotate medially over the corner of the glenoid Treatment implications: need secure surgical fixation which prevents roll back; and limiting ER for 3 weeks post opBurkhart, Arthroscopy 1998

49. Treatment Conservative Surgical Arthroscopic Open

50. Treatment Conservative: Activity modification Rotator cuff strengthening Throwing technique improvement Frequently fails with true SLAP lesion

51. Treatment Arthroscopy: Gold standard for Dx Evaluate and treat other pathology

52. Treatment Type I Debridement Results: not well documented 27 patients w/ variety of SLAP lesions treated w/ debridement alone: 78% excellent pain relief @1yr 63% @ 2 years only 45% able to return to pre-injury performance level @ 2 years Bigliani, Am J Sports Med 1993

53. Treatment Type II Repair Methods: Full arthroscopic evaluation, treatment of assoc. conditions, Secure fixation of labrum back to glenoid rim Fixation options: staple, suture anchor, bioabsorbable screw/tack

55. Treatment Type II Outcomes Snyder, J Shoulder & Elbow 1995 3/5 healed w/ debridement alone, 2 w/ extension into biceps anchor 6/7 healed w/ fixation, 1 w/ foramen at biceps insertion, + pain

56. Treatment Type II Outcomes Yoneda, JBJS 1991 10 type II lesions Rx’ed w/ nonabsorbable staples 80% Good & excellent- min. f/u 24 mos 4 fully healed, 6 superficial heal w/ good stability Savoie, Am J Sports Med 1993 15 type II lesions Rx’ed w/ transosseous sutures post-op all w/ good and excellent Rowe shoulder scores, all 6 throwing athletes returned w/o dec. velocity

57. Treatment Type II Outcomes Resch, J Shoulder & Elbow 1993 Stabilized 14/18 type II, titanium screws + absorbable tacks 6-30 mos f/u, removed screws at 3-5 months 8 full recovery, 4 improved w/ 2/4 partially returned to sports, 2 with no improvement Only 1/4 w/o fixation showed improvement

58. Treatment Type III Debridement of bucket portion Consider repair if possible Improvement in appearance of labrum in 3/3 type III Rx’ed w/ debridement alone at repeat examination

60. Treatment Type IV Debridement of bucket portion with stabilization of biceps anchor Variable results w/ overall good improvement in pain

61. Surgical Technique Goal of fixation: Stable repair of labrum to rim of glenoid Restore Glenohumeral stability by restoring continuity of circumferential labrum

62. Surgical Technique Multiple fixation methods: Staple fixation- frequent need for hwr removal Transosseous sutures (Savoie/Caspari) Suture Anchors (absorbable) Absorbable Tacks

66. Internal Impingement First described by Walch in 1992 Definition: Symptomatic contact b/w the undersurface of the supraspinatus tendon and the posterior glenoid rim. Occurs in 90 deg Abd & maximally ER arm, particularly w/ late cocking of throwing motion

67. Internal Impingement Clinical presentation is in competitive overhead athletes; Baseball, tennis, water polo most common Also in occupations w/ arm in similar positions reported in fork lift operators C/o posterior shoulder pain, worse w/ AB/ER

68. Internal Impingement PE often similar to subacromial impingement and SLAP lesion Differentiated best by Jobe relocation testing- where pt’s pain rather than apprehension relieved w/ post. pressure on humeral head w/ arm in ABER

73. Internal Impingement Paley, F. Jobe, Arthroscopy 2000 41 professional baseball players w/ shoulder pain Failed 3 mos of PT, NSAIDS Arthroscopy 26% w/ + Neer & Hawkins impingement signs 62% w/ + relocation test and subtle GH instability

74. Internal Impingement Paley, F. Jobe, Arthroscopy 2000 Arthroscopic findings: 100% contact of cuff and post. labrum/glenoid 93% undersurface RTC fraying 88% labral fraying w/ Ant fraying in 36% 17% w/ osteochondral injury 10% incidence of both bankart and slap lesions

75. Internal Impingement 10 Asymptomatic college baseball players Compared HX, PE and MRI findings in throwing (T) and nonthrowing (NT) shoulders RTC / posterior glenoid contact 10/10 T, 10/10 NT RTC abnormalities 4/10 T, 0/10 NT SLAP lesions 3/10 T, 0/10 NT Halbrecht, Arthroscopy 1999

76. Internal Impingement Conclusion: all Pts had RTC/glenoid contact on MRI in ABER, associated pathology seen only in throwing shoulder. No correlation b/w laxity on PE w/ MRI evidence of internal impingement. Halbrecht, Arthroscopy 1999

77. Internal Impingement Treatment: Activity modification Rotator cuff strengthening Throwing technique improvement RTC debridement w/ labral stabilization

78. SLAP SUMMARY Rare cause of operative shoulder pain (6%) Frequently associated w/ other lesions Result from a variety of mechanisms Are difficult to confirm on PE Respond favorably to proper surgical intervention

79. INTERNAL IMPINGEMENT SUMMARY Very rare cause of shoulder pain in the general population Seen almost exclusively in overhead athletes Result from a repetitive impaction of undersurface in ABER position Difficult to, but must be, differentiated from subacromial impingement May be associated w/ other lesions

80. THANK YOU