Dr. Brian Badman

Dr. Badman is a Hoosier native, born and bred in Fighting Irish country of South Bend. He attended Indiana University for both undergraduate and medical education. As an undergraduate, he was inducted into the Phi Beta Kappa Honor Society and graduated Summa Cum Laude, and, during medical school he was invited into the prestigious Alpha Omega Alpha honor society. Dr. Badman completed his orthopedic residency training at the University of Florida-Gainesville in 2005 and finished a shoulder and elbow fellowship at the Florida Orthopedic Institute in Tampa in 2006. His fellowship was performed with one of the busiest recons... Read Full Biography

Figure 1

Figure 1 SLAP Tear Classification

Figure 2

Figure 2 SLAP Tear Classification

Figure 3

Figure 3 MRI of SLAP Tear Coronal Imaging

Figure 4

Figure 4 Anthroscopic View of SLAP Tear

SLAP Tears and Bicep Pathology

What is it?

SLAP stands for "Superior Labral Anterior-Posterior" and essentially describes a disruption of the anchor attachment of the bicep tendon where it inserts on the top of the glenoid or socket. This complex was initially described by James Andrews and then later classified into tear patterns by Dr. Stephen Snyder (Figure 1).

As the bicep tendon enters the shoulder joint it blends with the bumper of tissue that helps stabilize the shoulder called the "labrum". This rim of tissue is a fibrocartilagenous structure that goes all the way around the socket (glenoid) but is more defined at the front and top of the glenoid. Referencing a clock, the bicep insertion is fairly broad and is located at the top of the glenoid between roughly the 11 o'clock and 1 o'clock positions (Figure 2). Thru the course of trauma (fall on an outstretched hand or a forceful downward pull on the arm), repetitive overhand activities (throwing athletes, weightlifters), or simply normal age and work-related wear and tear (patients older than 40 years), the insertion can become unstable creating positional type pain. This can often times be reproduced with a throwing motion or any position of the shoulder resulting in compression of the ball against the unstable tissue (arm against ear with direct compression of shoulder).

Symptoms:

Pain is the most frequent presenting complaint of a SLAP tear. The pain can often mimic other common shoulder disorders and frequently is positional, deep in nature, and may be localized to the anterior, superior, or posterior aspect of the shoulder and occasionally even the bicep groove. Patients occasionally may appreciate a popping sensation with overhead positions. Throwing athletes will often describe a loss in velocity with altered mechanics and description of a "dead arm" sensation.

Diagnosis:

The diagnosis of a SLAP tear is often a clinical one based on history, physical examination, and provocative testing. While many physical examination tests have been described, none of them are individually reliable and the diagnosis is often made based on the combination of multiple exam tests. The extent of tearing may be further evaluated with MRI arthrography which remains the most reliable imaging modality for identification of labral pathology. This essentially involves the injection of contrast dye into the shoulder joint prior to the MRI to allow for better visualization of any potential labral or SLAP tears (Figure 3). Arthroscopy remains the gold standard for definitive diagnosis (Figure 4).

Treatment:

Treatment is often based on the duration and severity of symptoms. Unfortunately, once the tissue tears away from the glenoid, the healing potential is often limited as the joint fluid of the shoulder serves as grease that impedes the ability of the tissue to scar back to the bone. Frequently, the initial management will be geared towards non-surgical measures which may include activity modification, therapy, and the possibility of an intra-articular steroid injection. Should the patient have severe pain or persistent symptoms, surgery may be necessary.

Surgical treatment is done arthroscopically on an outpatient basis. Surgical options are frequently dependent on the age of the patient and the quality of the tissue at the time of surgery and include SLAP repair, bicep tenodesis or bicep tenotomy. The bicep tendon serves a compressive function and may aid in shoulder stability during the throwing motion so unless the patient is a throwing athlete, functional or strength deficits caused by releasing the bicep tendon are typically nominal. In fact, both Brett Favre and John Elway played professional football after release and rupture, respectively, in each of their throwing shoulders without limitations. Historically, with the advent of suture anchor devices, the majority of SLAP tears (Type 2) have been treated with in-situ repair of the native tissue. The published outcomes however have noted varying degrees of success thru such treatment with "excellent" outcomes only reported in 15-30% of patients.1,2,3 In younger active patients, anything short of excellent can be met with frustration and disappointment. A trend, therefore, has been made to advise bicep tenodesis as an alternative in patients physiologically older than the age of 40.4 Several recent publications have demonstrated improved outcomes as compared to SLAP repairs with higher satisfaction ratings and higher return to sports.5,6 In my practice, I generally advise tenodesis in patients older than the age of 35. In younger patients, SLAP repair is generally recommended. Repair of SLAP tears in throwing athletes remains a very sensitive area with 64% of overhead athletes able to return to preinjury level of play and so surgery is often the last resort in this group of patients. 7

  1. DePalma AF. Surgery of the shoulder. 3rd ed. Philadelphia: JB Lippincott; 1983. p 58.
  2. Friel NA, Karas V, Slabaugh MA, Cole BJ. Outcomes of type II superior labrum, anterior to posterior (SLAP) repair: prospective evaluation at a minimum two-year follow-up. J Shoulder Elbow Surg 2010;19:859-67.
  3. Ide J, Maeda S, Takagi K. Sports activity after arthroscopic superior labral repair using suture anchors in overhead throwing athletes. Am J Sports Med 2005;33:507-14.
  4. Burns JP, BahK M, Snyder S. Superior labral tears: repair versus tenodesis. J Shoulder Elbow Surg 2011; 20: S2-S8.
  5. Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R. Arthroscopic treatment of isolated type II SLAP lesions: Biceps tenodesis as an alternative to reinsertion. Am J Sports Med 2009;37:929-36.
  6. Franceschi F, Longo UG, Ruzzini L, Rizzello G, Maffulli N, Denaro V. No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50: a randomized controlled trial. Am J Sports Med 2008;36:247-53.
  7. Gorantla K, Gill C, Wright RW. The outcome of type II SLAP repair: a systematic review. Arthroscopy 2010;26:537-45.
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