Arthroscopic Management of Combined Pathology: SLAP and Rotator Cuff Tears

Introduction

There is an abundance of literature regarding the all-arthroscopic treatment of rotator cuff tears, and it has been well established that these injuries have a high incidence of concomitant shoulder pathology. Patients with full-thickness rotator cuff tears demonstrate intraarticular pathology in 74% of cases, with labral tears being the most common combined pathology.

The advent of arthroscopic shoulder surgery brought with it the identification of previously undescribed glenohumeral pathology, namely the superior labrum anterior to posterior (SLAP) tear. The SLAP tear, initially described by Andrews and later coined by Snyder, was classically described as an isolated lesion in the overhead athlete. Numerous studies have shown excellent outcomes associated with the treatment of isolated SLAP tears, with 83% of patients reporting good-to-excellent satisfaction and a 65%–73% rate of return to previous level of play in athletes. The current standard of care for a type II SLAP tear that has failed conservative management is an arthroscopic repair using bioabsorbable sutures.

However, multiple studies have shown that 40%–52.7% of SLAP lesions occur concomitantly with partial or full-thickness rotator cuffs tears. Despite the scrutiny of these well-known and well-studied pathologies, until recently there has been little literature to guide the treatment of concomitant rotator cuff tears and SLAP tears. As such, the combined management of these lesions remains controversial.

In this chapter, we will present current treatment options and detail the surgical technique for addressing combined rotator cuff and SLAP lesions in the unique subset of patient populations in which this pathology is commonly encountered.

Procedure

We describe the all-arthroscopic treatment of combined SLAP lesions and rotator cuff tears. Treatment options vary in regards to patient age and activity level. Techniques for the treatment of young, overhead athletes with type II SLAP lesions and rotator cuff tears will be described, in addition to the treatment for middle-aged to older individuals with acute or degenerative SLAP lesions and rotator cuff tears.

Patient History

• Pathologic SLAP lesions commonly occur in two distinct patient populations:

  • Overhead athletes, such as baseball pitchers, swimmers, tennis players, or volleyball players.

  • People who have sustained an acute traumatic event via a traction or compression mechanism.

• There is a third group with degeneration and normal separation of the superior labrum, often noted on MRI scans. This is not pathologic and does not require treatment.

• Overhead athletes may describe pain of insidious origin, with mechanical symptoms of popping, locking, or catching, especially during throwing or rotational shoulder movements. Athletes may also complain of decreased velocity and stamina and altered mechanics (often termed “dead arm syndrome”). With combined rotator cuff tears, patients will also describe weakness with abduction and external rotation of the shoulder.

• The pathogenesis of combined SLAP lesions and rotator cuff tears in overhead-throwing athletes is as follows: Patients commonly develop increased glenohumeral external rotation, but this change is often at the expense of internal rotation. This glenohumeral internal rotation deficit (GIRD) is accompanied by a posterior capsular contracture, which shifts the glenohumeral contact point in a posterosuperior direction during overhead throwing activity. The throwing athlete will compensate for changes in the glenohumeral contact point by excessively externally rotating, and this action produces increased shear and torsional forces at the biceps anchor. This “peel-back” mechanism causes the biceps anchor to peel off the posterior superior glenoid.

• The change in vector forces not only accounts for increased forces about the biceps anchor, but also at the posterosuperior rotator cuff, resulting in characteristic partial undersurface tearing of the infraspinatus. This mechanism is referred to as internal impingement and occurs when the posterosuperior rotator cuff is pinched between the greater tuberosity and the posterosuperior glenoid labrum at a position of 90 degrees abduction and 90 degrees external rotation of the shoulder.

• In patients that undergo an acute trauma, several methods of injury to the superior labrum have been described as follows:

  • Traction with inferior subluxation of the humerus.

  • Direct compression or impaction with the arm in a flexed position may cause a SLAP lesion.

  • In a review of concomitant SLAP tears and rotator cuff tears, Voos et al. found that 80% of patients reported an acute traumatic event as the cause of their injury. Eighty percent showed clinical signs of rotator cuff weakness or positive impingement signs. Classic labral injury signs and symptoms, such as a positive apprehension sign and recurrent instability, were seen in 33% and 6%, respectively.

• Older patients may describe a more chronic clinical picture. An anterior superior labral tear of chronic origin may present initially with an asymptomatic deep popping during overhead activity. As the instability ensues, the repetitive superior translation or subluxation of the humeral head could damage the articular surface of the rotator cuff, resulting in a partial articular-sided cuff tear.

• Morgan et al. observed rotator cuff lesions in 31% of patients with chronic SLAP tears, and Snyder et al. noted a 40% rate of associated rotator cuff tears in their series of 140 patients with SLAP lesions.

• It is not known if rotator cuff tears are directly caused by instability secondary to superior labral injury. Increased patient age has been shown to be strongly correlated with rotator cuff tears, and recent histologic studies have confirmed that a decrease in superior labral chondrocytes and vascularity occurs with aging.

Patient Examination

• A thorough history and exam is critical in the diagnosis of this injury. The presence of concomitant injuries will make this diagnosis more difficult to elucidate, and physical exam tests must be made in the context of clinical history and patient demographic.

• Load and shift test: The humeral head is subluxed in the direction of the anterior-superior labrum (1 o’clock position in the right shoulder). The arm is raised in the opposite direction, tightening the injured ligament and relocating the humeral head. The test is positive when the head fails to relocate or when crepitations are produced, indicating labral tearing and glenoid chondromalacia.

• Supraspinatus Isolation Test: With the arm at 90 degrees of forward flexion and in full internal rotation, the patient is asked to resist downward pressure exerted by the examiner. A positive test will elicit pain, muscle weakness, or both.

• Whipple test: Patient is seated with arm flexed to 90 degrees and adducted until the hand is opposite the contralateral shoulder. The patient’s arm is held with the palm facing down, and the patient is asked to resist a downward force applied by the examiner. A positive test will produce pain and is specific for anterior supraspinatus tearing.

• Dynamic Labral Shear test: The patient is supine with the shoulder off the edge of the table. The shoulder is positioned at 90 degrees abduction and the elbow is flexed to 90 degrees. Maximal external rotation is applied to the shoulder, and the shoulder is passively elevated. A positive test reproduces the patient’s pain between 90 degrees to 120 degrees of abduction, and a painful click may be appreciated.

• Speed test: With the patient seated, the elbow of the affected extremity is fully extended and the forearm is placed in full supination. The examiner resists forward flexion from 0 degrees to 60 degrees. Increased pain at the shoulder, namely within the bicipital groove, is indicative of a positive test.

• O’Brien active compression test: The patient is standing with the shoulder at 90 degrees of flexion, 10 degrees of horizontal abduction, and maximum internal rotation with the elbow in full extension. A downward force is applied at the wrist of the involved arm, and the patient is asked to resist this force. The patient reports any pain in this position. The patient’s shoulder is then externally rotated with the forearm in supination. Downward force is reapplied at the wrist by the examiner. A positive test is indicated by pain, clicking, or crepitus with the shoulder in internal rotation and improved pain with shoulder internal rotation.

Imaging

• Plain Radiographs

  • Initial imaging studies include an AP, scapular Y, axillary, and Bernegeau view of the shoulder.

  • These radiographs are not specific for SLAP tears, but acromial morphology and concomitant shoulder pathology can be identified.

• Magnetic resonance imaging (MRI)

  • MRI is the study of choice for identifying SLAP lesions and rotator cuff pathology.

  • Magnetic resonance arthrography (MRA) is useful for identifying subtle injuries to the labral complex and (PASTA) partial articular-sided supraspinatus tendon avulsion tears.

  • The variable anatomy of the superior labrum make MRI and MRA interpretations quite challenging. Abduction and external rotation views allow for improved visualization of the superior and anterior labrum.

  • External rotation MRA improved the sensitivity and specificity of identifying SLAP lesions.

  • SLAP tears on MRI—increased signal in the superior labrum with T2 weighting and the appearance of contrast between the glenoid and superior labrum on coronal MRA

Treatment Options: Nonoperative and Operative

• Treatment options are guided by age, activity level, and the primary complaint of the patient. Treatment generally includes nonoperative rehabilitation, operative repair, and postoperative rehabilitation.

• Young, overhead athletes:

  • Conservative treatment should be attempted initially, as a significant percentage of these patients can be successfully treated with a rehabilitation program. It has been proposed that rotator cuff strength at 90 degrees of abduction is an important indicator of successful nonoperative treatment. Other factors, such as pain with forward flexion, pain with resisted abduction, and scapular dyskinesia, are also thought to predict failure with nonoperative treatment.

  • Surgical treatment of combined SLAP lesions and rotator cuff tears in young, overhead athletes is controversial, and there is a paucity of literature regarding this topic. SLAP repairs in isolation in this patient population have a reported success rate as high as 74%–92%. However, the rate of return to play for high-level throwers with combined SLAP lesions and rotator cuff tears is less encouraging and is quoted between 12.5% and 35%.

• Extrapolating data from the various reports of SLAP repair in overhead athletes can be challenging and perhaps misleading, as studies often group all overhead athletes into a single cohort. It is more appropriate to consider throwers as a separate category from other overhead athletes such as swimmers, volleyball players, or tennis players, for the demands placed on the throwing shoulder differ significantly from that of other overhead athletes. Also, many studies list “return-to-play” as a primary endpoint, rather than full return to prior level, which is of paramount importance to the high-level thrower.

• When overhead throwers sustain a concomitant SLAP and rotator cuff tear, the injury typically manifests as a type II SLAP lesion and a partial articular-sided rotator cuff tear. This combined injury is particularly difficult to treat in this population. Van Kleunen et al. found a 35% rate of return to a level of play similar to or greater than the preinjury level in 17 high school and collegiate pitchers with type II SLAP tears and partial infraspinatus tears that underwent repair. Neri et al. reported on 23 high-level baseball players with type II SLAP tears who underwent arthroscopic repair. They encountered concomitant partial-thickness articular-sided rotator cuff tears in 35%, and found that players with concomitant tears demonstrated a 12.5% return to prior level of play, compared to 80% return in the group without cuff tears. Conway reported on a small series of 14 professional baseball players with concomitant superior labral and intrasubstance rotator cuff tears that underwent arthroscopic repair. He reported an 89% return to prior level of play; however, follow-up was only 16 months, and thermal capsulorrhaphy was utilized in some patients.

• For recreational athletes, the rate of return to play is higher. Samani et al. reported a high rate of return (83%) in a series of 25 overhead athletes, in which 13 had combined SLAP lesions and rotator cuff tears.

• Currently the standard of care for type II SLAP lesions is arthroscopic repair using anchors. We advocate concomitant SLAP repair and rotator cuff repair in young, high-level throwers, young overhead athletes, patients younger than 35 years of age, and those patients with a primary complaint of instability.

• Recreational athlete greater than 35 years of age and older, less active patients:

• Combined lesions of the superior labrum and rotator cuff can make decision making difficult, especially in this particular population. Patient-specific protocols can be made, and the operative treatment tailored to fit the activity level and functional desires of each patient. Concomitant pathology of the shoulder is closely related to patient age, and this must be taken into account during the decision-making process. For instance, type II SLAP lesions are commonly associated with a Bankart lesion in patients less than 40 years of age, whereas SLAP lesions in patients older than 40 are associated with supraspinatus tears and osteoarthritis of the humeral head.

• There has been a recent increased focus on the combined SLAP lesion and rotator cuff tear in this patient population, with debate surrounding the appropriate management of the SLAP tear. Multiple studies have shown good results with concomitant SLAP and rotator cuff repair in this population. Savoie et al. reported on 40 patients (average age = 43) with a SLAC (superior labrum anterior cuff) lesion, defined as a partial articular-sided supraspinatus tear in conjunction with a type II SLAP tear. They were treated with a SLAP repair and debridement of the cuff tear, with overall patient satisfaction in 39/40 patients at 3 to 4 year follow-up.

• Voos, et al. reported on a group of 30 patients (mean age = 47) who underwent arthroscopic repair of combined rotator cuff and labral tears, including SLAP lesions (n = 14) and Bankart lesions (n = 16). They found a 90% good to excellent clinical result and a 77% rate of return to sport at 2.7-year follow-up.

• Levy et al. retrospectively reviewed 93 patients younger than 50 years of age who underwent SLAP repair. A rotator cuff tear was observed in 49 patients, with the majority (89%) being partial-thickness tears. The remaining 44 patients had no rotator cuff pathology. Rotator cuff tears were treated with either debridement or repair, depending on tear size. At 2-year follow-up, there were no differences in outcomes, and the authors concluded that rotator cuff repair did not negatively influence outcomes of SLAP repair.

• Strickland et al. reviewed 11 patients (average age = 47) with type II SLAP tears and full-thickness or partial-thickness cuff tears who underwent concomitant repair of both lesions. One-year follow-up demonstrated successful results in 10/11 patients, and the authors concluded that early passive range of motion was important in preventing postoperative stiffness.

• Forsythe et al. compared 34 patients (average age = 56.9) who underwent combined arthroscopic SLAP and rotator cuff tear repair to 28 patients (average age = 59.6) who underwent isolated arthroscopic rotator cuff repair. They found improved postoperative outcome scores in the concomitant repair group, and concluded that combined SLAP and rotator cuff repairs were effective in middle-aged patients.

• However, others have argued that debridement of the SLAP lesion or biceps tenotomy would result in improved patient outcomes, and that repair of the SLAP lesion in this patient population is associated with inferior outcomes. Abbott et al. performed a prospective randomized cohort study of 48 patients over the age of 45 years who underwent arthroscopic treatment for both minimally retracted supraspinatus tears and type II SLAP lesions. All patients underwent arthroscopic rotator cuff repair and subacromial decompression. A subgroup of 24 patients underwent arthroscopic debridement of the type II SLAP tear, while the second subgroup of 24 patients underwent SLAP repair. They found that those who underwent SLAP debridement demonstrated significantly better outcome scores and range of motion (particularly in internal and external rotation) than those who underwent repair. They argued that repair of the type II SLAP lesion resulted in increased stiffness, and that part of the normal aging process might involve degeneration of the superior labrum to afford improved range of motion in the glenohumeral joint.

• A randomized controlled trial performed by Franceschi et al. compared the outcomes of 63 patients over the age of 50 who underwent combined rotator cuff repair with either SLAP repair or biceps tenotomy. The tenotomy group displayed improved range of motion and higher UCLA (The University of California at Los Angeles) scores than the SLAP repair group, and a higher rate of postoperative stiffness was observed in the SLAP repair group. They concluded that there was no advantage to SLAP repair when associated with a rotator cuff tear in patients over the age of 50. However, patients in this study were restricted from overhead stretching for 6 weeks postoperatively to avoid damaging the repair, which could have negatively impacted the range-of-motion outcomes in the repair group.

• Recently Kim et al. reviewed 36 patients with SLAP lesions and large to massive rotator cuff tears. Patients underwent concomitant SLAP and rotator cuff repair, or biceps tenotomy and rotator cuff repair (average age = 61 and 63, respectively). The biceps tenotomy group demonstrated improved functional outcome scores and range of motion compared to the repair group. They concluded that biceps tenotomy might be more a more reliable method to address concomitant SLAP tears and large to massive rotator cuff tears.

• In conclusion, treatment options in this patient population must be tailored to the patient’s needs and activity level. A select group of patients may benefit from SLAP repair or biceps tenotomy, and shared decision making is encouraged. This group of patients includes recreational overhead-throwing athletes greater than 35 years of age, those with small to medium-sized rotator cuff tears, and those patients who wish to recover with a less involved rehabilitation program.

• Biceps tenotomy is encouraged in older patients (>40 years of age) with large to massive rotator cuff tears, revision surgeries, and those patients with concomitant glenohumeral arthritis.

Surgical Anatomy

• Superior labrum

  • Triangular fibrocartilaginous structure that outlines the glenoid and functions to deepen the glenoid fossa and provide stability to the humeral head. It functions as a static stabilizer of the glenohumeral joint and serves as the primary attachment site for the glenohumeral capsule and the long head of the biceps tendon.

  • The anterosuperior labrum demonstrates distinct anatomic variability in approximately 14% of the population.

• Sublabral recess (2.46%): A sulcus below the biceps tendon anchors the anterosuperior rim of the labrum.

• Sublabral foramen (7.67%): A groove between the normal anterosuperior labrum and the anterior glenoid.

• Buford complex (4.05%): Absent anterosuperior labrum with a cordlike middle glenohumeral ligament that attaches to the superior labrum at the biceps anchor.

• (The latter two variants may contribute to the development of type II SLAP tears.)

• Major common findings associated with labral injury include:

  • Type II or higher SLAP lesion

  • Peel-back lesion

  • Glenoid articular cartilage damage or chondromalacia

  • Posterior capsular thickness

  • Positive drive-through sign, indicating instability and decreased capsular tension

  • Patient age is important to consider in a patient with a suspected SLAP tear and rotator cuff tear. The pathoanatomy of the glenoid labrum is subjected to various changes throughout the normal adult life

  • 0–10 years of age: normal circumferential labral attachment without damage

  • 30-–50 years of age: fissuring and sublabral recesses at the superior and anterosuperior area of the glenoid labrum

  • Greater than 60 years of age: inconsistently attached superior labrum with tearing, fissuring, and labral detachment

• Biceps

  • Originates from the superior glenoid labrum and the supraglenoid tubercle

  • Intraarticular portion of the tendon passes over the humeral head before leaving the glenohumeral joint through the bicipital groove 32.

• Type I SLAP

  • Biceps anchor intact, with fraying of the inner margin of the superior labrum ( Fig. 53.1 )

    

• Type II SLAP

  • Superior labrum is pulled off the superior glenoid tubercle at the bicipital attachment.

  • Most commonly encountered clinically significant lesion

  • Anterior, posterior, and combined variants

• Type III SLAP

  • Anterior-to-posterior tear of the superior labrum in a bucket-handle configuration

  • There is no elevation of the biceps-labral attachment from the glenoid.

• Type IV SLAP

  • Bucket-handle labral tear that extends into the biceps tendon, resulting in a split in the tendon attachment

• Supraspinatus

  • Arises from supraspinous fossa and inserts on greater tuberosity

  • Functions in shoulder abduction, primarily at the initial 10 degrees to 15 degrees of motion

• Infraspinatus

  • Originates at the infraspinatus fossa and inserts on the greater tuberosity

  • Functions in external rotation and extension of the glenohumeral joint

• Rotator cuff footprint

  • Medial to lateral width of approximately 12–20 mm on the greater tuberosity

Surgical Indications

• SLAP repair and rotator cuff repair

  • Symptomatic lesion of the root of the biceps complex recalcitrant to conservative measures in athletes and other high-functioning individuals who are willing to participate in a prolonged rehabilitation program

  • Physical exam findings correlating with SLAP tear, and physical exam findings suggestive of at least one grade of rotator cuff weakness with stress-testing

  • Arthroscopically confirmed biceps anchor and rotator cuff pathology, as described above

• Biceps tenodesis/tenotomy plus repair

  • Older patients (patient age >40)

  • Physical exam findings correlating with SLAP tear, and physical exam findings suggestive of at least one grade of rotator cuff weakness with stress-testing

  • Presence of intraarticular biceps tendon fraying or tearing

  • Large to massive rotator cuff tear

Surgical Technique Setup