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Management of the Throwing Shoulder With a SLAP Tear

Introduction Pathology involving the superior labrum presents a diagnostic and therapeutic challenge for the arthroscopic surgeon. First described by Andrews and colleagues in 1985, Snyder later classified lesions of the superior labrum into four types and coined the term SLAP tear (superior labral tear anterior–posterior). Since that time, other authors have expanded this classification to the current inclusion of ten different types. Concomitantly, the incidence of…

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…

Arthroscopic Management of Spinoglenoid and Suprascapular Notch Cysts

Introduction Ganglion cysts around the shoulder joint can cause shoulder pain, and the symptoms are usually similar to those associated with common shoulder diseases. Since only 1% to 2% of all patients with shoulder pain have neuropathy of the suprascapular nerve, suprascapular nerve compression is not a disease primarily suspected in shoulder patients. Surgical treatment should be considered if patients have persistent pain in spite of…

The Proximal Long Head Biceps Tendon (LHBT) Rupture: LHBT Tenodesis for Symptomatic Chronic Ruptures and Revision LHBT Tenodesis

Introduction Ruptures of the long head of the biceps tendon (LHBT) usually occur in patients with intrinsic tendon degeneration and concomitant rotator cuff tears. Even though nonoperative management is successful in most patients, some patients may suffer from persistent symptoms such as weakness, pain, cramping, and cosmetic deformity. The same symptoms may arise after a surgical biceps tenotomy or after a failed biceps tenodesis. A variety…

Failed SLAP Tear: Diagnosis and Management

Introduction Superior labrum anterior-posterior (SLAP) tears are a cause of shoulder pain often found in overhead athletes, and less often in patients who have suffered a traumatic injury. SLAP tears are a detachment of the superior glenoid labrum (typically from 11 to 10 o’clock) with or without involvement of the long head of the biceps (LHBT) tendon anchor (where the LHBT originates at the supraglenoid tubercle…

Long Head of the Biceps Tendon Tenodesis: Subpectoral (Distal) Technique

Introduction Pathology of the long head of the biceps tendon (LHBT), in particular biceps tendonitis, is a common cause of anterior shoulder pain among overhead athletes and manual laborers. Diagnosis relies on history and physical examination, supplemented with magnetic resonance imaging (MRI) in questionable cases. Nonoperative treatment with supervised physiotherapy, nonsteroidal antiinflammatories, and corticosteroid injections is successful in most cases. In refractory cases, open subpectoral biceps…

Disorders of the Biceps Labral Complex: Arthroscopic Sub-Deltoid Tenodesis

Introduction Tenodesis of the long head of biceps is most commonly used for the surgical management of biceps tendinopathy, but may also be used for lower-demand patients with type 2 or 4 superior labrum anterior-posterior (SLAP) tears, either as an open procedure or arthroscopically. The loss of the intraarticular biceps doesn’t affect the stability of the shoulder in cadaveric models, but seems to remove this portion…

Long Head of the Biceps Tenodesis: Proximal Soft Tissue Fixation Without Anchors

Introduction Treatment of the long head of biceps (LHBT) tendon pathology is an area of great interest among orthopedic surgeons. Controversy persists in the literature regarding the function of the LHBT and the appropriate management of its disorders. Tendinopathy of the LHBT has inflammatory, degenerative, overuse-related, and traumatic causes. In fact, although isolated bicipital tendinitis has been described, LHBT tendinitis more commonly presents in combination with…

Current Techniques for Biceps Tenodesis

Introduction The long head of the biceps tendon (LHBT) is a frequent source of shoulder pain due to tendon instability or degenerative changes. Tendon instability can be located on the superior labrum anterior-posterior (SLAP) insertion site or at the bicipital groove. Details of SLAP repair are depicted in a different chapter of this book. In patients older than 40 years of age, current research demonstrates that…

How to Deal With Higher-Grade (Advanced) SLAP Lesions: Treatment of Type III, IV and V SLAP Tears

Introduction The treatment of lesions of the superior labrum has advanced considerably over the past two decades of shoulder arthroscopy, as has understanding of this complex structure. A rarely recognized source of shoulder pain in the latter part of the 20th century has now become one of the largest indications for shoulder surgery in board-certified candidates. Although less common than superior labrum anterior and posterior (SLAP)…

SLAP II Tears: Evaluation and Surgical Techniques for Fixation

Introduction The glenohumeral joint is the most mobile joint in the body with large arcs of motion in multiple distinct planes. Owing to limited osseous contribution to stability, the shoulder relies on the precise balance of a number of different soft-tissue stabilizers, including the deltoid, the biceps brachii, the scapular stabilizers, the rotator cuff musculature, the glenoid labrum, and associated glenohumeral ligaments. Sports, particularly overhead throwing,…

Slap Tears: How to Diagnose

Introduction Superior labral tears are a significant cause of pain and disability for the active individual. First described by Andrews in his series of 73 overhead-throwing athletes, knowledge and understanding of this pathology has improved substantially with the advent of more advanced arthroscopic techniques. Snyder et al built on the work of Andrews and coined the term “SLAP” lesion (superior labrum, anterior and posterior), and they developed…

Superior Labrum and Long Head of the Biceps

Introduction Both the glenoid labrum and the long head of the biceps play a significant role in normal shoulder function. Lesions of either structure can cause significant shoulder pathology, pain, and dysfunction. Problems with the biceps and labrum are commonly seen in overhead athletes, specifically pitchers. Significant controversy exists regarding diagnosis and appropriate management of lesions of the superior labrum–biceps complex. Treatment can vary from simple…

Tendon Transfers With a Reverse Arthroplasty: When and How?

Introduction Since the introduction of reverse shoulder arthroplasty in the 1980s, the treatment of rotator cuff dysfunction has been completely revolutionized. It has allowed improved functional results, as well as an improved quality of life for patients with rotator cuff insufficiency. Previously, those symptomatic patients could only be treated surgically with expectation of a rather limited outcome. Nowadays, reverse shoulder arthroplasty may be indicated for numerous…

Reverse Shoulder Arthroplasty for Cuff Deficiency: Surgical Technique

Introduction Rotator cuff arthropathy is a cause of shoulder pain and dysfunction consisting of rotator cuff deficiency, superior humeral head migration, and glenohumeral arthritis. History and physical examination with radiographs are the cornerstone of diagnosis, with magnetic resonance imaging (MRI) in select cases. Nonoperative treatment is first-line, including therapy for scapular and rotator cuff strengthening, activity modification, nonsteroidal antiinflammatories, and subacromial steroid injections. If nonoperative treatment…

Reverse Shoulder Arthroplasty for Cuff Deficiency: Rationale and Mechanics

Introduction Since being approved by the U.S. Food and Drug Administration in 2003, reverse shoulder arthroplasty (RSA) has become the standard of treatment for elderly patients with irreparable rotator cuff tears and arthritis. By 2020, it is projected that over 80,000 RSA procedures will be performed every year. A firm grasp on both patient selection and surgical technique will help guide surgeons as they treat this…

Hemiarthroplasty for Rotator Cuff Deficiency: Indications and Technique

Introduction The management of arthritis in the presence of a significantly deficient rotator cuff has remained a challenge. Although satisfactory outcomes using hemiarthroplasty (HA) have been reported in the past by many authors (Zuckerman et al, 2000; Arntz et al, 1991; Goldberg et al, 2008), the more recent availability of reverse shoulder arthroplasty (RSA) has significantly diminished the attraction of HA for such shoulders. Although HA…

Tendon Transfers for the Rotator Cuff Deficient Shoulder

Introduction Massive irreparable rotator cuff tears are a difficult problem to treat. Previously described treatments such as debridement alone or in conjunction with partial repair with the goal of pain relief have been inconsistent at best and often do not address or improve functional deficiencies. The younger active patient population is often unwilling to accept the lifelong limitations imposed by reverse total shoulder arthroplasty. Thus, tendon…

Rotator Cuff Arthropathy: What Is It?

Definition and Historical Review The term rotator cuff arthropathy was coined by Neer et al to indicate a nosologic condition characterized by arthritic degeneration of the glenohumeral joint consequent to the massive posterosuperior rotator cuff tear. About one century earlier, Adams, in his book on rheumatic gout, and Smith had described cases of shoulder arthropathy characterized by erosion of the upper portion of the humeral head, of…

Arthroscopic Trillat Procedure for Recurrent Anterior Shoulder Instability With Associated Irreparable Rotator Cuff Tear

Introduction Recurrent anterior shoulder instability in patients over 40 years old presents a difficult therapeutic problem when it is associated with an irreparable rotator cuff tear. This type of anterior instability, which is mainly secondary to the loss of the posterior check rein, was initially described by McLaughlin and was described by Craig as “instability from the posterior mechanism” whereby the intact anterior labrum and capsule…