Bryan L Reuss MD. Objectives: Orlando Orthopaedic Center Orlando, FL

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1 Bryan L Reuss MD Orlando Orthopaedic Center Orlando, FL breuss@mac.com Dr. Reuss earned his B.A. in Biology from the University of Kansas and his M.D. degree with Honors from the University of Nebraska College of Medicine. Dr. Reuss completed his Orthopaedic Surgery training at Orlando Regional Healthcare System. Following his residency, he pursued additional training in Sports Medicine by completing an Orthopaedic Sports Medicine Fellowship with the University of Cincinnati/Wellington Orthopaedics and Sports Medicine group. While there, he served as an Assistant Team Physician for the NFL s Cincinnati Bengals and the University of Cincinnati s football and basketball programs, as well as a physician for the ATP Masters Series of the Professional Tennis Tour. He also serves as a physician for Cirque du Soleil, USA Rugby, and the Arnold Palmer Invitational Golf Tournament. He is board certified in Orthopaedic Surgery and Sports Medicine, specializing in knee, shoulder, and hip injuries. For his efforts, The Athletic Trainers Association of Florida gave Dr. Reuss their Sports Medicine Person of the Year in Objectives: 1. Identify the characteristics of the most common SLAP tears. 2. Distinguish how surgical treatment will affect ADLs, rehabilitation, and return to play. 3. Illustrate how surgery and rehabilitation affect clinical and return to play outcomes. No conflicts of interest or disclosures reported.

2 SLAP Lesions in the Overhead Athlete (EBP Session) Maffet Type V SLAP Tear Bryan Reuss, M.D

3 Objectives 1) Identify the characteristics of the most common SLAP tears 2) Distinguish how surgical treatment will affect ADLs, rehabilitation and return to play 3) Illustrate how surgery and rehabilitation affect clinical and return to play outcomes 7 8 PICO Questions SLAP Tear P (population): Overhead athletes I (Intervention): Arthroscopic SLAP Repair C (Comparison Group): Non-operative treatment Andrews et al, AJSM, 1985 was first to describe superior labrum tears related to the biceps tendon Snyder et al, Arthroscopy, 1990 coined the term SLAP and categorized into 4 types O (Outcome/s): Pain-free return to play/function 9 10 Maffet et al, AJSM, Type 1: fraying and tearing with normal biceps anchor Type 2: Fraying and tearing with separation of the biceps anchor from superior glenoid (most common) Type 3: Bucket-handle tear without involvement of biceps anchor Type 4: Bucket-handle tear with extension into the biceps

4 The SLAP Dilemma Pascal Boileau: SLAP tears are the American Disease Anders Eckland: I haven t done a SLAP repair in 6 years Higher incidence reported in US not supported by European experience ABOS Part 2 database: 9.4% SLAP incidence (vs 3% incidence reported by Snyder) Anatomy Fibrous cartilage and dense fibrous collagen 50% of superior labrum attached to superior labrum and 50% attached to supraglenoid tubercle Vascularity decreases with age Labrum Effect on Stability 1) chock-block effect 2) Increases concavity-compression 3) Contributes to biceps stabilizing effect Labrum stability 10-20% increased GH stability due to labrum Depth, translation, Neg pressure (Matsen FA III, Harryman DT, Sidles JA. Mechanics of glenohumeral instability. Clinics Sports Med. 1991;10: ) 4) Increases overall depth Anatomic Variations There are 3 major types of superior labrum variations present in over 10% of people (Rao, et al JBJS 2003) Sublabral recess: beneath the biceps anchor Sublabral foramen: groove between labrum and cartilage Meniscoid-like Buford Complex: absent anterosuperior labrum and thick MGHL Important to recognize these normal variants prior to fixation

5 SLAP Tears in the Overhead Athlete The Overhead athlete causes unique and demanding loads on the shoulder especially the Superior Labrum complex Kinematics altered with repetitive throwing Increasing demands, lack of off-season or rest Increasing demands for a rapid return to sport 19 Pathomechanics of SLAP lesions Single Traumatic event (fall on outstretched arm, direct blow, forceful traction e=injury, etc) Repetitive overhead activity (throwing) High eccentric activity of biceps during arm deceleration (Andrews) Peel-Back (Burkhart and Morgan) Shepherd et al, AJSM, 2004 (all 8 simulated peel-backs resulted in a Type 2 SLAP) 20 Peel-Back Mechanism GIRD Glenohumeral Interal Rotation Deficit or GIRD is the pathologic loss of internal rotation in a throwers shoulder and is part of a cascade of pathology It is a relative loss of motion, ie compared to the unaffected shoulder It is caused by posterior capsular tightening It can become painful and cause other pathology (SLAP tears) Defined as loss of total internal rotation of that exceeds any gain in external rotation Clinical Presentation Dull, vague, elusive, intermittent pain Posterior/superior pain is common Late cocking phase of throwing Lose velocity Typically painful with specific movements RC can be painful at rest 23 Physical Exam Inspection: gross atrophy, winging, bony abnormality Palpation: AC joint ROM: Scapulothoracic and glenohumeral ROM (GIRD) Strength: RC strength Stability 24 4

6 Specific Tests Accuracy of Special Tests Active-Compression Test (O Brien) Biceps Load Test (Kim) Resisted Supination External Rotation Test Imaging XRays: Usually normal, but still done to rule out bony abnormality MR-Arthrogram over MRI Not all findings are clinically significant SLAP lesions are seen more commonly as people age

7 Mileski RA, Snyder SJ Superior labral lesions in the shoulder: Pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6: There is no physical finding specific for SLAP lesions of the shoulder. Diagnostic arthroscopy remains the only definitive way to diagnose SLAP lesion of the shoulder Treatment Non-Operative Treatment Goal is to Restore normal ROM and Strength, with Return to Play/Function Non-Operative Focus on Global Strengthening of the shoulder girdle (RC/Scapular stabilizers) NSAIDs, ICE, injections, Modalities, rest Operative Non-Op Outcomes Edward et al, AJSM, of 15 throwers with known SLAP lesions who were treated with non-op mgmt returned to play at same level or better Blaine et al, AANA, 2007 No statistically significant differences in pain relief and functional improvement compared to operative group Treatment Transition Often, non-op treatment fails, then operative treatment is indicted Type 1 and 3: Debride Type 2 and 4: Repair (Mileski and Snyder, JAAOS, 1998)

8 Operative Management Overhead athletes: quicker transition to operative management Technique depends on tear characteristics Younger patients/athletes: more likely to repair Older patients: more likely to debride, tenotomy, tenodesis Only factor associated with increased failure rate age > SLAP repairs 40 month mean f/u 37% failure rate 28% elected revision surgery 38 Systematic Review 40-94% good-excellent results 22-64% of overhead athletes returned to sports Most challenging demographic: overhead athletes Type II SLAP Tear Type II SLAP Repair

9 Knots yuck Smoooooth Altchek DW, Warren RF, Wickiewicz TL, Ortiz G. Arthroscopic labral debridement. A three year follow up study. Am J Sports Med. 1992;20(6):702 6 Field LD, Savoie FH, 3rd. Arthroscopic suture repair of superior labral detachment lesions of the shoulder. Am J Sports Med. 1993;21(6):783 90; discussion 90 Only 7% had long term relief of symptoms (despite 72% noting improvement at one year from surgery) 20 consecutive patients, all treated with suture repair. All with good to excellent results (ASES shoulder eval form and Rowe rating scale) Brockmeier SF, Voos JE, Williams RJ, 3rd, Altchek DW, Cordasco FA, Allen AA. Outcomes after arthroscopic repair of type II SLAP lesions. J Bone Joint Surg Am. 2009;91(7): Prospective study 47 patients 87% Good to excellent results ASES score improved from 62 to 95 74% able to return to previous level of competition Overhead athletes can reasonably be given a trial of rehab but if no improvement of pain and function, then surgery should be considered (92% of those with a discrete acute event able to return to previous level)

10 Rehab Guidelines Individualized Need to know which type of SLAP, surgery technique and concomitant procedures performed Understand mechanism to avoid duplicating stress on tissue: compression, traction, Peel-back Goal: Restore and enhance dynamic stability Rehab Guidelines Reduce Inflammation and Pain Normalize ROM Re-establish dynamic stability Improve scapular posture and NM control Correct biomechanics factors Gradual return to sports (hopefully!) Debridement Surgery Debridement Surgery Can be fairly aggressive No true restrictions AAROM and PROM immediately Full PROM expected by days post-op Isometrics first week Isotonic strengthening (shoulder and scapula) second week: ER/IR exercise tubing, side-lying ER, prone rowing/er/horizontal abduction, active scapular plane elevation/lateral raises Light biceps resistance at two weeks to avoid irritation Debridement Surgery Weeks 4-6: Controlled weight training activities Weeks 6-8: Plyometrics Weeks 7-10: Return to sport (interval sport program)- Dependent on full ROM, adequate strength and dynamic stability, and rehab progression. SLAP Repair Know the Type that was repaired, know the severity, know how many anchors used Emphasize dynamic stabilization to minimize GH translation Maintain ROM to below 90deg x 4 weeks to avoid strain on repair, minimize ER x 2 weeks (peel-back), progress IR/ER at 4 weeks, goal is for full ROM/plyometrics by 8 weeks, thrower s motion/weight training including bench press at 12 weeks, interval throwing at 16 weeks Minimize Biceps activity-no isolated biceps x 8weeks

11 Type IV SLAP Repair Type IV-Biceps flap resected Similar to Type II with regards to ROM advancement Differences lie in advancement of resisted biceps activity (i.e. No biceps for 12 weeks) Type IV: Flap/Biceps Repaired Summary Not an easy topic especially in the overhead athlete Biceps tendon and it s biomechanics are not completely understood Non-op and surgical treatment can both be utilized Even in overhead athletes, rehab first is reasonable Thank-You References Andrews JR, Carson WG, Jr., McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med. 1985;13(5): Wilk KE, Macrina LC, Cain EL, Dugas JR and Andrews JR. The Recognition and Treatment of Superior Labral (SLAP) Lesions in the Overhead Athlete. Intl J Sports Phys Ther, 2013 Oct; 8(5): Shepard MF, Dugas JR, Zeng N, Andrews JR. Differences in the ultimate strength of the biceps anchor and the generation of type II superior labral anterior posterior lesions in a cadaveric model. Am J Sports Med. 2004;32(5): Maffet MW, Gartsman GM, Moseley B. Superior labrum biceps tendon complex lesions of the shoulder. Am J Sports Med. 1995;23(1):93 Myers TH, Zemanovic JR, Andrews JR. The resisted supination external rotation test: a new test for the diagnosis of superior labral anterior posterior lesions. Am J Sports Med. 2005;33(9): O Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998;26(5):610 3 Schwartzberg RS, Reuss BL, Burkhart BG, et al. High Prevalance of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. The Orthopaedic Journal of Sports Medicine. 4(1):1-7, Houtz CG, Schwartzberg RS, Barry JA, Reuss BL, Papa L. Shoulder MRI Accuracy in the Community Setting. Journal of Shoulder and Elbow Surgery. 20: , Edwards SL, Lee JA, Bell JE, Packer JD, Ahmad CS, Levine WN, et al. Nonoperative treatment of superior labrum anterior posterior tears: improvements in pain, function, and quality of life. Am J Sports Med. 2010;38(7): Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg Mar-Apr. 6(2): Blaine, TA et al. Improved Outcomes with Non-Operative Treatment of Superior Labral Tears (SS-53). Arthroscopy, V 23, Issue 6, e27. Wilk KE, Arrigo CA, Andrews JR. Current concepts: the stabilizing structures of the glenohumeral joint. J Orthop Sports Phys Ther. 1997;25(6): Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6(4):274 9 Burkhart SS, Morgan CD. The peel back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy. 1998;14(6): Brockmeier SF, Voos JE, Williams RJ, Altchek DW, et al. Outcomes after Arthroscopic repair of Type-II SLAP lesions, J Bone Joint Surg AM. 2009; 91 (7): Field LD, Savoie FH, 3rd. Arthroscopic suture repair of superior labral detachment lesions of the shoulder. Am J Sports Med. 1993;21(6):783 90; discussion 90 Gorantla K, Gill C, Wright RW. The Outcome of Type II Slap Repair: a Systematic Review. Arthroscopy Apr; 26(4): Matsen FA III, Harryman DT, Sidles JA. Mechanics of glenohumeral instability. Clinics Sports Med. 1991;10: