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SLAP Lesions: Patient Presentation &

ExamIan K.Y. Lo, MD, FRCSC

McCaig Centre For Joint Injury and Arthritis ResearchUniversity of Calgary, Calgary, Alberta, CANADA

SLAP Lesions

• Andrews et al. 1985.– Initial description

• Snyder et al. 1990– General population

Diagnosis & Treatment

CONTROVERSIAL

Case: Pre-operative MRI

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Diagnostic Arthroscopy

How Would You Treat The SLAP Lesion?

A. Debridement

B. Knotted suture anchor repair

C.Knotless suture anchor repair

D.Biceps tenodesis

E. Biceps tenotomy

What’s The Clinical Picture?

The Tougher Question:Is This Really A

Symptomatic SLAP?

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SLAP Over-Diagnosis

• Over-Reliance

• Diagnosis by MRI– Radiologic SLAP lesion

• Diagnosis by Arthroscopy– Incidental SLAP

Epidemic Of SLAP Repairs

• National insurance data base 105%

Zhang et al. AJSM, 2012.

Wide Spectrum Of Results With SLAP Repair

• Systematic Review

• 12 studies, 380 pts

• Results– G/E 40-94%

– RTS 20-94%

– RtOS 20-64%

Gorantla et al. Artho, 2010.

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Over Treatment?

• ABOS Part II Audit 2003-2008

• 4975 (9%) SLAP repairs

• Mean Age: 36±13 y.o.– Maximum age: 85 yrs

• Poor results

• 26% pain free

• 13.1% normal function

Weber et al. AJSM, 2012.

They Don’t All Do Great!

• 40 unhappy SLAP repairs

• Age: 43 (16-58)

• Presentation– 75% Pain, ROM

– 22% Pain, N ROM

• Factors– 50% WCB

Katz et al. Arthroscopy, 2009.

I Know I Have A SLAP Lesion!

#1 ProblemMAKING THE DIAGNOSIS

• Symptomatic SLAP?– History

– Physical Exam

• Patient Diagnosis– Read my report

– Un-diagnose MRA

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What Does The Literature Use?

• Kibler & Sciascia

• Systematic review & survey

• History

• Physical

• Imaging

• Arthroscopy

Kibler et al. Artho, 2015.

35% DNR Hx

31% DNR P/E

27% DNR Imaging

96% Report Arthro

SLAP Lesions

• Diagnosis–Right patient

–Right clinical findings

–Right Imaging

–Right arthroscopic findings

GeneralClinical

Impression

History: Ideal Population

• Younger patient < 30-35 y.o.

• Isolated lesion

• Decline in OH athleticsvelocity

control

– Dead-arm

• Prodrome of symptoms– Acute injury

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History: Problematic Population

• Traction-Counter-traction– Fall

– Atraumatic

• Older population (> 30)

• Work comp

• MVA

Problematic Population: Lots of Associated Pathology

• 139 SLAP Lesion

• 88% have associated pathology– OA

– Bankart

– RCTs

• Isolated SLAPs Rare

Kim et al. JBJS Am, 2003.

“Care must be taken when ascribing

symptoms to a SLAP lesion when other pathologies are

present”

History

• Pain – Anterior pain?

• Biceps

– Posterior pain• Intermittent

• Positional

• Clicking, popping, catching– Non-specific

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Sick Scapula• Scapula inferior

• Coracoid tenderness

• Scapular dyskinesis

Kibler et al. BrJSM 2005.Burkhart et al. Arthro 2003.

Kinetic Chain• Stance leg

• Hip/Gluteweakness

• Core/Trunk

Range of Motion

• GIRD– Throwers shoulder

– RC/SLAP

• Global ROM– NOT SLAP

– AC, OA

IRD

Shoulder At Risk

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Strength

• RC/Deltoid/PS

• SSN entrapment

• Radiculopathy

Instability Exam

• Glenohumeral– Ant

– Post

– MDI

• Hypermobility– Beighton file:///.file/id=657136

7.860418

Special Tests

• O’Brien’s

• Biceps Load test I/II

• Labral tension test

• Anterior glide

• Relocation

• Dynamic shear test

Cook et al. JSES, 2012.Sodha et al. AJSM, 2017.

No testConsistent AccuracyReproducible UtilityUniversally Accepted

Only use if suspiciousOnly use if isolated lesion

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O’Brien’s Test

• Sensitive

• Non-specific

• AC joint

• Non-functional position

O’Brien et al. AJSM 1998.Knesek et al. AJSM 2013.

Relocation Test For Pain

• Posterosuperior pain

• Relieved with posterior force

• Beware of tight posterior capsule

Peel Back

Posterior Force Reduces Labrum

Dynamic Labral Shear• Good clinical utility

• Sensitivity: 0.72

• Specificity: 0.92

• Accuracy: 0.84

• + LR~ 31

Kibler et al. AJSM, 2009.Cheung et al. AAOS, 2007.

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Biceps Tests

• Groove pain

• Speed’s

• Yergason’s

• Upper Cut

• Saw

Kibler et al. AJSM 2009.

Choice of SurgeryRepair versus

Tenodesis

Arthroscopy Is Imperfect

Jia et al. AJSM 2011.Gobezie et al. AJSM 2008.

• Confirm Suspicion

• Questionable Reliability– Agreement

• Doesn’t tell us about symptoms– Asymptomatic AC OA

– Asymptomatic RCTs

SLAPs Can Be Asymptomatic Degenerative Finding

• 32 cadavers

• Age: 57 yrs (18-89)

• Multidisciplinary assessment

lesions with age

• #1 location SUPERIOR

Pfahler et al. JSES, 2003.

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The Asymptomatic SLAP

• 53 asymptomatic volunteers

• Age: 45-60 yrs old

• MRI 1.5 T

• 2 MSK Rads

• SLAPs

Schwartzberg R et al. AJSM, 2016.

55-71%

Conclusions

• Diagnosis difficult

• No unique clinical findings

• Questionable P/E tests

• Associated pathology

• Questionable populations

Conclusions

• Isolated lesion

• Appropriate population

• Positive exam

• Rare diagnosis

• ~2% of cases

Kurji et al. OAJSM, 2015.

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Thank-you