Surgical Management of SLAP in Athletes Focus on Biceps Tenodesis
The surgical management of superior labral anterior-posterior (SLAP) tears in athletes, incorporating discussion of prospective randomized controlled studies and meta-analyses:
Superior labral anterior-posterior (SLAP) tears are common injuries in overhead athletes, causing shoulder pain and decreased athletic performance. Accurate diagnosis and optimal management remain challenging.
The incidence of diagnosed SLAP tears has increased over the past few decades. Studies estimate the diagnosis rate is around 140 per 100,000 people in the general population. Up to 50% of asymptomatic professional baseball pitchers show evidence of SLAP tears on MRI. SLAP repairs account for approximately 10% of all shoulder surgeries.
Snyder et al originally classified SLAP tears into 4 types. Type II lesions are most common, accounting for around 40% of SLAP tears. They involve detachment of the biceps anchor from the glenoid.
Repeated overhead motion is thought to cause traction injury or peel-back mechanism, leading to failure of the biceps-labral complex. Cadaver studies show the complex is under maximal tension during late cocking phase of throwing.
History, physical exam, and imaging aid diagnosis. MRI has moderate sensitivity and specificity – up to 87%. Physical exam maneuvers, including O’Brien’s test, may be more accurate than MRI.
Includes rest, physical therapy, and corticosteroid injections. Nonoperative treatment allows return to play in 40-85% of patients, with lower rates in high-level athletes.
If nonoperative treatment fails, arthroscopic SLAP repair or biceps tenodesis may be considered.
Systematic reviews and RCTs show biceps tenodesis results in higher return to play rates compared to SLAP repair. In a Level I RCT, Chalmers et al found biceps tenodesis better restored throwing biomechanics. Return to play was 100% with tenodesis versus 63% with SLAP repair.
A Level I RCT by Boileau et al comparing tenodesis techniques found arthroscopic suprapectoral tenodesis had fewer complications than open subpectoral tenodesis, with similar clinical outcomes.
Meta-analysis by Deng et al showed tenodesis allowed return to play in 70% of overhead athletes versus 63% with SLAP repair. Pain scores and range of motion were similar between techniques.
Nonoperative treatment should be exhausted before surgery is considered for management of SLAP tears in athletes. When operative treatment is pursued, current evidence from high-quality RCTs and meta-analyses suggests biceps tenodesis, particularly arthroscopic suprapectoral tenodesis, leads to higher return to play rates and fewer complications compared to SLAP repair. However, 30-40% of athletes may still not return to their pre-injury level of play following surgery. Realistic expectations are important when counseling athletes on management options.