In May 2017, A Norwegian research team lead by Dr Cecilie Piene Schrøder, an Orthopedic surgeon, examined the effectiveness of the routine surgical procedures they were performing for SLAP lesions or tears of the shoulder. Here is what the research team noted:
- Labral repair and biceps tenodesis are routine operations for superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their effectiveness is lacking.
- We (the reserch team) evaluated the effect of labral repair surgery, biceps tenodesis surgery and sham (placebo) surgery on SLAP lesions.
So what Dr. Schrøder and his colleagues were looking for was to see if the surgeries they were performing actually worked by comparing them to a Sham or placebo surgery.
- They did a a double-blind, sham-controlled trial with 118 surgical candidates (average age 40 years), with patient history, clinical symptoms and MRI arthrography indicating an isolated type II SLAP lesion.
- Forty patients were randomly assigned to get a labral repair surgery.
- Thirty-nine patients received a biceps tenodesis surgery.
- Thirty-nine patients received a sham surgery.
- Results There were no significant between-group differences at any follow-up in any outcome.
- Conclusion Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied.(1)
In July 2018, Dr. Schrøder followed up his paper with a short piece published in the The open orthopaedics journal. Here he addressed criticism about his findings. When questioned on the usefulness of SLAP tear surgery, Dr. Schrøder responded: “Based on (our) results we have narrowed our indications for SLAP lesion surgery. We still treat some SLAP lesions surgically and individualize our treatment in each such cases. Most SLAP lesion patients, however, are ultimately treated non-operatively.”(2)
The Hospital of Special Surgery and the Mayo Clinic findings
A January 2018 study from the Hospital of Special Surgery and the Mayo Clinic discussed the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex.
“Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion.”(3)
A bicep tenodesis is a surgery to repair a damaged bicep tendon. A biceps tenodesis may be performed as an isolated procedure but more often is part of a larger shoulder surgery, including rotator cuff repair.A recent study from Rush University Medical Center warns of including this procedure during the bigger shoulder surgery:
“High-demand patients with biceps tendonitis in the setting of a SLAP lesion with labral instability who undergo combined tenodesis and SLAP repair have significantly worse outcomes than patients who undergo either isolated labral repair for type II SLAP tears or isolated biceps tenodesis for a SLAP tear and biceps tendonitis.”(4)
The more surgery, the worse the outcome.
The surgical treatment of SLAP tears continues to be challenging for both the physician and the patient. Of course it becomes much more challenging to the patient if the surgery does not work to the patient’s expectations. Here is a recent paper discussing these problems from doctors at the University of Minnesota and Saarland University in Germany.
- Tears of the superior labrum involving the biceps anchor are a common entity, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature particularly for young athletes.
- However, the results in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance (see below for further documentation).
- The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates as compared to younger patients. In this population, tenotomy or tenodesis of the biceps tendon (doctors will move the bicep tendon attachment to a different place on the bone – usually part of a more major surgery) is a viable alternative to SLAP repairs in order to improve clinical outcomes. (5)
Revision surgery for the failed SLAP tear surgery
A study from July 2018 in the The open orthopaedics journal (6) throws a lot of questions at the effectiveness of SLAP tear surgery.
- “Optimal treatment of type II superior labrum anterior and posterior (SLAP) tears is controversial. There has been a recent trend towards biceps tenodesis over SLAP repair in older patients. Few surgeons have performed combined biceps tenodesis and SLAP repair with inferior results.”
- “Failed SLAP repair is often multifactorial and a thorough workup is needed. Combined biceps tenodesis and SLAP repair can cause pain, stiffness, and dysfunction which can be successfully treated with arthroscopic superior capsular release.”
SLAP tear surgery does cause a lot of damage, this is why revision surgery is generally not successful.
Similar findings were observed by surgeons at New York University Hospital for Joint Diseases. They found that on average 10% of patients would need a second shoulder surgery at average two years after the initial SLAP lesion procedure and those procedures were expanded to include subacromial decompression (35%), debridement (26.7%). repeat SLAP repair (19.7%), and biceps tenodesis or tenotomy (13.0%). After isolated SLAP repair, patients aged 20 years or younger were more likely to undergo arthroscopic Bankart repair.
The doctors concluded: “We identified a 10.1% incidence of subsequent surgery after isolated SLAP repair, often related to an additional diagnosis, suggesting that clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions. In addition, the number of isolated SLAP repairs performed has decreased over time, and management of failed SLAP repair has shifted toward biceps tenodesis or tenotomy over revision SLAP repair in more recent years.(7)
Also in the July 2018 edition of The open orthopaedics journal, (8) is another study that suggests that for many patients, SLAP tear surgery is not ideal. Risk factors for failure of SLAP repair include age, smoking, obesity, being female and concomitant bicep pathology(weakened, injured biceps). The researchers of this study cited a previous study that found that once a patient has failed first time repair, 71% will fail conservative therapy and 32% will continue to have suboptimal outcomes after a second surgical intervention.
Doctors say no to surgery that athletes want
Is shoulder surgery the only answer for the athlete who wants a quick return to their sport? To many athletes the answer is yes because the alternative recommendations from their orthopedic specialist of ice, rest, physical therapy and wait six months is not the option they want.
Doctors at Houston Methodist Hospital however made this recommendation in published research in the American Journal of Sports Medicine, “Nonsurgical treatment should be considered for professional baseball players with documented SLAP lesions, as it can lead to acceptable RTP (Return-to-play) and RPP (return to prior performance (before injury)) rates.”(9)
For many, many years before these studies, patients came into the office and would tell us about their shoulder labrum tear and the surgery they had, and the pain they still suffer from, and their desperation not to have another surgery. After talking with the patient we discover that a torn labrum showed up on an MRI, the surgery was performed, but, the pain never went away. Something else was causing the pain. As suggested above in why the surgery fails at higher rate and secondary revision is equally prone to failure is that patient may not even have a Slap tear.
SLAP (labral) lesions may actually be rare injuries
Recently when Stephen C. Weber, MD presented the findings of his study that American Board of Orthopaedic Surgery (ABOS) Part II candidates (young surgeons) may be performing superior labral tear anterior to posterior (SLAP) repairs at greater rates than they should, he noted that the increase in surgeries were leading to poor outcomes and increased complication rates.
One of the reasons too many surgeries were being performed was because MRI suggested a SLAP tear when Slap tears were not there. Dr. Weber noted that magnetic resonance imaging (MRI) scans often produce false positives and that SLAP lesions are difficult to diagnose clinically. Numerous studies suggest that even experts disagree on how to define a type II SLAP tear.
“Furthermore, repairing SLAPs is not a benign process, and caring for failed SLAPs can be very difficult,” said Dr. Weber. “Complications include stiffness, persistent rotator cuff tears next to the portals, and damage to the articular cartilage.”
To treat a SLAP tear, you must treat the whole shoulder
SLAP lesions do not happen overnight unless you take a fall with your arm extended. Then you can have an acute tear. More typically SLAP lesions occur as the result of repetitive motion or wear and tear injury. SLAP lesions, therefore, do not happen in isolation, they happen as part of a degenerative shoulder disease problem. People who email me typically describe that they have a SLAP tear as well as a torn tendon, torn rotator cuff muscles, and chronic shoulder instability, sometimes with dislocation.
The have all the symptoms of a shoulder that is in a downward spiral: Pain and a lot of noise, clicking, grinding, and popping. They have limited range of motion and a significant decrease in strength.
It is for these reasons that shoulder surgery for SLAP tears and lesions is not effective. The surgery does not address the whole shoulder problem.
Stem cells and Platelet Rich Plasma Therapy are injection techniques that can accelerate the body’s own inflammatory response to repair the labral damage. But treating the whole shoulder capsule, we can not only repair the labrum, but we can also protect it from damage and shoulder instability caused by compromised shoulder structures, such as ligaments and tendons. By treating the whole shoulder, we can strengthen these weakened elements and stabilize the entire joint.
Ask Dr. Darrow about non-surgical treatment options for Shoulder Labrum tear
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1 Schrøder CP, Skare Ø, Reikerås O, Mowinckel P, Brox JI. Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial. British Journal of Sports Medicine. 2017;51(24):1759-1766. doi:10.1136/bjsports-2016-097098.
2 Schrøder CP. SLAP lesions, An Opinion Piece. The Open Orthopaedics Journal. 2018;12:342-345. doi:10.2174/1874325001812010342.
3 Calcei JG, Boddapati V, Altchek DW, Camp CL, Dines JS. Diagnosis and Treatment of Injuries to the Biceps and Superior Labral Complex in Overhead Athletes. Current Reviews in Musculoskeletal Medicine. 2018:1-9.
4 Chalmers PN, Monson B, Frank RM, Mascarenhas R, Nicholson GP, Bach BR, Verma NN, Cole BJ, Romeo AA. Combined SLAP repair and biceps tenodesis for superior labral anterior–posterior tears. Knee Surgery, Sports Traumatology, Arthroscopy. 2016 Dec 1;24(12):3870-6.
5. Brockmeyer M, Tompkins M, Kohn DM, Lorbach O. SLAP lesions: a treatment algorithm. Knee Surg Sports Traumatol Arthrosc. 2016 Feb;24(2):447-55. doi: 10.1007/s00167-015-3966-0. Epub 2016 Jan 27.
6. Han Y, Lee J, Park S, Suh E. Suppl-1, M5: Superior Capsular Release After Failed Combined Superior Labral Repair And Biceps Tenodesis For Slap Tear. The open orthopaedics journal. 2018;12:295.
7 Mollon B, Mahure SA, Ensor KL, Zuckerman JD, Kwon YW, Rokito AS. Subsequent shoulder surgery after isolated arthroscopic SLAP repair. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2016 Oct 31;32(10):1954-62.
8 Charles MD, Christian DR, Cole BJ. Suppl-1, M2: An Age and Activity Algorithm for Treatment of Type II SLAP Tears. The open orthopaedics journal. 2018;12:271.
9 Fedoriw WW, Ramkumar P, McCulloch PC, Lintner DM. Return to play after treatment of superior labral tears in professional baseball players. Am J Sports Med. 2014 May;42(5):1155-60. doi: 10.1177/0363546514528096. Epub 2014 Mar 27.