SLAP Lesions : Just because we can, doesn’t mean we should
Labral tear- SLAP lesion
MRI machines have become more powerful and radiologists become better at interpreting the findings. Perhaps that is why shoulder surgeons have noticed a significant increase in the number of SLAP lesions being diagnosed across all age groups. It is important to bear in the mind the research of DePalma performed over 70 years ago. During his autopsy studies he found that more then 75% of people over 60 had labral tears in the shoulder. Simply stated that means that the majority of these tears are not bothersome, do not hurt you and thus do not, in and of themselves require surgery. Again, as hard as it is to hear, some times our parts simply wear out. We treat patients and not MRI findings… so it is important that we listen to you describe your symptoms, correlate that with a proper physical exam and then determine what the cause of your pain is.
Are we over-treating SLAP lesions… and if so, why?
Dr David Geier recently discussed this same issue on his website too.
Some background information first.
What is a SLAP lesion or SLAP tear?
The two terms are synonymous. They mean the same thing. As the picture above shows, a SLAP lesion involves the tear of the glenoid labrum from the top of the socket of the shoulder. This video on shoulder anatomy may assist you further.
The superior labrum serves as the attachment for our biceps tendon inside the shoulder. The labrum plays a role in the stability of the shoulder. It helps keep the shoulder well seated within the socket during aggressive overhead activities such as pitching, swimming and playing volleyball. The superior labrum does not comes into play from a functional perspective during our normal daily activities of dressing, feeding, cleaning, weeding, gardening, running, cycling, etc.
Why do SLAP lesions hurt?
SLAP lesions can lead to a unique form of instability (where the shoulder is “loose”), and as previously mentioned, primarily occurs in over-head athletes. When the shoulder is loose because of a SLAP tear, and the player puts their arm up in the throwing positon they may feel pain in the back of the shoulder. We call this “internal impingement”. This occurs because the SLAP tear has led to a very subtle loosening (not enough for the shoulder to dislocate) which will hurt when the superior labrum (where the tear is) is stressed.
Do SLAP Lesion require surgery?
A troubling study was just released …
A study in May 2012 issue of The American Journal of Sports Medicine reflects this trend (towards operating on too many SLAP tears) . Alan L. Zhang et al looked at insurance data collected for over 11 million patients from 2004 to 2009. They found a remarkable 105% increase in SLAP repairs performed across the United States between 2004 and 2009.
The 20-29 year and 40-49 year age groups had the highest incidence of SLAP repairs. Males comprised approximately 75% of those surgical patients. Interestingly, SLAP repairs were performed more often in the West and the South compared to the Midwest and Northeast.
The majority of SLAP lesions or tears encountered in a typical orthopedists office do not need to be repaired and are usually not the source of pain. Even if the surgeon believes that the tear might be the source of pain, the results of repairing SLAP lesions has been relatively poor in patients over 35-40, so many researchers suggest that the tear not be fixed and that a biceps tenodesis be performed ( anchoring the biceps on the humerus and taking the stress off of the superior labrum.
SLAP lesions found in young pitchers, volleyball players, tennis players and swimmers can be fixed if the tear is leading to significant pain and the inability of the athlete to perform at their usual performance level. They do, however, have the option of changing positions, etc and not having surgery.
The results of SLAP lesion repairs and return to sports is also mixed. Some reports show that athletes can return to their prior performance levels, yet some recent literature shows that that might not be the case. The jury is still out on this.
Bottom line: SLAP lesions are very common. Just because you have one, does not mean you need surgery. If you are an overhead athlete and have internal impingement due to a SLAP tear you may chose to have surgery — but you may not be able to return to your prior level of functional performance. Tough decision making.
