Repairing a SLAP tear without surgery
Ross Hauser, MD., Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C., Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
David N. Woznica, MD., Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Repairing a SLAP tear without surgery
If you are reading this article you are likely someone very involved in sports or you have a physically demanding job. You may be a baseball pitcher or the parent of a baseball player, likely a pitcher, doing your research looking for that non-surgical alternative that will save the 2021 spring season for your son. You may be doing research for your daughter to keep her on the softball diamond. You may be a landscaper, tradesman or construction worker who does a lot of overhead work looking for the same thing, saving a season of work by getting your shoulder non-surgically repaired.
You have probably already been to a doctor for your SLAP tear
- You went to the doctor with concerns of pain, possibly a clicking sound and a sense of shoulder instability and loss of strength.
- In sports, like tennis, baseball and softball, your serve and your pitch (or throw from the outfield) may have lost a lot of steam, there is painful motion. Your shoulder may be catching or gets stuck.
- You may be a frustrated parent looking for something that will work and get your player back on the field.
- At the worksite, you have difficulty with things that require overhead movement.
Whatever the reason, you have a shoulder problem.
- It is a tear in the Glenoid Labrum, the fibrocartilagenous structure that forms a deep pocket that helps keep the humerus bone in the shoulder socket and provides a pain-free range of motion.
- SLAP stands for superior labrum anterior and posterior, meaning there’s a tear from front to back on the top of the glenoid labrum.
I went to the doctor. I was told SLAP tear surgery is the only way to recover. So now I wait.
Research: “Even in the most expert of hands, the rate of return to the preinjury level of performance ranges from 38% to 60% and is as low as 10% for pitchers.”
As we will see in the research in this article, doctors are exploring ways to make conservative, non-surgical options a better choice for patients. Why? Because surgeons are publishing study results suggesting that the surgical option is not the “cure-all to end-all,” when it comes to a SLAP tear. There is some disheartening research about the reality of surgery. Understanding your realistic options may help you make a realistic plan for recovery.
When discussing surgery, we always bring in the surgical option: This is from December 2018, the medical journal Arthroscopy: (1)
- “SLAP repair in throwing athletes should be approached with caution. Surgery may help improve symptoms but may not guarantee a return to the preinjury level of competition. Even in the most expert of hands, the rate of return to the preinjury level of performance ranges from 38% to 60% and is as low as 10% for pitchers.”
Is non-surgical conservative care a realistic option?
Research: The only traditional non-surgical treatment that worked was when shoulder muscular tightness was involved in the early stages of the tear and treatment focused on rest and rehabilitation.
Rest and rehabilitation are not typically the keywords that a young athlete or a competitive older athlete wants to hear. When someone with a SLAP tear comes into our office, the questions they have are centered around recovery time, “how long will I be down?” The patient’s decision to go to surgery may be based on the answer to how long it would take to recover from a SLAP tear if they went the non-surgical route.
Surgeons from Japan’s Nippon Medical School explored realistic non-surgical options for SLAP lesions. Here are the leaning points they published in the October 2018 issue of the Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation, and Technology. (2)
- Nonsurgical treatments are usually the first-line therapy for symptomatic SLAP lesion. However, some patients cannot obtain satisfactory improvement of their symptoms, leading to dysfunction of the shoulder and diminished pitching performance.
Forty-five baseball players with a SLAP lesion
The patients they looked at:
- Forty-five baseball players with SLAP lesion, average age 21.6 years, the youngest player was 16 the oldest was 36 years, and who underwent nonsurgical treatments
- The patients they did not include in the study were traumatic injury people, such as those who suffered a dislocation, fracture or injuries related to sports activities.
- Playing positions included pitcher (21 patients), catcher (3 patients), infielder (13 patients), and outfielder (8 patients).
- Of interest to note is that these players had shoulder problems for an average of 8 and a half months before nonsurgical treatments included physical therapy, such as range of motion, stretching, and rotator cuff exercises, as well as prescription of nonsteroidal anti-inflammatory drugs, if necessary, were given.
Who non-surgical treatments would work for and who it was not likely going to work for:
- The older the player, the less likely non-surgical treatments would work.
- The longer you played baseball, the longer the length of your playing years, the less likely non-surgical treatments would work.
- What position you played, pitchers would likely be less successful at non-surgical treatment.
- The longer you had the shoulder pain, the less likely non-surgical treatments would work.
- If you did not have full or at least a good partial range of motion in your shoulder, the less likely non-surgical treatments would work.
- Presence of Bone or Bennett spurs the less likely non-surgical treatments would work.
- Partial-thickness tears of the articular-side rotator cuff the less likely non-surgical treatments would work.
The only non-surgical treatment the doctors found that worked was when shoulder muscular tightness was involved in the early stages of the tear and treatment focused on rest and rehabilitation.
Is this why your SLAP tear conservative treatment failed? Because the treatments in general, beyond rest and shutdown, do not repair anything?
So if you went to a doctor with a problem in your shoulder:
- You then went for an MRI.
- SLAP lesion was identified.
- Physical therapy and exercise were tried.
- Pain and inflammation pills were tried.
- Rest and Ice were tried.
- You went back for another MRI. If the MRI is just as bad, you get recommended to SURGERY.
- IT IS IMPORTANT TO NOTE: There are many non-surgical less invasive procedures. This study examined physical therapy, exercise, and anti-inflammatory medications only. It did not examine regenerative medicine which we will below.
Maybe your shoulder problems are beyond a SLAP tear – Posterior glenohumeral instability in overhead athletes with SLAP tears
Let’s look at some of the learning points of a May 2020 study in The Journal of the American Academy of Orthopaedic Surgeons.(3) This paper examines Posterior glenohumeral instability and the failure of surgery.
First some learning points:
- Simply posterior shoulder instability is instability in the back of the shoulder.
- Understanding the complexity of posterior shoulder instability can make it difficult to diagnose and thereby difficult to treat,
- Posterior shoulder instability is typically seen in men who are involved in high impact/contact sports, and may have been brought on by an acute/impact injury.
- Posterior shoulder instability is not a isolated problem in shoulder patients. It is typically on one many problems including being a problem in patients with SLAP tears.
The (medical research) provides mixed results regarding the likelihood of overhead athletes with posterior glenohumeral instability and labral injury treated surgically returning to their preinjury level of sport performance.
Now for the research findings from the May 2020 study:
- “Posterior glenohumeral instability in overhead athletes presents a unique set of challenges for both diagnosis and treatment. Although a great deal of attention has been focused on the management of injuries to the biceps-labrum complex and rotator cuff in throwers, comparatively less has been written about posterior glenohumeral instability.”
- Generally, posterior instability comes secondary to either acute trauma or repetitive microtrauma, usually among collision athletes, weight lifters, and rowers. However, posterior glenohumeral instability resulting from pathology of the posterior capsulolabral (the posterior labrum and supportive soft tissue such as the shoulder ligaments and tendons) the tissues in throwers is a different entity, and the clinical assessment begins with an accurate differentiation between adaptive capsular laxity and labral injury with pathologic instability.
- Explanatory note: adaptive capsular laxity and labral injury with pathologic instability is when the ligament, tendons and labrum are injured, through acute or wear and tear injury, that they, the ligaments and tendons, cannot hold the shoulder in place. Chronic shoulder dislocation or glenohumeral subluxation result.
- SURGICAL OPTIONS: “Some posterior capsule labrum tears confirmed on arthroscopy will require nothing more than debridement. However, for more extensive lesions, surgical treatment must balance the necessity to repair torn capsulolabral tissues with the tendency to over constrain the shoulder.
- The (medical research) provides mixed results regarding the likelihood of overhead athletes with posterior glenohumeral instability and labral injury treated surgically returning to their preinjury level of sport performance.
A review of treatments: which will work, and when? Which will likely not work?
Physical therapy can delay the need for surgery in 2 out if of 3 patients
In August 2018, doctors at Tulane University published these findings in The Open Orthopaedics Journal.(4)
The management of SLAP lesions can be divided into 4 broad categories:
Category 1 Non-surgical methods that can help 2/3rds of patients
nonoperative management that includes scapular exercise, restoration of balanced musculature, and that would be expected to provide symptom relief in 2/3 of all patients
- Category 1: Non-operative management that includes scapular exercise to restore muscle balance in the shoulder wings. Shoulder exercises according to these researchers would be expected to provide symptom relief in 2/3 of all patients; enough to prolong or delay surgery.
Category 2 The Other 1/3rd of people for whom physical therapy did not delay the need for surgery:
- Category 2: Patients with a clear traumatic episode (larger tears) and symptoms of instability (possible chronic dislocations and subluxations) should undergo SLAP surgery and be divided into two surgical groups by age.
- If under 40 years old without biceps tenotomy or tenodesis or
- with (if over age 40) biceps tenotomy or tenodesis; (repair or cutting away of part of the bicep tendon).
- Biceps tenotomy is the cutting of the tendon to release its hold on the muscle and reduce spasms and stiffness. The muscle spasms and tightness is an attempt to stabilize the shoulder and prevent further injury. If you can repair the SLAP lesion, then biceps tenotomy is thought to speed recovery by removing the stimulus to spasm.
- Biceps tenodesis is usually reserved for patients over 40 because of its more radical nature. The Biceps tenodesis cuts the tendon to remove it from the labrum and then reattaches it directly to the bone.
Category 3 Patients who should get a different surgery
- Category 3: Patients with problems from overuse but without instability symptoms should be managed by biceps tenotomy or tenodesis; NOT slap tear surgery and
Category 4 Patients who need to throw
- Category 4: Throwing athletes should be in their own category and preferentially managed with:
- rigorous physical therapy centered on hip, core, and scapular exercise in addition to restoration of shoulder motion and rotator cuff balance. If this does not work then:
- Recommended surgeries include:
- Peel-back SLAP repair (Sewing the labrum down to prevent it from “peeling back,”
- Posterior Inferior Glenohumeral Ligament (PIGHL) release surgery. As in the tendon procedures, the ligament is cut to free up a frozen or limited range of motion shoulder
- And treatment of the partial infraspinatus tear with arthroscopic debridement procedure
- The diagnosis and management of SLAP lesions remain controversial.
- A detailed history and physical examination are more valuable than imaging.
- Non-operative management focused on scapular rebalancing is often effective.
- Surgery should include repair of the SLAP lesion if the history and physical examination are consistent with instability.
- Surgery, if performed, should be as minimal as possible to improve their chances of returning to sports and preinjury activity level.
Concern: The failure of SLAP lesion or SLAP tear surgery and repeated surgeries to fix what the first surgery could not
“The average time to that repeat shoulder surgery was a little more than 2 years later”
As you can see there are reasons surgery should be strongly reviewed is that the surgery may not help, may make your shoulder situation worse.
Research (5) from New York University says:
- of 2,524 patients who had a SLAP lesion surgical repair, after 3 to 11 years of follow-up, 10% of patients (254 of 2,524) underwent repeat surgical intervention on the same shoulder as the initial SLAP repair.
- The average time to that repeat shoulder surgery was a little more than 2 years later
- Subsequent procedures included:
- subacromial decompression a procedure that cuts ligaments and shaves down bone spurs on the acromion bone (35%),
- debridement, a “power washing” of the debris and damaged tissue in the shoulder (26.7%).
- repeat SLAP repair (19.7%),
- and biceps tenodesis or tenotomy (13.0%). This is a more radical procedure usually reserved for aging patients and involves cutting the tendon attachment of the bicep to the shoulder labrum and attaching it to the humerus bone (upper arm).
- After isolated SLAP repair (where only the SLAP lesion was arthroscopically repaired), patients aged 20 years or younger were more likely to undergo arthroscopic Bankart repair
- Patients over 30 were at risk for subsequent acromioplasty and distal clavicle resection
- The need for a subsequent procedure was significantly associated with Workers’ Compensation cases.
In a combined study from the University of Minnesota and German researchers, doctors found that if conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions could be achieved. However what was the measurement of success? If it was to return to sports, or improved function in older patients, it was not that successful.
- the results of arthroscopic repair in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance.
- 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.
These doctors also looked at the problem of “normal variations and degenerative changes” in the SLAP complex that needs to be distinguished from “true”SLAP lesions in order to improve results and avoid overtreatment.” Possibly avoid surgery based on the wrong recommendation.
Surgery as a diagnostic tool causes concern
In a recent review of SLAP lesion repair surgeries, one author, Stephen C. Weber, MD, noted the rise in both the number of repair surgeries and complications associated with them. This study looked at the American Board of Orthopedic Surgery database for SLAP lesion repairs.
- With 4,975 repairs in the database, only 26.3% of the patients reported a complete resolution of pain.
- Worse, only 13.1% of them reported normal function.
The author expressed concern over the number of young orthopedic surgeons performing SLAP lesion repairs and also the number of middle-aged and elderly patients receiving them given the complications associated.
He concluded that there should be a greater focus on educating young orthopedic surgeons so that they can recognize and treat SLAP lesions appropriately with the hopes of decreasing the number of surgical repairs performed.(7)
Four years later researchers suggest the best diagnostic tool is still surgery and doing some repair while you are in there.
- Doctors in the United Kingdom say magnetic resonance arthrography while having a high diagnostic accuracy for labral tears and Hill-Sachs lesions, is controversial. Arthroscopic diagnosis remains the gold standard. (8)
- University researchers in Turkey say “Although MRI is a good diagnostic tool for SLAP lesions, its use for the classification is limited.”(9)
“36.8% of these surgeries were considered a “failure” and 28% had to be redone”
“Arthroscopic revision type II SLAP repairs yield worse results than primary repairs as reported in the literature, with workers’ compensation patients and overhead athletes doing especially worse.”
The above recent study published in the American Journal of Sports Medicine analyzed the post-surgical outcomes of athletes with SLAP lesions (superior labrum anterior to posterior tears).(10)
One hundred seventy-nine military athletes were used in the study, all of which underwent surgery to fix an existing SLAP lesion. Out of all the operations, 36.8% of these surgeries were considered a “failure” and 28% had to be redone. That means that 66 individuals had a failed surgery and 51 had to go back into the operating room.
At two to five year follow-ups, a significant amount of these athletes still had decreased range of motion in the affected shoulder. Researchers concluded that an age greater than 36 years old was the factor that was associated with an increased chance of surgery failure. Other studies have shown similar statistics with many participants unable to ever return to their previous pre-surgery activity level.
The revision surgery to fix the first surgery
Surgeons writing in the Open Orthopaedics Journal (11) discuss what they see in patients with a failed SLAP tear surgery:
Causes for failed SLAP repair are:
- poor healing,
- recurrent injury,
- (suture) anchor placement,
- over-tensioning (the bicep tendon and labrum are pulled too tight)
- failure of metallic proud anchors,
- loose tacks,
In speaking of the problems of misdiagnosis, the surgeons noted:
- “Correct diagnosis of the initial SLAP tear is challenging. History and physical exam findings lack specificity. MRI or MRA can have a high rate of false positives.
- There is substantial inter and intraobserver variability amongst experienced shoulder arthroscopists with surgeons having difficulty distinguishing normal shoulders from type II SLAP tears.
- It has been noted that there was a trend to overtreat SLAP lesions in the US and it has been postulated that some patients with a failed SLAP repair underwent repair of a normal labral variant.”
In other words, people had surgeries on a labrum that did not need a surgery. The surgery worsened their condition.
The major long-term functional problem of surgical treatment for shoulder labrum tears is that the surgery usually confined itself to stapling or suturing the labrum itself and did not address damage occurring in the whole shoulder.
Treating the glenoid labrum or SLAP tear with sutures and staples would indicate the pain is coming from isolated tissue damage. It is thought by keeping the humeral head in the socket, chronic instability will go away. In reality, this is not the case. Any type of injury affects all the structures of the joint. In the patients we see at Caring Medical, this is not the case. People with shoulder labrum problems have whole shoulder joint instability, they have damage to the shoulder ligaments front and back, they have damage to the rotator cuff tendons and damage to the biceps tendon that surgery cannot address.
Back to Baseball the SLAP lesions in the Pitcher
Doctors at Houston Methodist Hospital published these findings in the American Journal of Sports Medicine:(12)
The published return-to-play (RTP) rates for athletes who have undergone surgical repair of superior labrum anterior-posterior (SLAP) tears vary widely and are generally accepted to be lower in the group of competitive throwers (baseball pitchers). Therefore the effectiveness of nonsurgical treatment should be explored.
The Houston group looked at 119 patients in a single professional baseball organization with persistent shoulder pain that limited the ability to compete.
- Sixty-eight patients had magnetic resonance imaging-documented SLAP lesions.
- All patients had failed 1 attempt at rehabilitation but had continued with supervised physical therapy.
- Treatment was according to an algorithm focusing on the correction of scapular dyskinesia and posterior capsular contracture with glenohumeral internal rotation deficit (GIRD), followed by a pain-free return to throwing.
- Scapular dyskinesis or SICK scapula syndrome is considered an overuse injury (common in throwing athletes) in which there is abnormal movement and resting location of the scapula.
- Posterior capsular contracture with glenohumeral internal rotation deficit (GIRD) also signifies the abnormal movement of the shoulder with overuse being a possible cause.
Those who failed 2 cycles of nonsurgical treatment were treated surgically.
Success was defined by 2 different standards:
(1) return-to-play (RTP), success was measured in accordance with previous study findings; and
(2) a more stringent standard of return to the same level/quality of professional competition (level A baseball, Double A baseball, Triple A baseball, etc.) with the incorporation of a return to preinjury individual performance statistics (earned run average, walks plus hits per inning pitched), termed “return to prior performance” (RPP).
- Sixty-eight athletes were identified with SLAP lesions.
- Twenty-one pitchers successfully completed the nonsurgical algorithm and attempted a return.
- Their return-to-play rate was 40%,
and their return to prior performance rate was 22%.
- Their return-to-play rate was 40%,
- The return-to-play rate for 27 pitchers who underwent 30 surgical procedures was 48%, and the RPP rate was 7%.
- For 10 position players treated nonsurgically, the return-to-play rate was 39%, and the RPP rate was 26%.
- The return-to-play rate for 13 position players who underwent 15 procedures was 85%, with an RPP rate of 54%.
- Nonsurgical treatment correcting scapular dyskinesia and GIRD had a reasonable success rate in professional baseball players with painful shoulders and documented SLAP lesions.
- The rate of return after surgical treatment of SLAP lesions was low for pitchers.
- The return-to-play rate and RPP rates were higher for position players than for pitchers.
- Nonsurgical treatment should be considered for professional baseball players with documented SLAP lesions, as it can lead to acceptable return-to-play rate and return to prior performance rates.
In a study from late 2016, doctors at Wayne State University School of Medicine published these findings:(13)
- Of the twenty-four Major League Baseball players who had SLAP tear surgical repair between 2003 and 2010 who met the study criteria:
- 62.5% were able to return-to-play at the Major League level after SLAP repair surgery.
- Of those able to return-to-play, 86.7% were able to return to prior performance.
However, the overall rate of return to prior performance, including those unable to return-to-play rate, was 54.2%. A little more than half had a successful surgery and return to prior performance. However, performance analysis of the return-to-play group revealed a statistically significant decrease in innings pitched for Major League pitchers throwing a mean 101.8 innings before the injury and 65.53 innings after injury.
Non-surgical regenerative medicine injection therapy for SLAP lesions
In the video above, Ross Hauser, MD explains how we treat SLAP tears. Here is a summary of the video transcript.
- SLAP Lesions or Tear are very common injuries we see.
- The shoulder labrum works with the shoulder ligaments to provide shoulder stability. When labrum or shoulder ligaments are injured, the shoulder becomes unstable, the shoulder can dislocate or pop out of place. There is a clicking sound on movement, athletes find that they have no overhand power.
- In our office we try to educate patients that if you have a labral tear, any kind of labral tear, the shoulder joint is unstable so it just injecting cortisone inside the joint just isn’t good enough you have to get comprehensive Prolotherapy. Why Prolotherapy? Because whatever the injury that caused the slap lesion will have likely injured the ligaments in the front of the shoulder and the back of the shoulder. Injury or tearing to the rotator cuff tendons and biceps tendon has probably occurred. So you have to get all those areas treated.
- Prolotherapy is a very good treatment for slap lesions
- There are different solutions that we use so normally we start with the dextrose Prolotherapy solution but sometimes we will use platelet rich plasma
- When I do prolotherapy for a slap lesion in the shoulder of person might get 30 separate injections and that way they are assured and I’m assured that we did all the areas that are involved in tendons the ligaments as well as the slap lesion. Typically people will get 4 treatments as far as rehabilitation after you get prolotherapy for a slap lesion after the first visit I normally waited have them do exercises that limit their shoulder motion so the elbow stays close to the side. As the shoulder joint stabilizes then I’ll liberalize the exercise program
- Some people don’t get better from prolotherapy with slap lesions because they don’t rehab it properly. They put the shoulder joint in an abducted and externally rotated position which puts increased strain on the labrum. In other words, they are putting the labrum under strain while it’s torn. Even though the prolotherapy is stimulating repair, you’re putting too much pressure on it
People with SLAP tears who call or email us, do so because they want to avoid surgery. Perhaps it is the athlete who cannot afford to miss a High School or Collegiate season or it is a house painter or the tree trimmer or the carpenter who cannot afford extended time away from his/her business.
The treatments we offer are
- Prolotherapy. This is a simple dextrose injection that promotes tissue healing through a controlled inflammation.
- Platelet Rich Plasma Injections which is the use of your own healing blood platelets to repair damaged tissue.
- For significant damage or when healing needs to be performed on a more accelerated method, we may prescribe stem cell therapy. This is the use of your own stem cells. We do not offer stem cells to every patient. We find that H3 Prolotherapy and PRP injections provide the patient’s goal of treatment within the time frame they are looking for. This procedure is explained in the video below.
As explained in the video above and presented in more detail here.
- A patient may get 30 separate injections in one Prolotherapy treatment.
- Why so many treatments? Because we are treating the entire shoulder joint complex. This includes the shoulder ligaments and tendons as well as the SLAP lesion. This, of course, would be especially beneficial to laborers and athletes because you are strengthening the other important areas of the shoulder.
- We typically recommend exercises that limit their shoulder motion so the elbow stays close to the side.
- We would discuss altering work-related movements to keep the elbow close, like how to swing a hammer or use power tools. For the athlete how to throw.
- It is important to keep pressure off the labrum while it is healing and rehab properly.
We will often see patients who went to their orthopedic surgeon and were able to receive a PRP injection into the shoulder. In our experience, we have found that you cannot simply offer a single platelet-rich plasma injection inside the joint and expect superior results. When Prolotherapy/PRP injections are offered here, as just mentioned, a patient may expect 30 injections in a comprehensive treatment.
Caring Medical published research
Ross Hauser, MD, Hauser M, Dolan E, Orlofsky A. Prolotherapy: a non-invasive approach to lesions of the glenoid labrum; a non-controlled questionnaire-based study. The Open Rehabilitation Journal. 2013;6:69-76. (14)
Lesions of the glenoid labrum are a common cause of shoulder instability and a frequent finding in patients with shoulder pain. Management of these patients typically involves an attempt to avoid surgery through conservative treatment. However, there is currently a dearth of conservative options that promote labral healing.
- Regenerative injection therapies, including prolotherapy, have shown promise in the treatment of several musculoskeletal disorders, but have not previously been applied to glenoid labral tear.
- Here we review several important aspects of these lesions and present an initial case series of 33 patients with labral tear that were treated in our clinic with intra-articular injections of hypertonic dextrose.
- Patient-reported assessments were collected by questionnaire at a mean follow-up time of 16 months.
- Treated patients reported highly significant improvements with respect to pain, stiffness, range of motion, crunching, exercise and need for medication.
- All 31 patients who reported pain at baseline experienced pain relief, and all 31 who reported exercise impairment at baseline reported improved exercise capability. Patients reported complete relief of 69% of recorded symptoms. One patient reported worsening of some symptoms. Prolotherapy for glenoid labral tear appears to be a safe procedure that merits further investigation.
If you have questions and would like to discuss your shoulder pain issues with our staff you get help and information from our Caring Medical staff.
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