Slap tear treatment without surgery | Comprehensive Prolotherapy
Danielle R. Steilen-Matias, MMS, PA-C
New research explored the many surgical options in the treatment of SLAP lesions, however, while there are many options, unfortunately, the success rates of these surgeries are being called into question.
SLAP stands for superior labrum anterior and posterior, meaning there’s a tear from front to back on the top of the glenoid labrum of the shoulder. The glenoid labrum is a fibrocartilagenous structure, like lips, in fact, the word labrum means “lips.” These lips/labrum forms a deep pocket that helps keep the humerus bone in the shoulder socket.
SLAP tear it is best to take action sooner rather than later
Labral injuries can come from acute trauma or natural wear and tear. When the labrum is torn, stretched, or otherwise pulled from its natural position, it is best to take action sooner rather than later. One reason to take quicker action is that it is usually not just the labrum itself that is injured, it is highly likely that the ligaments and tendons of the shoulder are also injured, whether by acute injury or the same wear and tear forces that have caused the degenerative tear in the labrum. Weakened ligaments and tendons increase vulnerability to future shoulder damage an as one continues to use the unstable shoulder, the body attempts to stabilize the joint by over growing bone (bone spurs).
When you have a labral tear, generally there are clicking sounds and a sense of shoulder instability and loss of strength. In sports, like tennis and baseball, for instance, your serve and your pitch may have lost a lot of steam. See our supporting article SLAP lesions in major league baseball pitchers. In that research we find doctors suggesting that nonsurgical treatment should be considered for professional baseball players with documented SLAP lesions, as it can lead to acceptable return-to-play and return-to-previous-performance rates.(1)
The SLAP surgical options examined
Research 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.(2)
In a combined study from 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 return to sport, or 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 a surgery based on the wrong recommendation.
Surgery as 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.(4)
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. (5)
- University researchers in Turkey say “Although MRI is a good diagnostic tool for SLAP lesions, its use for the classification is limited.”(6)
“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).
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 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 labral tear with sutures and staples would indicate the pain is coming from an 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.
This is also the type of damage that doctors who offer single shot injections of Platelet Rich Plasma or any type of stem cell therapy do not address as well.
Prolotherapy is a non-surgical procedure that uses the body’s natural immune system response in order to call more focused attention to an injured joint. This is done by injecting a dextrose proliferant solution) in and around the shoulder joint. This mild irritant causes inflammation and repair in that specific area.
We have found Prolotherapy to be a very good treatment for slap lesions. We encourage people to try Prolotherapy first before committing to a surgery that may offer less than hoped for results. It is somewhat rare that we will recommend anyone onto surgery after Prolotherapy treatments.
When Platelet Rich Plasma will not work for shoulder labrum tear and when it will
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, a patient may expect 30 injections and a comprehensive treatment. This type of treatment offers the patient a superior healing program to address the ligament and tendon laxity that contributes to whole shoulder instability and destructive joint motion on the labrum.
If you have questions and would like to discuss your shoulder pain issues with our staff you get get help and information from our Caring Medical staff.
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