Repairing a SLAP tear without surgery or biceps tenodesis

Ross A. Hauser, MD.

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 may also be someone who wants to go back to being a weekend athlete and play some sports that require you to lift your hand above your head.

You have probably already been to a doctor for your SLAP tear

Whatever the reason, you have a shoulder problem.

Article outline:

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)

More recently a May 2021 study in the Open Access Journal of Sports Medicine (2) from the Department of Orthopaedic Surgery, University of Utah Health states:

“Superior labrum anterior-posterior (SLAP) lesions are common in overhead athletes. Though some patients have asymptomatic lesions, many tears cause pain and diminished athletic performance.

Accurate diagnosis of SLAP lesions can be challenging as the sensitivity and specificity of both the physical exam and advanced imaging is questionable. Management is also difficult, as treatment can be life-altering or career-ending for many athletes.

If first-line nonoperative treatment fails, surgical options may be considered. The optimal surgical management of SLAP lesions in athletes is debated.

Historically, return to play rates among athletes who have undergone arthroscopic SLAP repair have been unsatisfactory, prompting clinicians to seek alternate surgical options. Biceps tenodesis (BT) has been postulated to eliminate biceps tendon-related pain in the shoulder and is increasingly used as a primary procedure for SLAP lesions.

Unfortunately, a large proportion of athletes undergoing either arthroscopic SLAP repair or Biceps tenodesis will not return to play.”

An April 2022 study in The American journal of sports medicine (20) comes from New York University Langone Health. In this paper doctors examined the occurrence of  return to play after biceps tenodesis for isolated SLAP tears in overhead athletes. Here the study team investigated clinical outcomes in overhead athletes undergoing biceps tenodesis for the treatment of symptomatic, isolated SLAP tears involving the biceps-labral complex.

Conclusion: “This study found that athletes undergoing biceps tenodesis for the treatment of a symptomatic, isolated SLAP tear had a high rate of return to play, good functional outcomes, and a low rate of revision surgery. ”

A March 2022  paper from George Washington University School of Medicine and the William Beaumont Army Medical Center, published in the journal Arthroscopy (21) reported on outcomes following biceps tenodesis combined with arthroscopic posterior labral repair of type VIII superior labrum anterior posterior (SLAP) lesions in active-duty military patients. They found that among thirty-two patients, thirty (93.75%) patients remained on active-duty military service and were able to return to preinjury levels of activity.

Post-surgery pain and the post-surgery MRI. What does this tell us?

Many patients and doctors agree to a shoulder labrum surgery if the case is “simple.” Let’s refer to a new book, Musculoskeletal Diseases 2021-2024, (3) in which the authors describe and comment on shoulder labrum tears.

“If there is no associated extension of the labral tearing into the proximal portion of the tendon of the long head biceps brachii and if there is no significant instability of the origin of the long head biceps, these are often treated with simple debridement and shaving of the frayed portion of the labrum. (In other words, if the injury is isolated to the labrum and has not extended into the long head biceps a simple arthroscopy can be performed.) If there is a significant extension of the tear into the biceps tendon and/or associated instability of the origin of the biceps tendon (biceps anchor), then a superior labral repair may be performed.”

But what if the patient has persistent pain after the surgery. Will the MRI help understand the problem or compound the problem? This is the challenge.

The radiologist in a successful surgery MRI review should see a “Differentiating residual cleft.” The authors note: “If a superior labral tear is repaired, a persistent cleft undercutting the labrum may be present on postoperative imaging.” However, in an abnormal MRI, which can be asymptomatic or symptomatic, telling the difference between “a residual (cleft) or recurrent tear can be challenging.” In other words, is the MRI showing a successful surgery or the continuation of tearing post-surgery?

The outcome of this challenging understanding of the successful surgery can be seen in some of the stories people tell us when they are exploring our treatment options. The stories go something like this:

Pain after successful surgery

I had shoulder labrum surgery recently. I found the surgery to be very successful. I got back to normal activity with no pain and no limits. However, without any injury or having done anything to it, my shoulder suddenly developed constant pain. I have a limited range of motion and pain when I try to reach for anything. An MRI revealed a SLAP tear. My doctors are not convinced the first surgery repaired everything “all the way.”

Cortisone recommendation after surgery

I had surgery. As the months went on the pain and loss of function in my shoulder increased. The pain goes from constant low-level pain to acute stabbing pain especially when I try to reach or grab for something. I have to “start all over again with physical therapy then cortisone and then if needed another surgery because my MRI is inconclusive.

Again, many people have very successful surgeries. These people are not the people we see at our center. We see the people with a similar tale to hose in this article.

What is the best rehabilitation program following SLAP tear or surgery? Doctors are not sure.

What is the best rehabilitation program following SLAP tear surgery

An October 2021 study (22) from the University of Kansas School of Medicine discussed the variability in rehabilitation programs following a SLAP tear surgical repair.

Here is what the Kansas researchers wrote: “Rehabilitation after a superior labral anterior posterior (SLAP) repair is an important aspect of patient outcomes; however, no standardized rehabilitation protocol has been defined. The purpose of this paper is to assess the variability of rehabilitation after a SLAP repair to understand the need for standardization to improve patient outcomes.” The researchers compared protocols by sling, range of motion (ROM), physical therapy, return to sport (RTS), return to throwing, and biceps engagement and tenodesis recommendations.”

The researchers found sixty different rehabilitation protocols.

The researchers concluded: “A lack of specificity within protocols in what return to throwing meant for functional ability made it difficult to compare protocols. Considering the large number of orthopedic programs, a relatively small number had published protocols. Further studies are needed to evaluate a standardized post-operative rehabilitation for SLAP repairs to improve outcomes.”

To reiterate: What is the best rehabilitation program following SLAP tear surgery? Doctors are not sure.

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 learning points they published in the October 2018 issue of the Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation, and Technology. (4)

Forty-five baseball players with a SLAP lesion

The patients they looked at:

Who non-surgical treatments would work for and who it was not likely going to work for:

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 with your shoulder:

What are we seeing in this image?

Some of the ligaments and connective tissue of the shoulder. Typically SLAP tears are not a problem by themselves, the tear can involve any or many of the supporting tissues of the shoulder capsule.

Some of the ligaments and connective tissue of the shoulder. Typically Slap tears are not a problem by itself, it can involve any or many of the support tissue of the shoulder capsule.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. (5) This paper examines Posterior glenohumeral instability and the failure of surgery.

First some learning points:

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 sports performance.

Now for the research findings from the May 2020 study:

A review of treatments: which will work, and when? Which will likely not work?

A March 2022 paper in the Journal of Bone and Joint Surgery Reviews (18) offers us an outline of treatment by suggesting “thorough understanding of the pathologic cascade (the components that is causing failure in the thrower’s shoulder) is paramount for professionals who care for throwing athletes. The successful treatment of this condition depends on the correct identification of the point in the cascade that is disturbed. The typical injuries described in the throwing shoulder rarely occur in isolation; thus, an overlap of symptoms and clinical findings is common. (In other words, it is not just one tear). The rationale for treatment is based on the pathophysiologic biomechanics and should involve stretching, scapular stabilization, and core and lower-body strengthening, as well as correction of throwing mechanics, integrating the entire kinetic chain. When nonoperative treatment is unsuccessful, surgical options should be tailored for the specific changes within the pathologic cascade that are causing a dysfunctional throwing shoulder.

The above suggestions seem obvious enough. Find the point of the throwing motion that is causing the pain and how it impacts the rest of the throwing motion and treat it. However, the research above does stress that in the throwing shoulder, whole shoulder instability should be addressed. This was also suggested in a February 2022 paper from the Sports Medicine Institute, Fudan University in China. (19) The doctors wrote:

“SLAP lesion destroys mechanisms of shoulder stability, while shoulder instability causes tears of the upper labrum and the long head of biceps tendon, showing a connection between shoulder instability and SLAP lesion. However, the existing evidence can only demonstrate that shoulder instability and SLAP lesion induces and promote the development of each other, instead of a necessary and sufficient condition.” In other words, when it comes to shoulder instability and SLAP tears there is no “magic bullet” to understand the process of shoulder instability even when obvious tears and lesions are present.

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. (6)

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 2 The Other 1/3rd of people for whom physical therapy did not delay the need for surgery:

Category 3 Patients who should get a different surgery

Category 4 Patients who need to throw

The conclusion: 

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 (7) from New York University says:

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 improve function in older patients, it was not that successful.

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.[8] 

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.

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. (9)

Four years later researchers suggest the best diagnostic tool is still surgery and doing some repair while you are in there.

“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). (12)

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 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 (13) discuss what they see in patients with a failed SLAP tear surgery:

Causes for failed SLAP repair are:

In speaking of the problems of misdiagnosis, the surgeons noted:

In other words, people had surgeries on a labrum that did not need 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.

Slap tear and Biceps Tenodesis – Surgery to fix the failed surgery

A June 2020 study in The American Journal of Sports Medicine gave this assessment of Biceps Tenodesis surgery for the overhead athlete. This is what the researchers from Wexner Medical Center at The Ohio State University wrote:(14)

“While surgical management has traditionally consisted of SLAP repair, high rates of revision and complications have led to alternative techniques, such as biceps tenodesis. While biceps tenodesis is commonly reserved for older non-overhead athletes, indications for its use have expanded in recent years.”

What this study wanted to do was to determine functional outcomes and return-to-sport rates among overhead athletes after biceps tenodesis for SLAP tear by examining pre-existing surgical outcome studies.

Conclusion: “Biceps tenodesis in the overhead athlete offers encouraging functional outcomes and return-to-sport rates, particularly in the recreational athlete. It can be successfully performed as an index (main) operation rather than SLAP repair, as well as in a younger patient population. Careful consideration should be given to elite overhead athletes, particularly pitchers, who tend to experience poorer outcomes.”

Back to Baseball the SLAP lesions in the Pitcher

Doctors at Houston Methodist Hospital published these findings in the American Journal of Sports Medicine:(15)

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.

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).

CONCLUSION:

In a study from late 2016, doctors at Wayne State University School of Medicine published these findings:(16)

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 of 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.

What are we seeing in this image?

In this illustration, the areas where Prolotherapy injections are given are demonstrated. This includes the biceps bracii muscle attachment which moves the shoulder and the forearm. The transverse Humeral Ligament works with the biceps brachii muscle to provide shoulder stability.

In this illustration, the areas of where Prolotherapy injections are given is demonstrated. This includes the biceps bracii muscle attachment which moves the shoulder and the forearm. Transverse Humeral Ligament which works with the biceps brachii muscle to provide shoulder stability.

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

As explained in the video above and presented in more detail here.

After treatment:

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. (17)

ABSTRACT

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.

Do you have a question about your shoulder?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your shoulder problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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1 Makhni EC. Editorial Commentary: Buyer Beware—Throwers Undergoing Type VIII SLAP Repair Should Do So With Very Reasonable Expectations. [Google Scholar]
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This article was update May 17, 2022

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