Journal of Athletic Training 2000;35(3):286-292

© by the National Athletic Trainers' Association, Inc

www.joumalofathletictraining.org

Superior Labral Lesions: Diagnosis and

Management
Donald F. D'Alessandro, MD*; James E. Fleischli, MDt;
Patrick M. Connor, MD*
*The Shoulder and Elbow Center, Miller Orthopaedic Clinic, Charlotte, NC; tCarolinas Medical Center,
Charlotte, NC

Objective: To review the pathoanatomy, classification, and in athletes associated with complaints of pain and clicking or
etiologies of lesions of the superior labrum and biceps anchor popping in the shoulder. The diagnosis can be difficult, as
(SLAP lesions) and to discuss the clinical presentation, with clinical findings may overlap with those of acromioclavicular or
emphasis on physical examination findings and current treat- rotator cuff problems and exist concomitantly with glenohu-
ment recommendations. meral instability.
Data Sources: We searched MEDLINE for English-language ConclusionslRecommendations: Superior labral lesions
articles published from 1985 to 1999 using the key words are a relatively newly defined cause of shoulder pain and
"superior labral lesion," "SLAP lesion," "labral tear," and "bi- disability. Knowledge about these lesions and a high index of
ceps tendon." Additional information was obtained from cross- suspicion are essential to identifying this important cause of
referencing pertinent articles and personal communications shoulder pain. Superior labral lesions are usually confirmed and
with experts in the field of shoulder arthroscopy. successfully managed arthroscopically.
Data Synthesis: The clinical presentation of superior labral Key Words: shoulder arthroscopy, SLAP lesion, labral tear,
lesions often includes a history of trauma or repetitive overuse biceps tendon

O ur knowledge of the superior labrum and biceps anchor gross anatomy, histology, and vascularity of the glenoid
has benefited from the excellent visibility and accessi- labrum in a cadaver study. The biceps tendon was found to
bility provided by the arthroscope, as this area was consistently insert directly into the most superior portion of the
previously difficult to assess through standard open ap- labrum. At the 12 o'clock position on the glenoid rim, the
proaches. Arthroscopy has now allowed us to define normal in hyaline cartilage extended over the superior edge, where the
vivo anatomy and to begin to understand the variety of labral attachment of the undersurface of the superior labrum con-
pathologies that can occur.1 sisted of thin connective tissue. A small recess or synovial
Over the past decade, a number of nonpathologic anatomic reflection just below the biceps insertion on the supraglenoid
variants have been recognized that must be distinguished from tubercle was usually present. The anterosuperior labrum was
labral pathology. Injuries to the superior glenoid labrum are loosely attached to the glenoid, and its configuration and
relatively uncommon, found in only 6% of a large series of histology resembled that of the meniscus in the knee. Thus, the
patients with symptomatic shoulders evaluated arthroscopi- glenoid labrum is commonly triangular in cross-section, with
cally.2 These injuries were initially classified and named SLAP its free edge pointing toward the glenohumeral articulation.
lesions (superior labral anterior and posterior lesions) by The superior and anterosuperior portions of the labrum are less
Snyder et al3 in 1990. It is important to understand that these vascular than the remainder of the labrum, a fact that may have
lesions not only involve the superior glenoid labrum but the important clinical implications regarding the healing potential
biceps and glenohumeral ligament attachments as well. of the superior labrum.
The superior and middle glenohumeral ligaments usually
Anatomy attach to the anterior-superior labrum, which in turn attaches to
The anterosuperior labrum extending from the biceps anchor the glenoid rim (Figure 1). However, normal variants of this
to the midglenoid notch (the 3 o'clock position on the glenoid anatomy must be recognized as nonpathologic. The sublabral
rim) is one of the most confusing and variable areas of foramen is a normal opening or hole between the labrum and
glenohumeral anatomy (Figure 1). Cooper et a14 described the glenoid rim. Its size can vary from only a few millimeters to
spanning the entire anterior-superior quadrant (Figure 2A). In
normal variants, the edges of both the labrum and glenoid are
Portions of this review article have been previously published in Joumal smooth, without the fraying or hemorrhage that would be more
of the Southem Orthopaedic Association, volume 4, number 3, 1995,
and are reprinted with permission from the Southem Orthopaedic suggestive of a pathologic detachment.
Association. In a review of 200 shoulder arthroscopies, Williams et a15
Address correspondence to Donald F. D'Alessandro, MD, Miller Ortho- found 24 (12%) such normal sublabral foramina. Seventy-five
paedic Clinic, 1001 Blythe Boulevard, Suite 200, Charlotte, NC 28203. percent of patients with sublabral foramina also exhibited a
E-mail address: [email protected] cord-like middle glenohumeral ligament (MGHL) that inserted

286 Volume 35 * Number 3 * September 2000

 I-,3ipr ;a5 p itus rm s A B
proci-ss
Coracoid
Acm omrmr iorl
Lorng head of the
ArtAi lir Cmp;lmIe X biceps tendon (LH3!

mtdrae-inatLs
J Muscle
Superior glenohuineral
Cilenoid cavity

:Clenoid labrum ( Subscapular recess

.hX
.
-Subscapularis tendon

Icr-~s minor ruL pi

L s !
a I Middle glenohUmeral
ligamnent (MGCHLL;

:i,: I- f' i.. r1 :, c

Figure 1. Arthroscopic anatomy of the glenohumeral joint.

directly into the superior labrum at about the 1 o'clock position

on the glenoid (Figure 2B). They also defined another uncom-
mon (1.5%) normal variant in this area termed the Buford
complex, consisting of a cord-like MGHL inserting at the base
of the biceps tendon, with a complete lack of anterosuperior
labral tissue (Figure 2C). The importance of these variants is
emphasized by a case report in which a cord-like MGHL was
misinterpreted as a labral detachment and stapled down.6
Severe restriction of external rotation resulted, which required
manipulation under anesthesia and capsular release. Figure 2. Normal anatomic variants of the anterosuperior glenoid
labrum and glenohumeral ligaments. A, Sublabral foramen. B,
CLASSIFICATION OF SUPERIOR GLENOID LESIONS Cord-like middle glenohumeral ligament. C, Buford complex (cord-
like middle glenohumeral ligament with absence of anterior-
Snyder et al,3 in 1990, divided superior labral lesions into 4 superior labral tissue).
distinct types according to the pathoanatomy noted at the time
of surgery. A type I SLAP lesion has degenerative fraying of
the superior labral edge, which remains firmly attached to the Reinhart et al9 proposed an alternative approach using
glenoid (Figure 3A). In type II lesions, the superior labrum and clinical criteria as a means of categorizing lesions. They
attached biceps tendon are stripped off the superior glenoid, reviewed 52 patients with injuries to the structures of the
destabilizing the biceps anchor (Figure 3B). Type III lesions superior glenoid. Patients were grouped according to clinical
involve a bucket-handle tear of the superior labrum, which may presentation, considering history, physical examination, and all
or may not displace into the joint. The peripheral edge of the the pathologic findings identified at arthroscopy, not just those
labrum and biceps anchor remains intact (Figure 3C). In type specific to the glenoid labrum. Understanding that SLAP
IV lesions, a bucket-handle tear is present as in type III but lesions can be isolated or associated with rotator cuff disease
with extension into the biceps tendon itself (Figure 3D). and glenohumeral instability is essential to making the appro-
Most superior labrum-biceps tendon complex tears fall into priate therapeutic recommendations.
1 of the above categories. In a large series of 140 superior
labrum injuries reviewed by Snyder et al,2 type II lesions were ETIOLOGY
the most common, representing 55% of all lesions, followed by
type I lesions (21%), type III lesions (9%), and type IV lesions, To understand the etiology of superior labral injuries, it is
(10%). Although other authors have labeled additional types of useful to first consider the 2 discretely different mechanisms of
SLAP lesion, the pathologic findings can usually be described injury that have been proposed in the literature: superior
in terms of a combination of the above standard types. Of the compression and inferior traction.
140 lesions reviewed by Snyder et al,2 5% were complex and An acute traumatic superior compression force to the shoul-
represented combinations of type II and III or type II and IV der, usually due to a fall onto an outstretched arm with the
lesions. shoulder positioned in an abducted and slightly forward-flexed
There is, however, 1 additional labral injury pattern that position at the time of impact, was the most common mecha-
warrants a designation as type V. Maffet et al7 described 14 nism of injury described in the initial series of Snyder et al.3 In
cases of a type V SLAP lesion characterized by an anteroin- a subsequent series, Snyder et al2 again found that the most
ferior Bankart lesion that continued superiorly to include a common mechanism of injury was a fall or direct blow to the
separation of the anterosuperior labrum and biceps tendon. shoulder, occurring in 31% of patients.
Warner et al8 reported this identical lesion in 7 cases of A significant number of patients with superior glenoid
arthroscopic repair of the combined Bankart and SLAP lesion lesions and concomitant impingement or rotator cuff disease in
in patients with instability. the absence of trauma have also been identified.9 Indeed,

Journal of Athletic Training 287

 c' 1985 review of 73 throwing athletes with superior labral
injuries, Andrews et all' hypothesized that large forces in the
biceps tendon during the deceleration phase of the throwing
motion may create SLAP lesions. Electromyographic studies
showing increased activity in the biceps after ball release
support this theory.'9'20
Underlying instability should always be considered the
potential cause for shoulder pain in the athlete, even in the
presence of more overt impingement findings. Biomechani-
cal studies have shown that lesions destabilizing the biceps
anchor may lead to increased translation of the glenohu-
meral joint. 11"517 Rodosky et al,'7 in a cadaveric study,
found that a superior labral lesion contributed to anterior
shoulder instability as it decreased the shoulder's resistance
to torsion and placed greater strain on the inferior glenohu-
13 o) meral ligament. In another cadaveric study, Pagnani et all"
noted that lesions of the superior labrum that destabilized
the insertion of the biceps resulted in significant increases in
anteroposterior and superoinferior translation in the lower
and middle ranges of shoulder elevation. Furthermore, most
clinical series of SLAP lesions contain a subset of patients
with concomitant subtle instability.7'9"2'4"8'21'22

CLINICAL PRESENTATION
The clinical presentation of superior glenoid lesions is
quite variable. A review of the literature does not identify a
specific constellation of historical or physical findings that are
pathognomonic for superior glenoid lesions.* In the series of
Snyder et al,2 lesions were most often found in males (91%). The
average patient age was 38 years, and the dominant shoulder was
Figure 3. Classification of superior glenoid or superior labrum and twice as likely as the nondominant shoulder to be involved. In
biceps anchor (SLAP) lesions, according to Snyder et al.3 A, Type 1: terms of occupation, 31% were heavy laborers, 18% were busi-
degenerative fraying of the superior labrum with the edge still ness personnel, 15% were sedentary, 11% were professionals, 8%
firmly attached to the glenoid. B, Type II: detachment of the were students, 15% had other occupations, and only 2% were
superior labrum and biceps tendon from the glenoid with resultant professional athletes.
destabilization of the biceps anchor.
C, Type bucket-handle tear
Ill:
of superior labrum. Remaining labrum and biceps anchor are
stable. D, Type IV: bucket-handle tear of superior labrum with HISTORY
extension into the biceps tendon.
The patient may or may not relate a specific event to the
onset of symptoms. As previously outlined, various mecha-
Snyder et a12 found partial-thickness or full-thickness rotator nisms of injury have been described, such as falling on an
cuff disease in 55 (40%) of 140 patients with SLAP lesions. outstretched arm or sustaining a direct blow to the shoulder or
Superior migration of the humeral head can result from a a sudden pull on the arm. Many patients do not have a history
rotator cuff that is not effectively performing its role as a of a single acute traumatic event but describe an insidious onset
humeral head depressor. The superior labrum and biceps of symptoms. In their original article on SLAP lesions, Snyder
anchor could theoretically be gradually lifted off the glenoid as et al3 could identify no specific cause in 22% (6/27) of their
a result of chronic repetitive superior translation of the humeral patients. In the more recent series by Snyder et al,2 which
head on the glenoid rim. included a diverse patient population, 14% of patients (19/140)
Other authors7'9-'7 supported the theory of an inferior had an insidious onset of symptoms. Reinhart et a19 attributed
traction mechanism on the basis of a sudden, traumatic, inferior the onset of symptoms to an acute event in only 52% of the
pull on the arm or repetitive microtrauma from overhead sports patients, whereas a gradual onset of symptoms occurred in
activity with associated instability. In the series reported by 48%. Interestingly, most of their patients (75%) were athletes,
Maffet et al,7 two thirds of patients had an acute traumatic and repetitive throwing or overhead activity was considered to
mechanism of injury, 9 of whom had sustained traumatic be the most likely mechanism of injury.
dislocations. In the series by Snyder et al2, 19% had an episode The most common complaint is deep shoulder pain localized to
of glenohumeral subluxation or dislocation, and 16% noted the the anterosuperior shoulder between the acromioclavicular (AC)
onset of pain after lifting a heavy object. Bankart lesions were joint and the coracoid, associated with overhead use of the
identified in 22% (31/140) of these patients at the time of extremity. In addition to deep shoulder pain, symptoms of
arthroscopy. clicking, catching, or popping are commonly described. In the
The throwing athlete appears to be prone to this inju- large series of Snyder et al2, 69/140 (49%) complained of
ry.7'9"16"18 Both biomechanical and clinical explanations exist
for the occurrence of SLAP lesions in overhead athletes. In a *References 2, 3, 6, 7, 9, 10, 14, 16, 18, 23-25.

288 Volume 35 * Number 3 * September 2000

mechanical symptoms. These mechanical symptoms should raise of impingement on examination, and a SLAP lesion may go
the clinician's suspicion for the presence of a SLAP lesion. undiagnosed until glenohumeral arthroscopy. Frick et al29
recently presented a retrospective review of 140 patients who
PHYSICAL EXAMINATION underwent glenohumeral arthroscopy before subacromial de-
compression. Previously undiagnosed intra-articular pathology
The physical examination findings in patients with superior was noted in 43% of the 140 patients, including 11 (18%)
glenoid lesions are also variable, but a number of provocative SLAP lesions. This study underscores the importance of
tests can suggest the diagnosis. A complete and careful performing concomitant diagnostic glenohumeral arthroscopy
physical examination can help to distinguish patients with an at the time of decompression in the population subject to
isolated SLAP lesion from those who have both a SLAP lesion impingement because associated intra-articular pathology is
and associated or concomitant problems.9 In general, the common and difficult to diagnose by physical examination.
patient with an isolated labral tear exhibits full range of motion Despite the efforts of numerous authors to find a reliable test
and has good rotator cuff strength. for the identification of SLAP lesions, a significant number of
A maneuver referred to as the clunk,26 or compression patients with superior glenoid lesions discovered at arthros-
rotation, test3 may be the most specific test for identifying copy have negative responses to these provocative tests pre-
labral pathology. With the patient in the supine position, the operatively. This point is illustrated by 4 recent studies,2'9'13'23
shoulder abducted to 900, and the elbow flexed to 90°, a in which positive findings specifically suggesting superior
compression force is applied through the arm to the glenohu- glenoid lesions were present in only 52%, 56%, 57%, and 65%
meral joint as the arm is rotated. A torn labrum may catch or of patients, respectively.
clunk during this maneuver, in a manner analogous to the All patients should be carefully assessed for evidence of
McMurray test for meniscal tears. A similar maneuver known instability, particularly those who are involved in overhead
as the crank test is performed by axially loading and rotating sports and those who may have subtle anteroinferior instability
the arm in a position of maximum forward flexion. Liu et al27 as the underlying cause of shoulder pain. As discussed earlier,
found this test to be particularly useful in the detection of both basic science and clinical studies have suggested that
glenoid labral tears. superior glenoid lesions can occur as a result of or coinciden-
The Neer impingement sign is negative in the classic antero- tally with instability. The anterior apprehension test, Jobe
lateral location but may elicit discomfort anteriorly undereath the relocation test, and sulcus sign can all be helpful when
AC joint, particularly if the humerus is internally rotated as the evaluating a shoulder for instability.3' Posterior pain with
maneuver is performed. It is performed as if testing for the Neer abduction and external rotation may indicate internal impinge-
impingement sign but with the arm in the forward-flexion rather ment of the undersurface of the rotator cuff on the posterosu-
than the forward-elevation plane. Another useful variation on this perior glenoid rim.30 A SLAP lesion, however, can also cause
theme is a resisted maneuver termed the O'Brien test.28 This test discomfort with these maneuvers. Therefore, positive findings
is performed with the elbow extended and the shoulder flexed to on these instability tests may not be diagnostic. A significant
900, adducted to 300 to 450, and internally rotated with the thumb percentage of patients with SLAP lesions may have increased
pointing downward. This position theoretically places the biceps humeral head translation. In 3 recent reports,3'7"3 between
under tension and in direct contact with the anterosuperior labrum. 15% and 70% of patients with superior glenoid lesions at
The examiner then resists the patient's attempts to elevate the arm arthroscopy also had signs consistent with instability when
from this position. If deep shoulder pain and weakness are examined under anesthesia.
elicited, the clinician should suspect the presence of an anterosu- In a detailed retrospective review analyzing the clinical
perior labral or biceps anchor injury. External rotation of the arm presentation of 52 patients with superior glenoid lesions,
in this position constitutes the second part of the O'Brien test and Reinhart et al9 described 3 distinct groups of patients: group 1,
produces relief of pain in the presence of a SLAP lesion. those with isolated superior glenoid lesions and no associated
Recently, Kibler30 described another test for superior labral disease; group 2, those with associated glenohumeral instabil-
tears called the anterior slide test. This test is based on creating ity; and group 3, those with associated subacromial, rotator
an anterosuperior force on the proximal humerus. It is per- cuff, or AC joint disease. Patients in group 1 had a single
formed with the patient's hands on the hips and the thumbs clinical pattern of presentation characterized by the young
pointing posteriorly. One of the examiner's hands is placed throwing athlete with pain during activity, a stable shoulder,
across the top of the shoulder from behind, while the other and a click on physical examination. In this group, accurate
hand is placed behind the elbow. A forward and slightly preoperative diagnosis was made in 88% of patients. However,
superiorly directed force is applied to the elbow and upper arm, in the other 2 groups with associated pathology, the correct
and the patient is asked to push back against this force. Pain preoperative diagnosis of a superior glenoid lesion was made in
localized to the front of the shoulder under the examiner's hand only 36% of patients.
or a pop or click in the same area, or both, is considered a The clinician can gain important information regarding the
positive test. The author reported a sensitivity of 78.4% and differential diagnosis with the judicious use of differential
specificity of 91.5% for the detection of superior labral tears lidocaine injections into the AC joint and subacromial space. It
confirmed at arthroscopy. is often difficult to distinguish the anterosuperior shoulder pain
These tests and provocative maneuvers for AC joint pathol- caused by AC joint arthrosis from pain due to anterosuperior
ogy and impingement syndrome significantly overlap. AC joint labral pathology. Complete relief of symptoms after lidocaine
pathology is often associated with point tenderness over the injection into the AC joint, with care not to penetrate through
acromioclavicular joint and pain in a more superfilcial location its inferior capsule, is useful in distinguishing between these 2
with provocative testing in contrast to the deep shoulder pain entities. If complete relief of symptoms is obtained and the
elicited from a SLAP lesion. However, it is difficult to provocative SLAP lesion tests are nonpainful after subacromial
differentiate the pain associated with a SLAP lesion from that injection of lidocaine (impingement test), then a clinically

Journal of Athletic Training 289

 ~e.:flW=dXB'-
significant superior glenoid lesion is less likely. If the patient's scopic debridement (Figure 4A).L,i "I" A motorized shaver
symptoms are not improved or are only partially diminished with a curved blade is particularly useful for debriding the
after a subacromial injection, then a superior glenoid lesion frayed labral edge back to a stable rim, taking care to preserve
should be considered. the biceps anchor. Posterosuperior labral fraying can occur in
young, overhead athletes as a result of abutment of the
RADIOGRAPHIC EVALUATION posterior undersurface of the rotator cuff and greater tuberosity
during the late cocking phase of the throwing motion. This
With the clinical presentation often unclear, radiographic mechanism has been termed internal impingement and usually
and imaging studies are frequently used to aid in the diagnosis. responds to simple debridement.9"19 Normal attritional degen-
Plain radiographs cannot identify a SLAP lesion, but assess- eration of the superior glenoid labrum occurs with age, and in
ment of the acromial morphology and the AC joint are useful patients more than 40 years old, it is sometimes difficult to
in considering associated disorders. The utility of magnetic determine whether superior labral fraying is clinically signifi-
resonance imaging (MRI) or computed tomography arthro- cant or just part of the aging process. More likely than not,
grams for diagnosing this lesion is touted in the radiology another primary pathologic process is responsible for the
literature.32-41 Chandnani et a139 prospectively compared MRI, symptoms in this older age group.
magnetic resonance arthrography (intra-articular gadolinium
used with MRI), and computed tomography arthrography in TYPE 11 LESIONS
the detection of glenoid labral tears, reporting sensitivities of
93%, 96%, and 73%, respectively. The critical feature of type II SLAP lesions is the pathologic
MRI appears to be somewhat less sensitive in the diagnosis of instability of the biceps insertion. Debridement alone of the
tears in the superior portion of the labrum. In a prospective study frayed labrum and biceps, leaving an unstable biceps anchor,
by Gusmer et al,40 unenhanced MRI detected superior labral tears does not provide reliable results.13'23 With the development of
with a sensitivity of 86%. Recently, magnetic resonance arthrog- operative arthroscopic techniques, the recommended treatment
raphy has been applied in an attempt to improve the accuracy of of type II lesions is debridement of the frayed tissue and repair
SLAP lesion detection because it more clearly defines injuries to of the detached biceps-labral complex back to the superior
the labrum than conventional MR imaging. In a retrospective glenoid. Various methods of fixation have been pro-
study by Chandnani et al,4' magnetic resonance arthrography posed, including staples,25 screws and washers,24 multiple
identified superior labral tears with a sensitivity of 89%, specific- transglenoid sutures,14 suture anchors,2,3,14 and absorbable
ity of 88%, and accuracy of 89%. tacks.8162445 Currently, the use of either suture anchors or
The value of imaging studies has been questioned in the absorbable tacks is favored by most surgeons. The biodegrad-
orthopaedic literature, in which detection of superior glenoid able tack (Suretac, Acufex and Microsurgical Inc, Norwood,
disease has been reported in only 9% to 38% of cases.2'3'9"14'15 MA) is available in both 6-mm and 8-mm sizes and is preferred
In the large series by Snyder et al,2 73 MRI studies were by the senior author (D.F.D.) because no knot tying is
available for preoperative evaluation. Of these, only 26% necessary and no metal is retained in the shoulder (Figure 4B).
suggested a superior glenoid lesion. Regardless of the imaging
studies used, a good history and physical examination, com- A
bined with a high index of suspicion, are necessary to make the [). R s.;c.ot.oo_IF_X°.. . . . . . .|...IS|. .....::.::.
diagnosis preoperatively.27

TREATMENT
Most patients with a suspected superior labral lesion should
undergo a period of conservative management, including rest,
physical therapy, and nonsteroidal anti-inflammatory drugs.
The natural history of superior glenoid lesions is unknown, and
no data are available regarding the efficacy of conservative
treatment for SLAP lesions. Despite efforts to make the
diagnosis preoperatively, most lesions are discovered and
treated surgically at the time of arthroscopic diagnosis. In fact,
the surgeon may often have a different presumptive diagnosis
in mind preoperatively. In the series reported by Maffet et al,7
75% of patients had a preoperative diagnosis of impingement
based on history and physical examination. Superior glenoid
lesions may also be found in association with shoulder insta-
bility. Thus, the surgeon must approach diagnostic arthroscopy
with an open mind and be prepared to address all pathologic
conditions encountered.42"

TYPE I LESIONS
For isolated superior glenoid lesions without confounding
instability or subacromial disease, management is relatively Figure 4. Operative management of superior labrum and biceps
straightforward. Treatment of type I SLAP lesions is arthro- anchor (SLAP) lesions. A, Type 1. B, Type 11. C, Type Ill. D, Type IV.

290 Volume 35 * Number 3 * September 2000

 The surgeon may sometimes find it difficult to decide able to return to their previous level of athletic performance. Field
whether the degree of mobility of the biceps anchor identified and Savoie14 repaired type 11 and IV SLAP lesions with multiple
at arthroscopy is truly pathologic. It is important to remember sutures and reported 100% good results at an average follow-up of
that the superior articular surface of the glenoid fossa extends 21 months. Pagnani et al'6 reported 22 superior glenoid lesions
directly to the synovial recess and into the undersurface of the with unstable biceps anchors (16 ype II, 6 type IV), which were
biceps anchor. No bone should be exposed in this location. It stabilized with absorbable tacks. At 2-year follow-up, 86% of the
is usually necessary to debride labral fraying back to a firm patients had satisfactory results, and no complications were
labral edge to allow complete inspection of the biceps anchor. related to use of the tack.
The presence of a hypermobile biceps anchor in association Two recent reports on the long-term results of arthroscopi-
with undersurface fraying or hemorrhage, or both, and exposed cally treated superior glenoid lesions are noteworthy. Samani
bone are suggestive of a type 11 SLAP lesion. et al47 presented the results of 25 patients with type 11 SLAP
lesions that were stabilized arthroscopically using a bioabsorb-
TYPE III LESIONS able tack. At average follow-up of 35 months, 24 (96%) of the
patients had good or excellent results (using the UCLA rating
Type III lesions represent bucket-handle tears of the labrum scale) and returned to their preinjury level of work and athletic
with an intact biceps anchor. Resection of the bucket-handle participation. Asymptomatic tack osteolysis was noted on
portion of the labrum, again confirming that the biceps origin postoperative radiographs in 2 patients.
is intact, is the recommended treatment and should yield Stetson et al"8 presented the long-term results of 140 SLAP
satisfactory results (Figure 4C).2'3"3'23 lesions with follow-up available on 130 patients at an average
of 3.2 years. Type I lesions were identified in 30 patients (23%)
TYPE IV LESIONS and were treated with debridement. Type 11 lesions were found
in 61 patients (47%) and were stabilized with suture anchors in
The management of type IV SLAP lesions depends on the most patients. Type HI lesions in 14 patients (11%) and type IV
amount of biceps tendon involved, as well as the stability of its lesions in 17 patients (13%) were debrided. Finally, complex
insertion. In most cases, the lesion includes a bucket-handle SLAP lesions were identified in 8 patients (6%) and treated
tear of the labrum and a tear involving a small portion of the with debridement and reattachment with a suture anchor. Using
biceps tendon. If less than approximately 30% of the width of the UCLA rating scale, 103 (79%) had a good or excellent
the biceps is involved, arthroscopic excision of the torn tissue result, 22 (17%) had a fair result, and 5 (4%) had a poor result.
is adequate treatment (Figure 4D).14 If the lesion involves a Complications included fragmentation of a bioabsorbable tack
larger portion of the biceps and superior labrum and the tissue in 5 patients, requiring surgical removal. Because of this
is of adequate quality, repair is indicated.14"6'42-44 Suture finding, the authors switched from the absorbable tack to a
anchors are useful in treating this lesion because the labrum removable screw-in suture anchor for stabilization of type II
and biceps both should be repaired and anchored.l4,42,46 If the SLAP lesions. These results suggest that the arthroscopic
biceps tear involves more than 50% of the tendon, particularly treatment of SLAP lesions provides reliable long-term results.
in an older person with symptoms referable to the biceps
tendon and a normal rotator cuff, consideration should be given
to primary biceps tenodesis.2'3 SUMMARY
RESULTS OF ARTHROSCOPIC TREATMENT OF Superior glenoid lesions or SLAP lesions are an infrequent
but important cause of shoulder pain and disability. Extremely
SLAP LESIONS variable presentations with nonspecific clinical and radio-
Grauer et al23 treated 13 patients with superior labral lesions graphic findings make preoperative diagnosis of superior
(4 type I, 6 type 1, 3 type IH) with debridement only and noted glenoid lesions difficult. In a patient with shoulder pain and
satisfactory results in 12 of the patients at an average follow-up mechanical symptoms such as clicking, catching, or popping, a
of 18 months. However, all patients noted occasional pain after high index of suspicion for labral lesions is necessary.
heavy activity or sports. Cordasco et al'3 reviewed the results These lesions can usually be diagnosed and managed arthro-
of arthroscopic debridement of 27 SLAP lesions (7 type I, 17 scopically. Type I lesions require only debridement of the
type II, 2 type III, 1 type IV). Initially, 78% of patients had frayed labral edge. Type II lesions are most common and are
excellent pain relief and 52% were able to return to their sports best treated with suture anchor or biodegradable-tack fixation
at the same level. However, these results deteriorated over time of the unstable biceps anchor. Type [I lesions should be
such that only 63% of patients still had excellent pain relief and treated with debridement of the bucket-handle portion of the
only 45% of patients were capable of returning to their superior labrum. Finally, type IV lesions may require debride-
previous athletic performance at 2-year follow-up. These ment of the torn portion of labrum and biceps tendon, arthro-
authors treated all types of SLAP lesions with debridement scopic repair and stabilization, or biceps tenodesis, depending
only, leaving the biceps anchor unstable in many cases. on the amount of biceps tendon involvement. Associated
Yoneda et al25 treated 10 type II SLAp lesions with arthro- pathology, including instability, impingement syndrome, and
scopic stapling and noted excellent or good results in 8 patients at rotator cuff tears are common. It is essential that these
follow-up at over 24 months. However, because of concerns about concomitant problems be recognized and treated appropriately
possible staple loosening, all patients underwent a second arthro- at the time of surgery to optimize the patient's outcome.
scopy for staple removal at 3 to 6 months. Resch et al24 reported Additional clinical experience and further studies are neces-
on 14 patients with type TT SLAP lesions repaired with screws sary to gain a better understanding of the underlying causes of
(6 patients) or absorbable tacks (8 patients). At mean follow-up of these lesions and to improve our ability to diagnose them
18 months, an excellent result was noted in 8 patients, who were preoperatively. As our knowledge of superior glenoid pathol-

Journal of Athletic Training 291

ogy improves, so will our ability to manage these lesions as we Arthroscopic stapling for detached superior glenoid labrum. J Bone Joint
strive for reliable and successful clinical results. Surg Br. 1991;73:746-750.
26. Andrews JR, Gillogly S. Physical examination of the shoulder in throwing
athletes. In: Zarins B, Andrews J, Carson W, eds. Injuries to the Throwing
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292 Volume 35 * Number 3 * September 2000