Published 9/1/2014
Maureen Leahy

When SLAP Repairs Fail

JAAOS article examines challenges surrounding diagnosis and management

A superior labral anterior-posterior (SLAP) tear is an injury to the superior glenoid labrum of the shoulder. Initial treatment for SLAP tears typically includes nonsurgical methods such as physical therapy, nonsteroidal anti-inflammatory medication, and activity modification. When conservative interventions fail, arthroscopy may be indicated. Although most SLAP tears heal favorably with arthroscopic repair, some patients report persistent pain or recurrent symptoms and seek additional treatment.

To learn more about SLAP tears and, in particular, failed SLAP repair, AAOS Now spoke with Brian C. Werner, MD, and Stephen F. Brockmeier, MD. They, along with Mark D. Miller, MD, authored the review article “Etiology, Diagnosis, and Management of Failed SLAP Repair,” appearing in the September 2014 issue of the Journal of the AAOS.

AAOS Now: Why is there controversy surrounding the diagnosis and management of SLAP tears?

Dr. Werner: The recognition of what a SLAP tear is and treatment algorithms for the management of SLAP tears continue to evolve. Over the past 5 years, certain groups of patients with SLAP tears have demonstrated that typical arthroscopic SLAP repair can yield a less predictable outcome. These groups include patients with atraumatic mechanisms of injury, patients older than age 30, worker’s compensation patients, and certain overhead athletes. The optimal management of SLAP tears in these patients remains controversial.

AAOS Now: How is a failed SLAP repair defined? What are the symptoms?

Dr. Brockmeier: We define a failed SLAP repair as pain and/or stiffness following SLAP repair surgery that does not resolve with conservative measures and that is not due to concomitant pathology. For example, some patients have symptoms that never resolve following a SLAP repair; in other patients, symptoms resolve, but return at a later date. It is important to note that in many patients with recurrent or persistent symptoms following a SLAP repair, the symptoms will ultimately be found to be due to something other than the SLAP repair.

AAOS Now: How is a failed SLAP repair diagnosed?

Dr. Werner: A failed SLAP repair remains a diagnosis of exclusion. A focused history and physical exam with provocative tests targeted to identify persistent or recurrent biceps or superior labral pathology are important. It is critical to be alert to and exclude concomitant diagnoses when examining these patients. Most patients with persistent or recurrent symptoms following a SLAP repair will require advanced imaging. At our institution, magnetic resonance imaging (MRI) with contrast arthrography is typically used, and the diagnosis is confirmed during arthroscopy (Fig. 1).

AAOS Now: What are the treatment options for a failed SLAP repair?

Dr. Brockmeier: Treatment options for a failed SLAP repair begin with continued conservative management, including rehabilitation-based modalities and modification of precipitating activities. If conservative therapies fail, revision SLAP repair or biceps-based treatments (including tenodesis or tenotomy) are all treatment options, tailored to the patient’s specific pathology, activity level, age, demand, and other patient-specific factors.

AAOS Now: What are the indications for revision vs biceps tenodesis or tenotomy?

Dr. Werner: This remains an area of evolving thought and research. Currently, we favor a biceps-based procedure in the setting of a previous SLAP repair. We will consider a revision SLAP repair in a very young patient or overhead athlete; however, we typically will proceed with an arthroscopic suprapectoral or open subpectoral biceps tenodesis for most patients with a failed SLAP repair.

AAOS Now: What should orthopaedic surgeons who treat SLAP tears keep in mind?

Dr. Brockmeier: Although SLAP repair is a common procedure and indicated for certain patients, it is not always successful. When failures do occur, it is important to exclude concomitant pathology and to manage the patients appropriately. It is also important to recognize those groups of patients in whom SLAP repair failure may more frequently occur and pursue other treatment options in these patients.

Disclosure information: Dr. Brockmeier—Biomet, MicroAire Surgical Instruments LLC, Arthrex, Inc., Tornier, Journal of Bone and Joint Surgery-American (JBJS), Springer, Orthopaedic Journal of Sports Medicine, Techniques in Shoulder and Elbow Surgery, American Orthopaedic Society for Sports Medicine (AOSSM), MidAtlantic Shoulder and Elbow Society; Dr. Miller—Saunders/Mosby-Elsevier, Wolters Kluwer Health - Lippincott Williams & Wilkins, JBJS, AOSSM, Miller Orthopaedic Review Enterprises; Dr. Werner—no conflicts.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

  • Symptoms of a failed SLAP repair include persistent pain and stiffness that do not resolve with conservative measures.
  • Diagnosis of a failed SLAP repair requires thorough patient assessment because the cause of symptoms is often multifactorial.
  • Use of advanced imaging such as MRI or contrast arthrography is indicated in most patients with persistent symptoms.
  • Treatment for failed SLAP repair is patient-specific and may include revision SLAP repair or biceps-based treatment such as tenodesis or tenotomy.