Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-015-3966-0
SHOULDER
SLAP lesions: a treatment algorithm
MatthiasBrockmeyer1 MarcTompkins2,3 DieterM.Kohn1 OlafLorbach1
Received: 10 October 2015 / Accepted: 23 December 2015
European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2016
Abstract Tears of the superior labrum involving the
biceps anchor are a common entity, especially in athletes,
and may highly impair shoulder function. If conservative
treatment fails, successful arthroscopic repair of sympto-
matic SLAP lesions has been described in the literature par-
ticularly for young athletes. However, the results in throw-
ing athletes are less successful with a significant amount of
patients who will not regain their pre-injury level of perfor-
mance. 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. In this
population, tenotomy or tenodesis of the biceps tendon is a
viable alternative to SLAP repairs in order to improve clini-
cal outcomes. The present article introduces a treatment
algorithm for SLAP lesions based upon the recent litera-
ture as well as the authors clinical experience. The type of
lesion, age of patient, concomitant lesions, and functional
requirements, as well as sport activity level of the patient,
need to be considered. Moreover, normal variations and
degenerative changes in the SLAP complex have to be dis-
tinguished from true SLAP lesions in order to improve
results and avoid overtreatment. The suggestion for a treat-
ment algorithm includes: type I: conservative treatment or
arthroscopic debridement, type II: SLAP repair or biceps
tenotomy/tenodesis, type III: resection of the instable
bucket-handle tear, type IV: SLAP repair (biceps tenotomy/
* Olaf Lorbach
olaf.lorbach@gmx.de
1
Department ofOrthopedic Surgery, Saarland University,
Kirrberger Str., 66421Homburg/Saar, Germany
2
Department ofOrthopaedic Surgery, University
ofMinnesota, Minneapolis, MN, USA
3
TRIA Orthopaedic Center, Minneapolis, MN, USA
tenodesis if >50% of biceps tendon is affected), type V:
Bankart repair and SLAP repair, type VI: resection of the
flap and SLAP repair, and type VII: refixation of the antero-
superior labrum and SLAP repair.
Keywords SLAP lesion Shoulder Superior labrum
Biceps tendon Treatment algorithm
Introduction
Tears of the superior glenoid labrum and the origin of the
long head of the biceps tendon were first described by
Andrews etal. [2]. They can lead to shoulder pain and
highly impaired shoulder function. The first classification,
and the name superior labrum anterior-to-posterior (SLAP)
lesion, was presented by Snyder etal. [46]. The lesion was
named as such because the injury of the superior labrum
begins posteriorly and extends anteriorly, stopping before
or at the mid-glenoid notch and including the anchor of
the biceps tendon to the labrum. Depending on the extent of
the labral lesion and the stability of the biceps anchor, they
divided the SLAP lesion into four distinct types (Fig.1).
Maffet etal. [33] expanded the classification to types V
VII (Table1). In 2011, Modarresi etal. [35] listed ten dif-
ferent types of SLAP lesions.
SLAP lesions are often associated with concomitant
shoulder pathologies. Snyder etal. [47] did an analysis of
140 injuries to the superior glenoid labrum. They reported
that 29% of lesions were associated with a partial-thick-
ness tear of the rotator cuff, 11% with a full-thickness tear,
and 22% with an anterior Bankart lesion. No concomi-
tant pathologies of the rotator cuff or anterior labrum were
seen in 28% of the SLAP lesion patients. In a retrospec-
tive review of 2375 shoulder arthroscopies, the incidence of
13

Fig.1Classification of SLAP lesions, arthroscopic and schematic
illustration of SLAP type IIV lesions (reprinted with permission
from Snyder etal. [46]; Figs.14, pp 276277)
Table1Additional classification of SLAP lesions (type VVII)
(according to Maffet etal. [33])
Type V Anteriorinferior Bankart lesion continues superiorly to
include separation of the biceps tendon
Type VI Unstable flap tear of the labrum is present in addition to
biceps tendon separation
Type VII The superior labrumbiceps tendon separation extends
anteriorly beneath the middle glenohumeral ligament
(Andrews-lesion)
SLAP lesions was indicated with 6% by Snyder etal. [47]
with type II lesions as the most common type of injury.
Maffet etal. [33] analysed 712 arthroscopic surgeries, and
they described an incidence of 11.8% for significant lesion
of the biceps tendonsuperior labrum complex.
Snyder etal. [46, 47] originally described that the
aetiology of SLAP lesions is traumatic. Several injury
mechanisms for SLAP lesions are described in the litera-
ture [2, 27, 51]. A fall upon the extended arm in a slightly
flexed and abducted position led to a lesion of the supe-
rior labrum caused by compression force and subluxation
of the humeral head cranially [46]. With trauma from an
external rotation and abduction force of the shoulder that
induces anterior shoulder instability, SLAP lesions can
often be seen as concomitant lesions [25]. But in most
cases SLAP lesions are overuse injuries. The most fre-
quent cause of SLAP lesions is due to microtrauma and
overuse from repeated throwing motions as frequently
described in the literature for baseball pitchers [46, 51].
SLAP lesions in pitchers or other overhead athletes ini-
tially result in a posterosuperior lesion of the labrum.
13
Knee Surg Sports Traumatol Arthrosc
The injury mechanism is characterized as the peel-back
mechanism. During the throwing motion, the shoulder
comes into an extremely abducted and externally rotated
position. That leads to high torsion loading at the origin
of the long biceps tendon with a peel back and resulting
injury of the superior labrum [5]. Moreover, functional
impairment due to a glenohumeral internal rotation defi-
cit (GIRD), a dyskinesia of the scapula or deficiencies of
the kinetic chain may also result in structural damage of
the biceps anchor by shifting the humeral head posterosu-
perior during the overhead motion [5]. Given all of these
possible mechanisms of injury, SLAP lesions are common
diagnoses in young athletes, especially overhead athletes.
Nevertheless, there are existing asymptomatic shoulders
of overhead athletes having a SLAP lesion on MRI as
described by Connor etal. [8]. These adaptive changes in
the upper labrum should be taken into account during the
diagnosis and therapy of SLAP lesions.
Arthroscopic treatment of symptomatic SLAP lesions in
young athletes leads to good clinical results and has gen-
erally been accepted as the most common treatment [28,
39]. However, the results in overhead throwing athletes are
less successful, and a significant amount of patients do not
return to their pre-injury activity level [3, 36].
SLAP lesions are increasingly being detected in an older
cohort of patients as well [40]. The treatment of SLAP
lesions for middle-aged and older patient groups is still
controversial with worse results and higher rates of revision
surgery following SLAP repair. Therefore, biceps tenotomy
or tenodesis is getting more and more attention as alterna-
tive treatments for SLAP lesions in this selective patient
group, especially with concomitant shoulder pathologies,
such as rotator cuff tears [23]. Patterson etal. [42] recently
analysed the data from the American Board of Orthopae-
dic Surgery Certification Examination Database, and they
indicated that the proportion of SLAP repairs has decreased
over time with an increase in biceps tenodesis and tenot-
omy for the treatment of SLAP lesions, with and without
coexisting rotator cuff tear.
Tenodesis of the biceps tendon may also be a viable
alternative to SLAP repair in high-level overhead athletes,
as the clinical results as well as the return to the pre-injury
level may be improved compared with SLAP repair, but
more literature is needed on this topic [3].
The present article introduces a suggestion for a treat-
ment algorithm for SLAP lesions based on current litera-
ture as well as clinical experience.
Diagnosis andclinical findings
Patients suffering from a SLAP lesion often complain of
shoulder pain, functional disorder, mechanical symptoms,
Knee Surg Sports Traumatol Arthrosc

and/or shoulder instability. The exact trauma mechanism Table2Sensitivity and specificity of common clinical tests to diag-
should be asked as it may give valuable information con- nose a SLAP lesion
cerning the potential shoulder pathology. Active and pas- Clinical test Sensitivity (%) Specificity (%) References
sive range of motion may detect a GIRD, dyskinesia of the
Speeds test 32 75 Holtby and
scapula, or other impairment of glenohumeral joint motion, Razmjou [21]
which may be responsible for the functional shoulder
Yergasons test 43 79 Holtby and
impairment. Moreover, shoulder pain related to the biceps Razmjou [21]
anchor can often be provoked in a throwing motion against Uppercut test 73 78 Kibler etal. [30]
resistance [32]. Bear-hug test 79 60 Kibler etal. [30]
There may be pain with palpation of the sulcus inter- Belly press test 31 85 Kibler etal. [30]
tubercularis due to an inflammation of the biceps sheath OBrien test 38 61 Kibler etal. [30]
caused by instability of the biceps tendon or synovitis/ Supine resist- 80 69 Ebinger etal.
tendinitis within the sulcus [32]. Specific clinical tests for ance test [13]
detecting a SLAP lesion amongst others are: Yergason test, Mayo shear test 80 Pandya etal.
Jobe relocation test, Kibler dynamic shear test, Berg and [41]
Cuillo SLAP-prehension test, Crank test, Bennett Speeds
test, OBrien active compression test, and Kims biceps
load test I+II. None of these tests, however, ensure the test [41] also show good results in terms of sensitivity and
accurate diagnosis of SLAP lesions and getting information specificity for detecting lesions of the biceps tendon. The
from the physical examination is challenging even for expe- available evidence of level I and II studies in the recent lit-
rienced orthopaedic surgeons since most of the tests cannot erature suggests that a combination of specific tests such as
distinguish between the different parts of the biceps ten- the Speeds and uppercut test is recommended for the clini-
don. This is in part due to the anatomic relation of the long cal detection of biceps tendon lesions.
head of the biceps tendon to the rotator interval and rotator MRI and MR arthrography are commonly used as imag-
cuff, so examination signs are often not specific. Athletes ing procedures to detect a SLAP lesion. Intra-articular con-
doing repetitive overhead motions, like pitchers, and suffer- trast media and articular effusion, as well as arm traction
ing from a SLAP lesion often present with a concomitant and external rotation, improve the sensitivity of the MRI to
articular-sited partial-thickness tear of the supraspinatus determine a SLAP lesion [7, 26].
tendon as a result of a superior instability. They report fre- Intra-articular and subacromial injections may be used
quent impingement-like complaints [17]. Therefore, it is to support the diagnosis and further offer a treatment option
essential to perform a complete and accurate clinical evalu- for temporary pain relief although generally they are not
ation related to possible rotator cuff pathologies and shoul- used as an isolated treatment since they do not treat the
der instability within the physical examination. underlying pathology.
The clinical tests to detect biceps pathology differ Arthroscopy of the glenohumeral joint remains the
widely concerning sensitivity and specificity and depend on gold standard treatment in patients with a suspected SLAP
the experience of the examiner [19] (Table2). In a prospec- lesion after failed conservative treatment. Arthroscopy pro-
tive study, Holtby and Razmjou [21] evaluated the sensitiv- vides the diagnosis of the exact type of SLAP lesion as
ity and specificity of the Speeds and the Yergasons tests well as potential coexisting shoulder pathologies and fur-
for detecting pathology of the biceps tendon, and they have ther allows a dynamic examination and testing of the stabil-
only moderate specificity. The preoperative clinical find- ity of the SLAP complex using an examination hook and
ings were compared with the intraoperative arthroscopic shoulder motion.
findings, and they determined that none of the tests pro-
vided adequate diagnostic accuracy for detecting biceps
tendon pathology. A positive result, however, was associ- Clinical results
ated with shoulder pathology. Kibler etal. [30] also evalu-
ated the diagnostic accuracy of different clinical tests for Good results have been reported for the debridement of
detecting a pathology of the biceps tendon. They analysed type I lesions [12]. However, arthroscopic debridement
the Speeds, Yergasons, uppercut, bear-hug, belly press, may not be a reasonable option for type II lesions as the
and OBrien tests. The highest sensitivity was shown to results reported in the literature demonstrate unacceptable
be in the bear-hug and upper cut tests, whereas the highest outcomes [9].
specificity was found for the belly press and Speeds tests. Arthroscopic repair of the type II lesions is preferable
The highest diagnostic accuracy was felt to be in the upper- with good to excellent postoperative results in the major-
cut test. The supine resistance test [13] and the Mayo shear ity of patients. OBrien etal. [39] as well as Kartus etal.

13

[28] reported good clinical results after arthroscopic repair
of type II SLAP lesions using suture anchors. After arthro-
scopic SLAP repair, approximately 85% of the patients are
reporting pain relief and return to sport rates of 7585%
are described [37].
Arthroscopic treatment of symptomatic SLAP lesions in
overhead athletes also leads to significant clinical improve-
ment. A significant amount of athletes, however, did not
reach their pre-injury level after SLAP repair [3, 4, 11, 20,
23, 43]. Approximately 30% of athletes had to end their
career due to the surgically related shoulder pathology [10].
Boileau etal. [3] compared the clinical results of SLAP
repair versus tenodesis of the biceps tendon in overhead
athletes and demonstrated significantly better results and a
higher return to pre-injury sport level for biceps tenodesis
patients compared with a patient cohort treated with SLAP
repair. Therefore, tenodesis of the biceps tendon may be a
viable first treatment alternative in overhead athletes. Moreo-
ver, biceps tenotomy and tenodesis are reliable alternatives to
SLAP repair in older patients (>40years) where SLAP repair
is often associated with minor clinical results, increased com-
plications, and higher rates of revision surgery due to persist-
ing postoperative pain or shoulder stiffness [1, 43].
When concomitant tears of the rotator cuff are present,
debridement of the labrum or biceps tenotomy showed
higher cumulative evidence in the literature than SLAP
repair for a middle-aged patient population [15]. Franc-
eschi etal. [16] also described better clinical results in
patients older than 50years who underwent biceps ten-
otomy compared to those with SLAP repair in cases with
SLAP lesions and coexisting rotator cuff tears.
Different surgical techniques exist for SLAP repair with
regard to the number of anchors used and their position
in relation to the long head of the biceps tendon. Kibler
etal. [29] found out that 35% of the papers they included
in their systematic review for current practice for surgical
treatment of SLAP lesions did not mention the number of
anchors used for the repair. Most of the other studies cited
using one to two anchors or one to four anchors. Approxi-
mately one-third of the papers did not report the exact posi-
tion of the anchors, and 35% of the studies described some
variation of positioning the anchor at a 12:00 position with
sutures anterior as well as posterior in relation to the biceps
attachment.
For type III lesions, several studies have showed that
the preferred treatment is the excision of the bucket-handle
labral tear and an additional labral repair if necessary [18,
44].
Treatment of type IV lesions is dependent on the size of
the biceps tendon tear. If the tear is <50% of the biceps
tendon diameter, an excision of the detached fragments
is performed and a labrum repair is done as necessary,
whereas a tenotomy or tenodesis of the long head biceps
13
Knee Surg Sports Traumatol Arthrosc
tendon is needed if more than 50% of the diameter of the
tendon is involved [38, 44].
Arthroscopic repair of SLAP lesions with extensive tears
can also lead to good results. In the retrospective study of
Huang etal. [22], the outcome of 18 cases of severe SLAP
lesions (type>IV) treated with arthroscopic capsulolabral
reconstruction was evaluated. They reported good results
concerning postoperative range of motion, pain, and an
improvement of the American Shoulder and Elbow Sur-
geons (ASES) score as well as the ConstantMurley score.
Nord etal. [38] described a debridement and a subsequent
repair of the remaining detached superior labrum for SLAP
lesions involving complex tears of the biceps tendon and
superior labrum (SLAP lesions types IIIVII). Kim etal.
[31] also described good treatment results for combined
arthroscopic Bankart and SLAP repair in cases of type V
SLAP lesions.
Suggested treatment algorithm
The initial treatment of patients with a suspected SLAP
lesion is non-operative (cooling, anti-inflammatory drugs, a
period of rest from sports, physical therapy). In the case of
functional pathology related to the superior labrumbiceps
complex, the underlying pathology should be treated,
including proprioceptive training, especially after shoulder
injuries, in order to prevent a re-injury. In overhead ath-
letes, special attention should be taken to possible techni-
cal failures of the overhead motion as a common reason for
functional pathology.
Scapulothoracic dyskinesis may be caused by shortening
or imbalance of the muscles or contracture of the posterior
capsule and should be addressed by an extensive physi-
cal therapy programme. Deficiencies of the kinetic chain
should also be corrected to restore function without any-
thing done with the SLAP tear.
If the non-operative therapy fails and symptoms persist
that prevent sport activities or activities of daily living,
operative treatment is indicated.
The surgical treatment of SLAP lesions requires a differ-
entiated approach (Fig.2). The exact type of lesion, the age
of the patient, concomitant lesions, and functional require-
ments, as well as sport activity level of the patient, should
be considered.
First, it is necessary to separate true SLAP lesions
from normal anatomic variations and degenerative changes
in the SLAP complex. Vangsness etal. [49] found that the
degree of the attachment of the biceps tendon fibres ante-
riorly and posteriorly to the superior labrum can differ
widely. Depending on the degree of attachment anteriorly
and posteriorly, they described four different variations.
Other known variations in the anatomy of the labrum and
Knee Surg Sports Traumatol Arthrosc

Type I: Conservave treatment or arthroscopic debridement

Type II: SLAP repair or Biceps tenotomy/tenodesis

Type III: Resecon (repair as required)

Type IV: SLAP repair (repair/resecon if < 50 % of BT is affected,

Biceps tenotomy/tenodesis if > 50 % of BT is affected)

Type V: Bankart-repair and SLAP repair

Type VI: Resecon (repair as required) Fig.3Arthroscopic view of a frayed SLAP complex in case of age-
related, degenerative changes

Type VII: Refixaon of anterosuperior labrum and SLAP repair

Fig.2Suggestion for a treatment algorithm for SLAP lesions

the glenohumeral ligaments are the Buford complex,

the sublabral hole, and an absent anterior and superior
labrum. The Buford complex is known as a normal cap-
sulolabral variant of the morphology of the middle gle-
nohumeral ligament (MGHL) where the MGHL is more
a cord-like structure getting merged into the anterosu-
perior labrum and in which the anterosuperior labrum is
often missing [54]. It is thought to be a predisposition for
a detachment of the SLAP complex compared to a more
flat morphology of the MGHL [45]. The sublabral hole
is another important normal variant in which the anterior
and superior labrum is not attached to the glenoid. It is
characterized by smooth edges with no fibrillations or tears
of the labrum. These normal anatomic variations are not
pathologic findings and should not be mistaken for SLAP
lesions; they require no specific operative intervention.
Degenerative changes in the SLAP complex like fray-
ing (Fig.3) or a slight hypermobility with a stable biceps
anchor also require no special treatment if patients do not
have concomitant positive clinical biceps tests or biceps
related pain. If the patient also presents with positive biceps
tests, pain related to the biceps tendon, or instability of the
biceps tendon due to an unstable biceps, especially with
concomitant rotator cuff tears, tenotomy or tenodesis of
the biceps tendon is indicated. Concomitant damage of the
anterosuperior cartilage of the humeral head is a frequent
finding in a shoulder with a chronic unstable biceps ten-
don. In this setting, it is reasonable to consider a tenodesis
or a tenotomy of the biceps tendon even if there is mini-
mal structural damage or instability of the biceps anchor
(Fig.4).
In symptomatic type I lesions with no further instability
or structural damage of the biceps tendon, an arthroscopic
Fig.4Arthroscopic view of an anterosuperior chondral lesion of the
humeral head as a sign for chronic instability of the biceps tendon
debridement is generally sufficient; this preserves the
attachment of the labrum and the biceps tendon.
In young, active patients (age <40years), an arthro-
scopic repair of the SLAP complex (SLAP repair) utilizing
a knotless or suture anchor technique is recommended for
type II lesions.
A standard posterior portal is used and the stability of the
SLAP complex is tested with a probe (Figs.5, 6). Debride-
ment of the SLAP complex is performed via an anterosupe-
rior working portal. An additional anterolateral portal in the
rotator interval can be used for anchor placement.
However, an additional lateral transmuscular portal is
used for positioning the far posterosuperior anchor. Two
anchors posterior of the biceps tendon are usually enough
to achieve a sufficient refixation. If the anterior part of the
biceps anchor is also instable, an additional anterior anchor
is added. If knotless anchors are used, the labrum is pierced
(Fig.7) or looped (Fig.8) using a modified lasso-loop tech-
nique. After final refixation of the SLAP complex, the sta-
bility is tested using a probe (Fig.9).
In middle-aged patients (age >40years) and patients
with moderate to severe degenerative changes in the biceps

13

Fig.5Arthroscopic view of SLAP type I lesion, stability test using
a probe
Fig.6Arthroscopic view of an instable SLAP type II lesion, stability
test using a probe
Fig.7SLAP repair: for the use of knotless anchors the anterosupe-
rior labrum is pierced
Fig.8SLAP repair: the labrum is looped for a knotless anchor fixa-
tion using a modified lasso-loop technique
13
Knee Surg Sports Traumatol Arthrosc
Fig.9Arthroscopic view after final SLAP repair
tendon as well as patients with concomitant rotator cuff
tears extending to the rotator interval, biceps tenotomy or
tenodesis is recommended.
In cases of type III lesions, the bucket-handle tear of the
superior labrum should be resected. Additional repair of
the SLAP complex might be reasonable only in rare cases.
Type IV lesions require an arthroscopic repair using a
suture anchor technique and/or a resection of the detached
fragments. Resection is preferred if less than 50% of the
diameter of the biceps tendon is affected, whereas a ten-
otomy or tenodesis of the tendon is needed if more than
50% of the diameter is involved. In type VVII lesions, a
combined injury of the SLAP complex and anterior shoul-
der instability requires arthroscopic repair of the SLAP
complex as well as anteroinferior stabilization. Associated
shoulder pathologies and intra-articular disorders should be
addressed during a single stage arthroscopy if possible.
Discussion
Kibler etal. [29] demonstrated in a recent systematic
review regarding the current practice for the surgical treat-
ment of SLAP lesions that is not possible to reach clear
consensus concerning current practice to be developed
because of the lack of precision and consistency of most of
the papers published. They described a wide variability in
the reported surgical aspects.
Nevertheless, in the decision-making process for the best
treatment for SLAP lesions, the exact type of lesion, the
age of the patient (<40 vs >40years), concomitant shoulder
pathologies (especially rotator cuff tears and rotator interval
pathology), the functional requirements of the patient, and
sport activity level of the patient should be considered. In
symptomatic SLAP type I lesions, the arthroscopic debride-
ment is suggested for young athletes [12], while biceps
tenotomy or biceps tenodesis is more often recommended
in older, non-athletic patients. Between 40 and 60years,
the biceps tenodesis is often preferred as treatment option
because of cosmetic rather than functional reasons. The
Knee Surg Sports Traumatol Arthrosc
arthroscopic treatment of unstable SLAP lesions in young
adults leads to good clinical results and has generally been
accepted as the most common treatment [24, 28, 37, 39].
SLAP repair in middle-aged and older patients (>40years)
is controversial. There are differences in the mechanism
of injury, tissue quality, capacity for healing, concomi-
tant lesions, and postoperative failure rates. Postopera-
tive problems and complications after arthroscopic SLAP
repair, such as stiffness of the shoulder joint with loss of
range of motion, may result in a prolonged period of per-
sistent pain and impaired shoulder function. In some cases,
these factors may prevent a return to the patients previous
level of sport. Moreover, higher rates of revision surgery
were found for the patients older than 40years undergo-
ing SLAP repair. Therefore, biceps tenotomy or tenodesis
may be a viable treatment option for SLAP II lesions in
these patients [15]. It should be noted, however, that there
are authors who have demonstrated comparable results
of SLAP repair in patients both older than 40years and
younger than 40years [1]. Trantalis etal. [48] performed
isolated arthroscopic repair of 25 type II SLAP lesions
with a mean age of 40.012years. They found signifi-
cant improvements in clinical outcomes. It seems, how-
ever, that a greater number of studies suggest that SLAP
repair should not be performed in patients over the age of
40years [11, 16]. But the evidence for this suggestion is
quite low [50]. Finally, it remains controversial on what age
a biceps tenodesis or tenotomy over SLAP repair should be
considered as well as the optimal first choice of operative
treatment in high-level overhead athletes.
In synopsis of the recent literature, a labral debridement,
or biceps tenotomy or tenodesis, is the preferred procedure
over SLAP repair if concomitant rotator cuff tears are pre-
sent in middle-aged and older patients [16, 23]. Moreover,
biceps tenotomy or tenodesis is also viable as revision pro-
cedures after failed SLAP repair [23, 34, 53]. Although
there is a lack of high-quality studies comparing revision
SLAP repair and biceps tenodesis in cases of failed SLAP
repair [50]. Until now, it remains unclear whether and when
to do a biceps tenodesis or tenotomy in the young over-
head athlete. Arthroscopic repair of a SLAP lesion (>type
I) has been demonstrated to be less successful than previ-
ously described [3, 36]. Boileau etal. [3] showed a higher
percentage of satisfied patients and of patients returning to
their previous level of sports following a biceps tenodesis
for type II SLAP lesions compared with those who under-
went a SLAP repair. Ek etal. [14] described good to excel-
lent results for both biceps tenodesis and SLAP repair in
patients with isolated type II SLAP lesions.
Waterman etal. [52] analysed a group of 192 consecutive
military service members with SLAP repair. They found
out favourable outcomes in the majority of the patients par-
ticularly with combined shoulder injuries and concomitant
procedures like rotator cuff repair and anteroinferior labral
repair. In 16% of patients after primary SLAP repair revi-
sion, surgery was necessary. Of these, patients undergoing
biceps tenodesis had a higher rate of return to active duty as
compared with revision SLAP repair.
The role of a combined SLAP repair and biceps teno-
desis is unclear, but early results as reported by Chalmers
etal. [6] suggest it may not produce the same outcomes as
SLAP repair or biceps tenodesis alone. They demonstrated
that a combined SLAP repair and biceps tenodesis in high-
demand patients with biceps tendonitis in the setting of a
SLAP tear and labral instability has significantly worse
outcomes compared with isolated labral repair or isolated
biceps tenodesis.
At least, there is low evidence in the recent literature on
the duration of non-operative treatment of SLAP lesions
before surgical treatment is indicated. It is depending on
the type of lesion, concomitant pathologies, age and pro-
fession of the patient, level of sporting activities, time of
the season in high-level athletes, intensity, and frequency
of physical therapy sessions and the level of suffering. The
right time for surgical treatment is an individual decision
and can vary from one patient to another. The most impor-
tant clinical clue for this decision is the fact of persisting
symptoms that prevent sport activities or activities of daily
living after exploiting the full potentialities of non-opera-
tive treatment.
Conclusions
A treatment algorithm for SLAP lesions is presented based
upon the recent literature and the authors clinical expe-
rience. The type of lesion, age of patient, concomitant
lesions, functional requirements, and sport activity level of
the patient need to be considered. Moreover, normal varia-
tions and degenerative changes in the SLAP complex have
to be distinguished from true lesions.
Compliance with ethical standards
Conflict of interest The authors report no conflict of interest.
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