Arthroscopic SLAP Repair (Shoulder)

Indication. A symptomatic, unstable Snyder type II SLAP lesion — the superior labrum and biceps anchor detached from the glenoid with greater than 5 mm of mobility and a positive peel-back sign — that has failed an adequate trial of non-operative care (a minimum of 3 months of physiotherapy and activity modification). Up to 30 percent of SLAP tears have concomitant pathology (Bankart lesion, partial cuff tear, paralabral cyst), so the indication is set after a full diagnostic work-up. Confirm the diagnosis before offering surgery. MR arthrogram is the gold standard (sensitivity greater than 90 percent for labral detachment); look for contrast undercutting the superior labrum, biceps anchor displacement and a paralabral cyst. Bedside provocation tests support the diagnosis: the O'Brien active compression test (67 percent sensitivity), the dynamic labral shear test, and a focused assessment of glenohumeral rotation and scapular rhythm. Plain MRI is only 60-70 percent sensitive and should not be the sole basis for surgery. Non-operative treatment first. A structured programme of posterior capsular stretching (sleeper stretch, cross-body adduction), scapular stabilisation and rotator cuff endurance improves symptoms in 50-70 percent of overhead athletes at 3-6 months. A prospective cohort (Edwards, 2015) of 179 patients showed that 55 percent avoided surgery with this regimen. A corticosteroid injection into the glenohumeral joint or biceps sheath gives short-term relief in 40-60 percent and is most useful as a diagnostic test; it does not address the underlying detachment. The one decision that matters. Once a true unstable type II lesion is confirmed, the choice is between suture anchor repair and biceps tenodesis, driven by patient age, biceps tendon quality and sport demand:

Contraindications. An asymptomatic SLAP lesion found incidentally (normal variants and degenerative changes are common and often painless) is not operated on. A type II lesion in a patient older than 50 with biceps tendinopathy is better managed by tenodesis. Isolated type I degenerative fraying without mechanical symptoms needs debridement only, if anything. Untreated GIRD greater than 20 degrees or scapular dyskinesis should be addressed before considering repair. Consent specifically for stiffness (5-10 percent requiring re-operation), persistent pain (10-15 percent), biceps anchor failure, anchor pull-out or chondral injury, suprascapular or axillary nerve injury (less than 1 percent), and the possibility of intra-operative conversion to biceps tenodesis if the tissue quality is poor.

The goal of the procedure is to reattach the detached superior labrum and biceps anchor to the glenoid so that the peel-back sign is abolished, while protecting the articular cartilage and the suprascapular nerve. The portals are the exposure — they are established first and dictate the angles for debridement, anchor placement and suture passage, so they are laid out in full as the opening steps below.

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Rehabilitation | Phase | Timing | Milestones | Precautions | |-------|--------|------------|-------------| | 1 — Protection | 0-4 weeks | Sling with abduction pillow; pendular and elbow/wrist range of motion from day 1; scapular setting from week 2 | No active biceps contraction or resisted supination for 8 weeks | | 2 — Motion | 4-10 weeks | Wean sling at 4-6 weeks; passive and active-assisted forward flexion; external rotation to 30-45 degrees by week 8; sleeper stretch from week 8-10 | Avoid aggressive external rotation beyond the planned envelope | | 3 — Strengthening | 10-16 weeks | Full active range of motion by week 12; progressive cuff and scapular strengthening; resisted biceps loading from week 12 | Address any residual GIRD with posterior capsular mobilisation | | 4 — Sport-specific | 16 weeks to 6 months | Interval throwing programme at 4-5 months; return to competition at 6-9 months | Full painless range, greater than 90 percent strength symmetry, completed interval programme | Most non-overhead patients return to desk work within 2-3 weeks and to sport at 6-9 months. Overhead athletes return to their previous level at lower rates — 50 to 70 percent versus 85 to 95 percent in non-overhead patients — so realistic pre-operative counselling is essential. Return to sport is not guaranteed and averages 6-9 months; I insist on correction of GIRD and scapular dyskinesis before allowing a throwing programme. Overhead-athlete considerations. Pre-operative GIRD greater than 20 degrees should be addressed with a posterior capsular release at the time of SLAP repair. Biceps tenodesis is generally avoided in elite throwers under 30 years unless the biceps is clearly pathologic, as the native anchor contributes to dynamic stability during late cocking. If persistent posterior tightness remains at 3 months, an arthroscopic posterior capsular release is considered before progressing the throwing programme. Complications

Persistent pain and failure. Causes include missed concomitant pathology (GIRD, Bankart lesion, cuff tear), poor tissue quality, an over-tensioned repair, anchor chondral injury, or untreated biceps tendinopathy. The overall re-operation rate is 5-10 percent and is higher in overhead athletes (up to 19 percent in some series). Revision options are biceps tenodesis (the most common), capsular release, or debridement of the failed repair.

Epidemiology. SLAP lesions are most common in overhead athletes and in patients aged 20-40 years, with an increased incidence of degenerative type I and II changes after the fourth decade. They are frequently associated with instability, rotator cuff disease and trauma (a fall on an outstretched arm or a traction injury). Roughly 30 percent of SLAP tears have concomitant pathology. Pathoanatomy. The long head of biceps originates from the supraglenoid tubercle and superior labrum; the superior labrum is a fibrocartilaginous structure continuous with the biceps tendon that stabilises the biceps anchor and contributes to glenohumeral stability through the superior and middle glenohumeral ligaments. The superior labrum is relatively hypovascular in its inner third, which explains its poor healing potential without repair, and it receives proprioceptive innervation from branches of the suprascapular and lateral pectoral nerves — explaining referred pain to the lateral shoulder and biceps.

Key evidence. Brockmeier (2009, level II) reported 87 percent good-to-excellent results at 2 years in 47 patients after type II SLAP repair, with return to sport in 74 percent of overhead athletes. Gorantla (2010, level III systematic review) found a mean return to sport at the previous level of 63-85 percent, lower in overhead than in non-overhead athletes. Multiple level I and II studies, including a randomised trial by Cvetanovich (2020), show that biceps tenodesis in patients older than 40 years yields equivalent or superior outcomes to repair with lower re-operation rates for stiffness and failure, and a 2021 systematic review confirmed reliable pain relief and return to sport with tenodesis when biceps pathology coexists. The consistent message — repair the unstable young anchor, tenodese the degenerative older anchor, and never operate on a normal variant — is the core of every SLAP viva.