SLAP s: Indications and Rehabilitation. Stephen C. Weber, M.D. Boston Shoulder and Sports Medicine 2013

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1 SLAP s: Indications and Rehabilitation Stephen C. Weber, M.D. Boston Shoulder and Sports Medicine ) Early history of labral lesions a) Doug Jackson- Labrum may play a role similar to that of the meniscus in the knee (Point of View, 1984). Lots of hope that debriding labral tears would be as common (and financially rewarding) as menisectomy of the knee. b) Andrew s early study (1) successful debridement of unspecified types of labral tears-1985 c) Almost immediate controversy as to pathology-kohn 1987 (39) i) Labral fissuring in 76% of cadavers with no known shoulder symptoms ii) Pointed out that many were normal variants-suggested that labral lesions were not clinically relevant unless they could displace into the joint 2) Definitively described by Snyder, et. al. (66) a) Clarified importance of labral lesions as attachments for biceps and ligaments b) Began the recommendation of repair, not debridement c) Type 3 and 4 fairly easy to separate pathology from benign d) Type 1 and 2 more difficult e) Clarified the normal sublabral hole and Buford complex 3) Lots of questions since a) Is it pathology or plica? b) Everyone has seen a plica c) Rarely pathology d) Often times an incidental finding e) There are certainly surgeons that see plicas in everyone f) Rates of plica removal are frequently used by insurance companies to flag bad surgeons 4) How do you separate pathology from plicas-needs to be: a) Clearly defined mechanism of injury b) Clearly definable on clinical exam c) Clearly definable on imaging studies d) Clearly definable surgically e) Clearly get better with surgical treatment 5) How do SLAP lesions hold up to these questions? a) Mechanism of injury i) Andrews (1) biceps overload ii) Snyder compression due to fall on abducted arm (66) iii) Jobe s internal impingement (56), Walch et al. (74) iv) Maffett and Gartsman pull on arm downwards traction injury (41) v) Peel back mechanism of Morgan and Burkhart (8) vi) No real agreement

2 b) Clinical examination. A multiplicity of tests, usually with glowing results by the surgeon who initially described the test, usually failing to be validated by subsequent reviewers i) Snyder biceps tension test and compression-rotation test (65) (1) Doesn t work (a) Weber (79) (b) Kim and Mc Farland (34,35) ii) Relocation test of Jobe (1) Works some (a) Weber (79) 70% sensitivity (b) Guanche (23) 73% sensitivity (2) Doesn t work (a) Mileski and Snyder (46) iii) Anterior slide test of Kibler (33) (1) Doesn t work (a) Mc Farland (35) iv) Liu s crank test (40) (1) Doesn t work (a) Ottl et al. (53) (b) Guanche (23) (c) Stenson (70) v) O Brien s Active Compression test (52) (1) Works some (a) Guanche (23) (b) Morgan (48) anterior lesions only (2) Doesn t work (a) Ottl et al. (53) (b) McFarland (35) (c) Stenson (70) vi) Mimori s pain provocative test (47) (1) Only ½ of patients actually arthroscoped vii) Bicep s load test of Kim (37) viii) Speed s and Yergason's (82) test (Holtby et al. (26)) (1) variable usefulness (2) Clinicians should understand that clinical examination tests do not perform consistently (26) ix) Final assessment (1) Kim and McFarland- our findings question the diagnostic value of the clinical assessment of SLAP lesions (35) (2) Snyder there is no physical finding specific for SLAP lesions of the shoulder (46) c) Imaging i) Arthrography and CT arthrography of historic interest ii) MRI generally found most accurate by radiologists, not surgeons (1) In our study only 4 of 99 patients with type II SLAP lesions were accurately diagnosed preoperatively by MRI (79)

3 iii) Contrast MRI of some improvement (1) 0ttl et al. (53) iv) Snyder diagnostic arthroscopy remains the only definitive way to diagnose SLAP lesions of the shoulder (46) v) Preoperative MRI was non-specific in identifying SLAP lesions. Green and Belanger (3) d) Surgically i) Normal variants emphasized early ii) Belanger and Green in many cases identified SLAP pathology may not be relevant to the clinical problem. (3) iii) Type III and IV SLAP very rare, usually clear iv) Type I SLAP usually normal variant, especially over 40 v) No clear criteria on how to separate normal labral separation from true type II SLAP vi) Two studies (Gobezie et al. (21) and Jia et al. (27) show that even fellowship trained observers cannot agree on what a SLAP lesion is. e) Isolated SLAP lesions are extremely rare in most published studies i) Most studies present to OR with other findings for treatment ii) Stetson presented outcomes of isolated SLAP lesions (69) with long-term follow-up this year (68) at AANA. iii) Recently Cohen et al (14) reviewed 41 patients with isolated SLAPS iv) Every other study repairs SLAP in association with correction of at least one other source of pathology v) Makes one wonder if treating SLAP was relevant to improvement 6) If you can t diagnosis it clinically, can t diagnosis it by imaging studies, can t agree on the pathology, and can t prove fixing the lesions helps, how real can it be? a) SLAP lesions are rare, but real i) Snyder et al. 3% (66) ii) Later studies 5.9% (65) iii) Weber 1.9% (79) iv) Handelberg et al. 6% (25) v) McFarland 6.6% (35) vi) Gartsman (41) 11.8% but more instability vii) If you re doing more than 10% SLAPS, you re doing plicas b) Avoid operating on normal variants i) Sublabral holes-first described by Cooper and Arnowsky. (JBJS 1992) ii) Buford complex presented by Snyder (Arthroscopy 1994) iii) Labral variants thoroughly reviewed by Ilahi, et al. (Arthroscopy 2002) (1) Wide variation in both ligaments and labrum (2) 18.5% sublabral hole (3) 6.5 % Buford complex iv) Labral degeneration-rarely the problem in older patients v) Why not operate? (1) Not a benign procedure-despite painting SLAP repair as a universally successful procedure, this is hardly the case (a) Cohen et al.14/29 (48.2%) return to sport with tacks (14)

4 (b) Cohen et al. 31% return to play multiple surgeons for single professional baseball organization (16) (c) Cohen et al. 84% return to play, but took 12 months (15) (d) Gorantla et al. review article 20-94% return to play in different published series (22) (e) Ide et al. 68% return to play (27) (f) Stetson et al. 74% good or excellent results in a series of pure SLAP lesions (68) (g) Van Kleunen et al.40% return to play with associated capsular release (73) (h) Park and Glousman (59) 42% return with revision SLAP repair (i) Park et al. much higher rate of failure with SLAP repair with PLA anchors (58) (2) Complications include (a) Stiffness reported by numerous authors. (b) Synovitis, cysts, and arthritis reported with bio implants (13,58) (c) Arthritis from prominent metal hardware (d) Two studies Cohen et al. (14) and Mair and Hurt (42) noted significant problems with trans-rotator cuff portals for SLAP repairs, primarily rotator cuff tears. This risk will increase with older patients c) Most SLAP I and II lesions in patients greater than 40 years of age are normal variants i) Goes back as far as DePalma classic study (AAOS Inst Course Lectures 1949) (1) Fetal labrum universally fixed (2) By second decade detachment and further degenerative changes were noted ii) Pfahler et al. (JSES 2003) noted that age related changes were common, and that these changes should be evaluated in the context of age related changes in normal shoulders. d) SLAP III and IV are easy to diagnose e) SLAP II remain a problem i) Meniscoid labrum a problem both on imaging studies and surgically ii) We suggested criteria of exposed bone or granulation tissue as diagnostic of pathology (79), also supported by Snyder (46). He also suggested displacement of more than 3-4 mm with traction on the biceps. iii) Sulcus score of Mihata and Tibone et al. (45) measures both length of labral detachment and depth to get a sulcus score. Higher scores were created with mechanical stretching in external rotation and abduction in cadavers. iv) Beware the SLAP repair in patients with poor quality biceps, especially over the age of 40. Generally better treated with tenotomy than repair. Significant number of redo SLAP s in our AANA and AOSSM presentation (76,77) had varying degrees of partial biceps ruptures. Presented again by Bicknell and Boileau (4) and yet again by Katz et al. (31). All patients with poor quality biceps and many patients older than 40 are better managed with tenodesis than SLAP repair. Franceschi et al. noted better results with RCR and tenotomy than with RCR and SLAP repair (19).

5 v) Burns and Snyder et al. (10) excellent summary from the experts. Recommend tenodesis age>40, and any patient with significant concomitant surgical pathology we prefer to focus on the major surgical pathology and debride labral tearing down to a stable base. (10) f) If you want to fix it, don t use tacks i) Tacks initially good, easy. (55,63) ii) Articular cartilage injuries Buss et al. 88% success rate with tacks in 2001 (60), but later showed 19% of patients with tacks delayed onset of symptoms with significant synovitis in all and 6% with significant chondral injuries (24). iii) Sassmanhausen, et al. (62) six tack failures referred to senior author (1) chondral injuries in 2 of 6 (2) loose tack diagnosed with MRI (3) all re-repaired with sutures iv) Implant breakage (50) v) Implant migration reported by Weber and Kauffman, both intraarticular and requiring removal under the medial scapula (78) g) Suture anchors and permanent sutures best (9,17,30,54,65-69,79,81,83) although complications can still occur (29). Morgan reports that he has recently switched back to resorbable PDS. Knot squeaking, especially with high strength suture can be a problem, causing secondary articular cartilage injury. h) Several recent reports on differing patterns of repair and their relative strengths (18,44,49,54,66,81). May not be relevant as fixation strength required is probably modest. Remember that posterior portals through the cuff risk iatrogenic cuff tear. 7) How are we doing? Weber et al. (80) review of ABOS Part II applicants experience with SLAP lesions. a) There were 4,975 SLAP repairs, representing 9.4% of all applicants shoulder cases. This is three times what the literature would support b) The rate of repair increased over the study period to 10.1% by c) Mean age of male patients was 36.4 years with a maximum of 85 years of age. Mean age of female patients was 40.9 with a maximum of 88 years of age. d) Pain was reported as absent in only 26.3% of patients at follow-up, and function as normal in only 13.1%. 40.1% of applicants self-reported their patients to have an excellent result. The self-reported complication rate was 4.4%. e) Procedure done far too often, and without respect for age of patients 8) Rehabilitation a) Blaine et al. showed that initial conservative management of SLAP completely appropriate, especially as exam/radiographs not specific (5) b) Isolated SLAP uncommon, rehab generally driven by concomitant repairs of rotator cuff, Bankart, other. c) Stiffness in 15-20% in most series-move early d) Several protocols available i) Burkhart and Morgan (9) ii) Passive external rotation of the shoulder with the arm at the side (not in abduction), and flexion and extension of the elbow are emphasized. The sling is discontinued after 3 weeks, and passive elevation is initiated. From week 3 to week 6, progressive passive motion as tolerated is permitted in all planes, and sleeper stretches are begun in patients

6 who did not have a posterior-inferior capsulotomy. From week 6 to week 16, stretching and flexibility exercises are continued. Passive posteroinferior capsular stretching is continued, as is external rotation stretching in abduction. Strengthening exercises for the rotator cuff, scapular stabilizers, and deltoid are initiated at 6 weeks. Biceps strengthening is begun 8 weeks postoperatively. At 4 months, the athletes begin an interval throwing program on a level surface. At 6 months, the pitchers may begin throwing full-speed, and at 7 months pitchers are allowed full-velocity throwing from the mound. (9) iii) Snyder (65) iv) My preferred protocol (1) Sling pendulum only for 1 week (2) Gentle PROM, pulleys till 3 weeks D/C sling (3) Active ROM, bands 6 weeks (4) No weights, sport 12 weeks. Start graduated throwing program when ROM OK and strength normal (5) Caution patients that overhead sports not likely for six months. 9) Summary a) SLAP lesions are rare injuries. Unless you do a high percentage of throwing athletes, it will be a small part of your shoulder practice. Reassess your indications if you do more than 10% SLAP repairs. b) Clinical, and radiographic factors will not allow you to routinely predict these patients c) SLAP over 40 and/or with significant concomitant pathology is best managed with tenodesis d) Counsel your patients; success rates are only from 20-75% and return to sport not guaranteed. References 1. Andrews JR, Carson WG, Jr, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985;13: Barber FA, Morgan CD, Burkhart SS, Jobe CM. Labrum/biceps/cuff dysfunction in the throwing athlete. Arthroscopy 1999;15(8): Belanger M, Green A. SLAP lesions: Defining clinical relevance. Arthroscopy 1999;15(5): Bicknell RT, Parratte S, Chuinard D, Jacquot N, Trojani C, Boileau P. Arthroscopic treatment of type II SLAP lesions: Biceps tenodesis as an alternative to reinsertion. Arthroscopy 2007;23(6): Supplement, Page e27). 5. Blaine TA. Edwards SL, Lee JA, Bell JE. Improved Outcomes with Non- Operative Treatment of Superior Labral Tears Arthroscopy 2007;23(6): Supplement, Page e27). 6. Boileau P, Krishnan SG, Coste JS, et al. Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation (in process citation). Arthroscopy 18(9): ,2002.

7 7. Brockmeier SF, Voos JE, Williams RJ, Altchek DW, Cordasco FA, Allen AA Outcomes after Arthroscopic Repair of Type-II SLAP Lesions 2009;91: Burkhart SS, Morgan CD. Technical note: The peel-back mechanism: Its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 1998;14(6): Burkhart SS, Morgan C. SLAP lesions in the overhead athlete. Orthop Clin North Am 2001;32(3): Burns JP, Bank M, Snyder SJ. Superior labral tears: Repair versus biceps tenodesis. J Shoulder Elbow Surg 2011;20(2)supp there are no reliable diagnostic or physical examination maneuver recommended tenodesis over 40. With significant concomitant surgical pathology we prefer to focus on the major surgical pathology and debride labral tearing down to a stable base. 11. Castagna A, Sacchi G, D Ortona A, Bungaro P. Rottura del capo lungo del bicipite, lesioni SLAP e conflitto superio-interno: trattamento chirurgico. G It Ort Trauma 28(Supp I): , Chen AL, Ong BC, Rose DL Arthroscopic management of spinoglenoid cysts associated with SLAP lesions and suprascapular neuropathy Arthroscopy (6):E Chochole MH, Senker W, Meznik C, Breitenseher MJ. Glenoid-labral cyst entrapping the suprascapular nerve: dissolution after arthroscopic debridement of an extended SLAP lesion. Arthroscopy 1997;13(6): Cohen DB; Coleman S; Drakos MC; Allen AA; O'Brien SJ; Altchek DW; Warren RF. Outcomes of isolated type II SLAP lesions treated with arthroscopic fixation using a bioabsorbable tack. Arthroscopy. 2006; 22(2): (ISSN: ). 14/29 return 15. Cohen CB, Reiter BK, Neuman B, Ciccotti MG. Results of Repair of Type II SLAP Tears in Throwers: Assessment of Return and Satisfaction. Proc Acad Orthop Surg 10:210, patients ASES scores 87.1 KJOK 71.6 return to play 12.5 months 84.1% returned to pre injury level. 16. Cohen SB, Sheridan S, Ciccotti MG. Return to sports for professional baseball players after surgery of the shoulder or elbow. Sports Health. 2011;3(1): /22 returned (31%) multiple surgeons, one club AAOS, AOSSM months to return 20% unable to play-ases scores high despite failure to return 17. Conway JE Arthroscopic repair of partial-thickness rotator cuff tears and SLAP lesions in professional baseball players. Orthop Clin N Amer 2001;32(3): Domb BG; Ehteshami JR; Shindle MK; Gulotta L; Zoghi-Moghadam M; MacGillivray JD; Altchek DW. Biomechanical comparison of 3 suture anchor configurations for repair of type II SLAP lesions. Arthroscopy. 2007; 23(2):135-40

8 19. Franceschi F, Longo UG, Ruzzini L, Rizzello G, Mafulli N, Denaro V. No advantages in repairing a type II superior labrum anterior to posterior (SLAP) lesion when associated with a rotator cuff repair in patients over age 50. Am J Sports Med 2008;36(2): Gartsman GM, Hammerman SM. Arthroscopic Biceps Tenodesis: Operative Technique Arthroscopy 16(5): , Gobezie R, Zurakowski D, Lavery K, et al. Analysis of interobserver and intraobserver variability in the diagnosis and treatment of SLAP lesions using the Snyder classification. Am J Sports Med. 2008;36(7): Gorantla K, Gill C,Wright RW The Outcome of Type II SLAP Repair: A Systematic Review. J Arthroscopy 2010;26,(4): Review return to play 20-94%. 23. Guanche CA, Jones DC Clinical testing for tears of the glenoid labrum. Arthroscopy 2003;19: Harms D, Buss DD, Freehill MQ, Atlihan D, Huber SM. PLLA Tack Synovitis following arthroscopic stabilization of the shoulder. Proceedings, 2002 Annual Meeting American Academy of Orthopaedic Surgeons. 2002;3: Handelberg F, Willem S, Shahabpour M, Huskins JP, Kuta J. SLAP lesions: A retrospective, multicenter study. Arthroscopy 1998;14(8): Holtby R ; Razmjou H. Accuracy of the Speed's and Yergason's tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. 2004; 20(3): Ide J, Maeda S, Takagi K. Arthroscopic Bankart repair using suture anchors in athletes: Patient selection and postoperative sports activity. Am J Sports Med 2004;32: % return previous level. 28. Jia X, Yakota A, McCarty EC, Nicholson GP, Weber SC, McMahon PJ, Dunn WR, McFarland EG. Reproducibility and reliability of the Snyder classification of superior labral anterior posterior lesions among shoulder surgeons. Am J Sports Med. 2011;Epub 1 Feb (DOI: / ). 29. Kaar TK,Schenck RC, Wirth MA, Rockwood CA. Complications of metallic suture anchors in shoulder surgery: A report of 8 cases. Arthroscopy 2001;17(1): Kartus J, Perko M. Arthroscopic repair of a type II SLAP lesion using a single corkscrew anchor. Arthroscopy 2002;18(3):E Katz LM, Hsu S, Miller SL, Richmond JC, Khetia E, Kohli N, Curtis AS. Poor Outcomes After SLAP Repair: Descriptive Analysis and Prognosis. Arthroscopy 2009;25(8): Kauffman JI, Weber SC, Higgins D Arthroscopic biceps tenodesis: Experience with the Castagna Technique. Proc Am Acad Orthop Surg 5:525, Kibler WB. Specificity and sensitivity of the anterior slide test in throwing athletes with superior glenoid labral tears. Arthroscopy 1995;11(3):

9 34. Kim KT, McFarland EG. Diagnostic value of clinical assessment in SLAP lesions: Can the detachment of the biceps anchor be detected by clinical assessment? Proceedings, 2002 Annual Meeting American Academy of Orthopaedic Surgeons. 2002;3: Kim KT, Queale WS, Cosgarea AJ, McFarland EG Clinical features of the different types of SLAP lesions: An analysis of one hundred and thirty-nine cases. Superior labrum anterior to posterior. J Bone Joint Surg 2003;85A(1): Kim KT, Cosgarea AJ, McFarland EG. Clinical Significance of SLAP Lesions: Different Clinical Features and Associated Pathologies According to the Patient Age. Proceedings, 2002 Annual Meeting American Academy of Orthopaedic Surgeons. 2002;3: Kim SH, Ha KI, Ahn JH, K SH, Choi HJ. Biceps load test: A clinical test for SLAP lesions of the shoulder. 2001;17(2): Kim SH, Ha KI, Kim SH, Choi HJ. Results of Arthroscopic Treatment of Superior Labral Lesions J Bone Joint Surg. 2002;84: Kohn D. The Clinical Relevance of Glenoid Labrum Lesions. Arthroscopy 3: , Liu SH, Henry MH, Nuccion SL A prospective evaluation of a new physical examination in predicting glenoid labral tears. Am J Sports Med 1996;24(6): Maffett MW, Gartsman GM, Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med 1995;23(1): Mair S, Hurt J. Rotator Cuff Tears as a Complication of Portal Placement Arthroscopy 2006;22(6):Supplement, Page e23). 43. Martin DR, Garth WP. Results of arthroscopic debridement of glenoid labral tears. Am J Sports Med (4): McMahon PJ, Burkart A, Musahi V, Debski RE. Glenohumeral translation are increased after a type II superior labrum anterior-posterior lesion: A cadaveric study of severity of passive stabilizer injury. J Shoulder Elbow Surg 1994;13(1): Mihata T, McGarry MH, Tibone JE, Abe M, Lee TQ. Type II SLAP lesions: A new scoring system-the sulcus score. J Shoulder Elbow Surg 2005;14(1 Supp S):19S-23S. 46. Mileski RA, Snyder SJ Superior labral lesions in the shoulder: Pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6: Mimori I, Muneta T, Nakagawa T, et al. A new pain provocative test for superior labral tears of the shoulder. Am J Sports Med 1999;27(2): Morgan CD, Burkhart SS, Palmeri M, et al. Type II SLAP lesions: Three subtypes and their relationship to superior instability and rotator cuff tears. Arthroscopy 1998;14(6):

10 49. Morgan RJ, Marshall AK, Peindl RD, Fleischli JEl A Biomechanical Comparison of Two Suture Anchor Configurations for the Repair of Type II SLAP Lesions Subjected to a Peel-Back Mechanism of Failure J Arthoscopy 2008:24(4): Musgrave DS, Rodosky MW SLAP lesions: Current concepts Am J Orthop 2001;30(1): Nord KD, Masterson JP, Mauck BM. Superior labrum anterior posterior (SLAP) repair using the Neviaser portal. Arthroscopy 2004;20 Suppl 2: O Brien SJ, Pagnani MJ, McGlynn SR, et al. The active compression test. Am J Sports Med 1998;26(5): Ottl GM, Haury J, Merl T, Imhoff A. SLAP Lesion: A prospective study with clinical diagnostics, MRT, MRT-arthrography, and arthroscopy, and the incidence of the SLAP lesion in 24 cadaver shoulders under MR-tomographic and arthroscopic control. Arthroscopy 1999;S72: Pagnani MJ, Deng XH, Warren RF et al. Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation. J Bone Joint Surg Am 1995;77: Pagnani JM, Speer KP, Altchek DW, et al. Arthroscopic fixation of superior labral lesions using a biodegradable implant: A preliminary report. Arthroscopy 1995;11: Paley KJ, Jobe KW, Pink MM, Kvitne RS, ElAttrache NS. Arthroscopic findings in the overhand throwing athlete: Evidence for posterior internal impingement of the rotator cuff. Arthroscopy 2000;16(1): Pandya NK, Hoffman GR, Colton A, Sennett BJ. Physical exam and magnetic resonance imaging (MRI) in the diagnosis of superior labrum anterior-posterior (SLAP) lesions of the shoulder. J Arthroscopy 2008;24(3) Park MJ, Hsu J, Harper C, Sennett B, Huffman GR. Poly Lactic Acid (PLDLA) Anchors are Associated with Reoperation and Failure of Glenoid Labrum Repairs Presented, AANA, 2011, San Francisco, CA. After controlling for associated factors in a multivariate analysis, the use of absorbable anchors, in particular PLDA anchors from Linvatec (OR 14.7, p<0.001) and having a work-related (OR 8.1, p<0.001)injury remained independent factors associated with both repeat surgery and after labrum repair.conclusion: The results of this study strongly support a recommendation against the use of poly-lactic 59. Park SD Glousman RE Outcomes of revision arthroscopic type II SLAP repairs Presented ASES, San Diego, % return to sport with revision. 60. Samani JE, Marston SB, Buss DD. Arthroscopic stabilization of Type II SLAP Lesions using an absorbable tack. Arthroscopy 2001;17(1): Sanders BS, Warner JJP, Pennington S, Lavery KP. Biceps tendon tenodesis: Success with proximal versus distal fixation. Presented, AAOS, San Diego, CA 2007.

11 62. Sassmannshausen G; Sukay M; Mair SD. Broken or dislodged poly-l-lactic acid bioabsorbable tacks in patients after SLAP lesion surgery. Arthroscopy. 2006; 22(6): Segmuller HE, Hayes MG, Saies AD. Arthroscopic repair of glenolabral injuries with an absorbable fixation device. J Shoulder Elbow Surg 1997;6(4): Sekiya JK, Elkousy HA, Rodosky MW Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique Arthroscopy 19(10): , Snyder SJ, Banas MP, Karzel RP: An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 1995;4: Snyder SJ, Karzel RP, Delpizzo W, et al. SLAP lesions of the shoulder. Arthroscopy. 1990;6: Snyder SJ, Rames RD, Wolbert E. Labral Lesions. In: McGinty JB, ed. Operative Arthroscopy New York: Raven Press, 1991; Stetson WB, Snyder SJ. Clinical Presentation and Follow-up of Isolated SLAP Lesions of the Shoulder. Presented, AANA, 2011, San Francisco, CA. only 74% G or E results. 69. Stetson WB, Snyder SJ, Karzel RP, Banas MP, Rahhal SE. Long term clinical follow-up of isolated SLAP lesions of the shoulder. Presented,65 th Annual Meeting of the AAOS, New Orleans, March 23, SLAP alone reference 70. Stetson WB, Templin K The Crank test, the O Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. Am J Sports Med 2002;30(6): Tennent TD, Beach WR, Meyers JF A review of the special tests associated with shoulder examination. Part II: Laxity, instability and superior labral anterior and posterior (SLAP) lesions Am J Sports Med 2003;31(1): Tomlinson RJ, Glousman RE. Arthroscopic debridement of glenoid labral tears in athletes. Arthroscopy 1995;11(1): Van Kleunen JP, Field LD, Savoie FH. Return to High Level Throwing after Combination Infraspinatus Repair, SLAP Repair, and Release of Glenohumeral Internal Rotation Deficit Presented, AANA, 2011, San Francisco, CA. 40% return to play. 74. Walch G, Boileau J, Noel E, et al. Impingement of the deep surface of the supraspinatus tendon on the posterior superior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg 1992;1: Waldt S, Burkart A, Lange P, Imhogg AB, Rummeny EJ, Woerler K. Diagnostic performance of MR arthrography in the assessment of superior labral anteroposterior lesions of the shoulder. 2004;182(5): Weber SC, Surgical Management of the Faled SLAP Repair. Sports Med Arth Rev. 2010;18(3):

12 77. Weber, S.C. Surgical Management of Type IV SLAP Lesions (SS-13) Arthroscopy: The Journal of Arthroscopic and Related Surgery 2008 ;24(6): Supplement, Pages e7-e Weber SC, Kauffman JI. Distant migration of a bioabsorbable implant in the shoulder J Shoulder Elbow Surg. 2006;15(6): Weber SC, Higgins DA. Arthroscopic management of type 2 SLAP lesions of the shoulder: Clinical and radiographic predictability and long-term follow-up. 69 th Meeting Proceedings, Am Acad Orthop Surg 2002;3: Weber SC, Payvandi S, Martin DF, Harrast JJ. SLAP Lesions of the Shoulder: Incidence Rates, Complications, and Outcomes as Reported by ABOS Part II Candidates. Proc Am Acad Orthop Surg 2010;11; Wolf BR, Selby RM, Dunn WR, MacGillivray JD. Lasso repair of SLAP of Bankart lesions: A new arthroscopic technique. Arthroscopy 2004;20(supp 2): Yergason RM. J Bone Joint Surg 1931;13: Yian E, Wang C, Millett PJ, Warner JJ. Arthroscopic repair of SLAP lesions with a bioknotless suture anchor Arthroscopy 2004;20(5):