The shoulder is a ball and socket joint. The socket of the shoulder (called the the glenoid) is where the humeral head (the ball) attaches itself and is covered by a soft fibrous tissue called a labrum. This labrum holds the ball and socket together. The shoulder (glenoid) labrum provides much needed joint stability due to the shallow socket and is also the attachment site for several major ligaments. Damage to the labrum can cause excessive instability, the beginnings of shoulder osteoarthritis, and chronic dislocation.
SLAP stands for superior labrum anterior and posterior, meaning there is a tear from front to back on the top of the glenoid labrum.
Labral injuries can come from acute trauma or constant shoulder motion. The labrum also gets more brittle with age due to natural wear and tear. When the labrum is torn, stretched, or otherwise pulled from its natural position, it is best to take action sooner rather than later. When injured, it is highly likely that the ligaments and tendons of the shoulder are also injured. This increases vulnerability to even further damage in the future. As one continues to use the unstable shoulder, osteoarthritis arises as the body attempts to stabilize the joint by overgrowing bone (bone spurs).
When you have a labral tear, generally there are:
- clicking sounds
- a sense of shoulder instability
- loss of strength.
The SLAP surgical options examined Research from New York University says:
- of 2,524 patients who had a SLAP lesion surgical repair, after 3 to 11 years of follow-up, 10% of patients (254 of 2,524) underwent repeat surgical intervention on the same shoulder as the initial SLAP repair.
- The average time to that repeat shoulder surgery was a little more than 2 years later
Subsequent procedures included:
- subacromial decompression a procedure that cuts ligaments and shaves down bone spurs on the acromion bone (35%),
- debridement, a “power washing” of the debris and damaged tissue in the shoulder (26.7%).
- repeat SLAP repair (19.7%),
- and biceps tenodesis or tenotomy (13.0%). This is a more radical procedure usually reserved for aging patients and involves cutting the tendon attachment of the bicep to the shoulder labrum and attaching it to the humerus bone (upper arm).
- After isolated SLAP repair (where only the SLAP lesion was arthroscopically repaired), patients aged 20 years or younger were more likely to undergo arthroscopic repair
- Patients over 30 were at risk for subsequent acromioplasty and distal clavicle resection
- The need for a subsequent procedure was significantly associated with Workers’ Compensation cases.(1)
In a combined study from University of Minnesota and German researchers, doctors found that if conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions could be achieved. However what was the measurement of success? If it was return to sport, or function in older patients, it was not that successful.
- The results of arthroscopic repair in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance.
- 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.
These doctors also looked at the problem of “normal variations and degenerative changes” in the SLAP complex that needs to be distinguished from “true”SLAP lesions in order to improve results and avoid overtreatment.” Possibly avoid a surgery based on the wrong recommendation.(2)
Arthroscopic surgery as diagnostic tool causes concern – hopes of decreasing the number of surgical repairs performed
In a recent review of SLAP lesion repair surgeries, one author, Stephen C. Weber, MD, noted the rise in both the number of repair surgeries and complications associated with them. This study looked at the American Board of Orthopedic Surgery database for SLAP lesion repairs.
- With 4,975 repairs in the database, only 26.3% of the patients reported a complete resolution of pain.
- Worse, only 13.1% of them reported normal function.
The author expressed concern over the number of young orthopedic surgeons performing SLAP lesion repairs and also the number of middle-aged and elderly patients receiving them given the complications associated.
He concluded that there should be a greater focus on educating young orthopedic surgeons so that they can recognize and treat SLAP lesions appropriately with the hopes of decreasing the number of surgical repairs performed.(3)
Years later researchers suggest the best diagnostic tool is still surgery and doing some repair while you are in there.
- 2017: Doctors in the United Kingdom say magnetic resonance arthrography while having a high diagnostic accuracy for labral tears and Hill-Sachs lesions, is controversial. Arthroscopic diagnosis remains the gold standard. (4)
“36.8% of these surgeries were considered a “failure” and 28% had to be redone”
A recent study published in the American Journal of Sports Medicine analyzed the post-surgical outcomes of athletes with SLAP lesions
- One hundred seventy-nine military athletes were used in the study, all of which underwent surgery to fix an existing SLAP lesion.
- Out of all the operations, 36.8% of these surgeries were considered a “failure” and 28% had to be redone.
- That means that 66 individuals had a failed surgery and 51 had to go back into the operating room.
At two to five year follow-ups, a significant amount of these athletes still had decreased range of motion in the affected shoulder. Researchers concluded that an age greater than 36 years old was the factor that was associated with an increased chance of surgery failure. Other studies have shown similar statistics with many participants unable to ever return to their previous pre-surgery activity level.(5)
Will staples hold your shoulder together?
The major long-term functional problem of surgical treatment for shoulder labrum tears is that the surgery usually confined itself to stapling or suturing the labrum itself and did not address damage occurring in the whole shoulder.
Treating the labral tear with sutures and staples would indicate the pain is coming from an isolated tissue damage. It is thought by keeping the humeral head in the socket, chronic instability will go away. In reality, this is not the case. Any type of injury affects all the structures of the joint.
Prolotherapy Injections for Slap Tears
Prolotherapy is a non-surgical procedure that uses the body’s natural immune system response in order to call more focused attention to an injured joint. This is done by injecting a dextrose proliferant solution) in and around the shoulder joint. This mild irritant causes inflammation and repair in that specific area. In more advanced the patients may be suggested to Platelet Rich Plasma Prolotherapy or Stem Cell Prolotherapy.
We have found Prolotherapy to be a very good treatment for slap lesions. We encourage people to try Prolotherapy first before committing to a surgery that may offer less than hoped for results. It is somewhat rare that we will recommend anyone onto surgery after Prolotherapy treatments.
The advantages of using Prolotherapy versus surgery for labral tears:
- Prolotherapy does not typically require time out of work.
- Prolotherapy accelerates the return to athletics.
- Prolotherapy is a fraction of the cost of surgery.
- Prolotherapy risks are minimal.
- Prolotherapy can treat all the injured structures of the shoulder at once.
The difference between Platelet Rich Plasma Prolotherapy and Platelet Rich Plasma Therapy
Patients will often report that they visited an orthopedic surgeon and received a PRP injection into the shoulder. Doctors more experienced in the techniques of regenerative injection therapies found that you cannot simply offer a single platelet-rich plasma injection inside the joint and expect superior results. When Prolotherapy/PRP injections are offered a patient should expect 30 injections and a comprehensive treatment. This type of treatment offers the patient a superior healing program to address the ligament and tendon laxity that contributes to whole shoulder instability and destructive joint motion on the labrum.
The Platelet Rich Plasma Prolotherapy treatment as demonstrated by Caring Medical Regenerative Medicine Clinics
If you have questions about this treatment, you can get help and information from Caring Medical Regenerative Medicine Clinics
1 Mollon B, Mahure SA, Ensor KL, Zuckerman JD, Kwon YW, Rokito AS. Subsequent Shoulder Surgery After Isolated Arthroscopic SLAP Repair. Arthroscopy. 2016 Oct;32(10):1954-1962.e1.
2 Brockmeyer M, Tompkins M, Kohn DM, Lorbach O. SLAP lesions: a treatment algorithm. Knee Surg Sports Traumatol Arthrosc. 2016 Jan 27.
3 Weber, SC, et al. Superior Labrum Anterior and Posterior Lesions of the Shoulder: Incidence Rates, Complications, and Outcomes as Reported by American Board of Orthopedic Surgery Part II Candidates. Am J Sports Med. 2012 May 24.
4 Saqib R, Harris J, Funk L. Comparison of magnetic resonance arthrography with arthroscopy for imaging of shoulder injuries: retrospective study. Ann R Coll Surg Engl. 2017 Apr;99(4):271-274. doi: 10.1308/rcsann.2016.0249.
5. Yıldız F, Bilsel K, Pulatkan A, Uzer G, Aralaşmak A, Atay M. Reliability of magnetic resonance imaging versus arthroscopy for the diagnosis and classification of superior glenoid labrum anterior to posterior lesions. Arch Orthop Trauma Surg. 2017 Feb;137(2):241-247.
6. Park S, Glousman RE. Outcomes of revision arthroscopic type II superior labral anterior posterior repairs. The American journal of sports medicine. 2011 Jun;39(6):1290-4. [Google Scholar]