Our understanding of SLAP tears, or superior labral tears of the shoulder, continues to evolve. In the past, we often rushed to surgical repair of a SLAP lesion, but now we understand that not all SLAP tears need to be repaired. In fact, repairing some types of SLAP tears in the wrong person could make them worse!
In this episode, we talk about the difference between a “good” SLAP tear and a “bad” SLAP tear.
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#AskMikeReinold Episode 343: Update on SLAP Tears: Good SLAPs vs Bad SLAPs
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Show Notes
• What Exactly Is a SLAP Tear? Top 5 Things You Need to Know About a Superior Labral Lesion
Transcript
Devin Limerick:
Yes. We have a question on SLAP tears from the AASBT meeting. Dr. Eric McCarty presented on our current understanding of SLAP tears and how there may be such thing as a good SLAP tear and a bad SLAP tear. Can you explain?
Mike Reinold:
Awesome. Good question. Thanks, D. Like it. Yeah, this was a good topic, I think, at the annual meeting of the sports academy. Again, Dr. Eric McCarty from Colorado came and gave a great presentation on updates on this. And I think it’s a good relevant topic because with SLAP tears over the years, we freaked out at the beginning. Everybody had SLAP tears, that sort of thing. And then you start to understand, well, maybe there’s some good SLAP tears and some bad SLAP tears that we should freak out about, that sort of thing. I thought it was a great topic that he did.
Working within baseball, I think we inherently realized this a decade ago that we’re not going to go crazy about SLAP tears, but the general population, and even just high level athletes, fitness athletes, somebody with shoulder pain, you get an MRI and you have a SLAP tear… It’s like the end of the world. It’s a little bit more confusing, those populations.
Who wants to start with this? I mean, maybe somebody that was there. I know Dave wants to jump in here too because you’ve got a good story. But Dan, you were there. You listened to the presentation. What was your take on this conversation?
Dan Pope:
Yeah, I thought it was a really good talk. I think as physical therapists, we’re always biased towards exercise. Whenever someone comes through the door, it’s like, okay, let’s try to get this person better with physical therapy, which I think is good, but there’s definitely a lot of populations, one of which being anterior shoulder instability. Someone has a traumatic dislocation and they’re young. They want to get back to football or rugby. If we just rehab them and throw them back, there’s a really good chance they’re just going to dislocate again. So these are folks who are thinking they came through the door. Let’s say we have direct access or are the first point of contact. I’m automatically thinking you should go back to the surgeon and talk to that person because the best case might be surgery as a primary treatment.
And I think SLAP tears are interesting. You kind of brought up the history of this. It seems like at the start, we were doing much more SLAP repairs and then finding that our return to sport rates and return to sport at prior level function wasn’t as good as we would like them to be. And realizing that SLAP tears can often be asymptomatic and then essentially, you almost need a SLAP tear to throw faster in baseball. So it was a positive adaptation for a lot of folks. And then also finding that conservatively, if we go slow enough, a lot of these folks do tend to get back, and those non-op rates of return to sport, in some ways, might be better or equal to performing surgery, right?
So I think what ends up being an issue is that you have a patient that comes through the door with a SLAP tear and we know if they’re bad enough or they have enough concomitant pathology, you may have to send them back to the doctor for potential surgery, right? And I think the thing that Eric… Was it McCarthy, right?
Mike Reinold:
Yeah.
Dan Pope:
Brought up was that we’re trying to differentiate between what is a good SLAP tear and what is a bad SLAP tear. And essentially, which of those SLAP tears are like, well, “We should probably send you back to the doctor faster to get this repaired and potentially not waste your time.” Because part of the issue is that if you have a really bad SLAP tear, you try to rehab this conservatively, which may take five, six months, and then you try to ramp back up to throwing and then it just hurts all over again. It’s almost like you just waste your time. Now you have to go back and get surgery, right? But we do know a big chunk of those folks are going to do really well if we just started off with conservative care. So how do we figure out which of those patients are appropriate for physical therapy versus going back and getting surgery?
And he had… And this is the first time I’ve heard this… I actually went online to see if I could find good SLAP versus bad SLAP to see if this is something in the literature that I’d missed. I didn’t find anything. So I think this is his own thoughts. But essentially, if someone has minimal functional impairments, they’re not that painful, they’re dealing with the type SLAP 1 or SLAP 2, and I think he was talking about SLAP 2Bs and Cs, which I don’t know a ton about, but apparently 2Bs are more common in overhead throwing athletes, whereas A, not as much. Or if there’s going to be a lot of instability, that’s a bad thing, right?
So SLAP… I’m sorry. I think I had you confused a little bit. So SLAP 1 and 2B, C are going to be in that good category, and SLAP 2A and then SLAP 3, 4, when you start getting into the world of concomitant pathology, especially folks that are very, very painful, have a lot of functional limitation early on, are probably the folks you want to send back to the physician from the get-go.
So at least in my mind as a physical therapist, I think this is vital, and something I didn’t understand early on in my career is when a patient comes through the door, you don’t have to heal everything with physical therapy. And plus, physical therapy isn’t always the best first thing to do. So thinking about how severe this issue is and sending back to the doctor, just getting an idea is probably a good path moving forward. So you give a person the best long-term outcome, but you don’t waste their time either. You know what I mean?
Mike Reinold:
Yeah. And I think to your point, Dan, there’s a large spectrum of… Spectrum. Did I say that wrong? That’s a funny word when you say it slowly like that. There’s a large spectrum of pathology that you can have with SLAPs, right? From some just frayed to some detachment to crazy bucket handle tears in the joint, and that’s just for the superior labrum. That doesn’t even include extensions, anterior, posterior, concomitant, stuff like that. So I think that’s another thing. It’s like you can’t just say a SLAP tear. You say like, “Well, all right, what does that mean? How bad?? How big? Where is it?” That sort of thing. So I think that is one good statement from that.
Dave, you’ve had some recent experience here with this conversation that I think is relevant for today. What do you got?
Dave Tilley:
Actually, funny because I was thinking about one patient, but now that I was thinking through my thoughts, I ironically have three patients all from Dr. Arun Ramappa with literally this exact situation. So all three of them… There’s a lot of really high level gymnasts with SLAP tears. So these three girls are all 16 to 18 years old, collegiate gymnasts or on scholarship soon. And one of them came to us mid-season and had really gnarly shoulder pain, but Arun thought that she was more of a cuff issue. She thought the SLAP was minimal. It wasn’t that big of a deal. It was some fraying, but it really wasn’t that serious on an arthrogram. So he actually said, “Let’s do PT. Let’s get through the season for nationals, get your scholarship,” but then now she’s actually shut down for six weeks. She’s training with us, but she’s more or less not really doing gymnastics. The cuff seems to be more the issue.
The second athlete had surgery with Arun, came in the fall, and was really struggling, starting to have some instability, some clicking, some popping, and she had a type 2 with a little bit of two anchors’ worth of repair. So in that situation, she was trying to get ready for a scholarship and stuff like that, and he and I and her all agreed, “Let’s just get this done. Let’s get you ready for senior year so you can be ready to go when you graduate and move on.” So she had surgery early in the fall and she’s fully back now. She’s back to everything, completely fine, no pain at all.
The third one is my two o’clock eval today. Had a very complex tear. Was on the phone with him before. He was like, “Well, this is actually into the bicep anchor, three anchor repair.” He’s like, “I’m really worried about her not getting into PT fast enough because she gets stiff and then has a bicep issue. She might need a tenodesis if it doesn’t go well next year.”
So literally, all three of them, I have a great sample size of three different cases, three different SLAPs, all on arthrogram, but one is very mild, probably more cuff stuff. One is needing surgery yesterday because it was really important to get the complex tear taken care of. Yeah.
Mike Reinold:
And I would say my whole caseload is all good SLAPs that we skillfully neglect.
Well, I think the main point too with that on the good SLAP thing right here is just take a step back and say, what is a SLAP tear? So it’s a superior labrum tear, right? All we know about SLAP tears is essentially that if you have a SLAP tear, you have increased glenohumeral translation. It increases the translation anterior-posterior of your humeral head. So it decreases your static stability. The bigger the tear, the uglier the tear, the more involved with the tear, the less stability you have. If you can build strength and dynamic stability and you can be able to tolerate that during your activities, whatever that may be, then you might be okay.
So you might have a bad SLAP in a low functional person, it might not be the end of the world. You might have a small SLAP or a good SLAP in a highly functional person, and that might be a big deal for that person. So really, the goal is to try to figure out where they fall on that spectrum. But I think we’ve evolved as a profession in a way that’s really positive, where we’ve identified that we’re not just going to put anchors down on everybody. It’s, “Okay, let’s try to identify who could respond well to rehab just by strength of dynamics if it’s a good SLAP, and who probably needs to get in there and surgically get involvement, a bad SLAP.” So that way we can ensure that they have the most success. They don’t develop arthritis in the future, that sort of thing.
Anyway, I thought it was a great talk by Dr. McCarty and I thought it was a question that a lot of people had, so we wanted to feature it in an episode here. I thought that was really good, but just keep that in mind with SLAPs, right? There’s good, there’s bad, and it depends on the person sometimes, right? But great stuff. If you have a question like that, head to mikereinold.com, click on that podcast link, and fill that form out, fill away, and we will answer your question on a future episode. But please, Apple Podcast, Spotify, subscribe, rate, review. We’ll see you on the next episode. Thank you.
