What are SLAP tears?

SLAP Tears - Biceps tendon partial tearSLAP, as used in regards to shoulder problems, is an acronym that means Superior Labrum Anterior Posterior. The labrum is a fibrocartilage structure that attaches to the rim of the shoulder socket. The labrum can tear away from its attachment point. Sometimes that generates pain. Labral tears in young people usually result from injury. Labral tears are extremely common in older patients and are thought to represent a natural aging process of the shoulder.

A Tricky Diagnosis

It is difficult to diagnose a labral tear as a cause for shoulder pain. There is no telltale sign on physical examination that yields a clear cut diagnosis of labral tear. There is also not a classic pattern of pain or dysfunction associated with labral tear. To make matters even more difficult for the shoulder practitioner, an MRI scan of the shoulder will commonly suggest a labral tear when there is no labral tear. When a test suggests that there is pathology and there is no pathology present, that is referred to as a “false positive”. False positives are very common when it comes to diagnosing labral tears. Internal observer reproducibility is poor when different specialists are asked to review the same MRI scan of a shoulder. If orthopedic radiologists are given the same images to look at but are blind to the information that others have interpreted, there’s not a high correlation between different radiologists concerning the diagnosis of labral tear.

So, what is the gold standard for diagnosing a labral tear? It might seem logical that looking at the labrum, as is done with arthroscopic surgery, would yield an accurate answer. That is not the case. When shoulder specialists are shown the same video or still photography of the labrum in question, they typically do not agree about the diagnosis.

Some generalizations about labral pathology can be made. In younger patients, labral tears are usually associated with a notable injury to the shoulder. Most patients that are candidates for surgery for a labral tear will show suggestion of a labral tear on an MRI study. Most of those same patients will show distinctive findings at surgery that suggest a labral tear.

In older patients, labral tears are very common as a variation of normal. It seems that as shoulders age, the labrum becomes susceptible to tearing with everyday activities. Most labral tears in older patients will not require surgical treatment.

In either case, SLAP tears often happen in the area that the biceps tendon attaches to the labrum.

What are disorders related to the biceps tendon?

The long head of the biceps tendon can cause quite a bit of discomfort about the shoulder. The biceps muscle has one connection in the elbow area. It has 2 connections around the shoulder area. The connection to the part of the shoulder blade known as the coracoid process is tough, durable and rarely causes problems. This connection is called the short head of the biceps. The connection called the long head is a notorious troublemaker. The long head biceps tendon is a tendon that goes from the belly of the biceps muscle to the top of the shoulder socket. It passes along the anterior aspect of the humerus. It moves in a special groove in the proximal humerus and then enters the shoulder joint. It travels across the top of the ball of the shoulder to connect at the top of the shoulder socket (the glenoid). Looking at the socket like the face of a clock one will usually find the biceps tendon somewhere between 11:00 and 1:00. The exact position of attachment varies from individual to individual.

Most biceps tendon problems seem to be a result of degeneration caused by aging. As the tendon degenerates, some of the individual tendon fibers break. The tendon has a structure that has some similarity to a rope. It is composed of thousands of individual tendon strands like the individual strands of a rope. As individual fibers break the tendon will tend to flatten out. A normal tendon is rounded and slightly smaller than a #2 pencil. I have seen some flattened out tendons at surgery that are almost an inch wide.

Almost everybody’s biceps tendon will begin to degenerate eventually. It seems that most biceps tendons don’t cause pain when they begin to degenerate. Some biceps cause a tremendous amount of pain. The pain is generally well localized in the vicinity of the bicipital groove.

The treatment of the biceps tendon problem has a lot in common with the treatment of a rotator cuff tendon problem. Treatment may include rest, supervised physical therapy, home exercises, activity modification, medication taken by mouth, medication administered by injection, and surgery.

Rest

SLAP Tears - Biceps tendon, healthyOne need not stop using the arm to rest the biceps tendon. It works hard when one is twisting the wrist repeatedly with a load in the wrist. It works hard when one is flexing the elbow repeatedly. One can rest the biceps tendon by simply diminishing those tasks that involve a lot of twisting of the forearm or flexing the elbow.

Supervised physical therapy

A regimen of strengthening the shoulder girdle musculature will often lessen biceps tendon pain. Often this is best undertaken with the advice of the physical therapist to coach on the proper way to do a home exercise regimen.

Home exercises

Exercises that strengthen the deltoid muscle, exercises that strengthen the biceps and triceps muscles, and a general upper body workout will sometimes lessen the pain of biceps tendon inflammation.

Medication taken by mouth

Anti-inflammatory medicine will sometimes diminish the pain caused by inflammation of the biceps tendon. Nonprescription medications such as ibuprofen or naproxen sodium are worth a try if one does not have a contraindication to these drugs. Prescription drugs for inflammation are usually no more effective than over-the-counter drugs for inflammation. Their main advantage is that they have fewer undesirable side effects.

Medication by injection

Injection of a small amount of cortisone around the biceps tendon is very effective in decreasing biceps tendon pain.

Surgery

There are many different surgeries appropriate for a biceps tendon problem that has failed to respond to nonoperative treatment. Most of these are arthroscopic. Some of them involve a minimal skin incision in addition to arthroscopy.

Arthroscopic Biceps Tenotomy

What surgery are you suggesting?

Because you are experiencing pain related to the biceps tendon, I am suggesting that we operate on your shoulder to cut the biceps tendon where it is attached inside your shoulder.

Pre-op Instructions     Post-op Instructions

What is arthroscopic biceps tenotomy?

It is a way of disconnecting the biceps tendon attachment at the top of the shoulder socket. Typically, a wound is made on the posterior aspect of the shoulder and another on the front of the shoulder. A third incision on the side of the shoulder is often made. These incisions are about 3/8 inch long. Through these incisions, one can enter the shoulder joint and perform the surgery.

Is it done in an operating room?

Yes.

How will I be anesthetized?

This is usually done under a general anesthetic. The surgery can also be done with just the shoulder anesthetized. That method involves numbing nerves to the shoulder. It is called an interscalene block. It is common to be sedated if the surgery is done with an interscalene block. The sedation is such that most patients will take a nap during the procedure. You and your anesthesia professional will decide which anesthetic is best for you.

Do I have to stay in the hospital?

No. This is an outpatient procedure in most cases.

What are the alternatives to surgery?

This surgery is done to improve function and decrease pain. If a patient finds that their pain and function are acceptable, it is reasonable to decline surgery. Some patients with significant biceps pain progress to worsening shoulder pain as the months go by, and others will improve. The decision on when to operate is up to the patient based on pain and function.

About Your Doctor

How many of these have you done?

I do not have an exact total. I have been performing surgery since 1981. I do operations on the shoulder at a rate in excess of 250 per year. I am a Board Certified Orthopaedic Surgeon. I have been in practice at Piedmont Orthopaedics since 1986. I subspecialize in my practice, and most of what I take care of relates to problems of the shoulder.

Risks

What are some of the things that could go wrong?

The anesthesia carries risks with it. The person who evaluates you for your anesthetic will discuss those risks with you. In general, complications from anesthesia are very, very rare, but they do exist.

How often does an infection occur?

Approximately 1% of shoulder surgeries of this type become infected soon after surgery.

What happens if there is an infection?

Infection will sometimes require that another operation be done on the shoulder. During that surgery the infection is washed out and intravenous antibiotics are often begun. Intravenous antibiotics may be necessary for 6 weeks, and long-term oral antibiotics may be necessary.

Will my shoulder get stiff?

It takes about 3 months to gain maximal flexibility of the shoulder after this operation. Almost all patients recovering from this operation feel very tight in the first couple of months after the operation. It will usually resolve with exercise and time. Stiffness after surgery for just biceps tenotomy is very rare.

Could I die?

No surgery is absolutely safe. It is possible that one could die from any type of operation. The death rate from this operation is profoundly low. I would estimate that it is less than 1 in 10,000. Other major events such as heart attack or stroke are extremely rare following this surgery.

Will I need a blood transfusion?

Almost certainly, no.

Will I have limitations on what I can do after it is healed?

No. It is safe to pursue all activities without restriction once completely healed.

Will it relieve my pain satisfactorily?

I find that about 90% of patients with arthroscopic biceps tenotomy are happy with their result. Another 5% are happy with reservations. As an example of what that means, a patient says their shoulder feels much better and performs better, but they still have some aching. Approximately 5% of patients feel as if the shoulder surgery was not beneficial to them.

A Common Sequence of Recovery

What is involved in this type of surgery?

In preparation of surgery, you will be asked to not eat or drink for at least 8 hours prior to surgery. Specific times to stop all food and drink will be given to you by your anesthesia professional. If you are on a drug that causes blood thinning such as Plavix or Coumadin, be sure to mention that to me. It may be important that those drugs be stopped well in advance of surgery. If you have rheumatoid arthritis or lupus and are on certain drugs for those conditions, they too may need to be stopped prior to surgery.

The anesthesia personnel who evaluate you for surgery will determine what lab work, if any, is needed. On the day of your surgery, you will be asked to arrive well in advance of the surgical time.

After surgery is over, you will need to remain at the facility for at least an hour. It is okay to eat or drink as soon as you feel like it after surgery. Your pain can be controlled by using the pain medication pills that I will prescribe for you. Pills will not eliminate all of the pain, but they will make it tolerable. Pain may be severe in the first few days. Pain can also be helped by the use of ice on the shoulder, sitting in an upright position as in a recliner and resting the arm in a position of maximal comfort to the side. Within the first two weeks of surgery, I usually recommend beginning some exercises to the shoulder. I will either instruct you in how to do these or ask a therapist to do so.

What about the overall recovery from this operation? How long does it take to completely recover?

Approximately 3 months is common.

Will I be hurting that long?

No. Generally within a week or two a person notices a significant diminution in their pain. They continue to gain further improvement for several weeks after that.

How long will I need prescription pain medication?

This varies widely. There are occasional patients who will use only a day or two of prescription pain medication. Much more commonly, I see patients using narcotic analgesics until about one week following surgery. One of the last discomforts to go away is nighttime pain, and many patients will still use a pain pill to help them sleep for as long as 3 weeks after surgery.

When are the sutures removed?

I use surgical glue. No sutures or staples require removal.

When can I get it wet?

The surgical glue is waterproof, so it is okay to take a bath or a shower from the very first day.

Is any special wound care required?

The scar will look prettier sooner if you rub vitamin E or cocoa butter into it.

Will I have to wear a sling?

Yes. A sling is provided at the time of surgery and the patient is instructed to use it until comfortable without it. Some patients will give it up in a day and others will use it for a week or more. If you are resting comfortably in a chair at home, it is fine for the sling to be off.

Will I lose function because you are cutting the tendon?

Yes. You will lose about 10% of forearm twisting power forever. Mechanics and patients who use their forearm vigorously for hard labor will notice this. Most patients don’t notice the change in everyday activities.

Will I be disfigured?

Most patients will notice that the shape of their biceps muscle is different after surgery. This shape change will be permanent. The muscle will be more rounded looking. It is sometimes called a “popeye muscle” because when you flex the biceps it’s noticeably more egg shaped than normal. Men will find this more noticeable because their muscle is much larger. Some women notice no change in the muscle shape.

Arthroscopic SLAP (Labral) Debridement

What surgery are you suggesting?

Due to a SLAP tear, I am suggesting that we operate on your shoulder to remove the torn part of your labrum with an arthroscopic technique. At least three incisions around the shoulder area will be made. Each is about ⅜ inch long.

Pre-op Instructions     Post-op Instructions

What is a SLAP debridement?

A SLAP repair is a method of removing the torn part of the labrum (cartilage) of the shoulder socket. Generally, it has torn away from the attachment point.

Is it done in an operating room?

Yes.

Will I be anesthetized?

This is usually done under a general anesthetic. The surgery can also be done with just the shoulder anesthetized. That method involves numbing nerves to the shoulder. It is called an interscalene block. It is common to be sedated if the surgery is done with an interscalene block. The sedation is such that most patients will take a nap during the procedure. You and your anesthesia professional will decide which anesthetic is best for you.

Do I have to stay in the hospital?

No. This procedure is done on an outpatient basis.

What are the alternatives to surgery?

This surgery is done to improve function and decrease pain. If you find that your pain and function are acceptable, it is reasonable to decline surgery. There is no clear evidence that ignoring a SLAP tear of the shoulder will do damage to the shoulder over the long run.

Will my shoulder get stiff?

Almost all patients will lose a little flexibility.

About Your Doctor

How many of these have you done?

I do not have an exact total. I have been performing surgery since 1981. I do operations on the shoulder at a rate in excess of 250 per year. I am a Board Certified Orthopaedic Surgeon. I have been in practice at Piedmont Orthopaedics since 1986. I subspecialize in my practice, and most of what I take care of relates to problems of the shoulder.

Risks

What are some of the things that could go wrong?

The anesthesia carries risks with it. The person who evaluates you for your anesthetic will discuss those risks with you. In general, complications from anesthesia are very, very rare, but they do exist.

How often does an infection occur?

Approximately 1% of shoulder surgeries of this type become infected soon after surgery.

What happens if there is an infection?

Infection will sometimes require that another operation be done on the shoulder. During that surgery the infection is washed out and intravenous antibiotics are often begun. Intravenous antibiotics may be necessary for 6 weeks, and long-term oral antibiotics may be necessary.

Will my shoulder get stiff?

It usually takes about 6 months to gain maximal flexibility of the shoulder after this operation. Some patients will take as long as a year to gain that maximum flexibility. Almost all patients recovering from this operation feel very tight in the first couple of months after the operation.

Could I die?

No surgery is absolutely safe. It is possible that one could die from any type of operation. The death rate from this operation is profoundly low. I would estimate that it is less than 1 in 10,000. Other major events such as heart attack or stroke are extremely rare following this type of surgery.

Will my arm look different?

Yes. In about 75% of cases the shape of your biceps muscle becomes more round looking. It will look different than your unoperated biceps muscle in most cases.

Will I need a blood transfusion?

Almost certainly, no.

Will it relieve my pain satisfactorily?

I find that about 85% of patients are very happy with the result after they have completely recovered from this type of surgery. Of the remaining 15%, most are improved, but some have reservations such as mild pain or weakness. About 1 in 20 patients feel like the surgery was not worth doing.

Will I have limitations on what I can do after it is healed?

No. It is safe to pursue all activities without restriction once completely healed.

A Common Sequence of Recovery

What is involved in this type of surgery?

In preparation of surgery, you will be asked to not eat or drink for at least 8 hours prior to surgery. Specific times to stop all food and drink will be given to you by your anesthesia professional. If you are on a drug that causes blood thinning such as Plavix or Coumadin, be sure to mention that to me. It may be important that those drugs be stopped well in advance of surgery. If you have rheumatoid arthritis or lupus and are on certain drugs for those conditions, they too may need to be stopped prior to surgery.

The anesthesia personnel who evaluate you for surgery will determine what lab work, if any, is needed. On the day of your surgery, you will be asked to arrive about 2 hours prior to your surgery time.

After surgery is over, you will need to remain at the facility for at least 1 hour. It is okay to eat or drink as soon as you feel like it after surgery. Your pain can be controlled by using the pain medication pills that I will prescribe for you. Pills will not eliminate all of the pain, but they will make it tolerable. Pain may be severe in the first few days. Pain can also be helped by the use of ice on the shoulder, sitting in an upright position as in a recliner and resting the arm in a position of maximal comfort to the side. I will probably recommend that exercises to your shoulder begin about two weeks after the operation.

How long does it take to completely recover?

Approximately 6 months is common.

Will I be hurting that long?

No. Generally, within a week or two a person notices a significant diminution in their pain. They continue to gain further improvement after that.

How long will I need prescription pain medication?

Most patients will use it regularly in the first week and periodically until about 2 weeks following surgery. Often by week 3, it is only used at night.

When are the sutures removed?

Usually, about two weeks following the surgery. Sometimes I use a surgical glue. It is waterproof and germ proof. If you have glue, there will be no stitches to remove.

When can I get it wet?

I apply a waterproof dressing at the time of surgery, so it is okay to take a bath or shower from the very first day. By one week following surgery, it is usually fine to get the wound wet in the bath, shower, or swimming pool. The surgical glue is waterproof, so if the surgical glue is used, it is okay to take a bath or shower from the very first day.

Will I have to wear a sling?

Yes. A sling is provided at the time of surgery and the patient is instructed to use it for the first few days following surgery. It can be removed in certain environments such as the safety of your home. It is important that you are confident that no one will bump into you and that you will not trip if your sling is off.

Beyond suture removal, is any special wound care required?

The scar will look prettier sooner if you rub vitamin E into the scar.