give my age away, but I changed that to the past 40 years. No comment. I began my journey with slap tears in baseball when I first began to scope the baseball throwing shoulder in the late 1970s and early 1980s. Actually, the first account of labral surgery in baseball throwers, and it's good to remember the history, believe it or not, was first reported in 1983 by Dr. Pappas of the Boston Red Sox as seen in open cases. It was called functional instability in the Journal of Sports Medicine. These were lesions of the glenoid labrum that allowed the shoulder to catch, click, and lock secondary to partially detached fragments becoming interposed between the articular surfaces. It was very similar to the meniscus in the knee, as a matter of fact. And surgical treatment in those days was by open excision. The one common and most frequent pathology that I was confronted with when I started looking into baseball throwing shoulder arthroscopically was an injury to the superior labrum. And I can promise you, I didn't know why. For lack of better terminology, I call that the biceps labrum complex. And I published my first paper on this subject in 1985 in the American Journal of Sports Medicine. And the hypothesis of that particular paper was that the biceps tendon asked to pull the labrum from its superior glenoid attachment during the deceleration phase of throwing. And the glenoid labrum tears were related to the long head of the biceps. So at least I was getting the pieces a little bit together. Here's what I found out in that particular paper. We did five studies like this, where we stimulated externally the biceps muscle. And with the scope in the shoulder, we looked to see what happened when the biceps muscle, at 90 degrees of abduction, was stimulated. And what do you see here? Tremendous contraction of the humeral head to the centering spot on the glenoid. And it gave me the impression that the biceps tendon was important in stabilization of the throwing at 90 degrees, and that it also pulled dramatically with over 200 pounds of force on the labrum at its attachment. In that early setting, I was only technically able to debride the slap tear. And believe it or not, the results were pretty gratifying. At that point in time, there was very little known about the pathophysiology of the baseball-throwing shoulder, and we studied this in our lab. And actually, it was further introduced relative to labral pathology by Dr. Snyder in his publication in 1990, when he coined the term superior labrum anterior posterior slap with a classification of one to four. And that was published in the Journal of Orthroscopy and Related Surgery. Y'all are all familiar with these four different types of slaps that he first introduced. The mechanism of injury was still debatable relative to slap lesions. Snyder said it was a fall on the outstretched arms. That was at least his population. I said it was due to the overhead throw, the traction injury by Moffitt. And then we had, of course, the GERD phenomenon as introduced by Morgan. And then we had the torsional peelback phenomenon introduced by Burkhardt and Morgan. And then, John Conway, I know you're here. Where are you? We had wheat pulling, which to me still gives the best explanation. Here's what we mean by wheat pulling. If you rock the biceps tendon, throwing back and forth, back and forth, back and forth, eventually it'll come out at its root. And I give that credit to John Conway, and I still like it. What about the pathophysiology of biceps labrum complex tears? Well, we learned a lot more about that. It's still being studied, and it's still being changed, as a matter of fact. Here's the peelback phenomenon that Burkhardt and Morgan introduced to us. This is the left shoulder. The scope's in the back. This is the internal impingement. And you see here, with external rotation into the cock position, the biceps tendon labrum complex, particularly the posterior labrum, peels off the back of its linoid attachment. Interesting enough, look up above, and you see the subacute injury to the undersurface of the infraspinatus, which is the partial tearing that we see associated with this phenomenon. For me, that's internal impingement for lack of better terminology. There it is in over rotation. Slaps with a peelback are considered adaptive by many experts today. I think it's a good thing to have, as long as it doesn't hurt. It allows them to reach back a little bit further and throw with greater velocity. As our understanding of slaps progressed with time and experience, we all began to follow a traditional treatment protocol through the years. And this is pretty much it. Type one was debrided. Type two, if it was a bad slap, we'd stabilize the biceps tendon and repair the slap. If it was a bucket handle, which is still a big problem, by the way, we would excise the bucket handle, which doesn't cure everything, believe me. And if it's a type four, we do an excision, repair the biceps if possible, and in most cases, we release the biceps and do a biceps tenodesis. We realize, though, that the slap lesion classification system, the type two, comprises about 80 to 90% of slaps found in throwers. And on your right is a good arthroscopic look down on the posterior superior labrum with a bad slap. We've also learned that operating on a slap in throwers did not always have a great result. Everybody in this room will probably agree to that. My current trends and recommendations, and believe me, I may change tomorrow, don't have your throwing shoulder operated on unless you absolutely have to. First time when I see a baseball player, that's the first thing I tell them. The indications for slap repair is based on failure of conservative treatment. What is conservative treatment? Well, that's to be debated, too. Conservative treatment should focus on associated pathology and core strength, along with others. The goals of rehabilitation are capsular stretching, particularly for the GERD phenomenon, rotator cuff strengthening, scapular stabilizers, and again, core strength. By the way, recent studies to report conservative treatment are rare, unfortunately. You must recognize good slap from a bad slap. A bad slap is recognized by the clinical evaluation, and more than the evaluation, it's the physical that's recognized by the history. And you can tell in the history if it's gonna be a bad slap or a good slap just by talking to the patient. Here's some MRIs on bad slaps where the dye leaks right up straight up into the labrum, and almost detaches it. And those are called bad slaps, and you can see those four different ones on this particular slide. What about the arthroscopic technique for type II slaps when you actually repair them? Well, that's changed a lot. It's done under diagnostic arthroscopic control, which is the gold standard. And this, for me, is the gold standard arthroscopic setup in the lateral decubitus position. The six points that guide you to the treatment of pathologic slaps begins in the examining room. Identify bad slaps from good slaps, and then when you're in there finally with an arthroscope, you need to identify normal versus pathologic anatomy, and sometimes that's very difficult to do. Treat only symptomatic labral tears. Be sure to establish an aggressive bleeding bone bed. How many of y'all seen the biceps labrum complex at the top of the shoulder actually bleed? And this shows us burn the bone to try to make sure we get a bleeding response. Use proper multiple anchor placement and tie on the tissue side. By the way, we're not using these type of anchors anymore. Stay organized. Start from the back and work toward the front so you don't have to work over your ties. By the way, the surgical team is paramount to get these complex procedures done in a quick and organized manner. If you're a single surgeon by yourself, I don't know how you can really do this. If you look on your right, there's six hands in putting in an anchor for a slap lesion. You should know and communicate with your physical therapist appropriate therapy, and I've said this many times, it's often more important than the surgical procedure itself. Currently I'm doing mostly debridements, similar to the techniques I used in the early 1980s instead of slap repairs. So it's come in a complete circle to some degree. We still do some repairs, though, when it's indicated. And when I do do a surgical repair, I use the knotless techniques of Ellitrosh. I certainly don't tie any knots anymore. We all know that the slap problems are confusing, real confusing, because some high-level throwers can function with it and others cannot. So you've got to decipher, is this really pathologic to this particular baseball player? What about my results? Well, we recently published this in the Journal of Sports Medicine, and it's called Return to Play and Outcome in Baseball Players After Superior Label Anterior-Posterior Repairs, and this is our results. We had 216 baseball players, mostly pitchers, greater than two-year follow-up, two to 10 years, and we had a 62% return to play overall. Now, you know that in orthopedic surgery, a really good procedure is 90% successful. Semi-good is maybe 80, 85%, and in these cases, we got 71%, we got 62% back, 59% back were pitchers. Non-pitchers got back better, they were 76%, and only 7.5% had to have a revision surgery or a biceps tenodesis. By the way, there was no significant difference in our study between high school kids, college kids, or their professional return to play rate. Question is, do we have the answer to SLAP lesions? Well, I think you probably all know that we don't. By the way, a large percentage still don't heal, especially in throwers. What about SLAP failures? Well, in most cases, we have moved to subpectoral tenodesis after a failure of SLAP repair. So, in conclusion, SLAP lesions are common. They do not always cause symptoms. If you want an excuse to operate on a SLAP, do what? Get an MRI. Technical advancements are still needed. I recommend certainly you move toward knotless SLAP techniques, and a high percentage of healing is still a problem, and debridement techniques are still useful and are back in vogue. As a matter of fact, a recent study by a major league baseball doctor showed that debridements were done in 80% of the cases where they operated on a SLAP. So, they're back to debriding in mostly two. SLAP results, by the way, are now more important than ever. Thank y'all very much. Thank you.

SLAP tears

baseball players

labral surgery

conservative treatment

return to play