Thank you all very much for asking me to give this talk and for allowing this time here. So we all know what SLAPs are. They've been around a long time. Andrews, Snyder, Type 1 to 4. The reality, if you really look at it, Type 12, I guess. The problems with this is, over the time, is that there's variable and inconsistent exam findings, identification of the injury, imaging techniques, treatment indication techniques, and more importantly, outcomes and function. So this hasn't been a best model for us. So we know, once again, that asymptomatics, there's a lot of people that have SLAP tears. We looked at a paper in 2013 that said that maybe the SLAP, this 11 to 1 lesion, may be adaptive pathology to allow this extra rotation in cocking. Dr. Sheehan and a cohort looked at this in JAOS in 2020. High incidence of posterior labral injuries in throwing athletes. So we know that other things may be going on in these athletes. Recent studies have evaluated, at the time of arthroscopy, the location on the glenoid and the incidence at that location of labral injuries associated with dysfunction. In other words, patients on the end of your arthroscope, they have a labral injury that's clinically significant. One we did in arthroscopy. The other is Alexiev and his group at Emory in General Schrodinger Elbow. And it's interesting, two groups doing it at the same time with not knowing the other is doing it. So this is our group, 167 patients with the clinical exam and imaging of a clinical diagnosis labral injury. We did arthroscopy, the ages, et cetera. And so we isolated, we classified these into location on the glenoid, superior from 1030 to 130, anterior 130 to 6, posterior 1030 to 6. If the lesion appeared to go over the boundary right there. So here's our pie graph that shows that the red is the slab, 7.2%. The kind of orange, the two point, well, the yellow is the superior, posterior is 22%. And then the greens are isolated posterior 26%. If you break these down or combine these, you find that some type of superior involvement only in 46% of this group. Some type of posterior involvement, 82, 86%. And combined lesions going across anterior, posterior, et cetera, superior, posterior, twice as common as the isolated. Now here are the data from the other Emory group. You see the numbers are almost the same. 86 versus 74 in posterior involvement. Posterior to posterior superior, 48%, 47%. Isolated posteriors, we had a lot of throwers, 26%. Isolated superiors, 7.2 in ours and 8.2 in theirs. So it breaks it down to maybe there's other things going on besides the slab. So right now the current concept we're working on is two main types of these lesions. One is that posterior, we call it slab 8 or slab 10, posterior superior. And the second is the isolated posterior due to humeral head compression and shear with internal impingement. Internal impingement appears to be the pathomechanical basis for this injury. Several papers now from 2009 all the way up to the present time look at internal impingement as the problem. This combines scapular protraction, humeral head, posterior translation, creating posterior compression and shear on the labrum. This is a rather busy slide, but basically it puts all these factors together. You have all the scapular problems, the scapular protraction, anterior tilt, decreased upper rotation, and then the humeral head posterior translation involving biceps tightness, including humeral interrotation, increased horizontal abduction, and now lately we've been finding this external rotation component. So it's probably a combination of all those things going on giving the posterior labrum injury. Conclusions from this going forward is maybe the slab is not the most comprehensive term to use for the pathoanatomy that causes the patient to be in your office. This is a quote from Alexa's paper. Inclusion of this wide variety of tears into a numbered classification lumped under slab tears is confusing and of limited clinical utility, and this has been my experience as well. We said, well, maybe you ought to call it something else. We call it clinically significant labral injury. More comprehensive and inclusive description of the possible pathoanatomy that you may see at the time of your arthroscopy. It describes an anatomic labral injury somewhere anterior, posterior, superior that's associated with the loss of labral rolls, which is a clinical dysfunction that we are looking at now, whether it's dynamic clinical stability or clinical symptoms. The injury is damaged to the labral anatomy in some fashion. Location may be variable in glenoid. Therefore, if you're going to look at these patients both by imaging and other ways, you've got to look at the entire labrum, especially posteriorly, and look for combined lesions around the glenoid. Thank you very much.

SLAP tears

identifying

treating

posterior labral injuries

clinically significant labral injury