We're going to talk about an overhead athlete with a slap tear. This is a 27-year-old female volleyball, high club level volleyball, works out a lot. With a 6-month history, a gradual onset right shoulder pain. She played a lot of volleyball over the summer. There's no one traumatic incident. The pain is worse with overhead serving, blocking, but really all overhead play. Doesn't impact ADLs or sleep. She's tried over-the-counter and said she's cut back on her workouts, but still has global anterior pain when she plays that's inhibiting her from playing. She presents with an MRI, as everybody does these days, and she's told she has a slap tear, and although she has a desk job, volleyball is her life and she cannot live with this. And on physical exam, she has normal appearance, no atrophy. I think it's important. You know, I have to admit, all the time I walk in the exam room, the fellow who's been in there examined the patient and they have a buttoned-up shirt on. I'm like, really? You've got to look at them and they've got to be in a gown so you can see. Is there atrophy? Is there winging? She's tender over the biceps. She has full mobility, but she does have dyskinesia on the right. I think it's really important in these athletes to look for that. No strength deficit, good cuff, no impingement, no instability, negative AC signs, and positive bicep signs. Here's her MRI. Her x-rays are normal as they typically are for a 27-year-old, but you still need to look. She has a non-orthogram MRI which shows a slap. Although MRA is the gold standard and is more sensitive and specific than MRI, most patients come with a normal MRI and I don't find it necessary to go back and get an MRA. I think what we need to realize, especially when we're counseling the patient, is the high incidence of asymptomatic slap lesions on MRI. We have good literature that shows it's very common. It's a very common finding, especially in overhead athletes to the point that there's discussion that is the slap tear a physiologic anatomic adaptation to overhead sports. If you address it, are you creating a non-anatomic situation for the athlete? All of that to say that for me all the time in these patients the treatment is conservative. We need to engage our therapy partners on this. A really big part for me with this patient is educating the patient to get them to buy in to the physical therapy and going over why and educating about the incidence of lesions and really honing in on the dyskinesia. If you can find something that you can convince them, if we can make this better, you can get better, I think that really helps. Shut them down, get prescription NSAIDs if they've done over-the-counter. Work with your PT, have a good PT protocol for your posterior capsule, your scapular mechanics, your core stability. For a lot of the athletes, a biomechanical evaluation of whatever overhead sport they are doing. I really think a good two to three months of buying in and doing the therapy, I really want to know that they did it. So she comes back and she did it because her dyskinesia is better. But she's still painful. She doesn't want to live with this. At this point I think this is something the groups can all discuss. I did do an injection. I do intra-articular because I feel it can get any intra-articular pathology and the injection will go down the groove and address the biceps rather than I've had unpredictable results with trying to do it in the bicep sheath. So we did this. The injection really helped. She went back to volleyball after four weeks. But the pain returned and she comes back and can't live with this. I think certainly it's debatable whether she should have waited longer until she went back to volleyball. Because I think sometimes if the injection calms it down and then they do another round of therapy they might get on the other side. This is an example of a patient, I had this video from 2007. Similar patient, 27-year-old female. I think we also need to realize a lot of these slap tears in the overhead athletes can extend posteriorly. So you need to be prepared for that. But what's interesting is that this is what I did back in 2007. So I did a slap repair with an anterior anchor with knots. And I look at this now. I was pretty proud of this in 2007 and now it's somewhat cringeworthy. And I've seen a lot of these patients. So I don't know if anybody else has. But these patients I high-fived myself on in 2007 have come back and found me. And they're not particularly happy 10 to 15 years later. So as a Mandalorian fan, although I wasn't really excited about Season 3, I don't think that this is the way any longer. And we know the outcomes of slap repairs are not great. So return to play, especially in overhead athletes, there's several papers that have shown it's unpredictable. It's lower than we would like. Preventure has shown high failure rate, high revision rate. And the complications, especially if you look at the way we used to do it, knot migration, loosening, the knot irritation, I mean, again, cringeworthy. I can't believe I even saved this picture here of those knots. And then the damage that you can do to the cartilage, to the labrum, the biceps pain, over-constraining and stiffness. And now multiple papers have shown that if you compare slap repair with biceps tenodesis, overall better satisfaction, better return to play, lower revision rate. Although the meta-analysis by Shin in 2021 didn't reach statistical significance, I think overall we have enough evidence that the biceps repair tenodesis is better. So my approach, and I think we should discuss arthroscopic, suprapec, subpec, onlay, inlay, discuss this. I do open subpec because I don't even want to have to address the residual anterior pain that maybe could be there and the discussion should you move the biceps distally. For me, I can better assess the length-tension relationship. I have less concern for failure or Popeye. And I really like the button and I feel like it's a really strong fixation. And here's just a quick video. I always reprep because I feel the arthroscopy fluid wipes away the prep. Open the fascia over the short head, put my finger in, pull that out. Obviously if you let the fellow do that, make sure you know what they're pulling out. But if your landmarks are good, we size it. I go for the smallest tunnel possible. I drill by cortical, drill my unicortical tunnel. And really what I like about this technique is that I see the biceps dock into the tunnel and I feel really confident that this is not going to fail. And then I think very important for post-op course, I do minimal sling. I've had some patients early on that were so afraid of pulling out their biceps they sat like this. And then they get stiff. I reassure them you have a solid repair. It's not going to come undone. Just no eccentric firing. Progressive range of motion and strengthening. Continue the scapular program. And then I feel like with this, the progression back to sports compared to the days of a slap repair is so much quicker, so much easier, and such an easier recovery. So I really let them get back when they're ready. Thank you.

volleyball player

slap tear

shoulder pain

overhead activities

conservative treatment