Overhead Athlete: Why can Type II SLAP
Repairs Fail ?
Craig D. Morgan, M.D.
Consultant:
Major League Baseball
Kansas City Royals Baseball
Cleveland Indians Baseball
Baltimore Orioles Baseball
The Morgan Kalman Clinic
Wilmington, Delaware, USA
Craig D. Morgan, M.D.
Disclosure
• Consultant: Arthrex Inc., Naples, FL
• Royalties
• Stock Options
• Consultant: Kansas City Royals,
Baltimore Orioles, Cleveland Indians
Cause of Type II SLAP Repair Failure =
PAIN
• Throwing with Recurrent GIRD may
cause a Recurrent SLAP II Retear.
• Symptomatic Subacromial Adhesions.
• Knot Stack Labral Abrasion.
• Unaddressed Concommitant SGHL
Anterior Rotator Interval Pathology.
Rarely if Ever does the Labrum not heal to the
Glenoid !
Why is Recurrent GIRD Evil ?
• It causes Posterior Superior GH
Instability in ABER.
• Result = Recurrent Type II SLAP Lesion.
The Shoulder at Risk = GIRD > 20 Degrees
TMA
by GIRD
Symptomatic Subacromial Adhesions
4%
Knot Stack Labral Abrasion
Knot Stack Labral Abrasion
2nd Look Arthroscopies Tell Me :
Permanent Knots may Irritate, cause Pain,
and may Break and become Loose Bodies
I Now Use #1 PDS Reloads
in My Suture Anchors
Or Avoid Knot Stack Abrasion with a Knotless
Suture Anchor Approach
Unaddressed Concommitant Rotator Interval
Pathology with Biceps Outlet Instability
Rotator Interval Lesions in Combination with
Traumatic Labral Pathology: SLAP Lesions,
Anterior Bankart Lesions, and Posterior
Bankart Lesions. Incidence, Diagnosis,
Treatment, and Prospective Clinical Outcomes
Aashish V. Jog, M.D.
Craig D. Morgan, M.D.
The Morgan Kalman Clinic
Wilmington, Delaware, USA
Rotator Interval - Biceps Outlet (Pulley/Sling) Anatomy:
Anterior Wall = SGHL, Posterior Wall = SS Tendon, Roof = CHL
Harryman DT, et al, JBJS, 1992. Walch G, et al, JSES, 1994. Werner A, et al. AJSM, 2000.
Rotator Interval – Biceps Outlet ( Pulley/ Sling )
Arthroscopic Anatomy: SGHL, SS Tendon, CHL
Isolated Rotator Interval Lesions in Throwers:
Morgan CD. Arthroscopic Treatment of Internal Impingement –
Part II: Throwing Acquired SGHL Injury with Biceps Pulley
Disruption. Chapter 11 in SURGICAL TECHNIQUES of the
SHOULDER, ELBOW, and KNEE in SPORTS MEDICINE, Cole
CJ and Sekiya JK Eds. Saunders Elsevier, 2013.
Shoulder Controversies, Napa, California, Sept. 2009 & 2011.
Mid Atlantic Shoulder and Elbow Society, Washington, DC Oct.
2012.
Professional Baseball Athletic Trainers Society, Baltimore, MD, Jan.
2013.
Reliable Diagnostic Parameters for Rotator
Interval Pathology: Clinical, MRI, & Scope
• Digital Pain in the Upper Bicipital Groove.
• Anterior Superior Shoulder Pain in ABER relieved by Jobe
Relocation Maneuver.
• Increased GH External Rotation and TMA on the Dominant versus
the Non-dominant Shoulder.
• Asymmetric Sulcus Sign on the Dominant versus the Non-dominant
Shoulder ( Neutral and ER).
• A Widened Rotator Interval on Sagittal Oblique Arthrogram MRI
with Bicep Tendon “Drop – Out” from central in the Pulley.
• Arthroscopic visualized Widened Biceps Outlet.
• Hyperemic Biceps, SGHL, and Upper MGHL with Parallel
Adhesions going into the Biceps Outlet.
• Laxity in the Upper MGHL.
The Morgan Study: 2006 - 2009
32 Isolated Throwing Acquired SGHL
Interval Lesions – All Diagnostic
Parameters Present
compared with a Control Group
31 age matched Overhead Athletes with
Scapular Dyskinesis without Intra-articular
Pathology – All Diagnostic Parameters
Absent
Mechanism of Injury:
Throwing Across Body with High Flexion Angle
during the Follow-Through Phase of Pitching
Results: Increased ER and TMA
SGHL Injured not in Control
• ER = Avg. 26 Deg. Range = 20 – 35 degrees
• TMA = Avg. 27 Deg. Range = 20 – 36 degrees
Results: GH Rotation Data – Both Groups
SGHL Injured Group: 32 Cases
IR t IR nt ER t ER nt GERG t GIRD t TMA t TMA nt
51
54
122
38-65 46-67 105-134
88
26
9
170
144
85-101
20-35
5-15
151-184
130-162
Control Group: 31 Cases
IR t IR nt ER t ER nt GERG t GIRD t TMA t TMA nt
42
25-62
55
89
84
45-74 88-109 80-101
6
0-12
15
148
0-25
130-158
154
128 160
Arthrogram MRI - Sagittal Oblique Images
Goniometric Measurement (Degrees)
The Sagittal Rotator Interval Angle
Sagittal Rotator Interval Angle
SGHL Injured vs. Control Group
SGHL Injured
Control Group
58 Degrees
25 Degrees
(44 – 68)
(22 – 30)
Arthroscopic Findings - SGHL Injured:
Widened Biceps Outlet and Pulley
Arthroscopic Findings - SGHL Injured:
Dorsal Biceps Hyperemic Synovitis
Arthroscopic Findings: SGHL Injured Group
Focal Hyperemia SGHL and MGHL
Arthroscopic Findings: “The Chandelier Sign”
SGHL Tear of Medial Inferior Biceps Pulley
SGHL Injured with the Following Pre-op Findings had a
Scope Interval Closure Procedure
Operative Repair: 2 North-South Capsular
Stitches between SGHL & MGHL
Pre & Postop Prospective Thrower’s
Clinical Rating Scale: 100 Points
Yes
No
• Pain Free Throwing
20
0
• Pre-Injury Velocity
10
0
• ER D within 10 degrees ND
20
0
• Symmetrical Sulcus Sign
20
0
• Pain Free ABER Test
20
0
• No Bicipital Groove Pain
10
0
100
0
TOTAL
Results – Prospective Thrower’s Clinical
Rating Scores: 1 &2 Years
SGHL Injured Group
Score
• Pre-operative
0
• 1 Year Post-operative
100
• 2 Year Post-operative
100
Complications
• 2 of 32 ( 6%) developed Sub-Acromial
Bursitis Symptoms during the Interval
Throwing Program.
• Both Patients became and remained pain
free following a Sub-Acromial Cortizone
Injection and 1 week of rest.
Purpose
To report a Series of Rotator Interval
Pathology in combination with Traumatic
Labral Lesions: II SLAP Lesions, Anterior
Bankart Lesions, and Posterior Bankart
Lesions.
January 2008 – December 2012
114 Patients
All had all Rotator Interval Diagnostic
Parameters Present
Labral Injury with Rotator Interval Lesion:
114 Cases
• Type II SLAP + ARIL
21
• Posterior Bankart + ARIL
21
• Anterior Bankart + ARIL
55
• Anterior Bankart, SLAP + ARIL
11
• Posterior Bankart, SLAP + ARIL
6
Labral Injury with Rotator Interval Lesion
Preoperative Findings
• Increased ER and TMA
(range = 15 – 30 degrees)
25 degrees
• Asymmetric Sulcus Sign
100%
• Ant. Sup. Pain in ABER
100%
• Sagittal Rot. Int. Angle
(range = 35 – 90 degrees)
57 degrees
Healed Labral Repair with Persistent Pain due
to an Unaddressed Rotator Interval Lesion:
• Anterior Bankart Lesion
12
• Posterior Bankart Lesion
4
• Type II SLAP Lesion
13
• Anterior Bankart + SLAP
2
Total
31
What is the Incidence of Combined Labral
Pathology with Rotator Interval Lesions?
January 2008 – December 2012
No ARIL
+ ARIL
%
• Anterior Bankart
78
66
46%
• Posterior Bankart
11
27
71%
• Type II SLAP
37
21
36%
Case Example: Anterior Bankart & ARIL
Case Example: Posterior Bankart & ARIL
Case Example: Type II SLAP & ARIL
Results: Combined Labral Repair & Interval
Closure: 114 Cases
• All Resolved their Preop ABER Pain.
• All Resolved their Increased ER & TMA to
within 5 degrees of the opposite shoulder.
• Complications: 6 Shoulders (5.2%) required
repeat arthroscopy for removal of
symptomatic Subcoracoid Adhesions before
becoming Pain Free.
Conclusions:
• Associated Rotator Interval Pathology can
present in combination with Traumatic Labral
Pathology.
• Failure to address Associated Rotator Interval
Pathology is the primary cause for Persisent
Pain following a Successful Labral Repair.
• Reliable Diagnostic Parameters for Predicting
concomitant Rotator Interval Pathology are
defined and should be evaluated Preop before
developing a Surgical Treatment Plan.
References:
• Harryman DT, et al. The role of the rotator interval capsule in passive motion
and stability of the shoulder. JBJS, 1992; 74: 53-66.
• Walch G, et al. Tears of the supraspinatus tendon associated with “hidden”
lesions of the rotator interval. JSES, 1994; 3: 353-360.
• Werner A, et al. The stabilizing sling for the long head of the biceps tendon in
the rotator cuff interval – a histoanatomical study. AJSM, 2000; 28: 28-31.
• LeHuec JC, et al. Traumatic tear if the rotator interval. JSES, 1996; 5: 41-46.
• Habermeyer P, et al. Anterosuperior impingementof the shoulder as a result of
pulley lesions: a prospective arthroscopic study. JSES, 2004; 13: 5-12.
• Gerber C, et al. Impingement of the deep surface of the subscapularis tendon
and the reflection pulley on the anterosuperior glenoid rim: a preliminary
report. JSES, 2000; 9: 483-490.
• Braun S, et al. Lesions of the biceps pulley. AJSM, 2011; 20: 1-6.
• Morgan,CD. Throwing Athlete: Arthroscopic Treatment of Internal
Impingement Part II: Throwing Acquired SGHL Injury with Biceps Pulley
Disruption. Chapter 11 in SURGICAL TECHNIQUES IF THE SHOULDER,
ELBOW, AND KNEE IN SPORTS MEDICINE, Cole CS and Sekiya JK Eds.,
Saunders Elsavier, Philadelphia, 3013.
Thank You