The overhead athlete: how to examine, test, and treat shoulder injuries. Intra-articular pathology

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

Superior labral anterior posterior lesions of the shoulder: Current diagnostic and therapeutic standards

Surgical treatment of superior labral anterior posterior (SLAP) lesion becomes more and more frequent which is the consequence of evolving progress in both, imaging and surgical technique as well as implants. The first classification of SLAP lesions was described in 1990, a subdivision in four types existed. The rising comprehension of pathology and pathophysiology in SLAP lesions contributed to increase the types in SLAP classification to ten. Concerning the causative mechanism of SLAP lesions, acute trauma has to be differed from chronic degeneration. Overhead athletes tend to develop a glenohumeral internal rotation deficit which forms the basis for two controversial discussed potential mechanisms of pathophysiology in SLAP lesions: Internal impingement and peel-back mechanism. Clinical examination often remains unspecific whereas soft tissue imaging such as direct or indirect magnetic resonance arthrography has technically improved and is regarded to be indispensable in detection of SLAP lesions. Concomitant pathologies as Bankart lesions, rotator cuff tears or perilabral cysts should be taken into consideration when planning a personalized therapeutic strategy. In addition, normal variants such as sublabral recess, sublabral hole, Buford complex and other less common variants have to be distinguished. The most frequent SLAP type II needs a sophisticated approach when surgical teatment comes into consideration. While SLAP repair is considered to be the standard operative option, overhead athletes benefit from a biceps tenodesis because improved patient-reported satisfaction and higher rate of return to pre-injury level of sports has been reported.

Diagnosis and management of superior labral anterior posterior tears in throwing athletes

Injury to the superior glenoid labrum is increasingly recognized as a significant source of shoulder pain and dysfunction in the throwing athlete. Several theories have been proposed to explain the pathogenesis of superior labral anterior posterior (SLAP) tears. The clinical examination of the superior labrum-biceps tendon complex remains challenging because of a high association of other shoulder injuries in overhead athletes. Many physical examination findings have high sensitivity and low specificity. Advances in soft tissue imaging such as magnetic resonance arthrography allow for improved detection of labrum and biceps tendon lesions, although correlation with history and physical examination is critical to identify symptomatic lesions. Proper treatment of throwers with SLAP tears requires a thorough understanding of the altered biomechanics and the indications for nonoperative management and arthroscopic treatment of these lesions.