The option of non-operative treatment for superior labrum anterior posterior tears
Athletes most prone to labral tears
Injuries to the superior labrum extending anterior and posterior (SLAP) to the biceps anchor are known to be a source of pain and disability for patients, and frequently occur in athletes, particularly ones involved in overhead sports. Treatment can be approached surgically, with procedures such as labral debridement and reattachment, or non-surgically with physical therapy and medication. While there are a number of reports showing successful outcomes for surgical repairs of SLAP tears, there is minimal data on patients who took the non-surgical route and had successful results. To establish a clearer understanding of non-operative treatment for SLAP tears and their potential for successful outcomes, a case series was performed.
Finding suitable subjects
To find subjects fitting the desired conditions, all patients who had experienced a SLAP tear at an institution were surveyed to determine if they fit the criteria. Though the number of possible candidates started large at 371, only 19 fit the specifications of having non-operative treatment alone. Patients who followed the non-operative course of action were prescribed non-steroidal anti-inflammatory (NSAIDs) drug treatment of various types and also underwent a physical therapy protocol. The focus of PT was on posterior capsular stretching and maintaining periscapular and glenohumeral strength and stability. Capsular stretches including the “sleeper stretch” and cross-body adduction stretches, and strengthening exercises included a core strengthening program, periscapular muscular strengthening exercises, and a rotator cuff strengthening program. Subjects were given a series of questionnaires to assess quality of life, pain and other factors before and after the non-operative intervention to detect any improvements brought about by treatment.
Significant improvements from non-operative treatment noted
Results showed there to be significant functional improvements from non-operative treatment, with American Shoulder and Elbow Surgeons (ASES) scores improving from 58.5 to 84.7 and Simple Shoulder test (SST) improving from 8.3 to 11. Pain scores also decreased from 4.5 to 2.1 on the Visual Analog pain scale (VAS) and quality of life was shown to improve, rising from 0.76 to 0.89 on the European Quality of Life measure (EuroQol). Eighteen of the 19 subjects who underwent non-operative treatment alone were active in sports prior to treatment, and 15 of them were overhead athletes. Fortunately, all 18 subjects returned to sports eventually, with only two taking more than six months and 13 (71%) returning to pre-participation levels. On the other hand, only 10 of the 15 (67%) overhead athletes returned to a level of performance as good as or better than pre-injury participation. Additional findings showed that about half (49%) of patients surveyed with SLAP tears did not require surgery. When these functional results were placed side-by-side with results from operative interventions, the overall improvements experienced by patients were comparable.
Overhead injures give the most trouble
The most glaring issue with both treatments was cases with overhead athletes. Other studies focusing on operative treatments also showed difficulty in returning overhead athletes to their pre-injury level of play, with one logging a figure of only 14 of 29 doing so. It appears that no matter the treatment, bringing overhead athletes back to the same level of performance they experienced prior to the tear is still a daunting task, pointing out a serious need to investigate alternative treatments focused on overhead cases alone. In the meantime, it's explicitly pointed out here that patients with minor tears and minimal pain can undergo non-operative treatment and experience nearly the same results as surgery would provide. Operative fixation should therefore only be reserved for more extreme cases where patients don't improve significantly enough after three months of non-operative treatment.
-Summarized by Greg Gargiulo
-As reported in the June 3, '10 edition of The American Journal of Sports Medicine
