Jonathan D. Gelber, MD, MS; Lonnie Soloff, DPT, PT, ATC; Mark S. Schickendantz, MD


J Am Acad Orthop Surg. 2018;26(6):204-213. 

In This Article

Surgical Management in the Face of Adaptive Changes

Group 1

Group 1 injuries are related to internal impingement, which can lead to labral and rotator cuff injuries. When patients with group 1 injuries are evaluated, it is extremely important to understand that their shoulders have adaptive changes that allow them to perform at a high level. Merely attempting to restore their shoulders to normal without taking into consideration these adaptive changes will prevent these athletes from returning to preinjury form. One of these adaptive changes is anterior capsulolabral pseudolaxity, which allows for increased external rotation and abduction. Thus, when a SLAP lesion is repaired in an overhead athlete, the surgeon should focus more on managing the posterior SLAP tear (if present) and be wary of placing anchors anterior to the biceps because this will tighten the shoulder anteriorly and reduce the hyperexternal rotation available to the athlete.

Although type I SLAP tears typically can be débrided successfully, the outcomes of type II SLAP repairs are more unpredictable in the overhead athlete. Low-level evidence has shown that it takes 11 to 12 months for RTP after a type II SLAP repair in the overhead athlete.[47,48] A case series of arthroscopic repairs of type II SLAP tears in overhead athletes showed that although a 93.3% satisfaction rate was achieved with the repairs, the athletes believed they had reached only a mean rate of 84.1% of their preinjury performance level.[47] A systematic review of type II SLAP lesion repairs with a 2-year follow-up showed that for all athletes studied, only 73% returned to their previous level of play; for overhead athletes, even fewer returned to their previous level of play (63%).[49]

When an RCT is encountered, the surgeon is often faced with the dilemma of débriding or repairing it. In the experience of the senior author (M.S.S.), an RCT in an overhead athlete is a relatively shallow, partial articular lesion (<50% thickness). In this case, it is typically better to simply débride the partial tear rather than attempt to repair it.

Most rotator cuff lesions are ulcerative lesions with an associated delamination, making anatomic repair extremely difficult if not impossible. In a retrospective study of 82 professional pitchers with small partial-thickness RCTs treated with surgical débridement, Reynolds et al[50] reported that, of 67 pitchers with RTP data, 76% were able to return to competitive pitching at the professional level, although only 55% achieved RTP at the same or higher performance level. This is in contrast to a markedly lower performance level for pitchers with full-thickness tears. Mazoué and Andrews[51] evaluated a series of 12 professional pitchers with full-thickness RCTs treated with mini-open repair and found that only 1 pitcher was able to return to a high competitive level. The remaining patients either never returned or pitched a half season or less.

Low-level evidence is available for concomitant SLAP and rotator cuff repairs, specifically in overhead athletes with GIRD. In a series of 17 overhead athletes with GIRD who underwent SLAP repair combined with repair of the infraspinatus, Van Kleunen et al[52] reported that only 6 patients (35%) returned to preinjury or higher levels of performance. Six players were unable to return to play (35%) and five of the 17 patients studied (29%) returned to play at a lower level, "either playing the same position or else forced to switch to another position of play because of a decline in throwing velocity." The authors concluded that these patients were unlikely to return to their preinjury level of play.[52]

A level III study of 23 collegiate or professional overhead athletes revealed that at least 1 year (mean, 3 years) after type II SLAP lesion repairs, only 57% returned to preinjury level of competition despite high American Shoulder and Elbow Surgeons scores.[53] The athletes' RTP correlated with the presence of a partial-thickness RCT. The same study indicated that for the evaluation of the overhead athlete, the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score was a more accurate assessment tool than the American Shoulder and Elbow Surgeons score.[53]

Group 2

The second group of injuries involves internal impingement with acquired secondary anterior instability. For patients with group 2 injuries, the same principles apply regarding débridement versus repair of either a SLAP tear or RCT. In addition, the secondary instability should be addressed, and anterior labrum tears should be repaired as indicated. When the surgeon notes a persistent drive-through sign after repair of the SLAP lesion, plication of the anterior band of the IGHL may be considered. Plication of the area of the anterior capsule that appears most attenuated, including ≥20% of the anterior capsule within the plication, is recommended.[54]

Few data are available on outcomes in patients with group 2 injuries, and RTP is less predictable in these patients than in patients with group 1 injuries. The only level II comparative study to analyze concomitant SLAP and Bankart repairs versus Bankart repairs alone found that patients with combined lesions did not have any more failures after surgery than did patients with an isolated Bankart lesion.[55]

Group 3

Treatment of the overhead athlete with symptomatic primary or multidirectional instability is challenging. Before surgery is considered, the athlete needs to keep the rotator cuff strong and balanced and follow a scapular strengthening and maintenance program. Throwing volume should be monitored in these athletes because they tend to break down and experience pain after their cuff fatigues.

Should an exhaustive course of therapy be unsuccessful, surgical management in the form of a capsular shift may be considered. The capsular shift can be accomplished using sutures with or without anchors and either plicating the capsule to itself or to the labrum. Anterior, inferior, and posterior planes of laxity must be addressed. This is accomplished with a so-called 270° repair involving the rotator interval and the anterior and posterior bands of the inferior glenohumeral ligament.

The RTP rate in patients with group 3 injuries is highly unpredictable, and plication of the anterior capsule may restrict the athlete's necessary external rotation. As with group 2 injuries, evidence on outcomes is limited; however, a level III cohort study with a mean follow-up of 3.3 years following arthroscopic pancapsular suture anchor plication showed that 23 of 30 patients (76.7%) had returned to sport at or near their preinjury level.[56] The authors of the study also noted that there was a substantial difference in RTP in patients with traumatic versus atraumatic onset of symptoms (83% versus 44%, respectively).