Who should a patient with a type II Superior Labrum Anterior to Posterior (SLAP) lesion, tendinopathy, and joint effusion, on oral contraceptives, be referred to for management?

Referral for Type II SLAP Lesion with Tendinopathy and Joint Effusion

Refer this patient to an orthopedic surgeon, specifically one with expertise in shoulder surgery or sports medicine, as type II SLAP lesions with associated tendinopathy and joint effusion require surgical evaluation and potential intervention that is beyond the scope of conservative management alone. 1, 2

Why Orthopedic Surgery Referral is Indicated

Joint Effusion as a Red Flag

• The presence of joint effusion is uncommon with isolated tendinopathy and indicates intra-articular pathology requiring different management. 3, 4
• Joint effusions suggest significant intra-articular injury beyond simple tendinopathy, which aligns with the type II SLAP lesion diagnosis. 3
• This combination of findings (SLAP tear + effusion + tendinopathy) represents complex shoulder pathology that warrants surgical consultation. 1

Type II SLAP Lesions Require Specialized Assessment

• Type II SLAP lesions involve tears of the superior glenoid labrum with involvement of the long head of the biceps tendon insertion, requiring arthroscopic evaluation and potential surgical intervention. 5
• MR arthrography is considered the gold standard for imaging traumatic shoulder pain and diagnosing SLAP tears, which the orthopedic surgeon may order if not already obtained. 1
• Management decisions for type II SLAP lesions depend on multiple factors including age, activity level, mechanism of injury (traumatic vs. overuse), and presence of instability symptoms. 2, 6

Specific Type of Orthopedic Surgeon

Preferred Specialist Characteristics

• Seek an orthopedic surgeon with fellowship training in sports medicine or shoulder/upper extremity surgery, as they have specialized expertise in arthroscopic management of SLAP lesions. 1
• Pediatric orthopedic surgeons are appropriate for skeletally immature patients with sports injuries including shoulder instability. 1
• For adult patients, a general orthopedic surgeon with significant shoulder arthroscopy experience is appropriate. 1

What the Orthopedic Surgeon Will Consider

Age-Based Treatment Algorithm

• For patients under 35-40 years old with traumatic injury and instability symptoms, SLAP repair is typically recommended. 2, 5
• For patients over 35-40 years old, biceps tenodesis or tenotomy is preferred over SLAP repair due to higher failure rates of repair in this age group. 2, 6, 5
• The oral contraceptive use is relevant for surgical planning but does not change the referral indication. 2

Surgical Options the Specialist Will Evaluate

• SLAP repair with suture anchors (preferred for younger patients with traumatic injury). 6, 7
• Biceps tenodesis (suprapectoral or subpectoral approach for middle-aged or older patients). 5
• Biceps tenotomy (for older, lower-demand patients). 5
• Treatment of concomitant rotator cuff pathology if present. 2

Conservative Management While Awaiting Consultation

Initial Treatment to Implement Immediately

• Relative rest with activity modification to reduce repetitive loading, but avoid complete immobilization which causes muscle atrophy. 3, 8
• NSAIDs (oral or topical) for pain relief, with topical formulations preferred to minimize systemic side effects. 3, 4
• Ice application through a wet towel for 10-minute periods for short-term pain relief. 3

What NOT to Do

• Do not inject corticosteroids into the shoulder joint or tendon substance before orthopedic evaluation, as this may complicate surgical planning and can inhibit healing. 3, 8
• Avoid complete immobilization, as this accelerates muscular atrophy and deconditioning. 3, 8
• Do not delay referral expecting conservative management alone to resolve a type II SLAP lesion with joint effusion. 2, 5

Expected Timeline

Referral Urgency

• This is not an emergency requiring acute surgical management, but referral should be made within 2-4 weeks. 1
• Most patients with type II SLAP lesions who fail conservative management (typically 2-3 months) will ultimately require surgical intervention. 2, 6
• Approximately two-thirds of SLAP lesions may improve with nonoperative management including scapular exercises and restoration of balanced musculature, but the presence of joint effusion makes this less likely. 2