What is the recommended management of a superior labrum anterior‑to‑posterior (SLAP) lesion, including conservative care, corticosteroid injection, and surgical options (arthroscopic repair versus biceps tenodesis) based on patient age and activity level?

Treatment of SLAP Lesions

Initial Management: Conservative Treatment First

Conservative management should be the first-line treatment for most SLAP lesions, particularly in patients without traumatic injury, mechanical symptoms, or high-demand overhead athletic requirements. 1, 2

Conservative Treatment Protocol

• Complete rest from aggravating activities until asymptomatic, with elimination of throwing or overhead activities for a minimum of 6 weeks. 3

• Implement a structured rehabilitation program emphasizing rotator cuff and periscapular muscle strengthening, along with scapular stabilizer exercises. 3, 4

• Address scapular dyskinesis, as poor scapular coordination contributes significantly to both rotator cuff and labral injuries. 3, 4, 2

• Consider intra-articular corticosteroid injection for symptomatic relief, which has shown significant effects on pain reduction in middle-aged patients (30-45 years) with SLAP lesions. 5

• NSAIDs can be used as part of initial conservative management for pain control. 4

• Duration: Continue conservative treatment for 3-6 months before considering surgical intervention, as approximately 71% of young active patients and 85% of middle-aged recreational athletes achieve successful outcomes with nonoperative management. 1, 5

Predictors of Conservative Treatment Failure

Conservative management is less likely to succeed in patients with:

• History of acute trauma 1
• Positive compression-rotation test (mechanical symptoms) 1
• High demand for overhead activities (competitive throwing athletes) 1, 2
• Persistent symptoms after 3-6 months of appropriate rehabilitation 2, 5

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Surgical Management: When Conservative Treatment Fails

Age-Based Surgical Algorithm

Patients Under 30 Years Old (Especially Overhead Athletes)

• Arthroscopic SLAP repair is the preferred surgical option for younger athletes (<30 years) involved in overhead sports (baseball, tennis, volleyball). 2, 6

• Repair technique: Use knotless anchor repair to reattach the labral anchor back to the superior glenoid rim. 2

• Important caveat: SLAP repair has relatively high failure rates, with only 40% of professional baseball players successfully returning to play after repair. 2

• Consider biceps tenodesis as an index procedure even in younger athletes, as emerging evidence suggests encouraging functional outcomes and return-to-sport rates despite traditional age restrictions. 2

Patients Over 30-35 Years Old

• Biceps tenodesis is the first-line surgical treatment for middle-aged or older patients (>35 years) with Type II SLAP tears, due to higher failure rates observed with arthroscopic SLAP repair in this age group. 2, 6

• Biceps tenodesis is also preferred for:

  • Non-overhead athletes 2
  • Patients receiving workers' compensation 2
  • Those with concomitant rotator cuff tears 2
  • Failed SLAP repairs 2

• Technique options: Either arthroscopic suprapectoral or mini-open subpectoral biceps tenodesis. 6

Alternative: Biceps Tenotomy

• Biceps tenotomy is preferred in middle-aged or older, lower-demand patients. 6

• Long-term functional outcomes are similar between tenodesis and tenotomy, though more patients experience a 'Popeye' sign, biceps fatigue, or cramping after tenotomy. 6

• Biceps tenodesis is preferred over tenotomy in younger, more active patients to avoid cosmetic deformity and functional limitations. 6

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Critical Decision Points

When to Proceed Directly to Surgery

• Elite overhead athletes with traumatic SLAP tears and mechanical symptoms who cannot modify their activity demands 1, 2

• Patients with persistent symptoms preventing participation in sports or activities of daily living after 3-6 months of appropriate conservative treatment 2, 5

Common Pitfalls to Avoid

• Do not rush to surgery in young athletes without first attempting a comprehensive 3-6 month trial of conservative management, as 71% can avoid surgery. 1

• Do not perform SLAP repair in patients over 35 years as the index procedure—biceps tenodesis has superior outcomes in this age group. 2, 6

• Do not overlook scapular dyskinesis during rehabilitation, as failure to address this contributes to treatment failure. 3, 4, 2

• Do not assume all overhead athletes require surgery—40% of professional baseball players return to play with rehabilitation alone. 2