Current Concepts
The Disabled Throwing Shoulder: Spectrum of Pathology
Part II: Evaluation and Treatment of SLAP Lesions in Throwers
Stephen S. Burkhart, M.D., Craig D. Morgan, M.D., and W. Ben Kibler, M.D.
A s we stated in Part I, Pathoanatomy and Biome-
chanics in the April issue of the Journal, the
pathologic cascade that leads to production of a SLAP
lesion is devastating to the overhead athlete. Once the
SLAP lesion is produced, the thrower can no longer
perform. It is imperative that the orthopaedic surgeon
be able to accurately diagnose and adequately treat
this pathologic lesion, which we believe is the most
common cause of the dead arm.
PHYSICAL FINDINGS WITH SLAP
LESIONS
One of us (C.D.M.) has reviewed and correlated the
results of 4 preoperative physical examination tests in 81
cases.1 The tests were (1) bicipital groove tenderness, (2)
Speed test, (3) O’Brien cross-arm test, and (4) the Mod-
ified Jobe relocation test. A correlation of the 4 physical
examination tests with the presence and anatomic loca-
tion of a type 2 SLAP lesion was done and statistical
analysis was performed generating specificity and sensi-
tivity data. The Speed test and O’Brien test were found
to be highly specific for anterior type 2 SLAP lesions,
whereas the modified Jobe relocation test was highly
specific for posterior SLAP lesions, the usual type of
“thrower’s SLAP.” The anterior scapular slide test, de-
vised by one of us (W.B.K.),2 is another useful test for
detecting anterior SLAP lesions. Other biceps tension
tests, such as those described by Kim et al.,3,4 and
O’Driscoll5 have been reported, but we do not have any
significant clinical experience with these tests.
Address correspondence and reprint requests to Stephen S.
Burkhart, M.D., 540 Madison Oak Dr, Suite 620, San Antonio, TX
78258, U.S.A.0749-8063/03/1905-3489-2$30.00/0
© 2003 by the Arthroscopy Association of North America
0749-8063/03/1905-3489-2$30.00/0
doi:10.1053/jars.2003.50139
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 5 (May-June), 2003: pp 531-539
One of the authors (S.S.B.)6 has correlated arthro-
scopically observed pathology with the maneuvers per-
formed in the modified Jobe relocation test (Fig 1). The
first part of the test brings the arm into the provocative
position of abduction and external rotation, where it
usually causes pain in the posterosuperior part of the
shoulder. Arthroscopically, the thrower with a dead arm
usually demonstrates a positive peel-back sign in this
position. If the second part of the Jobe relocation test is
then performed by applying a posteriorly directed force
to the proximal humerus, the pain is typically relieved.
As this is done, the surgeon can observe arthroscopically
that the biceps tendon is put on traction by this maneuver
and that the subluxed labrum reduces to a normal posi-
tion. We believe that this reduction of labral subluxation,
with reversal of the labral peel-back, results in relief of
the pain that is experienced in the peel-back position of
abduction and external rotation. That is, in the painful
provocative position of abduction-external rotation in the
Jobe relocation test, one sees arthroscopically that the
posterosuperior labrum is subluxed; then the posteriorly
directed force of the Jobe relocation maneuver (on the
proximal humerus) reduces the labral subluxation,
thereby relieving the pain.
A method of reducing the effect of impingement on
physical examination is to perform the scapular retrac-
tion test.7 Repositioning the scapula in retraction de-
creases glenoid antetilting and reduces mechanical im-
pingement and pain. This test is used to distinguish
secondary impingement (caused by scapular protraction)
from primary impingement.
ARTHROSCOPIC FINDINGS AND
TECHNIQUE OF SLAP REPAIR
SLAP repairs are performed arthroscopically in the
lateral decubitus position. Balanced suspension of 5 to
10 lb is used, with the arm in 30° to 45° of abduction
531
532 S. S. BURKHART ET AL.
 DISABLED THROWING SHOULDER: PART II 533

and 20° of forward flexion, using the Star Sleeve

Traction system (Arthrex, Naples, FL). General anes-
thesia is administered in each case and a warming
blanket is used to prevent hypothermia. An arthro-
scopic pump maintains the intra-articular pressure at
60 mm Hg.
A posterior viewing portal and anterior working
portal are established and a routine diagnostic arthro-
scopy is performed. In evaluating the biceps-superior
labral complex, the superior labrum must be directly
probed and examined as it may often appear normal to
visualization alone. The arthroscopic sign that is di-
agnostic for a posterior SLAP lesion is the positive
peel-back sign. However, other arthroscopic findings
that are indicative of an unstable biceps-superior la-
brum complex may be present. Such findings include
a superior sulcus greater than 5 mm in depth, a dis-
placeable biceps root, and a positive drive-through
sign. FIGURE 2. Unstable biceps root that is easily displaceable with a
An angled arthroscopic probe is used to test the probe.
stability of the biceps/superior labrum attachments to
the glenoid. A normal superior sublabral sulcus cov-
ered with articular cartilage can be seen up to 5 mm also found it to be positive because of the “pseudo-
medially beneath the labrum. If the sublabral sulcus is laxity” associated with SLAP lesions.1
greater than 5 mm or if the labral attachments at the To perform the peel-back test, one must remove the
medial limit of the sulcus are tenuous, one must be arm from traction and observe the superior labrum
suspicious of a SLAP lesion. arthroscopically as an assistant brings the arm to 90°
Next, the biceps root is assessed as to whether it is abduction and 90° external rotation (Fig 3). Perform-
easily displaceable with a probe (Fig 2). An unstable ing this dynamic peel-back maneuver in a shoulder
biceps root and superior labrum are easily displaced with a posterior SLAP lesion will cause the entire
medially on the glenoid neck. Occasionally, the biceps biceps/superior labrum complex to drop medially over
root will be unstable to probing, yet tenuous superior the edge of the glenoid, often quite dramatically. It is
labral attachments are present. We believe that such important to note that isolated anterior SLAP lesions
cases represent interstitial disruption of medially lo- often have a negative peel-back test, but other arthro-
cated attachments, and we routinely complete the le- scopic signs of a SLAP lesion (enlarged sublabral
sion, prepare the bone bed, and then repair the lesion. sulcus, displaceable biceps root, and positive drive-
Testing the drive-through sign is accomplished by through sign) are usually positive. However, overhead
sweeping the arthroscope from superior to inferior athletes do not generally have isolated anterior SLAP
between the glenoid and humeral head to see if the lesions, but rather have posterior or combined poste-
arthroscope can be easily “driven through” the joint. rior-anterior SLAP lesions. These posterior SLAP le-
Although a positive drive-through sign has been con- sions in throwers display a positive peel-back test.
sidered in the past to be a sign of instability,8 we have Once the diagnosis of a SLAP lesion is made, it is

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FIGURE 1. (A) Arthroscopic view of a left shoulder with a SLAP lesion showing the normal location of the superior labrum with the arm
at the side. (B) Provocative Jobe relocation maneuver of forced passive abduction and external rotation causes posterosuperior shoulder pain
(not apprehension) in a patient with a posterior SLAP lesion. (C) Arthroscopic view of the pathologic anatomy in a left shoulder during the
provocative Jobe maneuver showing a positive peel-back test, with medial subluxation of the biceps-superior labral complex. (D)
Diagrammatic representation of peel-back, with subluxed superior labrum. (E) Posteriorly directed force on the proximal humerus relieves
the pain that was caused by the provocative Jobe maneuver. (F) Arthroscopic view of the pathoanatomy during the application of the posterior
force during the Jobe test (same patient as in 1A and 1C). The force on the proximal humerus creates a tensile force in the biceps tendon,
which reduces the subluxed labrum, thereby relieving the pain. (G) Diagrammatic depiction of the biceps tensile force produced by the Jobe
relocation maneuver, which reduces the subluxed labrum to its anatomic position.
534 S. S. BURKHART ET AL.

FIGURE 4. The anterosuperior portal used to access the superior

glenoid for suture anchor placement, suture passing, and knot
tying. The portal is typically located 1 cm off the anterolateral tip
of the acromion. The anterosuperior portal provides a 45° angle of
approach to the corner of the superior glenoid. (Note: Figs 5-10 are
of a left shoulder viewed through a posterior viewing portal.)

the acromion (Fig 4). A spinal needle is used to

precisely locate this portal so that it provides a 45°
angle of approach to the anterosuperior corner of the
glenoid for proper placement of the suture anchor. The
anterosuperior cannula is also used for passing sutures
through the labrum and for tying arthroscopic knots.
Through the anterior portal, a motorized shaver is

FIGURE 3. The dynamic peel-back test. As the arm is brought

from (A) the resting position into (B) 90° abduction and 90°
external rotation, the biceps-superior labral complex displaces me-
dially over the edge of the glenoid, confirming a posterior SLAP
lesion.

important to perform the repair expeditiously, because

swelling may occur that obliterates the supralabral
recess and obscures visualization.
Three portals are used in SLAP repair: a standard
posterior viewing portal, an anterior portal located just
above the lateral border of the subscapularis tendon,
FIGURE 5. The bone bed is prepared beneath the superior labrum
and an anterosuperior portal. The anterosuperior por- via the anterior cannula using a motorized shaver to debride down
tal is located just lateral to the anterolateral corner of to a bleeding bone bed.
 DISABLED THROWING SHOULDER: PART II 535

FIGURE 6. Arthroscopic suture anchor insertion: (A) A 3.5-mm Arthrex Spear delivery guide placed through anterosuperior portal beneath
root of biceps. Angled opening of Spear guide allows retraction of biceps-superior labral complex by the guide while visualizing the
instrumentation through the angled mouth. Pilot hole for suture anchor produced by 2-mm punch. (B) A 3-mm tap placed through delivery
device to create threaded channel for suture anchor. (C and D) A 3-mm biodegradable BioFASTak suture anchor, placed through a delivery
guide into prethreaded channel, may accommodate 1 or 2 sutures per anchor.

used to prepare the bone bed on the superior neck of
the glenoid, beneath the detached labrum (Fig 5). The
soft tissues must be carefully debrided down to a
bleeding base of bone, taking care not to remove bone.
Fixation of SLAP lesions is best achieved by means
of suture anchors and simple translabral loop sutures.
The most critical element to resisting peel-back forces
in a mechanically effective manner is to position a
tight suture loop just posterior to the root of the
biceps, with the loop attached to a suture anchor
placed beneath the root of the biceps.
We prefer to use biodegradable screw-in suture
anchors (Arthrex Bio-FASTak) or biodegradable
push-in suture anchors (Arthrex BioSutureTak). To
536 S. S. BURKHART ET AL.

prepare the hole in the bone for the screw-in anchor,

the Spear guide (Arthrex) is inserted along with a
pointed trochar punch that is impacted into the bone
with a mallet to create a pilot hole (Fig 6A). Next, a
tap is placed through the Spear guide to create a
helical channel for the screw threads (Fig 6B). Then
the Bio-FASTak suture anchor is inserted up to the
laser mark on the inserter, and the inserter is removed
(Fig 6C and D). The eyelet of the Bio-FASTak will
accommodate 1 or 2 No. 2 braided sutures. For supe-
rior labral lesions that extend posteriorly to overlie the
posterosuperior quadrant, a second anchor is placed
through a posterolateral portal (Port of Wilmington1,9;
Fig 7). The Spear guide is passed through the rotator
cuff near the musculotendinous junction of the in-
fraspinatus by this approach. Because the diameter of
the Spear guide is only 3.5 mm, it is preferred rather
than a standard 7-mm arthroscopy cannula for deliv-
ery of the suture anchor through the Port of Wilming-
ton, in order to minimize damage to the rotator cuff
due to portal placement. The only instrument that is
placed through the posterolateral portal is the 3.5-mm
Spear guide. This posterolateral portal is only used for
anchor placement; suture passage and knot tying for
the posterior anchor are accomplished through the
anterosuperior portal. The steps for creating the pre-
tapped hole and inserting the anchor are the same as
for the more anteriorly placed anchor.
Suture passage through the labrum is next (Fig 8).
The BirdBeak suture passers (Arthrex) are used for
this step. The 45° BirdBeak is ideal for passing sutures
posterior to the biceps through the anterosuperior can-
nula and the 22° BirdBeak is best for passing sutures
anterior to the biceps through the anterior cannula.
The BirdBeak passer penetrates the labrum from su- FIGURE 7. The posterolateral portal (Port of Wilmington) used to
perior to inferior, grasps the suture, then is withdrawn place a suture anchor in the posterosuperior quadrant of the gle-
to pull the suture out the anterosuperior cannula. If the noid. (A) The portal is located 1 cm lateral and 1 cm anterior to the
posterior acromial angle. (B) Intra-articular view of the angle of
SLAP lesion extends anteriorly beyond the 1 o’clock approach to the posterosuperior glenoid afforded by this portal (left
position, a separate suture anchor may be placed in shoulder, posterior viewing portal).
that position for fixation of that portion of the labrum.
Finally, secure arthroscopic knots are tied (Fig 9).
The sutures create simple loops around the labrum that remain positive, one might consider adjunctive mea-
must be very tight to neutralize the peel-back forces. sures for capsular tightening, either by suture plication
Stacked reversing half-hitches tied with a double- or electrothermal application to the anterior band of
diameter knot pusher (Surgeon’s Sixth Finger, Ar- the inferior glenohumeral ligament.
threx) create a secure knot. Alternatively, complex One of us (C.D.M.) has used adjunctive measures
sliding knots backed up with 3 reversing half-hitches consisting of electrothermal shrinkage or mini-plica-
can provide adequate knot security. tion applied to the anterior band of the inferior gleno-
After the repair, the peel-back and drive-through humeral ligament if external rotation is greater than
tests are again performed to be sure that they are 130° with the arm in 90° abduction, and poste-
negative, indicating that the pathology has been cor- rior-inferior capsular release in throwers who are
rected (Fig 10). If the drive-through sign were to “stretch nonresponders” following vigorous super-
 DISABLED THROWING SHOULDER: PART II 537

vised stretching for loss of internal rotation. If the

surgeon uses electrothermal shrinkage, he must do this
only in patients without generalized ligamentous lax-
ity, so that the electrothermal energy is applied to
collagen tissue that has normal elastic properties.

FIGURE 9. (A) Secure arthroscopic knots are tied using arthro-

scopic double-diameter knot pusher (Surgeon’s Sixth Finger). (B)
The suture loop that provides labral fixation at the posterior biceps
root is the most critical one to resist peel-back forces.

FIGURE 8. Arthroscopic suture passage: (A) A 45° suture passer
(BirdBeak) penetrates the labrum from superior to inferior at the
posterior root of the biceps. (B) The BirdBeak captures a suture
limb from the anchor and is then withdrawn to pull the suture limb
out the anterosuperior cannula.
POSTOPERATIVE REHABILITATION
PROTOCOL FOR SLAP REPAIR
The operated arm is placed at the side in a sling with
a small pillow. All procedures are performed on an
538 S. S. BURKHART ET AL.
FIGURE 10. (A) After repair with the arm in neutral position, and
(B) after repair with the arm in abduction and external rotation. The
biceps vector has shifted posteriorly, but the labrum does not shift
medially because the peel-back forces have been successfully
neutralized by the sutures.
outpatient basis. Passive external rotation of the shoul-
der with the arm at the side (not in abduction), and
flexion and extension of the elbow are emphasized
immediately. Patients who required a posterior-infe-
rior capsulotomy are begun on posterior-inferior cap-
sular stretches (“sleeper stretches”) on the first post-
operative day. The sling is discontinued after 3 weeks,
and passive elevation is initiated. From week 3 to
week 6, progressive passive motion as tolerated is
permitted in all planes, and sleeper stretches are begun
in patients who did not have a posterior-inferior cap-
sulotomy. From week 6 to week 16, stretching and
flexibility exercises are continued. Passive posteroin-
ferior capsular stretching is continued, as is external
rotation stretching in abduction. Strengthening exer-
cises for the rotator cuff, scapular stabilizers, and
deltoid are initiated at 6 weeks. Biceps strengthening
is begun 8 weeks postoperatively.
At 4 months, the athletes begin an interval throwing
program on a level surface. They continue a stretching
and strengthening program, with particular emphasis
on posterior-inferior capsular stretching. At 6 months,
the pitchers may begin throwing full-speed, and at 7
months pitchers are allowed full-velocity throwing
from the mound. All throwing athletes are instructed
to continue posteroinferior capsular stretching indefi-
nitely. One must remember that a tight posteroinferior
capsule probably initiates the pathologic cascade to a
SLAP lesion, and that recurrence of the tightness can
be expected to place the repair at risk in a throwing
athlete.
Editor’s Note: Part III: The “SICK” Scapula,
Scapular Dyskinesis, the Kinetic Chain, and Rehabil-
itation will appear in Vol. 19, No. 6.
Acknowledgement: The authors wish to thank Jeff
Cooper, P.T., A.T.C. (Head Athletic Trainer, Philadelphia
Phillies), and Phil Donley, P.T., A.T.C., M.S. (consultant,
Philadelphia Phillies), for their assistance in the preparation
of this manuscript.
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