Superior Labrum Lesions Guidelines

Updated: Nov 24, 2021
  • Author: Riley J Williams, III, MD; Chief Editor: Craig C Young, MD  more...
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Guidelines Summary

NATA Recommendations for Management of SLAP Lesions and Return to Play in Overhead Athletes


In 2018, the National Athletic Trainers' Association (NATA) issued the following recommendations for management of SLAP (superior labrum, anterior and posterior) lesions in overhead athletes [46] :

  • Patients with SLAP lesions should undergo 3-6 months of nonoperative management with the goals of decreasing pain, improving shoulder function, and returning to previous activity levels (grade B recommendation)
  • Nonoperative management may include prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections to decrease pain and inflammation (grade C recommendation)
  • Supervised rehabilitation should address deficits in shoulder internal rotation (IR), total arc of motion, and horizontal-adduction range of motion (ROM), as well as periscapular and glenohumeral muscle strength, endurance, and neuromuscular control (grade C recommendation)
  • To be considered for surgical intervention, a patient with a SLAP lesion should have failed to improve after 3-6 months of nonoperative management, as signaled by inability to regain pain-free ROM and near-normal rotator cuff strength and return to the prior or desired activity level (grade B recommendation)
  • Repair of a type II SLAP lesion at the biceps anchor can be considered in those with episodes of biceps-anchor instability, shoulder instability, or persistent pain with overhead activity (grade B recommendation)
  • Debridement of the labrum is an option for type and select type III (bucket-handle) lesions; biceps tenodesis or tenotomy may be considered if the biceps is hypertrophied, frayed, or synovitic; repair of the SLAP tear with biceps tenodesis or tenotomy is a possibility for those with an unstable biceps anchor; biceps tenodesis or tenotomy is not typically advocated in baseball players or athletes younger than 18 years (grade C recommendation)
  • Other surgical considerations include release of the posterior glenohumeral capsule ligament (if thickened and contractured) in addition to SLAP repair and debridement of a ganglion or paralabral cyst, with or without concurrent SLAP repair (grade C recommendation)
  • During repair of a SLAP lesion in an overhead-throwing athlete, anchor placement should preserve the required external-rotation (ER) ROM in the abducted and externally rotated position (grade B recommendation)

Outcomes and return to play

NATA recommendations regarding return to play for overhead athletes treated for SLAP lesions include the following [46] :

  • Patients undergoing surgical or nonsurgical management of SLAP lesions should be educated to expect a patient-rated outcome (PRO) of 85% of normal function at an average of 2-3 years (grade C recommendation)
  • Patients should be informed to expect 80% satisfaction within 2-3 years of surgery; however, the level of satisfaction is lower for overhead athletes (67% excellent rating) (grade C recommendation)
  • Patients should understand the need to regain 90% of ROM in order to return to full activities; however, limited evidence suggests that ROM deficits up to 15º may persist at 2 years (grade C recommendation)
  • Before starting a sport-specific or interval return-to-sport program, patients should be educated to regain at least 70% of strength as compared with the uninvolved side (grade C recommendation)
  • Patients should be informed that the criterion for return to sport is primarily time-based; guidelines suggest return to sport-specific training at around 4 months post surgery and progression to full activities over the following 2-3 months (grade C recommendation)
  • Patients should be informed that after nonoperative management, the rate of return to sport is in the range of 40-95%; however, these rates are based on only two studies (grade C recommendation)
  • Patients should be informed that regardless of the type of treatment provided, an average of 75% of patients with a SLAP tear (range, 20–94%) are able to resume some level of sport activity (grade C recommendation)
  • Patient education after surgical intervention should include the fact that the rate of return to sport for overhead athletes is lower than that for nonoverhead athletes or nonathletes; whereas 55% of all athletes return to the same or higher level of sport activity and 31% return at a lower level of participation or with limitations, only 45% of overhead athletes return to the same or a higher level, 34% return at a lower level or with continued limitations, and 24% cannot return (grade C recommendation)
  • Consistency in reporting PROs, the time and level of return to play, and the type of treatment used is recommended for adequate and accurate determination of the success of management