High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders

Abstract

Background:The incidence of superior labral surgery has increased in the past decade in the United States, and a contributing factor could be an increased rate of superior labral tears diagnosed with magnetic resonance imaging (MRI). Prior MRI studies of the asymptomatic shoulder have focused on rotator cuff pathology or pathology in a narrow and specific group of athletes. Labral abnormalities have not previously been thoroughly evaluated in asymptomatic middle-aged individuals.Purpose:To evaluate the prevalence of superior labral tears diagnosed by MRI in the asymptomatic shoulders of middle-aged people (age range, 45-60 years).Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 53 asymptomatic adults (age range, 45-60 years) with no history of surgery or injury to either shoulder were included in the study. Physical examinations of all shoulders were performed. Noncontrast MRI (1.5 T) was performed in 1 randomly determined shoulder of each subject. Two fellowship-trained musculoskeletal radiologists who were blinded to the purpose of the study and ages of the subjects evaluated each MRI.Results:Radiologists interpreted the MRIs as consistent with superior labral tears in 55% and 72% of the cohort. Comparison of the radiological evaluations of the superior labra were moderate (κ = 0.410, P = .033). There were no differences in readings for superior labral tear regarding age (P = .87), sex (P = .41), whether the dominant shoulder underwent MRI (P = .99), whether the subject worked a physical job (P = .08), or whether the subject participated in overhead sports for a period of 1 year (P = .62).Conclusion:Superior labral tears are diagnosed with high frequency using MRI in 45- to 60-year-old individuals with asymptomatic shoulders. These shoulder MRI findings in middle-aged populations emphasize the need for supporting clinical judgment when making treatment decisions for this patient population.Clinical Relevance:To avoid overtreatment, physicians should realize that superior labral tears diagnosed by MRI in individuals between the ages of 45 and 60 years may be normal age-related findings.

The Snyder Classification of Superior Labrum Anterior and Posterior (SLAP) Lesions

“…In the original series describing the Snyder classification [22], a large proportion of the original 27 patients were found to have concomitant shoulder disorders, and it is possible that the observed superior labral disorder could have been an incidental finding. A subsequent study showed a high prevalence of SLAP tears in asymptomatic middle-aged individuals [20].…”

“…This may be partly attributable to the difficulty in understanding even normal superior labral anatomy and age-related changes that can occur [20]. The presence of a sublabral sulcus is not considered abnormal, yet our understanding regarding how to differentiate a normal sublabral foramen from a SLAP lesion is not well characterized or described.…”

“…The confidence interval for likelihood ratios all included 1.0, indicating that Speed's and Yergason's tests could not rule in or rule out a SLAP lesion in comparison to arthroscopy [12]. Studies investigating MRI and MR arthrography in diagnosing SLAP tears have reported sensitivity and specificity ranging from 66% to 98% and 13% to 89%, respectively [6,7,9,20,21,23]. Variation in study design, MRI methods, and lack of reliability among observers likely accounts for such a wide discrepancy [16].…”

Editorial Commentary: Pursuit of Value-Based Care for SLAP Lesions: More Work to Be Done

“…Cross-sectional studies have shown that there is a high prevalence of SLAP pathology identified in middle-aged patients with asymptomatic shoulders. 3 Given the high prevalence of this condition, diagnosing a SLAP tear (especially in middle-aged patients) as the isolated clinical entity attributable for shoulder dysfunction can be challenging especially because SLAP tears are often identified at surgery for patients with other painful shoulder conditions. In fact, there is considerable controversy as to whether SLAP tears are an actual clinical problem in middle-aged patients.…”

Treating SLAP II lesions with sham surgery

“…Since then the classification has been expanded by others but it should be noted that Snyder’s classification was based on a traumatic initiating episode causing the lesion, which was only diagnosed on arthroscopy, and not a degenerative process which may be akin to the difference between an acute and degenerative tear of the rotator cuff. Indeed, it should be noted that up to 72% of patients between the ages of 45 and 60 years old were noted to have a SLAP lesion on MRI and were asymptomatic for the lesion, and therefore may be an age-related phenomenon 3. A cohort where no distinction is made between acute injury and degenerative SLAP lesions could possibly lead to a type II statistical error.…”