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- SLAP lesion
- SLAP tear
- superior labral anterior posterior tear
- biceps anchor tear
The most common classification system for SLAP (Superior Labrum Anterior Posterior) lesions was described by Snyder et al. They identified 4 types of superior labral lesions involving the biceps anchor. Type I represents A degenerative fraying with no detachment of the biceps insertion. Type II is the most common type and represents detachment of the superior labrum and biceps from the glenoid rim. Type III represents a bucket-handle tear of the labrum with an intact biceps tendon insertion to bone. Finally, type IV lesions, the least common type represents an intra-substance tear of the biceps tendon with a bucket-handle tear of the superior aspect of the labrum.1 (Level of evidence 2A) ,4( Level of evidence 5)
The Type II SLAP lesions have been further divided into three subtypes depend¬ing on whether the detachment of the labrum involves the anterior aspect of the labrum alone, the posterior aspect alone, or both aspects. The above classification system has been ex¬panded to include an additional three types:
- Type V: a Bankart lesion that extends superiorly to include a Type II SLAP lesion.
- Type VI: an unstable flap tear of the labrum in conjunction with a biceps tendon separation.
- Type VII: a superior labrum and bi¬ceps tendon separation that extends anteriorly, inferior to the middle gle¬nohumeral ligament.1(Level of evidence 2A)
Clinically Relevant Anatomy
A SLAP tear or lesion occurs when there is damage to superior part of the glenoid labrum. SLAP stands for superior labral tear from anterior to posterior. The glenoid labrum is a circumferential rim of fibrocartilage that helps to deepen the ball and socket joint of the shoulder aiding in stabilization of the shoulder joint and provides an attachment for the ligaments of the shoulder.
To understand the etiology of superior labral injuries, it is useful to first consider the 2 discretely different mechanisms of injury that have been proposed in literature: superior compression and inferior traction. An acute traumatic superior compression force to the shoulder, usually due to a fall onto an outstretched arm with the shoulder positioned in an abducted and slightly forward-flexed position at the time of impact, was the most common mechanism of injury. In a subsequent series was found that the most common mechanism of injury was a fall or direct blow to the shoulder, occurring in 31% of patients. A significant number of patients with superior glenoid lesions and concomitant impingement or rotator cuff disease in the absence of trauma has also been identified. Indeed, Snyder et al found partial-thickness or full-thickness rotator cuff disease in 55 (40%) of 140 patients with SLAP lesions. Superior migration of the humeral head can result from a rotator cuff that is not effectively performing its role as a humeral head depressor. The superior labrum and biceps anchor could theoretically be gradually lifted off the glenoid as a result of chronic repetitive superior translation of the humeral head on the glenoid rim. Other authors supported the theory of an inferior traction mechanism on the basis of a sudden, traumatic, inferior pull on the arm or repetitive microtrauma from overhead sports activity with associated instability.2 (Level of evidence 5)
The most common complaint in patients that present with SLAP lesions is pain. The majority of patients with SLAP lesions will also complain of painful clicking and/or popping in the shoulder. Athletes performing overhead movements, espeacially pitchers, may develop “dead arm” syndrome in which they have a painful shoulder with throwing and can no longer throw with preinjury velocity.
SLAP tears are often seen with other shoulder problems such as bursitis and rotator cuff tears.
A negative passive compression test results in an absence of any SLAP lesion. A positive anterior apprehension maneuver, anterior slide test, Jobe relocation test, passive compression test, Speeds test, and Yergason test or a combination of a positive Jobe relocation test and active compression test or Jobe relocation test and anterior apprehension maneuver provides the therapist with the research-based confidence required to rule in a SLAP lesion. For ruling in a SLAP lesion, the greatest diagnostic value should likely be placed on a positive passive compression test.1(Level of evidence 2A)
SLAP lesions are difficult to diagnosis as they are very similar to those of instability and rotator cuff disorders. Several special tests can be used to help identify the presence of a SLAP lesion including the clunk test, the crank test, o’ briens, anterior slide test, biceps load test I and II, and the active compression test.
MRI is the most common imaging tool used to diagnose labral lesions, although may not show a SLAP tear and so often times an MRI with a dye injected, MR arthogram, into the shoulder is ordered. This is able to detect a SLAP tear better than a normal MRI
add links to outcome measures here (see Outcome Measures Database)
The surgical intervention depends on the type of labral lesion but an advanced arthroscopic technique is most commonly used. Studies of surgical labral repairs are generally good to excellent for return to pre injury level of function.
Knowing the type of SLAP lesion is important for post op rehab. Type I and III SLAP lesions are treated by debridement and because the biceps tendon is stable, post-op rehab can progress as tolerated. There are no restrictions of ROM. In Type II and IV labral lesions it is important to avoid stress on the repaired area post-operatively. ROM limitations should be followed closely and active biceps work must be limited for the first 6 weeks.
Physical Therapy Management
Given that conservative management seems only successful in few patients, mainly in type I SLAP lesions, it is only implemented in patients with this type of lesion or patients who do not wish to undergo surgery.5 (Level of evidence 4)
Patients should abstain aggravating activities in order to relief pain and inflammation.4,7 If necessary, NSAID’s and intra-articular corticosteroid injections can be applied to help diminish complaints.4 (Level of evidence 5) ,5 (Level of evidence 4 ),6(Level of evidence 5) This way, physical treatment can be started sooner6. This course of treatment should focus on restoring strength of the rotator cuff, shoulder girdle, trunk, core and scapular musculature. And restoring normal shoulder motion4 (Level of evidence 5) ,5 (Level of evidence 4) ,6 (Level of evidence 5). Regaining GIRD is a crucial aspect in the rehabilitation of SLAP lesion.4 (Level of evidence 5) By the use of posterior capsule stretching exercises, such as sleeper stretch and cross body adduction stretches5 (Level of evidence 4), 7 (Level of evidence 1B) (fig. 2), redevelopment of the internal rotation can be accomplished.4(Level of evidence 5),5 (Level of evidence 4) When conservative treatment fails, a surgical approach is in order.4 (Level of evidence 5) ,6(Level of evidence 5)
After surgery patients are placed in a sling for 3 to 4 weeks, which immobilizes the shoulder in internal rotation.4(Level of evidence 5) Postoperative rehabilitation is determined by the type of SLAP lesion, the chosen surgical procedure and other concomitant pathologies and procedures performed.4 (Level of evidence 5)
Example of a rehabilitation program for specific type of SLAP lesions can be found in the article listed under ‘Resources’.
Generally pendulum and elbow range-of-motion exercises are allowed during the period of immobilization. External rotation must absolutely be avoided and abduction limited to 60°.4(Level of evidence 5) Active-assisted and passive techniques are used at 4 weeks post-operative to increase shoulder mobility. Between week 4 and 8 internal and external rotation ROM are progressively increased to 90° of shoulder abduction. Resistance exercises can be initiated at approximately 8 weeks post-operative3 (Level of evidence 2B),4 (Level of evidence 5), in which scapular strengthening should be emphasized. Since the metabolism of cartilage depends partly on its mechanical environment, resistance training can contribute to gaining mobility8(Level of evidence 1B). However, the achievement of adequate shoulder mobility is an important condition to begin resistance training. At month 4 to 6, dependent on the type of sport, patients should be able to start sport-specific training and gradually return to their former level of activity.4 (Level of evidence 5)
add text here relating to key evidence with regards to any of the above headings
Dutton Mark. Orthopaedic examination, evaluation, and intervention. New York: McGraw Hill; 2004.
Dessaur WA. (2008). Diagnostic Accuracy of Clinical Testing for Superior Labral Anterior Posterior Lesions: A Systematic Review Journal of Orthopaedic and Sports
Robert Manske, Daniel Prohaska. Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete. Physical Therapy in Sport 11, 2010, p.110-121.(Table 4). Rehablitation following arthroscopic type II SLAP repair.
Note: Strength training first weeks: 13 repetitions - 4 sequences – 1 to 3 minutes of rest between sequences
Strength training, build up to: 20 repetitions – 3 sequences – 1 minute of rest between sequences
Stretching: Total stretching time = 30 seconds for each stretch → 3x10” – 2x15” – 1x30” (build up)
30 to 60 seconds of rest between each stretch9(Level of evidence 5)
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Recent Related Research (from Pubmed)
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