SLAP Lesion

Original Editor - Kristin Sartore, Venugopal Pawar

Top Contributors - Venugopal Pawar, Lucinda hampton, Fasuba Ayobami, Rachael Lowe, Kim Jackson, Admin, WikiSysop, Claire Knott, Amrita Patro, Wanda van Niekerk and Vasileios Tyros

Introduction

Glenoid labrum (marked lig.)

Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum. They involve the superior glenoid labrum, where the long head of biceps tendon inserts. They may extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. Unlike Bankart lesions and anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions, they are not usually (20%) associated with shoulder instability.

Four types of SLAP lesions involving the biceps anchor are identified:

1. Degenerative fraying with no detachment of the biceps insertion.
2. Detachment of the superior labrum and biceps from the glenoid rim. Most common. In younger patients (<40 years of age) these are associated with Bankart lesions and in older patients (>40 years of age) they are seen with rotator cuff tears.
3. Bucket-handle tear of the labrum with an intact biceps tendon insertion to the bone.
4. Intra-substance tear of the biceps tendon with a bucket-handle tear of the superior aspect of the labrum. Least common .

Epidemiology

It is estimated that SLAP tears account for 80% to 90% of labral pathology in the stable shoulder, however they are usually seen in association with other shoulder pathologies and rarely in isolation. SLAP tears account for approximately 1% to 3% of injuries in sports medicine centres and approximately 6% of shoulder arthroscopy procedures show SLAP tears.

Age variations: From the average age of 35, the superior labrum is less firmly attached to the glenoid than in people under the age of 30. There is an age-related effect in which the older the patient is, the more likely he will incur a SLAP lesion, due to age-related changes of the labrum.

Etiology

In the acute setting, SLAP injuries are most frequently seen in falls onto an outstretched arm. In this situation the shoulder is abducted and slightly forward-flexed at the time of the impact.Other mechanisms of injury include:

• Repetitive throwing, Throwers can have repetitive microtraumata. At the moment of the impact the glenohumeral contact point is shifted posterosuperiorly and increased shear forces are placed on the posterior-superior labrum, which results in a peel-back effect and eventually in a SLAP lesion.
• Hyperextension,
• Heavy lifting,
• Direct trauma.

Clinical Presentation

The most common complaint in patients that present with SLAP lesions is pain. Pain is typically intermittent and often associated with overhead movements.Isolated SLAP lesions are uncommon.The majority of patients with SLAP lesions will also complain of:

• sensations of painful clicking and/or popping with shoulder movement
• loss of glenohumeral internal rotation range of motion
• pain with overhead motions
• loss of rotator cuff muscular strength and endurance
• loss of scapular stabiliser muscle strength and endurance
• inability to lie on the affected shoulder
  

Athletes performing overhead movements, especially pitchers, may develop “dead arm” syndrome in which they have a painful shoulder with throwing and can no longer throw with pre-injury velocity.They may also report a loss of velocity and accuracy along with discomfort in the shoulder.

It is important to keep in mind that the scapula is an important factor during shoulder movements. When the scapula does not perform its action properly there is a scapular malposition. This decreases the normal shoulder function.It changes the activation of the scapular stabilising muscles. , which are the serratus anterior, rhomboid major and minor, levator scapulae and trapezius. The rotator cuff muscles are important as well to anchor the scapula and guide the movement.

Differential Diagnosis

The differential diagnosis for chronic shoulder pain includes many etiologies:

• Impingement: eg Subcoracoid, Calcific tendonitis.
• Rotator Cuff pathology
• Degenerative pathology
• Proximal Biceps pathology eg subluxation, tendonitis.

Diagnostic Procedures

SLAP lesions are difficult to diagnose as they are very similar to those of instability and rotator cuff disorders. At first the clinician can test the tenderness to palpation at the rotator interval which can be helpful in the diagnostic procedure. The rotator interval is an anatomic space between the Supraspinatus tendon, the Subscapularis tendon and the processus coracoideus. This rotator interval has a triangular shape in which the supraspinatus is superiorly located, the subscapularis inferiorly and the processus coracoideus medially. It contains the coracohumeral and the superior glenohumeral ligament, the biceps tendon and the anterior joint capsule. If you know where these structures are situated, you can try to palpate the rotator interval.

• This can be followed by these tests that are positive when there is a presence of a SLAP lesion: positive anterior drawer (53%), positive apprehension at 90° of abduction and maximal external rotation (86%), and positive relocation test (86%).
• In addition, 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 I and II test, and the Active Compression test.

SLAP injury MRI

MR arthrogram: Most experts consider that arthroscopy is the best way to diagnose SLAP lesion.

The investigation of choice is an MR arthrogram, which is variably reported as having accuracies of 75-90%, although distinguishing between subtypes can be difficult.

Outcome Measures

See Category:Shoulder - Outcome Measures

This measure is a useful example Western Ontario Rotator Cuff (WORC) Index

Examination

Clinical examination to detect SLAP lesions is an extremely challenging procedure because the condition is frequently associated with other shoulder pathologies in patients presenting this type of condition.

As with most shoulder conditions, the history including the exact mechanism of injury should be documented. It is important to keep in mind that while labral pathologies are frequently caused by overuse, the patient may also describe a single traumatic event. The physical examination is also very important in determining the correct diagnosis, however physical examination should not be used in isolation because the literature does not confirm that special tests can accurately identify SLAP lesions.

There are numerous physical examination procedures described to detect the SLAP lesion:

1. Biceps load test II
2. O’Brien test
3. Anterior apprehension test
4. Speeds Testt
5. Yergason’s test
6. Compression rotation test
7. Dynamic labral shear test

A combination of 2 sensitive tests and 1 specific test is more efficient to diagnose a SLAP lesion ^{[reference needed]}.

Sensitive tests include:

• Compression rotation test
• O’Brien test
• Anterior apprehension test

Specific tests include:

• Speed’s test
• Yergason’s test
• Biceps load test II

If one of the three tests is positive, this will result in a sensitivity of about 75%. But if all three tests are positive this will result in a specificity of about 90%.

Most experts consider that arthroscopy is the best way to diagnose SLAP lesion.

Treatment/Management

For the vast majority of SLAP injuries, the initial management is nonoperative. Nonoperative management modalities include: Anti-inflammatory medications, cryotherapy/cooling/ice application, rest and activity modification

1. Type I tears: Commonly asymptomatic and do not require treatment
2. Type II tears: Need surgical reattachment
3. Type III tears: Normally need resection of the bucket handle tear

If non-operative treatment modalities fail, operative management is considered, while keeping in mind each patient’s age, concomitant pathologies, functional requirements, occupational demands, and sport-specific goals.

This 2 minute video shows SLAP Repair Arthroscopic Double loaded anchor Y config. Ideal graphic animation, using Antero-Sup portal avoiding rotator cuff portal.

Physical Therapy Management

Conservative Management: A small subset of patients, for example those with type I SLAP lesions, can try conservative treatment. Initially this involves cessation of throwing activities, followed by a short course of anti-inflammatory medication aimed at reducing pain and inflammation. When the pain has subsided, physical therapy focuses on restoring normal shoulder motion. Strengthening of the shoulder girdle musculature is critical for normal shoulder bomechanics.

Postoperative Rehabilitation (following SLAP repair) varies according to the type of SLAP lesion, the surgical procedure performed (debridement versus repair), and any other shoulder pathology. Usually the patient's shoulder is immobilised for a short period, followed by restoring motion and, lastly, commencing strengthening exercises. What follows is an example of a postoperative guidelines for patients who have had a SLAP repair with no associated pathology.

• Week 0 to 3 weeks postoperatively: Patient's shoulder is immobilized in internal rotation in a sling. Client not allowed any external rotation and abduction is limited to 60°. Pendulum and elbow range-of-motion exercise are performed.
• Week 4-8 weeks: Sling use stopped, shoulder motion is increased using active-assisted and passive techniques. limited external rotation to 30° to minimize strain on the labrum. Internal rotation and external rotation range-of-motion activities are progressed to 90° of shoulder abduction.
• Week 8 week: Initiate resistance exercises, focusing on scapular strengthening, provided adequate motion has been achieved Approximately 115° to 120° of shoulder external rotation must be achieved before starting scapular strengthening. Resisted biceps activity (elbow flexion and forearm supination) prohibited for 2 months to protect the healing of the biceps anchor.
• Week 16: Sport-directed throwing program can commence in overhead athletes. See details below.
• Week 24 : Contact sports are generally
  

Week 16: Sport-directed throwing program. Exercises can be chosen on the basis of several EMG studies and clinical recommendations regarding the rehabilitation of patients with SLAP lesions.
These exercises are:

• forward flexion in a side-lying position
• prone extension
• seated rowing
• serratus punch (protraction with the elbow extended)

• knee push-up plus

• forward flexion in external rotation and forearm supination
• full can (elevation in the scapular plane in external rotation

• internal rotation in 20° of abduction
• external rotation in 20° of abduction
• internal rotation in 90° of abduction
• external rotation in 90° of abduction
• forearm supination, elbow flexion in forearm supination
• uppercut (combined forward flexion of the shoulder and flexion and supination of the elbow)
• internal rotation diagonal
• external rotation diagonal

These exercises, with increasing low to moderate activity, can be applied in the early and intermediate phases of nonoperative and postoperative treatment for patients with proximal biceps tendon disorders and SLAP lesions.

SLAP lesion repair often fails, and biceps tenodesis or tenotomy seems to be an acceptable alternative treatment for SLAP lesions. Furthermore, this technique has now become the most preferable treatment for failed SLAP repairs.The indications for biceps tenodesis as the index procedure for a symptomatic SLAP lesion depends on:

• the patient’s age
• activity level
• arm dominance
• type of sport.

If a biceps tenodesis is performed a minimum of 10 weeks is recommended without biceps activity to allow the repaired soft tissue to fully incorporate into the bone tunnels.

Clinical bottom line

SLAP lesions are lesions of the superior labrum in which there are several types described. A SLAP lesion is mainly caused by a fall on an outstretched arm where there is an important superior compression on the labrum which causes a tear of the labrum. A typical symptom is intermittent pain that also occurs in overhead movements. To diagnose this condition it is important to use several different tests and not only one. Physical examination is not easy because of the fact that SLAP lesions are often associated with other shoulder pathologies. For the physical examination the therapist uses the tests described in ‘Diagnostic Procedures’, but apart from that he can also test the glenohumeral and scapulothracic range of motion because there could occur a dyskinesis caused by the SLAP lesion. For the treatment of SLAP lesion one uses often a medical treatment where the surgeon uses advanced arthroscopic techniques. But a physical treatment is also possible. This includes stretching, strengthening, and stabilisation exercises.
It is important to note that every treatment depends on the type of the SLAP lesion and that conservative treatment may fail and is not suited to every patient.