The findings can be rather subtle, especially in obese patients. Tears of the glenoid labrum fibrocartilage, also known as superior labral anterior to posterior (SLAP) lesions, are suspected clinically or noted on magnetic resonance (MRI) imaging. Stress distribution in the superior labrum during throwing motion. The following causes have been found: The two most common mechanisms are falling on an outstretched arm in which there is a superior compression, and a traction injury in the inferior direction.[6]. [10][13][14] Multiple tests of the shoulder should be used to gain information collectively towards suspicion for labral pathology. Poor outcomes after SLAP repair: descriptive analysis and prognosis. [11], It is important to keep in mind that the scapula is an important factor during shoulder movements. [10]The majority of patients with SLAP lesions will also complain of: 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. 1173185. SLAP - Superior Labrum Anterior to Posterior InjuryReparación Quirúrgica, por medio de Artroscopía de la Lesión de SLAP, que consiste en una lesión del Rodet. [16]SLAP lesion is mostly combined with a lesion of the proximal head of the biceps because it attaches on the superior part of the labrum glenoidalis. External rotation must absolutely be avoided and abduction limited to 60°. Upon observation, the posterior shoulder (when viewed from the patient's side) will be relatively flat relative to the anterior fullness. et al., Anatomy of the Shoulder Joint. However, the study acknowledges that more than half of the treatment of patients who were initially prescribed non operative management failed and these patients went on to undergo arthroscopic surgery. Suprascapular nerve compression from a paralabral cyst may occur. Tear pattern involves larger superior labral flaps without detachment of the LHBT insertion. The patient reported 75% . Find top doctors who treat Labral tears near you in Liverpool, NY. Presence of concomitant LHBT tendinitis or tendinosis: The odds ratio for revision surgery was 5.1 in the setting of LHBT tearing/fraying. [2]Generally, pendulumand elbow range-of-motion exercises are allowed during the period of immobilization. Physical examination is not easy because of the fact that SLAP lesions are often associated with other shoulder pathologies. [25][32] Additionally, infection, failure of repair, residual pain, neurovascular injury, and recurrent instability may occur. Burkhart SS, Morgan CD. Brockmeyer M, Tompkins M, Kohn DM, Lorbach O. A positive test includes a reproduction of the pain and/or a painful click or catch in the joint line along the posterior joint line between 120 and 90 degrees of abduction, Surgical treatment: arthroscopic debridement, Surgical treatment: SLAP repair versus biceps tenotomy/tenodesis. A SLAP lesion (superior labrum, anterior [front] to posterior [back]) is a tear of the rim above the middle of the socket that may also involve the biceps tendon. 163 likes. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Summarize interprofessional team strategies for improving care coordination and communication to enhance outcomes for patients affected by superior labral anterior to posterior (SLAP) lesions. As with most shoulder conditions, the history including the exact mechanism of injury should be documented. The shoulder joint is composed of the glenoid (the shallow shoulder "socket") and the head of the upper arm bone known as the humerus (the "ball"). SLAP Tear of the Shoulder. This 2 minute video shows SLAP Repair Arthroscopic Double loaded anchor Y config. SLAP lesions demonstrate a predilection for young laborers, overhead athletes, and middle-aged manual laborers. [28] It is generally recognized that the majority of patients with symptomatic SLAP lesions will fail conservative management, particularly throwers. Charles MD, Christian DR, Cole BJ. Oper Tech Sports Med, 2012;20 (1):46 – 56, MYERS J.B. et al., Sensorimotor deficits contributing to glenohumeral instability. Clinicians should keep in mind the utilization of MRA may promote the overdiagnosis of asymptomatic (or clinically irrelevant) SLAP lesions and thus exercise best clinical judgment in ordering specific advanced imaging modalities. The term SLAP stands for Superior Labrum Anterior and Posterior. [2][3] Repetitive overhead motions, such as those with baseball pitchers, other overhead athletes, and manual laborers, place these individuals at an increased risk for SLAP tears as well. Acta Orthop Traumatol Turc., 2014;48(3): 290-297, MANSKE R. et al., Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete. Tuoheti Y, Itoi E, Minagawa H, Yamamoto N, Saito H, Seki N, Okada K, Shimada Y, Abe H. Attachment types of the long head of the biceps tendon to the glenoid labrum and their relationships with the glenohumeral ligaments. However, the ideal treatment of SLAP tears was never fully elucidated, and thus the increasing recognition of SLAP injuries brought about an increased incidence of SLAP repair rates across institutions. Unstable SLAP lesions are typically repaired with anchor fixation, and the extent of the injury typically determines the pattern of repair. In the setting of chronic anterior instability, the clinician may appreciate a palpable anterior fullness. As function is restored without pain, a gradual return to sport is recommended on a case-by-case basis, dependent upon clinical exam. As symptoms diminish, a structured rehabilitation protocol focusing on rotator cuff and pericapsular strengthening exercises are utilized. Superior labrum-biceps tendon complex lesions of the shoulder. American Journal of Sports Medicine, 2008;36:353-359, COOK C. et al., Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesion. “Type III plus anterior shoulder instability.”, Type III tear pattern plus extension into the LHBT. [19], As our knowledge regarding the actual clinical significance of SLAP tear presentations continued to evolve from 2010 and beyond, the initial rise in the incidence rate of SLAP repairs performed reached its peak before subsequently declining over the last decade. Glenohumeral internal rotation deficit (GIRD) is a common associated finding in throwing athletes. Nonoperative management modalities include: Anti-inflammatory medications, cryotherapy/cooling/ice application, rest and activity modification. National trends in the diagnosis and repair of SLAP lesions in the United States. The ultimate goal of fixation for all repair techniques is to provide a robust and stable fixation, promoting the stability of the glenohumeral joint and allowing for adequate rehabilitation without failure of repair.[9]. J Shoulder Elbow Surg., 2012;21(1):13 – 22, MESERVE B.B. Tears of the glenoid labrum These exercises are: 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. Tenodesis patients are protected for four weeks, and avoidance of supination and flexion of the elbow is recommended. This decreases the normal shoulder function. Andrews JR, Carson WG, McLeod WD. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. The rotator cuff muscles are important as well to anchor the scapula and guide the movement. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. Initial physical examination includes visual inspection for gross asymmetry and muscle atrophy. Often seen in association with shoulder instability and anterior labral tears. [2]Given that conservative management only seems to be successful in a 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. Arthroscopy, 2010. This rotator interval has a triangular shape in which the supraspinatus is superiorly located, the subscapularis inferiorly and the processus coracoideus medially. Specific testing of the supraspinatus muscle can be difficult when passive ROM is limited. At four weeks, progressive range of motion exercises are continued; however, active external rotation and abduction are still avoided. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) Nonoperative PT regimens focused on correcting for scapular dyskinesia and glenohumeral internal rotation deficit (GIRD).[49]. The labrum is the attachment site for the shoulder ligaments and supports the ball . Some tests isolate the tension placed on the superior labrum by the biceps via provocative maneuvers in active and passive forms. They also noticed that the type II SLAP lesions in patients under 40 were associated with a Bankart lesion, other than a type II SLAP lesion in patients under 40 years old, whose SLAP lesion were associated with a tear of the supraspinatus tendon and osteoarthritis of the humeral head.[6]. The examiner initially supports the elbow, and a positive test occurs if the elbow does not maintain this position upon the examiner removing the supportive force. A sulcus between the supraglenoid tubercle and the labrum may also give a false-positive result and is deemed a pseudo SLAP tear. The physical requirements of military service may contribute to an increased. The bucket-handle tear of the superior labrum is resected, additionally with the repair of the SLAP complex (rare) if needed. Initial reported performance of these tests has not been reproduced by independent investigat … ), which permits others to distribute the work, provided that the article is not altered or used commercially. [43] Katz LM, Hsu S, Miller SL, Richmond JC, Khetia E, Kohli N, Curtis AS. Superior labrum lesions, or frequently referred to as superior labrum anterior to posterior (SLAP) tears, are a subset of injuries of the labrum in the shoulder that occur in acute and chronic/degenerative settings. Variability in the anatomy of the biceps anchor and tendinous origin translates to varying levels of strain on the superior labrum. In a SLAP injury, the top (superior) part of the labrum is injured. A positive test is noted if the patient reports pain over the bicipital groove and/or subluxation of the LHB tendon. [18][23], Operative intervention in adults has been reported to be successful between 80 and 97% of patients in several populations. Background:Injuries to the superior glenoid labrum represent a significant cause of shoulder pain among active patients. Sixteen commonly used shoulder rehabilitation exercises can be chosen on the basis of several EMG studies and clinical recommendations regarding the rehabilitation of patients with SLAP lesions. The patient is eventually advanced to a strengthening phase, which includes trunk, core, rotator cuff, and scapular musculature. Strengthening exercises can be initiated at six weeks postoperatively.[33]. A Superior Labrum Anterior to Posterior (SLAP) tear is an injury to the labrum of the shoulder, which is the ring of cartilage that surrounds the socket of the shoulder joint. Additionally, adolescents also demonstrated successful outcomes with operative repair in regards to pain and function; however, there remain similar considerations regarding return to sport. The origin of the long head of the biceps from the scapula and glenoid labrum. Clinicians should obtain a comprehensive history should when evaluating patients presenting with acute or chronic shoulder pain. Active strengthening of the biceps is still avoided. Specific physical examination of SLAP tears is difficult as they typically present with other pathology in the shoulder. Immediately post operative Patient will remain in an immobilizer for four weeks. [39]. StatPearls Publishing, Treasure Island (FL). [36] Etiology Gentle passive and limited active range of motion exercises is recommended for the first four weeks. Important variations in the normal anatomy of the labrum have been identified. A SLAP tear stands for Superior Labrum, Anterior to Posterior. NSAIDs and cryotherapy device/ice pack application can be beneficial for pain control. In fact, superior outcomes have been reported in this particular subset of athletic patients following non-surgical management alone. Avoid extremes of abduction and external rotation. Clavert P, Bonnomet F, Kempf JF, Boutemy P, Braun M, Kahn JL. The deltoid muscle often demonstrates atrophy in chronic dislocators. SLAP tear patients typically admit to resolution or reduction of symptoms at rest. Ther., 2013; 8(5): 579-600, HURI G. et al, Treatment of superior labrum anterior posterior lesions: a literature review. Any evidence of significant muscular weakness may hint at an underlying associated neurologic deficit. Part II candidates. [49][57], Risk factors for revision surgery are critical in discussing overall patient expectations and discussing the risks of continued pain, stiffness, dysfunction, and the potential need for further surgery in the future. Ther., 2013;8(5):617-629, CLAVERT P., Glenoid labrum pathology. Anteroinferior labral tears decreased posterior stability and posterosuperior labral tears decreased anterior and anteroinferior stability, largely because of loss of the suction cup effect. As several types of SLAP tears can also be associated with instability, the general stability of the shoulder should be evaluated. [20], Erickson et al. SLAP-lesion-specific physical examination tests have been developed to improve clinical acumen. The incidence of SLAP tears is a controversial topic in the current literature. [2][9][6][12], Non-operative management focuses on the initial restriction of provoking maneuvers. SLAP tear type is determined by the anatomical location of the tear as well as the severity of its extension. Patient complaint of pain is not a good gauge for progression. el slap es una lesión en el hombro (2), específicamente en la parte superior del labrum glenoideo y es conocida como "slap" debido a sus siglas en inglés (superior labrum anterior to posterior) es decir que el labrum ha sufrido una rotura o se ha desgarrado de anterior hacia posterior y por lo general se debe a la tracción que ejerce el tendón de … [2]In the first step of conservative management, patients should abstain from aggravating activities in order to provide relief to the pain and inflammation. Assisted and passive techniques are used at 4 weeks post-operative to increase shoulder mobility. The examiner instructs the patient to perform a boxing “uppercut” punch while placing their hand over the patient’s fist to resist the upward motion. [37] [40]. Anti-inflammatory medications, cryotherapy/cooling/ice application, rest and activity modification. Type II is the most common type and represents a detachment of the superior labrum and biceps from the glenoid rim. [1][2]  Snyder developed the initial 4-subtype classification of these lesions. [15][16], Nonoperative management has efficacy for many symptomatic SLAP tears and should be considered for initial treatment. Weber et al. Vangsness CT, Jorgenson SS, Watson T, Johnson DL. 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. So there are conflicting views in the literature about the repairs in the older patients.[27]. Comprehensive Review of Provocative and Instability Physical Examination Tests of the Shoulder. Unlike Bankart lesionsand ALPSA lesions, they are uncommonly (20%) associated with shoulder instability 5. The labrum and the long head of the biceps tendon (LHBT) are torn and avulses off the glenoid cavity. et al., A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. In addition, understanding how to treat a SLAP tear in the setting of other concomitant injuries is imperative. The odds ratio for revision surgery was 3.5 in the setting of LHBT tendinitis alone. McCausland C, Sawyer E, Eovaldi BJ, Varacallo M. Boesmueller S, Nógrádi A, Heimel P, Albrecht C, Nürnberger S, Redl H, Fialka C, Mittermayr R. Neurofilament distribution in the superior labrum and the long head of the biceps tendon. Hill L, Collins M, Posthumus M. Risk factors for shoulder pain and injury in swimmers: A critical systematic review. Journal of Science and Medicine in Sport, 2014;17(5): 463–468, MAENHOUT A. et al., Quantifying acromiohumeral distance in overhead athletes with glenohumeral internal rotation loss and the influence of a stretching program. Hippensteel KJ, Brophy R, Smith MV, Wright RW. SLAP lesions of the shoulder. J. Andrews JR, Carson WG, McLeod WD. http://creativecommons.org/licenses/by-nc-nd/4.0/. Etiology Int. In: StatPearls [Internet]. Outcome of the isolated SLAP lesions and analysis of the results according to the injury mechanisms. [27] It is the anatomic manifestation of a congenital failure of fusion of the labrum, which attaches to the glenoid with a smooth margin or a medial slip. In throwing athletes, a progressive throwing program that is directed toward the patients' specific sport and position can be initiated after 3 months.[2]. Gorantla K, Gill C, Wright RW. There are several proposed mechanisms for the cause of SLAP tears. In the absence of compressive symptoms, a range of non-operative treatments can be considered, including observation, anti-inflammatories, or percutaneous aspiration. Regardless of the underlying etiology, patients presenting with symptomatic SLAP tears will commonly report the acute onset of deep shoulder pain accompanied by mechanical symptoms such as popping, locking, or catching with various shoulder movements. Also, posterior shoulder joint capsular contractures should be addressed with various stretching and strengthening programs. In addition to axillary nerve function, motor function of the elbow, wrist, and hand should undergo an assessment to rule out the possibility of a brachial plexus injury associated with the dislocation. Patients often complain of vague, deep shoulder pain and mechanical clicking with exacerbating activities. An interprofessional team approach involving clinicians (including PAs and NPs), therapists, and orthopedically-trained nurses will provide the best results. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Ebinger N, Magosch P, Lichtenberg S, Habermeyer P. A new SLAP test: the supine flexion resistance test. Intra-articular contrast media and articular effusion, as well as arm traction and external rotation, improve the sensitivity of the MRI to determine a SLAP lesion. Superior Scapes, Liverpool, New York. [18] However, in younger patients presenting with shoulder instability, the SLAP injury may be present and contributing to symptoms, especially in the setting of an acute anterior and/or posterior labral tear. First described in the 1980s, extensive study has followed to elucidate appropriate evaluation and management. Chronic anterior and posterior instability patients may also exhibit corresponding posterior and anterior acromial prominences, respectively. The acronym "SLAP" stands for Superior Labrum Anterior Posterior, and is used to describe a tear or detachment of the shoulder's superior glenoid labrum; generally originating at the anchor site for the long head of the biceps tendon and extending into anterior or posterior portions of the labrum. 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%). Superior migration of the humeral head can result from a rotator cuff that is not effectively performing its role as a humeral head depressor. Adolescent Posterior-Superior Glenoid Labral Pathology: Does Involvement of the Biceps Anchor Make a Difference? Sports. Pathophysiology. Following the observational component of the physical examination, the active and passive ROM are both documented; this may be limited in the setting of initial follow-up in the clinic after an acute instability event or the setting of any complex instability case, especially in the setting of glenoid bone loss. Western Ontario Rotator Cuff (WORC) Index, https://radiopaedia.org/articles/superior-labral-anterior-posterior-tear, http://www.sportsmedicinedr.com/?page_id=715, https://www.ncbi.nlm.nih.gov/books/NBK538284/, https://www.physio-pedia.com/index.php?title=SLAP_Lesion&oldid=315450. Superior labrum anterior to posterior (SLAP) tears are a subset of labral pathology in acute and chronic/degenerative settings. [15], According to William F.B., SLAP lesions had an association of 43% with the medial sheath lesion. “Type II plus anterior shoulder instability.”. A detailed neurovascular examination is performed and documented, complete with muscle strength testing. SLAP lesions represent a specific pattern of injury that involves the partial or complete detachment of the superior labrum and/or the biceps tendon. Athletes and overhead laborers should also be placed on restricted sport-specific timeline protocol, and manual laborers should receive appropriate occupational modifications. This factor may have a potential impact on patients experiencing persistent pain following various types of SLAP repairs. The upper, or superior, part of your labrum attaches to your biceps tendon. [29]This course of treatment should focus on restoring strength of the rotator cuff, shoulder girdle, trunk, core and scapular musculature, restoring normal shoulder motion, and training to improve dynamic joint stability. [28][30]By stretching the posterior capsule and restoring internal rotation, through posterior capsule stretching exercises, such as sleeper stretch and cross body adduction stretches, and exercises for scapula stabilisation , pathologic contact between the supraspinatus tendon and the posterosuperior labrum. et al., Shoulder rotator strength and torque steadiness in athletes with anterior shoulder instability or SLAP lesion. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Schultz KA, Nelson R. Superior Labrum Lesions. Multiple exam maneuvers point to either labral involvement via impingement or compression mechanisms. Kwak SM, Brown RR, Resnick D, Trudell D, Applegate GR, Haghighi P. Anatomy, anatomic variations, and pathology of the 11- to 3-o'clock position of the glenoid labrum: findings on MR arthrography and anatomic sections. SLAP lesions first gained recognition in the 1980s. Functional exercise and light strengthening can be progressively incorporated. Phys. Discussing the goals of the patient is also critical as the recovery time between various procedures is vastly different. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Understanding the rigorous rehabilitation required from advanced procedures helps the patient understand what is expected on their road to recovery. Also suprascapular neuropathy secondary to cyst compression in the spinoglenoid notch may occur in association with SLAP tears. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. Snyder et al. Superior labral anterior to posterior (SLAP) lesions constitute a recognized clinical subset of complex shoulder pain pathologies. [10], For the vast majority of SLAP injuries, the initial management is nonoperative. [1], In various patient populations, internal impingement is also a culprit of SLAP tears. Maffet MW, Gartsman GM, Moseley B. If the non-operative therapy fails and symptoms persist that prevent sports activities or activities of daily living, then this would indicate the need for operative treatment. The skin should be observed for the presence of any previous surgical incisions, lacerations, scars, erythema, or induration. Am J Sports Med., 2009;37:929–936, OH, J. H. et al., The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion. Isolated tenotomy patients typically can resume activity within a week. 2009 Oct-Dec; 43(4): 342–346, WILK K.E. In this position, the force on the biceps coupled with the posterior glide of the humerus results in the peeling off of the posterosuperior quadrant of the glenoid and posterior labrum. Horizontal mattress with a knotless anchor to better recreate the normal superior labrum anatomy. [10][11] Furthermore, the respective incidence rates for the clinical diagnosis of SLAP lesions and the incidence of SLAP repairs remain limited given the paucity of available high-quality studies reporting available epidemiologic data and surgical management trends. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. Management must consider a multitude of factors, including the patient’s age, activity level, sport-specific requirements, occupational demands, and expectations of a good to excellent outcome. Patients presenting with concerns over a potential SLAP tear should receive education regarding the contemporary clinical knowledge we now have regarding these injuries. SLAP lesions are difficult to diagnose as they are very similar to those of instability and rotator cuff disorders. Am. The Type II SLAP lesions have been further divided into three subtypes depending on whether the detachment of the labrum involves the anterior aspect of the labrum alone, the posterior aspect alone, or both aspects. The outcome of type II SLAP repair: a systematic review. Explain how to diagnose a superior labral anterior to posterior (SLAP) lesion. Pain is typically intermittent and often associated with overhead movements. 2022 Dec . [53][54][55] A number of authors report good results in athletes, including those with sport-specific overhead demand requirements. This can help avoid stressing the dynamic and static stabilizers of the shoulder in hopes of limiting stress at the glenoid-labrum interface. Smith R, Lombardo DJ, Petersen-Fitts GR, Frank C, Tenbrunsel T, Curtis G, Whaley J, Sabesan VJ. A superior labrum anterior and posterior (SLAP) tear involves a tear in the 10 o'clock to 2 o'clock positions on the You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Physical examination and magnetic resonance imaging in the diagnosis of superior labrum anterior-posterior lesions of the shoulder: a sensitivity analysis. reported in 2016 that an institutional trend from 2004 to 2014 (including four fellowship-trained orthopedic surgeons) revealed decreasing rates of total SLAP repairs performed. Kuhn JE, Lindholm SR, Huston LJ, Soslowsky LJ, Blasier RB. The endemic rate of variations of labral anatomy visible on MRI in asymptomatic overhead throwers should prompt caution before concluding that the labrum is the source of the patient’s pain. That is usually the journal article where the information was first stated. Ek ET, Shi LL, Tompson JD, Freehill MT, Warner JJ. The examiner then applies terminal external rotation until resistance is appreciated. Athletes and overhead laborers should also be placed on a restricted sport-specific timeline protocol, and manual laborers should receive appropriate occupational modifications. It compared good shoulder function with the shoulder function of patient that followed successful conservative management in the form of scapular stabilization exercises and posterior capsular stretching. The test registers positive only if it elicits pain deep inside the shoulder joint or at the shoulder's dorsal aspect along the joint line during the resisted movement. Throwing athletes and weightlifters can be injured this way. For example, in older patients with or without rotator cuff repair, the repair of the SLAP correlates with inferior results compared to intentional neglect or performing a bicep tenodesis/tenotomy regarding stiffness, persistent pain, and need for revision surgery. Ascertaining patients’ goals is also paramount as post-intervention physical demands and expectations of a high-level athlete are likely different than the aging population. A sublabral foramen with a cord-like middle glenohumeral ligament. SLAP tears involve the superior glenoid labrum, where the long head of bicepstendon inserts. http://creativecommons.org/licenses/by-nc-nd/4.0/ Schrøder CP, Skare O, Gjengedal E, Uppheim G, Reikerås O, Brox JI. Isolated type II superior labral anterior posterior lesions: age-related outcome of arthroscopic fixation. [15], SLAP tear itself accounts for 80–90% of labral pathology in stable shoulder but it’s only found in 6% on arthroscopy. http://creativecommons.org/licenses/by-nc-nd/4.0/. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Return to play after treatment of superior labral tears in professional baseball players. SLAP tears are typically defined as superior labrum fraying/tearing from the glenoid. OK to begin biceps resistance exercises beyond 6 to 8 weeks postoperative. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. The recess/sulcus can be present during fetal development as early as 22 weeks of pregnancy, persisting throughout childhood and into adulthood. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. [2][28]This way, physical treatment can be started sooner. Classically advocated by Snyder as his original case series from 1990 reported about half of the patient presentations were status post a fall onto an outstretched arm with the arm in varying degrees of shoulder abduction. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). [23][26][27][28][29][30] Non-overhead athletes return to sport at a consistently higher rate, although some patients inevitably are unable to return to participation. This activity reviews the evaluation and treatment of SLAP tears and highlights the role of the interprofessional team in managing patients with this condition. The examiner manually resists supination while the patient also externally rotated the arm against resistance. The examiner places his or her hand over the patient’s elbow while instructing the patient to resist the examiner’s downward force applied to the arm. This increase constituted a jump in case volume reporting from 765 to 4313 annual SLAP repairs. The variation in SLAP tear reporting may be attributed to some SLAP tears being considered an incidental finding on advanced imaging or at the time of arthroscopy. The age of the patient has an impact on the superior labrum. [15] Additionally, we now recognize that SLAP lesions commonly occur in asymptomatic overhead athletes. et al., The effect of age on the outcomes of arthroscopic repair of type II superior labral anterior and posterior lesions. The rotator interval is an anatomic space between the Supraspinatus tendon, the Subscapularis tendon and the processus coracoideus. Resisted elbow flexion, resisted forearm supination. Trends in the diagnosis of SLAP lesions in the US military. At first the clinician can test the tenderness to palpation at the rotator interval which can be helpful in the diagnostic procedure. [12], Similarly, a 2012 study reported the rising incidence of arthroscopic SLAP repair rates within New York State from 2002 to 2010, noting a 464% increase in the number of SLAP repairs. Common SLAP-provoking sports include but are not limited to: Overhead sports (volleyball, baseball pitchers, javelin, swimming), History or current manual/physical laborer occupations, Atraumatic, insidious onset of anterior shoulder pain, Symptom exacerbation with overhead activities, Pain radiating down the anterior arm from the shoulder, Clicking or audible popping reported in the setting of proximal biceps instability. Passive and active-assist forward elevation encouraged, may progress limitations depending on surgeon preference. Tenodesis can be performed by subpectoral, all-arthroscopic, and mini-open techniques. Type VII: a superior labrum and biceps tendon separation that extends anteriorly, inferior to the middle glenohumeral ligament. INTRODUCTION SLAP tear refers to a specific injury of the superior portion of the glenoid labrum that extends from anterior to posterior in a curved fashion. It is important to discuss the patients’ activities such as athletics, profession, and baseline activity level. Observation of neck posturing, muscular symmetry, palpable tenderness, and active/passive ROM should undergo evaluation. Glenoid labrum tears related to the long head of the biceps. Sports Med, 2013;41:444-460, NURI A. et al., Superior labrum anterior to posterior lesionsof the shoulder: Diagnosis ans arthoscopic management. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. The goal of physical therapy (PT) modalities should be to treat any underlying pathologic shoulder biomechanics that may have been present at baseline before the acute injury. For debridement procedures and stable SLAP patterns, passive and active range of motion exercises begin within the first week of surgery. [46]. Sometimes morphological varieties can be confused with pathological aspects and therefore diagnosis should be established following careful analysis of the case history and a physical examination. Weber SC, Martin DF, Seiler JG, Harrast JJ. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. For the treatment of SLAP lesion one uses often a medical treatment where the surgeon uses advanced arthroscopic techniques. There are a lot of different mechanisms of injury that can result in a SLAP lesion. Typically, an MR arthrogram (MRA) is performed to evaluate the shoulder labrum. Type II is the most common type and represents a detachment of the superior labrum and biceps from the glenoid rim. [Level 2-3]. Superior labrum-biceps tendon complex lesions of the shoulder. AJSM 2013. [29] Previous reports have emphasized the LHBT as a potentially dominant source of anterior shoulder pain at clinical presentation. Burkhart SS, Morgan CD, Kibler WB. [32]The indications for biceps tenodesis as the index procedure for a symptomatic SLAP lesion depends on: 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.[11]. Describe treatment considerations for patients with superior labral anterior to posterior (SLAP) lesions. Also, a wide array of implant options are available depending on surgeon preference. In these clinical scenarios, the recommendation is to reassure the patient and educate them regarding the high incidence rate of “incidental” or “clinically irrelevant” SLAP injuries. [3][5], The long arm of the biceps inserts directly into the superior labrum, which also provides stabilisation to the superior part of the joint. Furthermore, biceps tenodesis may provide a viable alternative for the salvage of a failed SLAP repair. [19][21] The recent overlying trend appears to favor tenodesis rather than repair; however, the decision for the type of intervention remains patient-specific. The beam can otherwise be rotated while the patient is neutral in the coronal plane. Demographic trends in arthroscopic SLAP repair in the United States. [24][25] Several of these studies, however, are heterogeneous and successful treatment is a matter of definition. The examiner applies a perpendicular external rotational force to try and lift the patient’s handoff of the shoulder. After probing to confirm the diagnosis of a SLAP tear, a shaver can be used to resect unstable flaps of tissue that are deemed irreparable. In this situation the shoulder is abducted and slightly forward-flexed at the time of the impact. This increase translated to a population-based increased incidence rate from 4 per 100000 patients in 2002 to 22.3 per 100000 patients in 2010. Taylor SA, Degen RM, White AE, McCarthy MM, Gulotta LV, O'Brien SJ, Werner BC. A Treatment-Based Algorithm for the Management of Type-II SLAP Tears. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. [27], Alpantaki et al. Below is a list of tests used to evaluate the labrum and the biceps. 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. Some SLAP tears present in the degenerative setting with no definitive onset of symptoms or discrete mechanisms. Results are widely varied in these athletes, demonstrating the return to the prior level of sport between 7% and 84%. [12] These concepts are further realized by the fact that a formal diagnosis code was not available until 2001, and it took until 2003 to institute a separate Current Procedural Terminology (CPT) code: 29807. Surgical treatment: SLAP repair versus resection. [17], Beside biceps tears, other problems, such as bursitis and rotator cuff tears, are often identified, in combination with SLAP lesions,[18]According to Morgan CD et al., Rotator cuff tears were present in 31% of patients whit SLAP lesion and were found to be lesion-location specific.[19]. Neri BR, ElAttrache NS, Owsley KC, Mohr K, Yocum LA. But a physical treatment is also possible. Scapulothoracic motion and scapular winging should also be evaluated during active and passive motion. SLAP tears are a common coexisting injury in patients with other shoulder pathologies, and they do not always account for the primary cause of symptoms. Posterosuperior Labral Tears. Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. Erickson BJ, Jain A, Abrams GD, Nicholson GP, Cole BJ, Romeo AA, Verma NN. [38] Contribution to the study of the pathogenesis of type II superior labrum anterior-posterior lesions: a cadaveric model of a fall on the outstretched hand. 27, issue 4, p. 556-567, BOILEAU P. et al., Arthroscopic treatment of Isolated Type II SLAP lesions. This can lead to instability and, ultimately, impingement of the superior labrum with degenerative tearing. The resulting tear of the labrum can then be debrided or fixed depending upon the severity of the tear. Initially rest post the acute (or acute-on-chronic) injury should be implemented. SLAP lesions are lesions of the superior labrum in which there are several types described. [37] The location you tried did not return a result. An anatomical study of 100 shoulders. Examiners should observe and compare bilateral shoulder girdles for any notable asymmetry, scapular posturing, muscle bulk comparison, or any atrophic changes. Those potentially contributing to patient-reported symptoms may require surgery, and depending on the particular SLAP tear pattern and the presence (or absence) of other associated shoulder pathologies, the recommended surgical technique(s) may vary. A shoulder SLAP tear is when the labrum frays or tears because of an injury. The labral insertion of LHBT is left unaffected. Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes. A structured rehabilitation program and open communication between the interprofessional team, including primary care, sports medicine, orthopedics, physical therapists, and specialty trained nurses, are important to ensure a step-wise approach is followed to achieve maximum patient satisfaction and function. Healing time constraints are critical. Specific attention should be paid to scapulothoracic motion, as altered mechanics of the global shoulder complex can be the result of or a contributing factor to SLAP tears. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. [24]  These four types were described based on macroscopic observation of 105 cadaveric shoulder specimens: Tuoheti et al. StatPearls Publishing, Treasure Island (FL). Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. In older patients and the setting of suspected concomitant shoulder pathologies (e.g., rotator cuff injuries or biceps tendon pathology), specialized testing for these pathologies also merits consideration. sensations of painful clicking and/or popping with shoulder movement, loss of glenohumeral internal rotation range of motion, loss of rotator cuff muscular strength and endurance, loss of scapular stabiliser muscle strength and endurance, inability to lie on the affected shoulder. Determining the onset of symptoms and mechanism (trauma, dislocation, or exacerbating maneuvers with overhead activity) can clue an examiner into labral pathology. 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. Outcomes after arthroscopic repair of type-II SLAP lesions. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. SLAP lesion repair often fails, and biceps tenodesis or tenotomy seems to be an acceptable alternative treatment for SLAP lesions. Intervention and outcome: A conservative chiropractic treatment plan in addition to physical therapy was initiated. [9]Isolated SLAP lesions are uncommon. Moreover, clinicians began reporting on the critical importance of differentiating younger, active patient populations (e.g., under 40 years old) and overhead athletes from the older patients (e.g., over 40 years old) with degenerative SLAP tears secondary to repetitive overhead manual laborer occupations. A structured advancement of strengthening sports specific rehabilitation and dynamic exercises are continued for several months. SLAP tears may present in a relatively nonspecific fashion and association with other shoulder pathologies. When refering to evidence in academic writing, you should always try to reference the primary (original) source. ( It can be caused by a forceful overhead motion, or when you try to catch something heavy. Shin SJ, Lee J, Jeon YS, Ko YW, Kim RG. The patient is standing, and the arm of interest is positioned at 90 degrees of forward flexion, 10 degrees of adduction, and internally rotated so the thumb points toward the floor. The palm is facing upward. Further, the age of patients operated on for SLAP tears was decreasing, and the majority of SLAP repairs still being performed by the latter half of the study were limited to mostly Type II SLAP tears. A SLAP lesion (superior labrum, anterior [front] to posterior [back]) is a tear of the labrum above the middle of the glenoid that may also involve the biceps tendon. 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. Superior Labrum Anterior Posterior Lesions. A positive test consists of pain elicited in the bicipital groove when the patient attempts to forward elevate the shoulder against examiner resistance; the elbow is slightly flexed, and the forearm is supinated. Radiographic imaging is necessary for all patients with acute or chronic shoulder pain. Radiopedia Superior labral anterior posterior tear Available: CHRISTOPHER C. et al., SLAP Lesions: An Update on Recognition and Treatment. J. A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. The possibility of generalized hyperlaxity of tissues in all patients with instability should also be considered, and a Beighton score can easily be obtained. Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. Secondary to fraying related to Internal Shoulder Impingement. Alleviation of pain and return of range of motion may result in treatment success for some; however, in overhead athletes, many patients are unable to return to their prior level of sport or performance. [17] Anatomical variations such as a Buford complex, a thickened middle glenohumeral ligament (MGHL), and absent anterosuperior labrum may be confused with a SLAP tear as well. In this mechanism, a “peel-back” avulsion of the superior labrum by a torsional force via the biceps anchor. Sports Med Arthrosc.,2010;18:162-166. et al., The Diagnosis, Classification, and Treatment of SLAP Lesions. You may get a SLAP tear if you: Additionally, classification and severity of the SLAP tear, in combination with concomitant pathology, affects the type of operative management selected. In the acute setting, traumatic injury can occur in traction/torsion and compressive/subluxation mechanisms. Jost B, Zumstein M, Pfirrmann CW, Zanetti M, Gerber C. MRI findings in throwing shoulders: abnormalities in professional handball players. Search doctors, conditions, or procedures . This activity will review the pathophysiology, classification, and treatment options for SLAP lesions and examine the role of physicians, physician assistants, nurses, physical therapy teams, and medical assistants in optimizing collaboration to ensure patients receive high-quality care, which will lead to enhanced outcomes. To diagnose this condition it is important to use several different tests and not only one. SLAP lesions: a treatment algorithm. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) [36], Mayo Shear Test (also known as the Modified O’Driscoll Test or the Modified Dynamic Labral Shear Test: The involved shoulder is positioned at neutral, the elbow is flexed to 90 degrees, the forearm is supinated, and the patient makes a fist. et al, The recognition and treatment of superior labral (SLAP) lesions in the overhead athlete. [5], There remains debate regarding whether the so-called peel-back mechanism versus the deceleration phase of throwing is most responsible for the pathologic forces driving SLAP tears in overhead athletes. Furthermore, this technique has now become the most preferable treatment for failed SLAP repairs. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Holtby R, Razmjou H. Accuracy of the Speed's and Yergason's tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Treatment failure and complications are dependent upon intervention, patient adherence to rehabilitation protocols, and patient-specific factors. In the setting of chronic anterior instability, the clinician should attempt to assess the current status of the axillary nerve, although chronic dislocators often exhibit normal deltoid function and internal and external rotator strength. Orthop Traumatol Surg Res., 2015;101(1):19-24, STETSON, W. (2010). Also, shoulder girdle proprioceptive training is beneficial to help prevent re-injury.
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