questions
8

SLAP Lesion

Topic updated on 05/03/16 5:18am
Introduction
  • Superior Labrum  from Anterior to Posterior tears 
  • May occur as isolated lesion or be associated with
    • internal impingement
    • rotator cuff tears (usually articular sided)
    • instability (may be subtle)
  • Mechanisms
    • repetitive overhead activities (often seen in throwing athletes)
    • fall on outstretched arm with tensed biceps
    • traction on the arm
  • Pathophysiology
    • in throwers may be due to tightness of the postero-IGHL which shifts the glenohumeral contact point posterosuperiorly and increases the shear force on the superior labrum
    • SLAP lesion increases the strain on the anterior band of the IGHL and thus compromises stability of shoulder
Anatomy
  • Anatomy of glenohumeral joint
  • Glenoid labrum
    • function
      • chock block to subluxation
    • composition
      • composed of fibrocartilagenous tissue
    • blood supply
      • from suprascapular, circumflex scapular, posterior humeral circumflex arteries
      • labrum receives blood from capsule and periosteal vessels and not from underlying bone
      • anterior-superior labrum has poorest blood supply
    • stability
      • superior labrum
        • anchors biceps tendon (weak link that leads to SLAP lesion)
        • most common pattern of biceps tendon attachment to the superior labrum is posterior to the 12 o'clock position
    • anatomic variants
      • sublabral recess
        • can be confused with a tear on MRI
      • meniscoid appearance (1%)
Classification
 
SLAP Classification
Type Description % Images
I
Labral and biceps fraying, anchor intact
11%
II
Labral fraying with detached biceps tendon anchor
41%
III
Bucket handle tear, intact biceps tendon anchor (biceps separates from bucket handle tear)
33%
IV

Bucket handle tear with detached biceps tendon anchor (remains attached to bucket handle tear)

15%
V
SLAP lesion and anterior labral tear (Bankart lesion)
m
m
VI
Superior flap tear
m
m
VII
SLAP lesion with capsular injury
m
m
  • Snyder Classification: Original classification which includes Types I-IV
  • Maffet sub-classification: Includes the original I-IV and adds Types V-VII
Presentation
  • Symptoms
    • vague deep shoulder pain (there is often a lag between the time of injury and the onset of symptoms)
    • mechanical symptoms of popping and clicking
    • weakness, easy fatigue, and decrease athletic performance
  • Physical exam 
    • provocative tests
      • active compression test (O'Brien's test) 
      • Crank test
      • Dynamic labral shear test
    • biceps tendon tenderness
    • patients commonly have GIRD
    • apprehension positive in 85% of patients
    • physical findings of suprascapular neuropathy secondary to a spinoglenoid cyst
Imaging
  • Radiographs
    • should be normal
  • MRI
    • T2 linear signal intensity between the superior labrum and the glenoid rim
    • sensitivity ~50% and specificity ~90% which increases with arthrogram
    • may see an associated paralabral ganglion cyst
      • usually in the spinoglenoid notch
      • may result in denervation changes to infraspinatus
  • Arthroscopy
    • diagnosis can only be confirmed with arthroscopy
    • look for erythema and tearing under labrum to differentiate from normal recess
    • "peel back" test shows "peel back" of the labrum with 90° of external rotation and abduction
Treatment
  • Nonoperative
    • physical therapy, NSAIDs
      • indications
        • first line of treatment
        • address GIRD, scapular dyskinesia, rotator cuff
        • incidental SLAP finding
          • in older patients (>45 years) having arthroscopic rotator cuff repair, it is not necessary to repair a SLAP lesion that is found incidentally. It may actually lead to stiffness if it is repaired.
  • Operative 
    • arthroscopic debridement and stabilization of the labrum and biceps tendon
      • indications
        • severe symptoms that have failed nonoperative management
      • complications
        • overdrilling the glenoid can injury the suprascapular nerve 
Techniques
  • Arthroscopic debridement and stabilization of the labrum and biceps tendon 
    • approach
      • standard arthroscopic approach to the shoulder
    • technique
      • Type I - debride labrum
      • Type II - reattach labrum 
      • Type III - debridement of flaps 
      • Type IV
        • if tendon involvement < 1/3, then excise the bucket
        • if tendon involvement >1/3, same and perform biceps tenodesis or tenotomy.
      • decompress any cysts
    • rehabilitation  
      • week 1-4
        • sling with passive forward elevation. Avoid extremes of abduction and external rotation
        • passive and active assisted flexion in the scapular plane 
      • week 4-6
        • progress to active ROM, isometrics
      • week 6-12
        • functional exercise and light strengthening
      • week 12+
        • advance strength and ROM, sport-specifics 
        • typical return to sport around 6 months 

 

Please Rate Educational Value!
4.0
Average 4.0 of 39 Ratings

Qbank (8 Questions)

TAG
(OBQ12.1) Figure A is an arthrosopic image from a right shoulder in the lateral decubitus position as viewed from the posterior portal. Which one of the following rehabilitation techniques should be avoided in the patient that is 2 weeks post-operative from the surgical repair shown in Figure A? Topic Review Topic
FIGURES: A          

1. Active assisted elevation in the scapular plane
2. Passive forearm pronation
3. Passive external rotation at 90 degrees of abduction
4. Open chain passive elbow flexion
5. Passive assisted elevation in the scapular plane

PREFERRED RESPONSE ▶
TAG
(OBQ12.110) Which of the following rehabilitation exercises is most appropriate immediately following the repair of the injury seen in figure A? Topic Review Topic
FIGURES: A          

1. Passive external rotation at 90 degrees of abduction
2. Isotonic rotator cuff strengthening
3. Isokinetic resistive elbow flexion
4. Passive and active assisted flexion in scapular plane
5. Concentric latissimus pull down exercises

PREFERRED RESPONSE ▶
TAG
(OBQ10.37) A 26-year-old outfielder undergoes arthroscopic repair of a right shoulder type 2 SLAP tear with two labral anchors in the 11 and 1 o’clock positions. Postoperative rehabilitation for this SLAP repair should include: Topic Review Topic

1. Immediate full active range of motion that simulates sport-specific activities
2. Full-time sling wear with no active nor passive motion for at least 6 weeks until labral tissues heal
3. Rotator cuff strengthening by post-operative week two to prevent disuse atrophy and shoulder instability
4. Limited passive motion for 4 weeks then progressive active motion until 8 weeks followed by sport specific strengthening until at least 12 to 16 weeks postoperatively
5. Eccentric open chain biceps contraction exercises beginning at postoperative week 2 to retrain the biceps muscle and stimulate SLAP healing at the biceps anchor on the glenoid

PREFERRED RESPONSE ▶
TAG
(OBQ10.46) What percent of shoulders have a posterior or posterior dominant attachment of the long head of the biceps onto the glenoid? Topic Review Topic

1. 0%
2. 15%
3. 30%
4. 70%
5. 100%

PREFERRED RESPONSE ▶
TAG
(OBQ04.40) Which of the following best describes a Buford complex? Topic Review Topic

1. Normal anatomic variant characterized by a cord-like MGHL and an absent anterosuperior labrum
2. Normal anatomic variant characterized by a cord-like SGHL and an absent posterosuperior labrum
3. Abnormal arthroscopic finding characterized by a cord-like MGHL and an absent anterosuperior labrum
4. Abnormal arthroscopic finding characterized by a cord-like SGHL and an absent posterosuperior labrum
5. Normal anatomic variant characterized by a cord-like MGHL and a sublabral foramen at the anterosuperior labrum

PREFERRED RESPONSE ▶
TAG
(OBQ04.236) A 32-year-old overhead athlete catches himself with his right hand while slipping on ice and injures his right shoulder. He fails to improve with therapy, anti-inflammatory medicines, and rest. His MRI is demonstrated in Figure A. What is the most likely diagnosis? Topic Review Topic
FIGURES: A          

1. HAGL
2. SLAP tear
3. ALPSA
4. Bankart
5. Loose body

PREFERRED RESPONSE ▶
Sorry, this question is available to Virtual Curriculum members only.

Click HERE to learn more and purchase the Virtual Curriculum today!





Videos

video
This talk reviews the diagnosis and treatment of SLAP tears. Dr. Benjamin S. Sha...
3/17/2013
580 views
4
video
Shoulder Exam: Exam to detect a SLAP tear
3/9/2013
6718 views
4
video
Shows one technique for arthroscopic repair of a Type II SLAP lesion using knotl...
9/2/2012
419 views
3
video
This is a arthroscopic view of labral pathology in a shoulder. The biceps ancho...
12/10/2011
228 views
0
See More Videos

Groups


Evidence



Topic Comments