lesión slap labrum superior

Brockmeier SF, Voos JE, Williams RJ, Altchek DW, Cordasco FA, Allen AA., Hospital for Special Surgery Sports Medicine and Shoulder Service. Between week 4 and 8, internal and external rotation ROM are progressively increased to 90° of shoulder abduction. CORR 2012. Pathophysiology. These tears are common in overhead throwing athletes and laborers involved in overhead activities. 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.[6]. Sports Phys. They can extend into the tendon, involve the glenohumeral ligamentsor extend into other quadrants of the labrum. Waterman BR, Arroyo W, Heida K, Burks R, Pallis M. SLAP Repairs With Combined Procedures Have Lower Failure Rate Than Isolated Repairs in a Military Population: Surgical Outcomes With Minimum 2-Year Follow-up. 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. Radiographic imaging is necessary for all patients with acute or chronic shoulder pain. What this means is that the labrum is torn at the superior (top) of the glenoid. [56], Clinicians should recognize that inferior outcomes have been demonstrated in the literature following revision arthroscopic SLAP repairs and high-level (i.e., professional) overhead athletes. J Orthop Sports Phys Ther, 2009; 39(2):71-80, PEAT M., Functional anatomy of the schoulder complex. Multiple exam maneuvers point to either labral involvement via impingement or compression mechanisms. The adjusted annual incidence rate for SLAP lesions increased from 0.31 cases per 1000 person-years in 2002 to 1.88 cases per 1000 person-years in 2009, with an average annual increase of just over 20% during the study period. Injuries to the labrum in this region can result in labral symptoms, biceps symptoms or both. et al., A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. Scapulothoracic dyskinesia may result from any degree of imbalance of the shoulder girdle muscles and static/dynamic glenohumeral joint stabilizers. Superior labrum anterior to posterior lesions and the superior labrum. 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. Describe treatment considerations for patients with superior labral anterior to posterior (SLAP) lesions. In 2005, an MRI analysis of professional handball players demonstrated abnormalities in 93% of shoulders, with only 37% being symptomatic.[48]. In the age category 30 to 50, there are more chances of tears/defects in the superior and anterior-superior regions of the labrum (noted in cadavers). Alternatively, the biceps anchor may be sacrificed, and a biceps tenotomy or tenodesis performed. It is important to discuss the patients’ activities such as athletics, profession, and baseline activity level. Gorantla K, Gill C, Wright RW. http://creativecommons.org/licenses/by-nc-nd/4.0/ Patel KV, Bravman J, Vidal A, Chrisman A, McCarty E. Biceps Tenotomy Versus Tenodesis. Ideal graphic animation, using Antero-Sup portal avoiding rotator cuff portal. It is associated with pain and instability and an inability of the patient to perform overhead movements. By six to nine months, a gradual return to sport is undertaken dependent upon the painless progression of activity and clinical exam. It contains the coracohumeral and the superior glenohumeral ligament, the biceps tendon and the anterior joint capsule. [39]. Katz LM, Hsu S, Miller SL, Richmond JC, Khetia E, Kohli N, Curtis AS. Explain how to diagnose a superior labral anterior to posterior (SLAP) lesion. An anatomical study of 100 shoulders. In fact, superior outcomes have been reported in this particular subset of athletic patients following non-surgical management alone. Mathew CJ, Lintner DM. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. A positive test is a pain or a painful pop over the anterior shoulder near the bicipital groove region. [8], Throwers can have repetitive microtraumata. Their findings show no difference between the two age groups. A total of four types of superior labral lesions involving the biceps anchor have been identified. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. It is essential to understand that not all SLAP tears are created equal. 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. et al., Rehabilitation Exercises for Athletes With Biceps Disorders and SLAP Lesions: A Continuum of Exercises With Increasing Loads on the Biceps. 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. Interestingly enough, the anterior aspect of the superior labrum and the labral region anterior to the LHBT origin have the highest density of these fibers.[32]. The aim of this paper is to provide a brief description of the different surgical techniques employed to address Type II SLAP lesions (arthroscopic repair, biceps tenodesis, and biceps tenotomy) and provide a review of available literature regarding outcomes and prognostic factors associated with each technique. 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. The labral insertion of LHBT is left unaffected. Fedoriw WW, Ramkumar P, McCulloch PC, Lintner DM. Compression-type injuries 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. Healing time constraints are critical. [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]. Weber et al. The cocking phase of throwing can place direct posterosuperior impingement on the superior labrum. Additionally, specific biceps testing can be used; however, they are not reliable for SLAP tears as they can be positive with other pathologies. Clinicians should inquire regarding certain history elements that may help differentiate SLAP tears from other shoulder injuries. NSAIDs and cryotherapy device/ice pack application can be beneficial for pain control. BackgroundPrevious studies have demonstrated increased glenohumeral translations with simulated type II superior labral anterior posterior lesions, which may explain the sensation of instability in. [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. It can also be caused by repetitive motions. 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. Kampa RJ, Clasper J. 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. Type VII: a superior labrum and biceps tendon separation that extends anteriorly, inferior to the middle glenohumeral ligament. Outcome of the isolated SLAP lesions and analysis of the results according to the injury mechanisms. Superior labral anterior posterior (SLAP) lesions of the glenoid have proven difficult to diagnose clinically. SLAP Lesions: Trends in Treatment. ( [15][16], Nonoperative management has efficacy for many symptomatic SLAP tears and should be considered for initial treatment. Unstable SLAP lesions are typically repaired with anchor fixation, and the extent of the injury typically determines the pattern of repair. Also, shoulder girdle proprioceptive training is beneficial to help prevent re-injury. The true AP image is taken with the patient rotated between 30 and 45 degrees offset the cassette in the coronal plane. Additional subtypes for type II tears, as well as additional tear patterns, were described in subsequent years. The upper, or superior, part of your labrum attaches to your biceps tendon. Traumatic injuries commonly occur following acute, index events based on one of the following mechanisms:[2], Compared to the acute, traumatic SLAP injuries, the overhead athlete is more likely to present with attritional-based etiologies. Re. The long head of the biceps tendon attaches in the glenoid as part of the labrum at roughly 12:00. 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. Comprehensive Review of Provocative and Instability Physical Examination Tests of the Shoulder. Gradually, active strengthening and improvement of neuromuscular control are undertaken from two to four weeks. [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. 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. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Shoulder pain is the third most common musculoskeletal complaint seen in outpatient clinics. SLAP tear patients typically admit to resolution or reduction of symptoms at rest. SLAP lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization. IF > 50% of the biceps tendon is affected, perform tenotomy/tenodesis, Surgical treatment: Bankart repair plus SLAP repair, Surgical treatment: Suture/anchor fixation of anterosuperior labrum plus SLAP repair, Surgical treatment: SLAP repair versus biceps tenotomy/tenodesis; gentle debridement of any cartilage/chondral unstable flap, Internal (including SLAP lesions, GIRD, little league shoulder, posterior labral tears), Partial- versus full-thickness tears (PTTs versus FTTs), Subluxation–often seen in association with SubSc injuries, Unidirectional instability–seen in association with an inciting event/dislocation (anterior, posterior, inferior), Suprascapular neuropathy–can be associated with a paralabral cyst at the spinoglenoid notch, Muscle ruptures (pectoralis major, deltoid, latissimus dorsi), Fracture (acute injury or pain resulting from long-standing deformity, malunion, or nonunion). Initial physical examination includes visual inspection for gross asymmetry and muscle atrophy. A 2017 level III case-control study highlighted the potential risk factors for revision surgery following SLAP repair, with the inclusion of nearly 5000 patients in the database query[58]. Examiners should observe and compare bilateral shoulder girdles for any notable asymmetry, scapular posturing, muscle bulk comparison, or any atrophic changes. At first the clinician can test the tenderness to palpation at the rotator interval which can be helpful in the diagnostic procedure. Some tests isolate the tension placed on the superior labrum by the biceps via provocative maneuvers in active and passive forms. [25], Another potential nidus predisposing certain patients to SLAP tears is the presence of a sublabral recess (or sublabral sulcus). [5]In one study, half of the cases that had a SLAP lesion were 40 years old patients who showed signs and symptoms of instability after a history of acute trauma, repetitive injury, fall on an outstretched arm, or an injury from heavy lifting. [1], In various patient populations, internal impingement is also a culprit of SLAP tears. Co-existing cervical radiculopathy should be ruled out in any situation where a neck and/or shoulder pathology is a consideration. The recess/sulcus can be present during fetal development as early as 22 weeks of pregnancy, persisting throughout childhood and into adulthood. The examiner applies a perpendicular external rotational force to try and lift the patient’s handoff of the shoulder. Consultations should include primary care sports medicine specialists experienced in managing SLAP tears nonoperatively. Trends in the diagnosis of SLAP lesions in the US military. Brockmeyer M, Tompkins M, Kohn DM, Lorbach O. Find top doctors who treat Labral tears near you in Liverpool, NY. Assisted and passive techniques are used at 4 weeks post-operative to increase shoulder mobility. 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. As function is restored without pain, a gradual return to sport is recommended on a case-by-case basis, dependent upon clinical exam. ), which permits others to distribute the work, provided that the article is not altered or used commercially. Clinical testing for tears of the glenoid labrum. For the treatment of SLAP lesion one uses often a medical treatment where the surgeon uses advanced arthroscopic techniques. et al., Schoulder injuries in the overhead athlete. [26], In contrast, a sublabral hole or sublabral foramen is typically located at the 12 to 2 o’clock position. Initial reported performance of these tests has not been reproduced by independent investigat … 2009 Oct-Dec; 43(4): 342–346, WILK K.E. Identify the etiology of superior labrum lesions (SLAP tears) medical conditions and emergencies. This increase constituted a jump in case volume reporting from 765 to 4313 annual SLAP repairs. The available evidence of level I and II studies in the recent literature suggests that a combination of specific tests such as the Speed’s and uppercut test is recommended for the clinical detection of biceps tendon lesions. Horizontal mattress with a knotless anchor to better recreate the normal superior labrum anatomy. As a surgical treatment for SLAP lesions, SLAP repair has been traditionally performed. 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. That is usually the journal article where the information was first stated. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. A 2012 study evaluating trends in SLAP repair found SLAP tears were more common in men (greater than 3:1) compared to women. There is an increasing body of literature evidence now recognizing that appropriate patient selection is critical. In addition, understanding how to treat a SLAP tear in the setting of other concomitant injuries is imperative. A sublabral recess or foramen can be misread as a labral tear. [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. [Updated 2022 Jul 6]. This 2 minute video shows SLAP Repair Arthroscopic Double loaded anchor Y config. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. There is no gold standard physical exam test that specifically identifies SLAP tears. Special tests that are helpful in this regard include the Spurling maneuver, myelopathic testing, reflex testing, and a comprehensive neurovascular exam. Less common than SLAP Lesions. 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. SLAP tears involve the superior glenoid labrum, where the long head of bicepstendon inserts. The identification of these normal variants can help to prevent the misdiagnosis of labral lesions. The arm is released from traction and brought into an abducted/externally rotated position. 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. Smith R, Lombardo DJ, Petersen-Fitts GR, Frank C, Tenbrunsel T, Curtis G, Whaley J, Sabesan VJ. 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. 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. Para ayudar a estabilizar el hombro, hay un anillo de tejido firme, llamado labrum, alrededor de la cavidad del hombro. A SLAP tear stands for Superior Labrum, Anterior to Posterior. 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. Park JH, Lee YS, Wang JH, Noh HK, Kim JG. Burkhart previously described demonstrating a ‘‘peel-back’’ sign during arthroscopy. Neri BR, ElAttrache NS, Owsley KC, Mohr K, Yocum LA. Long-term results after SLAP repair: a 5-year follow-up study of 107 patients with comparison of patients aged over and under 40 years. After exhausting non-operative treatment modalities, operative management is considered in tandem while keeping in mind each patient’s age, concomitant pathologies, functional requirements, occupational demands, and sport-specific goals. The results of biceps reinsertion are disappointing compared with biceps tenodesis. Kuhn JE, Lindholm SR, Huston LJ, Soslowsky LJ, Blasier RB. [26]Because of unsatisfactory results in older patients, Boileau et al., suggested arthroscopic biceps tenodesis in these patients. 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. Tears of the glenoid labrum 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. et al., Anatomy of the Shoulder Joint. The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs. 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. The pathophysiology, diagnosis, and nonsurgical management of SLAP tears are reviewed . 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. [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. Posterosuperior Labral Tears. El labrum glenoideo, recordemos, es un anillo de fibrocartílago que aumenta el diámetro efectivo de la glenoides respecto a la cabeza humeral. Avoid extremes of abduction and external rotation. A paralabral cyst found on MRI is a diagnostic clue for a SLAP tear. Subsequently, Snyder et al defined the pattern of superior labral injury in 27 patients who were described as having superior labrum anterior posterior (SLAP) lesions. Focus on stretching the posterior capsule is also a focus of rehabilitation. At four weeks, progressive range of motion exercises are continued; however, active external rotation and abduction are still avoided. The patient reported 75% . [11], When we consider some tests individually, one can consider the Speed’s test and O’Brien’s test helpful in the diagnosis of anterior lesions and the Jobes Relocation Test is often positive in a posterior lesion[6][23] According to Meserve et al, the O’Brien test is the most sensitive test (47%-78%) and the Speed’s test the most specific (67%-99%). [24]  These four types were described based on macroscopic observation of 105 cadaveric shoulder specimens: Tuoheti et al. Ilahi OA, Labbe MR, Cosculluela P. Variants of the anterosuperior glenoid labrum and associated pathology. first described the classification of SLAP tears in 1990. Orthop Traumatol Surg Res., 2015;101(1):19-24, STETSON, W. (2010). The authors noted that in cases of a positive peel-back sign (i.e., not present in normal shoulders during an arthroscopic examination), the biceps anchor assumes a more vertical and posterior angle that is dynamically visible. Superior Labral Anterior-Posterior (SLAP) Tears in the Military. Chang D, Mohana-Borges A, Borso M, Chung CB. As mentioned, this concept can also be applied to the young, athletic population as well. SLAP tears are typically defined as superior labrum fraying/tearing from the glenoid. You may get a SLAP tear if you: Aflatooni JO, Meeks BD, Froehle AW, Bonner KF. Describe treatment considerations for patients with superior labral anterior to posterior (SLAP) lesions. This means your labrum is. Describe interprofessional team strategies for improving care coordination and communication to advance the treatment of superior labrum lesions (SLAP tears) and improve outcomes. Vangsness CT, Jorgenson SS, Watson T, Johnson DL. [28] It is generally recognized that the majority of patients with symptomatic SLAP lesions will fail conservative management, particularly throwers. They found that tenodesis is superior to the repair of type II SLAP tears in older population. 163 likes. II. Secondary to fraying related to Internal Shoulder Impingement. The Journal Of Orthopaedic And Sports Physical Therapy, 1985;6(4):225-228, KOZIAK A. et al, Magnetic resonance arthrography assessment of the superior labrum using the BLC system: age-related changes mimicking SLAP-2 lesions. J. Over the last two decades, our knowledge and appreciation of SLAP tear recognition, diagnosis, treatment, and potential surgical management has evolved dramatically. Etiology Tenodesis can be performed by subpectoral, all-arthroscopic, and mini-open techniques. Initial evaluation of the shoulder typically starts with x-rays to rule out osseous pathology. et al., Shoulder rotator strength and torque steadiness in athletes with anterior shoulder instability or SLAP lesion. [16] For those with atrophy, weakness, or continued pain, surgical decompression is indicated. MRI and MR arthrography (MRA) are commonly used imaging modalities to detect a SLAP lesion. The recognition and treatment of superior labral (slap) lesions in the overhead athlete. 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. In the absence of compressive symptoms, a range of non-operative treatments can be considered, including observation, anti-inflammatories, or percutaneous aspiration. The above classification system has been expanded to include an additional three types:[2], The major joint of the Glenohumeral Joint, which is also called the ‘ball in a socket’ joint because of the humeral head (ball) that articulates with the glenoid cavity (glenoid fossa of scapula or socket). Strengthening exercises can be initiated at six weeks postoperatively.[33]. Indeed, Snyder et al found partial-thickness or full-thickness rotator cuff disease in 55 (40%) of 140 patients with SLAP lesions. Hippensteel KJ, Brophy R, Smith MV, Wright RW. In this study (also studying over 100 shoulder cadaver specimens), the attachment sites clarified the findings from the previous study: The latter study is the contemporary consensus agreement regarding the LHBT attachment patterns. [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. Moreover, the macroscopic attachment types correlated to the specimen histologic sectioning observed in the sagittal section. Superior Labrum Anterior to Posterior Tear (SLAP Lesions) Associated with Biceps Tenosynovitis. [11], Despite the aforementioned limitations, the contemporary consensus regarding SLAP tears is that they account for 80% to 90% of labral pathology in the stable shoulder, although they are typically seen in association with other shoulder pathologies and rarely present in isolation. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Also suprascapular neuropathy secondary to cyst compression in the spinoglenoid notch may occur in association with SLAP tears. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. [8], A 2015 study investigated the adjusted incidence rates of SLAP tears as reported in the Defense Medical Epidemiological Database between 2002 and 2009. 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. So there are conflicting views in the literature about the repairs in the older patients.[27]. Strength, stability and motion are the components of shoulder function that should be focused on during rehabilitation. As demonstrated above, a dedicated focus on rehabilitation in nonoperative and postoperative patients is vital. The age of the patient has an impact on the superior labrum. Important variations in the normal anatomy of the labrum have been identified. [43] Outline the appropriate evaluation of superior labrum lesions (SLAP tears). Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. Superior Labrum Anterior Posterior Lesions. As several types of SLAP tears can also be associated with instability, the general stability of the shoulder should be evaluated. [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. Isolated type II superior labral anterior posterior lesions: age-related outcome of arthroscopic fixation. Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography. [2][28]This way, physical treatment can be started sooner. Superior Scapes | Liverpool NY SLAP - Superior Labrum Anterior to Posterior InjuryReparación Quirúrgica, por medio de Artroscopía de la Lesión de SLAP, que consiste en una lesión del Rodet. Degenerative SLAP tears often affect overhead laborers with increasing degrees of association in patients over 40 years old[8], It is important to appreciate the limitations in our ability to accurately report the definitive epidemiological trends as the contemporary recognition and diagnosis of SLAP injuries remains debated. Surgical treatment of isolated type II superior labrum anterior-posterior (SLAP) lesions: repair versus biceps tenodesis. Also, posterior shoulder joint capsular contractures should be addressed with various stretching and strengthening programs. A detailed sensory examination should take place in all acute and chronic instability patients. Physical examination is not easy because of the fact that SLAP lesions are often associated with other shoulder pathologies. In the appropriate patient, NSAIDs and cryotherapy device/ice pack application can be beneficial for pain control. External rotation must absolutely be avoided and abduction limited to 60°. Depending on location, it can lead to combined supraspinatus and infraspinatus weakness (suprascapular notch) or isolated infraspinatus atrophy (spinoglenoid notch).[15][16]. In SLAP repairs with unstable patterns, a more gradual approach is taken. A positive test is denoted by pain located at the joint line during the initial maneuver (thumb down/internal rotation) in conjunction with reported improvement or elimination of the pain during the subsequent maneuver (palm up/external rotation). initially described four types of attachment patterns of the long head of the biceps tendon (LHBT) to the superior glenoid rim and the superior labrum. Rossy W, Sanchez G, Sanchez A, Provencher MT. It can happen because of a road accident or a fall onto an outstretched arm. The findings can be rather subtle, especially in obese patients. Resistance exercises can be initiated at approximately 8 weeks post-operative, in which scapular strengthening should be emphasized. There is a wide variety of pathology, and patient-specific characteristics and goals heavily influence treatment options. Popp D, Schöffl V. Superior labral anterior posterior lesions of the shoulder: Current diagnostic and therapeutic standards. Given the clinical complexity of SLAP injuries and concomitant shoulder pathologies, early consultation with an orthopedic surgeon is encouraged. Original Editor - Kristin Sartore, Venugopal Pawar, Top Contributors - Venugopal Pawar, Lucinda hampton, Fasuba Ayobami, Kim Jackson, Rachael Lowe, Claire Knott, Amrita Patro, Wanda van Niekerk, Vasileios Tyros, Admin and WikiSysop. SLAP lesions: a treatment algorithm. First described in the 1980s, extensive study has followed to elucidate appropriate evaluation and management. Unlike Bankart lesions and ALPSA lesions, they are not usually (20%) associated with shoulder instability.[1]. 27, issue 4, p. 556-567, BOILEAU P. et al., Arthroscopic treatment of Isolated Type II SLAP lesions. Ther., 2013; 8(5): 579-600, HURI G. et al, Treatment of superior labrum anterior posterior lesions: a literature review. Gentle passive and limited active range of motion exercises is recommended for the first four weeks. At month 4 to 6, dependent on the type of sport practiced, patients should be able to start sport-specific training and gradually return to their former level of activity.[2]. The arm is stabilized against the patient’s trunk, and the elbow flexed to 90 degrees with the forearm pronated. Phys Ther Sport., 2010;110-121, KNESEK M. et al., Diagnosis and management of superior labral anterior posterior tears in throwing athlets. Int. Patients with SLAP lesions complain of. Miniaci A, Mascia AT, Salonen DC, Becker EJ. [3]But the humeral head is larger than the fossa and so the socket covers only a quarter of the humeral head. [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. Search doctors, conditions, or procedures . - Clinical Presentation and Follow-up of Isolated SLAP Lesions of the Shoulder (SS-04) - Classification and Treatment: - labrum is assessed, including stability of the biceps labral attachment, as well as biceps tendon; - SLAP tears will show more than 5 mm of exposed superior glenoid bone and often a peel back sign; - peel back sign: 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"). This maneuver is repeated with the patient’s arm now rotated, so the palm faces the ceiling. The most common complaint in patients that present with SLAP lesions is pain. Sports. SLAP lesions are often seen in combination with other shoulder problems and this makes it difficult to diagnose. Treatment failure and complications are dependent upon intervention, patient adherence to rehabilitation protocols, and patient-specific factors. Typically, SLAP lesions are from about 10:00 - 2:00 if you were to visualize a clock face. Type I concerns degenerative fraying with no detachment of the biceps insertion. In the setting of chronic anterior instability, the clinician may appreciate a palpable anterior fullness. et al., A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. Forced shoulder abduction and elbow flexion, Type I – Fraying of the superior labrum with intact biceps anchor, Type II – Fraying of the superior labrum with detached biceps anchor, Type III – Bucket handle tear of the superior labrum with intact biceps anchor, Type IV – Bucket handle tear of the superior labrum with detached biceps anchor (remains attached to the torn labrum), Type VI – Type II + unstable flap either anteriorly or posteriorly, Type VII – Type II + anterior extension inferior to the MGHL, Type VIII – Type II + posterior labrum extension, Type X – Type II + reverse Bankart lesion, Other labral pathology and/or instability. Background:Injuries to the superior glenoid labrum represent a significant cause of shoulder pain among active patients. Am J Sports Med., 2012;40(9):2105-2112, COOLS A .M. advertisement. The arthroscopic criterion for a type II SLAP lesion includes the ability to demonstrate (usually with an arthroscopic probe) the definitive separation of the superior labrum from the supraglenoid cartilage rim. 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. Characteristics of LHBT-associated pathologies have been previously described and may include any combination of the following: Additionally, a thorough history includes a detailed account of the patient’s occupational history and current status of employment, hand dominance, history of injury/trauma to the shoulder(s) and/or neck, and any relevant surgical history. This can help avoid stressing the dynamic and static stabilizers of the shoulder in hopes of limiting stress at the glenoid-labrum interface. Recent studies have reported on the diagnostic accuracy of specific tests concerning diagnosing SLAP tears: O’Brien/Active Compression 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. Surgical treatment: SLAP repair versus resection. 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. Unlike Bankart lesionsand ALPSA lesions, they are uncommonly (20%) associated with shoulder instability 5. J. This activity reviews the evaluation and treatment of SLAP tears and highlights the role of the interprofessional team in managing patients with this condition. Superior labrum anterior posterior lesions.Available: PROVENCHER M.T. [36] Management of paralabral cysts is dependent upon location and concomitant symptomatic nerve compression. An interprofessional team approach involving clinicians (including PAs and NPs), therapists, and orthopedically-trained nurses will provide the best results. [10], For the vast majority of SLAP injuries, the initial management is nonoperative. [23] Vangsness et al. In the acute traumatic setting, a fall onto an extended and abducted arm leads to a compressive and superior directed force from the humeral head into the superior labrum. Phys Ther., 1986;66:1855-1865, CARMICHAEL S.W. Trends in the early 2000s showed an increase in SLAP repairs. A Treatment-Based Algorithm for the Management of Type-II SLAP Tears. Suprascapular nerve compression from a paralabral cyst may occur. [2] This position has also been implicated in a sport-specific traumatic force (hyperabduction or traction) as well as during the cocking phase of throwing. [47] Moreover, it is important to recognize other shoulder pathologies, such as shoulder impingement (external or internal), rotator cuff syndrome, LHBT tendinopathy, and acromioclavicular (AC) arthritis, are all common pain generators in the middle-age population. StatPearls Publishing, Treasure Island (FL). Glenoid neck preparation is with a tissue elevator, rasp, and/or shaver instrument. Falling on an outstretched arm is an acute traumatic superior compression force to the shoulder. [13][14], The glenoid labrum is often involved in shoulder pathology. They may complain of night pain, which is a common complaint with several shoulder pathologies. the author postulates that forces that affect the biceps anchor may also damage the pulley system of the bicipital sheath and, as such, this anatomic structure should be evaluated, especially when SLAP lesions are present. [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. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. [13][14], The highest incidence rates of SLAP lesions present in the 20- to 29-year-old and 40- to 49-year-old age groups. [38] Some SLAP tears present in the degenerative setting with no definitive onset of symptoms or discrete mechanisms. 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. Any evidence of significant muscular weakness may hint at an underlying associated neurologic deficit. Essential to full recovery from a Type II SLAP ( S uperior L abral tear from A nterior to P osterior) Lesion is protection of the repaired labrum. It can be caused by a forceful overhead motion, or when you try to catch something heavy. [21]However in another study by Alpert et al., it is shown that type II SLAP repairs using suture anchors can yield good to excellent results in patients older and younger than age 40. While MRA has a sensitivity and specificity of 82% to 100% and 71% to 98%, respectively, there are normal anatomic variants that can be confused with a SLAP tear. [36] Several authors recommend against repair in these populations.[23][31]. [57] Professional baseball pitchers demonstrate relatively inferior outcomes regarding return to play and return to prior performance level. In throwing athletes, a progressive throwing program that is directed toward the patients' specific sport and position can be initiated after 3 months.[2]. [2][9][6][12], Non-operative management focuses on the initial restriction of provoking maneuvers. Habermeyer P, Magosch P, Pritsch M, Scheibel MT, Lichtenberg S. Anterosuperior impingement of the shoulder as a result of pulley lesions: a prospective arthroscopic study. , which are the serratus anterior, rhomboid major and minor, levator scapulae and trapezius. [13][12]It changes the activation of the scapular stabilising muscles. Patient complaint of pain is not a good gauge for progression. Clinicians should focus on the potential relevance of the SLAP lesion as it attributes to the specific patient’s pain and dysfunction. A standard detailed history is required, as with all patients presenting to the clinic. This rotator interval has a triangular shape in which the supraspinatus is superiorly located, the subscapularis inferiorly and the processus coracoideus medially. Poor outcomes after SLAP repair: descriptive analysis and prognosis. [20], Erickson et al. [4][3]A circumflexial rim of fibrocartilaginous tissue called glenoid labrum firmly attaches to the glenoid fossa thereby increasing the articular surface area and the stabilisation of the glenohumeral joint. 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. Understanding the rigorous rehabilitation required from advanced procedures helps the patient understand what is expected on their road to recovery. Am J Sports Med., 2010;38:2299–2303, EDWARDS S.L. lesión SLAP (Superior Labrum Anterior to Posterior) es una lesión de la parte superior del labrum glenoideo del hombro, generalmente centrada en la inserción del tendón de la cabeza larga del músculo bíceps braquial, aunque puede extenderse e involucrar al labrum anterior y posterior, así como estructuras circundantes. SLAP Lesions: Trends in Treatment. 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. Oper Tech Sports Med, 2012;20 (1):46 – 56, MYERS J.B. et al., Sensorimotor deficits contributing to glenohumeral instability. It deepens the cavity by approximately 50%. [1] In 1985, Andrews first described superior labral pathologies, and Snyder later coined the term “SLAP lesion” because of the location and characteristic tear extension patterns. Burkhart SS, Morgan CD. Patterson BM, Creighton RA, Spang JT, Roberson JR, Kamath GV. Andrews JR, Carson WG, McLeod WD. Tenodesis patients are protected for four weeks, and avoidance of supination and flexion of the elbow is recommended. Ultimately, nonoperative and operative management yields successful results for many patients; however, treatment success is highly dependent upon the patient's functional level and treatment goals. [24] As patients age, typically beyond 40 years of age, repair becomes consistently inferior to tenodesis or tenotomy. SLAP (superior labrum anterior and posterior) tears are injuries to the uppermost part of the labrum, where the biceps tendon attaches to the shoulder. Skeletal Radiology, 2014;43: 1065 – 1070, POWELL S.E. As knowledge has evolved through time, with improvements in magnetic resonance imaging (MRI) quality, SLAP tears subsequently became a more frequent diagnosis. The specific etiology underlying the various SLAP tear presentations is multifactorial and remains a topic of debate and controversy. It also becomes more brittle with age, and can fray and tear as part of the aging process. Detailed and focused attention should be given to appropriately delineating the extent of all potential underlying shoulder girdle pathologies. A stabilizing role of the glenoid labrum: the suction cup effect J Shoulder Elbow Surg. Isolated tenotomy patients typically can resume activity within a week. 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. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. To diagnose this condition it is important to use several different tests and not only one. [Level 2-3]. The determination of appropriate anchor placement depends on the predominant region of instability regarding the superior labral-biceps tendon complex. Superior migration of the humeral head can result from a rotator cuff that is not effectively performing its role as a humeral head depressor. SLAP tear type is determined by the anatomical location of the tear as well as the severity of its extension. In the ensuing decades, other groups, including Morgan et al. The origin of the long head of the biceps from the scapula and glenoid labrum. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. [22] Tenotomy can lead to a cosmetic deformity with retraction of the biceps muscle. A shoulder SLAP tear is when the labrum frays or tears because of an injury. [2]In the first step of conservative management, patients should abstain from aggravating activities in order to provide relief to the pain and inflammation. Schultz KA, Nelson R. Superior Labrum Lesions. What causes it? The rotator interval is an anatomic space between the Supraspinatus tendon, the Subscapularis tendon and the processus coracoideus. 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. A multifaceted approach to treatment is required for successful outcomes. Hansen CH, Asturias AM, Pennock AT, Edmonds EW. [46]. 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. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) “Type II plus anterior shoulder instability.”. Previous authors have advocated for the use of simple versus mattress sutures and the option for knotless fixation devices to minimize the risk of having a bulky knot create symptoms postoperatively.[51][52]. Type III represents a bucket-handle tear of the labrum with an intact biceps tendon insertion to the bone. There are numerous physical examination procedures described to detect the SLAP lesion: A combination of 2 sensitive tests and 1 specific test is more efficient to diagnose a SLAP lesion [reference needed]. Varacallo M, Tapscott DC, Mair SD. A subsequent study found that the most common mechanism of injury was a fall or direct blow to the shoulder, occurring in 31% of patients. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Erickson BJ, Jain A, Abrams GD, Nicholson GP, Cole BJ, Romeo AA, Verma NN. StatPearls Publishing, Treasure Island (FL). Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. [11], It is important to keep in mind that the scapula is an important factor during shoulder movements. Previous studies have demonstrated non-operative management successful for 22 to 85% of patients. Athletes and overhead laborers should also be placed on restricted sport-specific timeline protocol, and manual laborers should receive appropriate occupational modifications. Multiple reports on high-level (i.e., professional) overhead throwers have demonstrated equivalent outcomes regarding return to play and return to play performance in athletes managed with operative versus nonoperative modalities alone. In most cases Physiopedia articles are a secondary source and so should not be used as references. Additionally, classification and severity of the SLAP tear, in combination with concomitant pathology, affects the type of operative management selected. Superior labral anterior to posterior (SLAP) lesions constitute a recognized clinical subset of complex shoulder pain pathologies. Approximately 40% of the long head of biceps tendon (LHBT) attaches to the labrum. 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. [9][10][11][12] While the O’Brien test (active compression) originally reported 100% sensitive and 99% specific results, several studies have stated lower rates. The examiner then applies a downward resistive force just distal to the elbow while asking the patient to perform a throwing motion. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. 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. Johannsen AM, Costouros JG. SLAP lesions demonstrate a predilection for young laborers, overhead athletes, and middle-aged manual laborers. [2]Regaining GIRD is a crucial aspect in the rehabilitation of SLAP lesions. Failure of the biceps superior labral complex: a cadaveric biomechanical investigation comparing the late cocking and early deceleration positions of throwing. Finally, SLAP tears can occur in a degenerative setting for the aging population. 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