Given the clinical complexity of SLAP injuries and concomitant shoulder pathologies, early consultation with an orthopedic surgeon is encouraged. Increasing age, activity level, obesity, female sex, smoking, and concomitant shoulder pathology are risk factors for failure. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. Part II candidates. [15], SLAP tear itself accounts for 80–90% of labral pathology in stable shoulder but it’s only found in 6% on arthroscopy. A positive test is noted if the patient reports pain over the bicipital groove and/or subluxation of the LHB tendon. A paralabral cyst found on MRI is a diagnostic clue for a SLAP tear. An Age and Activity Algorithm for Treatment of Type II SLAP Tears. American journal of sports medicine,2009;37:2252-2258. SLAP lesions demonstrate a predilection for young laborers, overhead athletes, and middle-aged manual laborers. Stress distribution in the superior labrum during throwing motion. Type I concerns degenerative fraying with no detachment of the biceps insertion. Superior migration of the humeral head can result from a rotator cuff that is not effectively performing its role as a humeral head depressor. 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]. Sports Med, 2013;41:444-460, NURI A. et al., Superior labrum anterior to posterior lesionsof the shoulder: Diagnosis ans arthoscopic management. Schrøder CP, Skare O, Gjengedal E, Uppheim G, Reikerås O, Brox JI. Retrieved from, WILLIAM F.B., Correlation of the SLAP lesion with lesions of the medial sheath of the biceps tendon and intra-articular subscapularis tendon .Indian J Orthop. et al., A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. [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. 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]. [16] For those with atrophy, weakness, or continued pain, surgical decompression is indicated. To reduce the risk of injury, especially in overhead athletes, there should be a focus on flexibility, periscapular, and shoulder girdle strengthening as well as proper mechanics. 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 involved shoulder is positioned at neutral, the elbow is flexed to 90 degrees, the forearm is supinated, and the patient makes a fist. This can help avoid stressing the dynamic and static stabilizers of the shoulder in hopes of limiting stress at the glenoid-labrum interface. Para ayudar a estabilizar el hombro, hay un anillo de tejido firme, llamado labrum, alrededor de la cavidad del hombro. [29] Previous reports have emphasized the LHBT as a potentially dominant source of anterior shoulder pain at clinical presentation. In the acute setting, traumatic injury can occur in traction/torsion and compressive/subluxation mechanisms. Trends in the diagnosis of SLAP lesions in the US military. Ideal graphic animation, using Antero-Sup portal avoiding rotator cuff portal. The highest incidences of SLAP repairs were found in the 20 to 29 and 40 to 49 decades at 29.1 and 27.8 per 10,000 patients, respectively. 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. Johannsen AM, Costouros JG. The palm is facing upward. Results are widely varied in these athletes, demonstrating the return to the prior level of sport between 7% and 84%. Erickson BJ, Jain A, Abrams GD, Nicholson GP, Cole BJ, Romeo AA, Verma NN. Ebinger N, Magosch P, Lichtenberg S, Habermeyer P. A new SLAP test: the supine flexion resistance test. The arm is released from traction and brought into an abducted/externally rotated position. Type VI: an unstable flap tear of the labrum in conjunction with a biceps tendon separation. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) [3]But the humeral head is larger than the fossa and so the socket covers only a quarter of the humeral head. A stabilizing role of the glenoid labrum: the suction cup effect J Shoulder Elbow Surg. Initially rest post the acute (or acute-on-chronic) injury should be implemented. There are several proposed mechanisms for the cause of SLAP tears. The true AP image is taken with the patient rotated between 30 and 45 degrees offset the cassette in the coronal plane. Focus on stretching the posterior capsule is also a focus of rehabilitation. Zhang AL, Kreulen C, Ngo SS, Hame SL, Wang JC, Gamradt SC. The rotator interval is an anatomic space between the Supraspinatus tendon, the Subscapularis tendon and the processus coracoideus. World J. A positive test is a pain or a painful pop over the anterior shoulder near the bicipital groove region. The palm is on the anterior aspect of the contralateral shoulder, with the elbow flexed to 90 degrees. However, the achievement of adequate shoulder mobility is an important condition to begin resistance training. The patient reported 75% . et al., Shoulder rotator strength and torque steadiness in athletes with anterior shoulder instability or SLAP lesion. Summarize interprofessional team strategies for improving care coordination and communication to enhance outcomes for patients affected by superior labral anterior to posterior (SLAP) lesions. Type III represents a bucket-handle tear of the labrum with an intact biceps tendon insertion to the bone. Also, posterior shoulder joint capsular contractures should be addressed with various stretching and strengthening programs. Until now only one study looked at results from physical management on SLAP lesion. Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. 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. 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. Co-existing cervical radiculopathy should be ruled out in any situation where a neck and/or shoulder pathology is a consideration. Active strengthening of the biceps is still avoided. Pertinent elements in history taking to best elucidate the nature of a potential SLAP tear (or other associated shoulder injuries) include:[33][34][35]. [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. [2]Generally, pendulumand elbow range-of-motion exercises are allowed during the period of immobilization. Charles MD, Christian DR, Cole BJ. [11][13][24], There is a lot of discussion about which test is most accurate, but most experts consider that arthroscopy is the best way to diagnose SLAP lesion. [7] Internal impingement can also result from rotator cuff tears via chronic posterosuperior or anterosuperior migration/subluxation of the humeral head.[8]. [28] It is generally recognized that the majority of patients with symptomatic SLAP lesions will fail conservative management, particularly throwers. It can also be caused by repetitive motions. A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. reported surprising trends after mining the American Board of Orthopaedic Surgery (ABOS) Part II database. 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. They found that tenodesis is superior to the repair of type II SLAP tears in older population. 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. In these situations, evaluating the patient’s history of repetitive overhead activity or general functional history will help isolate suspicion towards the superior labrum. 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. Gradually, active strengthening and improvement of neuromuscular control are undertaken from two to four weeks. Suprascapular nerve compression from a paralabral cyst may occur. Neri BR, Vollmer EA, Kvitne RS. J Shoulder Elbow Surg., 2012;21(1):13 – 22, MESERVE B.B. The recess/sulcus can be present during fetal development as early as 22 weeks of pregnancy, persisting throughout childhood and into adulthood. 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]. [18][23], Operative intervention in adults has been reported to be successful between 80 and 97% of patients in several populations. [28][30]can be prevented. Trends in the early 2000s showed an increase in SLAP repairs. Return to play after Type II superior labral anterior-posterior lesion repairs in athletes: a systematic review. [2]In the first step of conservative management, patients should abstain from aggravating activities in order to provide relief to the pain and inflammation. Describe treatment considerations for patients with superior labral anterior to posterior (SLAP) lesions. In addition, several special tests can be used to help identify the presence of a SLAP lesion including the Clunk test, the crank test, O’ Briens, Anterior Slide test, Biceps Load I and II test, and the Active Compression test. Falling on an outstretched arm is an acute traumatic superior compression force to the shoulder. Arthroscopic all-intra-articular decompression and labral repair of paralabral cyst in the shoulder. Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes. SLAP lesions represent a specific pattern of injury that involves the partial or complete detachment of the superior labrum and/or the biceps tendon. Am. [26], In contrast, a sublabral hole or sublabral foramen is typically located at the 12 to 2 o’clock position. [16][17] Many Major League Baseball (MLB) team physicians now recognize these asymptomatic “tears” as adaptive changes in high-level, experienced overhead throwers and MLB pitchers, analogous to meniscal cleavage planes.[18]. Insertion to the superior glenoid remains intact. SLAP tear patients typically admit to resolution or reduction of symptoms at rest. 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. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Part II candidates. [7], Degenerative SLAP tears can develop secondary to the normal “wear-and-tear” patterns seen in patients with advanced age. Alpantaki K, McLaughlin D, Karagogeos D, Hadjipavlou A, Kontakis G. Sympathetic and sensory neural elements in the tendon of the long head of the biceps. Multiple exam maneuvers point to either labral involvement via impingement or compression mechanisms. [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. [2][28]This way, physical treatment can be started sooner. The patient places their hand on the contralateral (normal) shoulder in a “self-hug” position. [4] Other studies have shown rates between 6% and 26% at the time of arthroscopy. Any evidence of significant muscular weakness may hint at an underlying associated neurologic deficit. [15][16], Nonoperative management has efficacy for many symptomatic SLAP tears and should be considered for initial treatment. A structured advancement of strengthening sports specific rehabilitation and dynamic exercises are continued for several months. [2][9][6][12], Non-operative management focuses on the initial restriction of provoking maneuvers. Varacallo M, Tapscott DC, Mair SD. Access free multiple choice questions on this topic. Understanding the rigorous rehabilitation required from advanced procedures helps the patient understand what is expected on their road to recovery. Outline the appropriate evaluation of superior labrum lesions (SLAP tears). 27, issue 4, p. 556-567, BOILEAU P. et al., Arthroscopic treatment of Isolated Type II SLAP lesions. [46]. SLAP tears may present in a relatively nonspecific fashion and association with other shoulder pathologies. Additionally, specific biceps testing can be used; however, they are not reliable for SLAP tears as they can be positive with other pathologies. [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. Several authors have proposed surgical treatment algorithms depending on the specific type of SLAP lesion identified on advanced imaging, clinical exam, and intraoperative arthroscopy. 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. Katz LM, Hsu S, Miller SL, Richmond JC, Khetia E, Kohli N, Curtis AS. Clinicians should focus on the potential relevance of the SLAP lesion as it attributes to the specific patient’s pain and dysfunction. Un desgarro del labrum superior del hombro (SLAP, por sus siglas en inglés) es un tipo específico de lesión en el hombro. 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. Moreover, patients will often present with an MRI final report stating a SLAP tear was present on imaging. There are several different patterns of SLAP tears with varying degrees of instability and magnitude of labral damage. Furthermore, biceps tenodesis may provide a viable alternative for the salvage of a failed SLAP repair. Typically, an MR arthrogram (MRA) is performed to evaluate the shoulder labrum. Waterman BR, Cameron KL, Hsiao M, Langston JR, Clark NJ, Owens BD. Yeh ML, Lintner D, Luo ZP. [31], When conservative treatment fails, a surgical approach is in order. 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. Am J Sports Med., 2010;38:1456–1461, SACCOL M.F. Unlike Bankart lesions and ALPSA lesions, they are not usually (20%) associated with shoulder instability.[1]. 2022 Dec . [2]By the use of posterior capsule stretching exercises, such as sleeper stretch and cross body adduction stretches, and exercises for scapula stabilisation, redevelopment of the internal rotation can be accomplished. Since the metabolism of cartilage depends partly on its mechanical environment, resistance training can contribute to gaining mobility. Most of them had a type II SLAP lesion. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). J Orthop Sports Phys Ther, 2009; 39(2):71-80, PEAT M., Functional anatomy of the schoulder complex. Access free multiple choice questions on this topic. Burkhart SS, Morgan CD. [24] As patients age, typically beyond 40 years of age, repair becomes consistently inferior to tenodesis or tenotomy. [38] 2009 Oct-Dec; 43(4): 342–346, WILK K.E. et al., Non operative treatment of superior labrum anterior posterior tears - improvements in pain function and quality of life. The pathophysiology, diagnosis, and nonsurgical management of SLAP tears are reviewed . Glenoid labrum tears related to the long head of the biceps. This maneuver is repeated with the patient’s arm now rotated, so the palm faces the ceiling. Radiopedia Superior labral anterior posterior tear Available: CHRISTOPHER C. et al., SLAP Lesions: An Update on Recognition and Treatment. SLAP tears involve the superior glenoid labrum, where the long head of biceps tendon inserts. Determining the onset of symptoms and mechanism (trauma, dislocation, or exacerbating maneuvers with overhead activity) can clue an examiner into labral pathology. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Ther., 2013;8(5):617-629, CLAVERT P., Glenoid labrum pathology. The ABOS database houses the collection of International Classification of Diseases, Tenth Revision (ICD-10), and CPT coding across eligible ABOS Part II candidates during their respective board collection periods. ), which permits others to distribute the work, provided that the article is not altered or used commercially. [25][32] Additionally, infection, failure of repair, residual pain, neurovascular injury, and recurrent instability may occur. 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. More research is necessary regarding the histologic characterization of the superior labrum-LHBT complex. ), which permits others to distribute the work, provided that the article is not altered or used commercially. By weeks five to six, strengthening exercises are started, and active external rotation and abduction motions are allowed. Etiology Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum, and can often be confused with a sublabral sulcus on MRI. Unstable SLAP lesions are typically repaired with anchor fixation, and the extent of the injury typically determines the pattern of repair. If one were to liken the glenoid to a clock face, these occur in the 10 o’clock to 2 o’clock position. The patient stands with his or her involved arm flexed 90 degrees at the elbow and abducts the shoulder in the scapular plane to above 120 degrees. Type II is the most common type and represents a detachment of the superior labrum and biceps from the glenoid rim. The examiner then applies a downward resistive force just distal to the elbow while asking the patient to perform a throwing motion. Ilahi OA, Labbe MR, Cosculluela P. Variants of the anterosuperior glenoid labrum and associated pathology. 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. You may get a SLAP tear if you: The examiner then applies terminal external rotation until resistance is appreciated. Type I concerns degenerative fraying with no detachment of the biceps insertion. Physical examination is not easy because of the fact that SLAP lesions are often associated with other shoulder pathologies. [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. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. A tear of the labrum below the middle of the glenoid socket that also involves the inferior glenohumeral ligament is called a Bankart lesion. [38] Specific testing of the supraspinatus muscle can be difficult when passive ROM is limited. A detailed sensory examination should take place in all acute and chronic instability patients. [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. Hansen CH, Asturias AM, Pennock AT, Edmonds EW. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) Sports Phys. Am J Sports Med.,2014 ;42(6):1315-1322, WEBER S.C., Surgical management of the failed SLAP repair. Superior Scapes, Liverpool, New York. Tennent D, Pearse E. A Percutaneous Knotless Technique for SLAP Repair. 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. 163 likes. The cocking phase of throwing can place direct posterosuperior impingement on the superior labrum. While Snyder’s group reported that SLAP repairs represent about 3% of shoulder cases in a large tertiary referral center, ensuing studies from the first decade of the 2000s reported a consistent rise in the overall increased rate of SLAP repairs performed at many other institutions. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. The examiner applies a perpendicular external rotational force to try and lift the patient’s handoff of the shoulder. Please enter a valid 5-digit Zip Code. Clinicians should inquire regarding certain history elements that may help differentiate SLAP tears from other shoulder injuries. [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. Patel KV, Bravman J, Vidal A, Chrisman A, McCarty E. Biceps Tenotomy Versus Tenodesis. 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. [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. [9] The physical examination is also very important in determining the correct diagnosis[11], however physical examination should not be used in isolation because the literature does not confirm that special tests can accurately identify SLAP lesions. In the appropriate patient, NSAIDs and cryotherapy device/ice pack application can be beneficial for pain control. Book an appointment today! The bucket-handle tear of the superior labrum is resected, additionally with the repair of the SLAP complex (rare) if needed. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. The odds ratio for revision surgery was 3.5 in the setting of LHBT tendinitis alone. [9], Postoperative rehabilitation for tenotomy and tenodesis of the biceps is typically included within the above protocols. [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. Glenohumeral internal rotation deficit (GIRD) is a common associated finding in throwing athletes. Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes. Find top doctors who treat Labral tears near you in Liverpool, NY. [15] Additionally, we now recognize that SLAP lesions commonly occur in asymptomatic overhead athletes. Superior Scapes | Liverpool NY A multifaceted approach to treatment is required for successful outcomes. Sling immobilization until 4 weeks postoperative, Early shoulder pendulum exercises, periscapular muscle activation exercises. Scapulothoracic motion and scapular winging should also be evaluated during active and passive motion. Shoulder pain is the third most common musculoskeletal complaint seen in outpatient clinics. Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. 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. 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. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. A typical symptom is intermittent pain that also occurs in overhead movements. Mathew CJ, Lintner DM. Summarize interprofessional team strategies for improving care coordination and communication to enhance outcomes for patients affected by superior labral anterior to posterior (SLAP) lesions. [37] Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. [Level 2-3]. et al., The effect of age on the outcomes of arthroscopic repair of type II superior labral anterior and posterior lesions. 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. So there are conflicting views in the literature about the repairs in the older patients.[27]. 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. That is usually the journal article where the information was first stated. [19], Types I and III SLAP tears may be selected to undergo simple debridement as the integrity of the biceps anchor is not completely compromised. The labrum is susceptible to injury with trauma to the shoulder joint. Also, shoulder girdle proprioceptive training is beneficial to help prevent re-injury. 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. Re. The Neviaser portal is often utilized and established under direct visualization once confirming the appropriate trajectory are achieved. A SLAP tear can be caused by trauma to the shoulder. SLAP tears involve the superior glenoid labrum, where the long head of bicepstendon inserts. Clinicians should obtain a true anteroposterior (AP) image of the glenohumeral joint (also known as the “Grashey” view). A systematic approach to diagnosis is essential to exclude life-threatening presentations of shoulder pain such as myocardial infarction or aortic dissection. 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. Examiners should observe and compare bilateral shoulder girdles for any notable asymmetry, scapular posturing, muscle bulk comparison, or any atrophic changes. The following algorithm has been previously proposed[41], Multiple SLAP repair techniques have been previously described. 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. Strengthening exercises can be initiated at six weeks postoperatively.[33]. First described in the 1980s, extensive study has followed to elucidate appropriate evaluation and management. This rotator interval has a triangular shape in which the supraspinatus is superiorly located, the subscapularis inferiorly and the processus coracoideus medially. 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. 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. Cadaveric studies have demonstrated that SLAP tears are more likely to occur with the shoulder in a forward flexed position than positions in extension. Andrews JR, Carson WG, McLeod WD. Las lesiones SLAP ( Superior, Labrum, Anterior, Posterior ) son lesiones que comprometen al Labrum Superior y la Inserción del Tendón del Bíceps en el mismo. In throwing athletes, a progressive throwing program that is directed toward the patients' specific sport and position can be initiated after 3 months.[2]. Patterson BM, Creighton RA, Spang JT, Roberson JR, Kamath GV. The beam can otherwise be rotated while the patient is neutral in the coronal plane. Superior labral anterior posterior (SLAP) lesions of the glenoid have proven difficult to diagnose clinically. Int. [41] It is critical to discern whether the labrum alone is responsible for the patient’s symptoms and whether restoring the labral attachment and biceps root to the glenoid will help. Review the management options available for superior labrum lesions (SLAP tears). Observation of neck posturing, muscular symmetry, palpable tenderness, and active/passive ROM should undergo evaluation. [5][6] Specific populations, however, can present with increased rates of SLAP tears, with one study demonstrating upwards of an 83% prevalence in overhead athletes.[1]. Identify the population(s) most at risk for superior labral anterior to posterior (SLAP) lesions. In fact, superior outcomes have been reported in this particular subset of athletic patients following non-surgical management alone. 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). Read more, © Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. Active and passive motion needs to be assessed and compared to the contralateral side. 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. 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. Superior Labrum Anterior Posterior Lesions. Occur secondary to sudden jerking movements or after lifting heavy objects, Can occur after an unexpected pull on the arm. Also suprascapular neuropathy secondary to cyst compression in the spinoglenoid notch may occur in association with SLAP tears. The examiner places one hand on the joint line of the shoulder and the other hand on the elbow. They may extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. Over the last two decades, our knowledge and appreciation of SLAP tear recognition, diagnosis, treatment, and potential surgical management has evolved dramatically. [20], Erickson et al. The incidence of SLAP tears is a controversial topic in the current literature. The skin should be observed for the presence of any previous surgical incisions, lacerations, scars, erythema, or induration. [36], Mayo Shear Test (also known as the Modified O’Driscoll Test or the Modified Dynamic Labral Shear Test: SLAP lesions first gained recognition in the 1980s. This decreases the normal shoulder function. Outcome of the isolated SLAP lesions and analysis of the results according to the injury mechanisms. Special tests that are helpful in this regard include the Spurling maneuver, myelopathic testing, reflex testing, and a comprehensive neurovascular exam. An honest dialogue of outcomes with each patient is vital before selecting the appropriate intervention. [25] later clarified these attachment types and included their relationships with the glenoid attachment of the glenohumeral ligaments. A positive test includes pain or a painful click on the anterior or posterior joint line. SLAP tears involve the superior glenoid labrum, where the long head of biceps tendon inserts. Snyder et al. 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: StatPearls [Internet]. This means your labrum is. By six to nine months, a gradual return to sport is undertaken dependent upon the painless progression of activity and clinical exam. [23] Vangsness et al. Also, a wide array of implant options are available depending on surgeon preference. It is associated with pain and instability and an inability of the patient to perform overhead movements. Burkhart SS, Morgan CD. [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. Dougherty MC, Kulenkamp JE, Boyajian H, Koh JL, Lee MJ, Shi LL. SLAP Lesions: Trends in Treatment. [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. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. [15], According to William F.B., SLAP lesions had an association of 43% with the medial sheath lesion. Moreover, the macroscopic attachment types correlated to the specimen histologic sectioning observed in the sagittal section. A Magnetic Resonance Arthrogram revealed a HAGL lesion. The age of the patient has an impact on the superior labrum. Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction. Immediately post operative Patient will remain in an immobilizer for four weeks. Unlike Bankart lesionsand ALPSA lesions, they are uncommonly (20%) associated with shoulder instability 5. Gentle ROM activities are recommended. Anti-inflammatory medications, cryotherapy/cooling/ice application, rest and activity modification. Tenodesis patients are protected for four weeks, and avoidance of supination and flexion of the elbow is recommended. There are a lot of different mechanisms of injury that can result in a SLAP lesion. SLAP lesions of the shoulder. Additional subtypes for type II tears, as well as additional tear patterns, were described in subsequent years. [2][10]Postoperative rehabilitation is determined by the type of SLAP lesion, the chosen surgical procedure and other concomitant pathologies and procedures performed. Tears of the glenoid labrum Hill L, Collins M, Posthumus M. Risk factors for shoulder pain and injury in swimmers: A critical systematic review. Return to play after treatment of superior labral tears in professional baseball players. Provocative Examination Testing/Maneuver: Other standard views include the axillary lateral view and “scapular Y”/outlet views. 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. In this mechanism, a “peel-back” avulsion of the superior labrum by a torsional force via the biceps anchor. SLAP lesions are lesions of the superior labrum in which there are several types described. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Shin SJ, Lee J, Jeon YS, Ko YW, Kim RG. 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. Burkhart SS, Morgan CD, Kibler WB. Am J Sports Med., 2010;38:2299–2303, EDWARDS S.L. The deltoid muscle often demonstrates atrophy in chronic dislocators. SLAP lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization. Isolated tenotomy patients typically can resume activity within a week. Ther., 2013; 8(5): 579-600, HURI G. et al, Treatment of superior labrum anterior posterior lesions: a literature review. Variability in the anatomy of the biceps anchor and tendinous origin translates to varying levels of strain on the superior labrum. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. Management of paralabral cysts is dependent upon location and concomitant symptomatic nerve compression. Assisted and passive techniques are used at 4 weeks post-operative to increase shoulder mobility. [2]Regaining GIRD is a crucial aspect in the rehabilitation of SLAP lesions. A tear of the rim below the middle of the glenoid socket that also involves the inferior glenohumeral ligament is called a Bankart lesion. 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. Athletes and overhead laborers should also be placed on a restricted sport-specific timeline protocol, and manual laborers should receive appropriate occupational modifications. Incidence of SLAP lesions in a military population. What causes it? This can lead to instability and, ultimately, impingement of the superior labrum with degenerative tearing. Secondary to fraying related to Internal Shoulder Impingement. An anatomical study of 100 shoulders. It also becomes more brittle with age, and can fray and tear as part of the aging process. Erickson BJ, Jain A, Abrams GD, Nicholson GP, Cole BJ, Romeo AA, Verma NN. Approximately 40% of the long head of biceps tendon (LHBT) attaches to the labrum. Maffet MW, Gartsman GM, Moseley B. Passive and active-assist forward elevation encouraged, may progress limitations depending on surgeon preference. Injuries to the labrum in this region can result in labral symptoms, biceps symptoms or both. Asymptomatic tears should be observed. O'Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. Rowbotham EL, Grainger AJ. 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. , which are the serratus anterior, rhomboid major and minor, levator scapulae and trapezius. 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 … Kampa RJ, Clasper J. A physical exam led to differential diagnoses of a Superior Labrum Anterior to Posterior (SLAP) lesion, Bankart lesion, and bicipital tendinopathy. SLAP lesions demonstrate a predilection for young laborers, overhead athletes, and middle-aged manual laborers. J. In most cases Physiopedia articles are a secondary source and so should not be used as references. It can happen because of a road accident or a fall onto an outstretched arm. Chronic anterior and posterior instability patients may also exhibit corresponding posterior and anterior acromial prominences, respectively. Upon observation, the posterior shoulder (when viewed from the patient's side) will be relatively flat relative to the anterior fullness. 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. In a labrum SLAP tear, SLAP stands for superior labrum anterior and posterior. It is important to discuss the patients’ activities such as athletics, profession, and baseline activity level. Compression-type injuries 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 labrum anterior to posterior lesions and the superior labrum. The physical requirements of military service may contribute to an increased. [Updated 2022 Sep 4]. The term SLAP stands for Superior Labrum Anterior and Posterior. [23][27] The most common complications after surgical fixation are residual pain and stiffness. Posterosuperior Labral Tears. 1173185. As function is restored without pain, a gradual return to sport is recommended on a case-by-case basis, dependent upon clinical exam. The determination of appropriate anchor placement depends on the predominant region of instability regarding the superior labral-biceps tendon complex. Outcomes after arthroscopic repair of type-II SLAP lesions. Describe interprofessional team strategies for improving care coordination and communication to advance the treatment of superior labrum lesions (SLAP tears) and improve outcomes. Care must be taken to avoid exercises activating the biceps. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Recent studies have reported on the diagnostic accuracy of specific tests concerning diagnosing SLAP tears: O’Brien/Active Compression Test: Nonoperative PT regimens focused on correcting for scapular dyskinesia and glenohumeral internal rotation deficit (GIRD).[49]. Miniaci A, Mascia AT, Salonen DC, Becker EJ. There is a wide variety of pathology, and patient-specific characteristics and goals heavily influence treatment options. [18], Schwartzberg reported MRI documented SLAP lesions can be present in up to 72% of middle-aged, asymptomatic patients. J. 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. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. Maffet MW, Gartsman GM, Moseley B. Superior labrum anterior posterior lesions.Available: PROVENCHER M.T. Several authors recommend against repair in these populations.[23][31]. Care must be taken to avoid iatrogenic nerve injury during decompression. Brockmeyer M, Tompkins M, Kohn DM, Lorbach O. Journal of orthopaedic & sports physical therapy, 2009;39(2): 2009, MORGAN CD et al., Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears, Arthroscopy 1998 Sep;14(6):553-65, GASKILL T.R., The rotator interval: pathology and management, Journal of Arthroscopy and Related Surgery 2011, vol. Surgical treatment: SLAP repair versus resection. Finally, SLAP tears can occur in a degenerative setting for the aging population. et al., Schoulder injuries in the overhead athlete. Superior Labral Anterior-Posterior (SLAP) Tears in the Military. Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography. In this situation the shoulder is abducted and slightly forward-flexed at the time of the impact. The labrum and the long head of the biceps tendon (LHBT) are torn and avulses off the glenoid cavity. 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. Type I tears are usually asymptomatic and do not require treatment, Type II tears require surgical reattachment, Type III tears usually require resection of the bucket handle tear, serratus punch (protraction with the elbow extended), forward flexion in external rotation and forearm supination, full can (elevation in the scapular plane in external rotation, forearm supination, elbow flexion in forearm supination, uppercut (combined forward flexion of the shoulder and flexion and supination of the elbow). Avoid extremes of abduction and external rotation. Physical examination and magnetic resonance imaging in the diagnosis of superior labrum anterior-posterior lesions of the shoulder: a sensitivity analysis. [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. [12]They may also report a loss of velocity and accuracy along with discomfort in the shoulder. A sling with an abduction pillow is typically utilized with avoidance of external rotation and abduction. The most common complaint in patients that present with SLAP lesions is pain. Varacallo M, Tapscott DC, Mair SD. Glenoid labrum tears related to the long head of the biceps. 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. Less common than SLAP Lesions. Utilizing dedicated formal PT regimens can help ensure each “SLAP tear” diagnosis is most appropriately managed to help mitigate the risks of inferior patient outcomes. [1][2]  Snyder developed the initial 4-subtype classification of these lesions. [30][31], Boesmueller recently histologically characterized the most proximal extent of the LHBT, specifically the neurofilament distribution, as the tendon transitions into the superior labral complex. Gorantla K, Gill C, Wright RW. If you know where these structures are situated, you can try to palpate the rotator interval.[20]. SLAP lesions: a treatment algorithm. 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. [10], For the vast majority of SLAP injuries, the initial management is nonoperative. Am J Sports Med., 2012;40(9):2105-2112, COOLS A .M. Cook C, Beaty S, Kissenberth MJ, Siffri P, Pill SG, Hawkins RJ. A SLAP tear stands for Superior Labrum, Anterior to Posterior. 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. 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. 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. The labrum is a cup-shaped rim of cartilage that lines and reinforces the ball-and-socket joint of the shoulder. [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. The labral insertion of LHBT is left unaffected. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Patient complaint of pain is not a good gauge for progression. The study was a one year follow-up study of with 19 patients. 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. Detailed and focused attention should be given to appropriately delineating the extent of all potential underlying shoulder girdle pathologies. Chang D, Mohana-Borges A, Borso M, Chung CB. Glenoid neck preparation is with a tissue elevator, rasp, and/or shaver instrument. 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 rotator cuff muscles are important as well to anchor the scapula and guide the movement. 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]. 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. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. Chronic instability patients will almost always exhibit at least a mild degree of asymmetry. AJSM 2013. Previous studies have demonstrated non-operative management successful for 22 to 85% of patients. Identify the etiology of superior labrum lesions (SLAP tears) medical conditions and emergencies. [Updated 2022 Jul 6]. Shon MS, Jung SW, Kim JW, Yoo JC. [25], Another potential nidus predisposing certain patients to SLAP tears is the presence of a sublabral recess (or sublabral sulcus). SLAP lesion repair often fails, and biceps tenodesis or tenotomy seems to be an acceptable alternative treatment for SLAP lesions. 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. Treatment failure and complications are dependent upon intervention, patient adherence to rehabilitation protocols, and patient-specific factors. As mentioned, this concept can also be applied to the young, athletic population as well. In these scenarios, SLAP tears present with the insidious onset and progressive deep shoulder pain in young athletes with the arm in the abduction and external rotation position during the late-cocking phase of throwing. Risk Factors for Revision Surgery After Superior Labral Anterior-Posterior Repair: A National Perspective. The patient stands with his or her hand of the involved arm placed on the ipsilateral hip with the thumb pointing posteriorly. Find a doctor near you. 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. [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%). 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. A Treatment-Based Algorithm for the Management of Type-II SLAP Tears. 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. This increase constituted a jump in case volume reporting from 765 to 4313 annual SLAP repairs. The Journal of Manual & Manipulative Therapy, 2001;9(2):71 – 83, WILK K.E. Initial reported performance of these tests has not been reproduced by independent investigat … [21] Furthermore, SLAP tears account for approximately 1% to 3% of injuries presenting to sports medicine referral centers, and SLAP tears are present in approximately 6% of shoulder arthroscopy procedures.[2][21][22]. To diagnose this condition it is important to use several different tests and not only one. Superior Labrum Anterior to Posterior Tear (SLAP Lesions) Associated with Biceps Tenosynovitis. Fraying occurs at the free edge of the labrum. Surgical treatment of isolated type II superior labrum anterior-posterior (SLAP) lesions: repair versus biceps tenodesis. 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"). As symptoms diminish, a structured rehabilitation protocol focusing on rotator cuff and pericapsular strengthening exercises are utilized. [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. From the average age of 35, the superior labrum is less firmly attached to the glenoid than in people under the age of 30.
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