[57] Professional baseball pitchers demonstrate relatively inferior outcomes regarding return to play and return to prior performance level. Review the management options available for superior labrum lesions (SLAP tears). Brockmeyer M, Tompkins M, Kohn DM, Lorbach O. 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. Clinicians should inquire regarding certain history elements that may help differentiate SLAP tears from other shoulder injuries. 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. The origin of the long head of the biceps from the scapula and glenoid labrum. Glenoid labrum tears related to the long head of the biceps. As mentioned, this concept can also be applied to the young, athletic population as well. Several authors recommend against repair in these populations.[23][31]. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Unlike Bankart lesionsand ALPSA lesions, they are uncommonly (20%) associated with shoulder instability 5. Sports Med Arthrosc.,2010;18:162-166. The Journal of Manual & Manipulative Therapy, 2001;9(2):71 – 83, WILK K.E. 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. [11], It is important to keep in mind that the scapula is an important factor during shoulder movements. Return to play after Type II superior labral anterior-posterior lesion repairs in athletes: a systematic review. Meserve BB, Cleland JA, Boucher TR. Superior labrum-biceps tendon complex lesions of the shoulder. Gorantla K, Gill C, Wright RW. 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. [1] Patient-specific considerations and appropriate utilization of both non-surgical and surgical interventions are of the utmost importance to maximize results while minimizing complications. The Neviaser portal is often utilized and established under direct visualization once confirming the appropriate trajectory are achieved. [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. Demographic trends in arthroscopic SLAP repair in the United States. Chang D, Mohana-Borges A, Borso M, Chung CB. 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]. A standard detailed history is required, as with all patients presenting to the clinic. Glenohumeral internal rotation deficit (GIRD) is a common associated finding in throwing athletes. The resulting tear of the labrum can then be debrided or fixed depending upon the severity of the tear. Gradually, active strengthening and improvement of neuromuscular control are undertaken from two to four weeks. Aflatooni JO, Meeks BD, Froehle AW, Bonner KF. 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. Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. [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. The cocking phase of throwing can place direct posterosuperior impingement on the superior labrum. Onyekwelu I, Khatib O, Zuckerman JD, Rokito AS, Kwon YW. [40]. Type VI: an unstable flap tear of the labrum in conjunction with a biceps tendon separation. Part II candidates. [26], In contrast, a sublabral hole or sublabral foramen is typically located at the 12 to 2 o’clock position. 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. 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]. Varacallo M, Tapscott DC, Mair SD. Type I concerns degenerative fraying with no detachment of the biceps insertion. As a surgical treatment for SLAP lesions, SLAP repair has been traditionally performed. Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes. This activity reviews the evaluation and treatment of SLAP tears and highlights the role of the interprofessional team in managing patients with this condition. In 2005, an MRI analysis of professional handball players demonstrated abnormalities in 93% of shoulders, with only 37% being symptomatic.[48]. Int. A tear of the labrum below the middle of the glenoid socket that also involves the inferior glenohumeral ligament is called a Bankart lesion. 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. Posterosuperior Labral Tears. SLAP lesion repair often fails, and biceps tenodesis or tenotomy seems to be an acceptable alternative treatment for SLAP lesions. Comprehensive Review of Provocative and Instability Physical Examination Tests of the Shoulder. [Level 2-3]. Am J Sports Med.,2014 ;42(6):1315-1322, WEBER S.C., Surgical management of the failed SLAP repair. Scapulothoracic motion and scapular winging should also be evaluated during active and passive motion. Also, a wide array of implant options are available depending on surgeon preference. SLAP lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization. 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. “Type II plus anterior shoulder instability.”. [46]. An Age and Activity Algorithm for Treatment of Type II SLAP Tears. 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). 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. Below is a list of tests used to evaluate the labrum and the biceps. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Stress distribution in the superior labrum during throwing motion. The recognition and treatment of superior labral (slap) lesions in the overhead athlete. Alternatively, the biceps anchor may be sacrificed, and a biceps tenotomy or tenodesis performed. J Orthop Sports Phys Ther, 2009; 39(2):71-80, PEAT M., Functional anatomy of the schoulder complex. Schrøder CP, Skare O, Gjengedal E, Uppheim G, Reikerås O, Brox JI. Background:Injuries to the superior glenoid labrum represent a significant cause of shoulder pain among active patients. The examiner has the patient’s arm at 90 degrees of elbow flexion, and IR testing is performed by the patient pressing the palm of his/her hand against the belly, bringing the elbow in front of the plane of the trunk. The determination of appropriate anchor placement depends on the predominant region of instability regarding the superior labral-biceps tendon complex. The developmental anatomy of the neonatal glenohumeral joint. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Superior Labral Anterior-Posterior (SLAP) Tears in the Military. A tear of the rim below the middle of the glenoid socket that also involves the inferior glenohumeral ligament is called a Bankart lesion. A SLAP tear can be caused by trauma to the shoulder. By six to nine months, a gradual return to sport is undertaken dependent upon the painless progression of activity and clinical exam. The rotator cuff muscles are important as well to anchor the scapula and guide the movement. Trends in the early 2000s showed an increase in SLAP repairs. Recent studies have reported on the diagnostic accuracy of specific tests concerning diagnosing SLAP tears: O’Brien/Active Compression Test: Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. To diagnose this condition it is important to use several different tests and not only one. In a SLAP injury, the top (superior) part of the labrum is injured. The location you tried did not return a result. In addition, understanding how to treat a SLAP tear in the setting of other concomitant injuries is imperative. Access free multiple choice questions on this topic. In addition to axillary nerve function, motor function of the elbow, wrist, and hand should undergo an assessment to rule out the possibility of a brachial plexus injury associated with the dislocation. The patient lies supine on the exam table with his or her arms resting in full elevation with the forearm and hand supported by the table. Increasing age, activity level, obesity, female sex, smoking, and concomitant shoulder pathology are risk factors for failure. They found that tenodesis is superior to the repair of type II SLAP tears in older population. The labrum and the long head of the biceps tendon (LHBT) are torn and avulses off the glenoid cavity. A physical exam led to differential diagnoses of a Superior Labrum Anterior to Posterior (SLAP) lesion, Bankart lesion, and bicipital tendinopathy. [38] Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Andrews JR, Carson WG, McLeod WD. Advances in contemporary diagnostic capabilities and arthroscopic management techniques have led to evolving management paradigms since the original descriptions of SLAP-type lesions. et al., Non operative treatment of superior labrum anterior posterior tears - improvements in pain function and quality of life. The therapist can choose the 2 sensitive tests out of the following 3: For the specific test, the therapist may choose out of the 3 following: If one of the three tests is positive, this will result in a sensitivity of about 75%. Anti-inflammatory medications, cryotherapy/cooling/ice application, rest and activity modification. SLAP tears involve the superior glenoid labrum, where the long head of biceps tendon inserts. By weeks five to six, strengthening exercises are started, and active external rotation and abduction motions are allowed. Variability in the anatomy of the biceps anchor and tendinous origin translates to varying levels of strain on the superior labrum. [13][14], The glenoid labrum is often involved in shoulder pathology. 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. The differential diagnosis for chronic shoulder pain includes several etiologies: Although Level I and II studies in the literature are lacking regarding outcomes following arthroscopic type II SLAP repairs, most studies report overall favorable results and good outcomes in the appropriately selected patients. They can extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. [53][54][55] A number of authors report good results in athletes, including those with sport-specific overhead demand requirements. Specific physical examination of SLAP tears is difficult as they typically present with other pathology in the shoulder. They may extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. 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]. et al., Rehabilitation Exercises for Athletes With Biceps Disorders and SLAP Lesions: A Continuum of Exercises With Increasing Loads on the Biceps. 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]. et al., Schoulder injuries in the overhead athlete. Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. http://creativecommons.org/licenses/by-nc-nd/4.0/ Active strengthening of the biceps is still avoided. The true AP image is taken with the patient rotated between 30 and 45 degrees offset the cassette in the coronal plane. Clinicians should keep in mind the utilization of MRA may promote the overdiagnosis of asymptomatic (or clinically irrelevant) SLAP lesions and thus exercise best clinical judgment in ordering specific advanced imaging modalities. The labrum is susceptible to injury with trauma to the shoulder joint. In the chronic setting, degenerative changes within the shoulder may be present, and while testing of the superior labrum may be positive, it may not be the main cause of their symptoms. Identify the etiology of superior labrum lesions (SLAP tears) medical conditions and emergencies. [3][4] further subdivided the SLAP classification schemes to ultimately delineate ten different types of SLAP tear patterns, including combined SLAP- and Bankart-type injuries seen in specific associative patterns. [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. 2009 Oct-Dec; 43(4): 342–346, WILK K.E. 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. [15], According to William F.B., SLAP lesions had an association of 43% with the medial sheath lesion. Demographic trends in arthroscopic SLAP repair in the United States. Surgical Trends in the Treatment of Superior Labrum Anterior and Posterior Lesions of the Shoulder: Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database. SLAP-lesion-specific physical examination tests have been developed to improve clinical acumen. Ek ET, Shi LL, Tompson JD, Freehill MT, Warner JJ. [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. Consultations should include primary care sports medicine specialists experienced in managing SLAP tears nonoperatively. O'Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. 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. As with most shoulder conditions, the history including the exact mechanism of injury should be documented. Discussing the anatomic role exacerbating mechanisms have on either non-operative or operative management can help give understanding as to the importance of avoiding those maneuvers. Sports Med, 2013;41:444-460, NURI A. et al., Superior labrum anterior to posterior lesionsof the shoulder: Diagnosis ans arthoscopic management. The endemic rate of variations of labral anatomy visible on MRI in asymptomatic overhead throwers should prompt caution before concluding that the labrum is the source of the patient’s pain. 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. Tenodesis can be performed by subpectoral, all-arthroscopic, and mini-open techniques. advertisement. Jost B, Zumstein M, Pfirrmann CW, Zanetti M, Gerber C. MRI findings in throwing shoulders: abnormalities in professional handball players. 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. [11] There are studies who combined few of the tests but the data differ too much therefore it’s difficult to make a general conclusion. Please enter a valid 5-digit Zip Code. Detailed and focused attention should be given to appropriately delineating the extent of all potential underlying shoulder girdle pathologies. 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. [28][30]can be prevented. The pathophysiology, diagnosis, and nonsurgical management of SLAP tears are reviewed . The patient reported 75% . Fealy S, Rodeo SA, Dicarlo EF, O'Brien SJ. Falling on an outstretched arm is an acute traumatic superior compression force to the shoulder. Initial evaluation of the shoulder typically starts with x-rays to rule out osseous pathology. [15]There are two regions where anatomic variants can appear: the superior region, where it’s mostly related to age, and the anterosuperior region, where sometimes there is no labrum (12%) or a cord like ligament that is in continuity with the biceps footplate (13,5%). Johannsen AM, Costouros JG. The following causes have been found: The two most common mechanisms are falling on an outstretched arm in which there is a superior compression, and a traction injury in the inferior direction.[6]. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. Superior Scapes, Liverpool, New York. Radiographic imaging is necessary for all patients with acute or chronic shoulder pain. A sulcus between the supraglenoid tubercle and the labrum may also give a false-positive result and is deemed a pseudo SLAP tear. Outcomes after arthroscopic repair of type-II SLAP lesions. [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. Athletes and overhead laborers should also be placed on restricted sport-specific timeline protocol, and manual laborers should receive appropriate occupational modifications. A sublabral foramen with a cord-like middle glenohumeral ligament. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. [17], Beside biceps tears, other problems, such as bursitis and rotator cuff tears, are often identified, in combination with SLAP lesions,[18]According to Morgan CD et al., Rotator cuff tears were present in 31% of patients whit SLAP lesion and were found to be lesion-location specific.[19]. These injuries are not solely limited to young throwing athletes as originally described, and SLAP tears commonly can be seen in various patient populations with varying degrees of actual clinical relevance. Other standard views include the axillary lateral view and “scapular Y”/outlet views. 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. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. More research is necessary regarding the histologic characterization of the superior labrum-LHBT complex. http://creativecommons.org/licenses/by-nc-nd/4.0/. What causes it? 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. Superior labral anterior to posterior (SLAP) lesions constitute a recognized clinical subset of complex shoulder pain pathologies. ), which permits others to distribute the work, provided that the article is not altered or used commercially. Typically, an anti-inflammatory and/or corticosteroid injection are utilized as initial treatment as well. Kuhn JE, Lindholm SR, Huston LJ, Soslowsky LJ, Blasier RB. 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. 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. 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. 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. This can lead to instability and, ultimately, impingement of the superior labrum with degenerative tearing. [7] Internal impingement can also result from rotator cuff tears via chronic posterosuperior or anterosuperior migration/subluxation of the humeral head.[8]. Initial physical examination includes visual inspection for gross asymmetry and muscle atrophy. These tears are common in overhead throwing athletes and laborers involved in overhead activities. Ebinger N, Magosch P, Lichtenberg S, Habermeyer P. A new SLAP test: the supine flexion resistance test. Access free multiple choice questions on this topic. 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. It is associated with pain and instability and an inability of the patient to perform overhead movements. Park JH, Lee YS, Wang JH, Noh HK, Kim JG. Ideal graphic animation, using Antero-Sup portal avoiding rotator cuff portal. The beam can otherwise be rotated while the patient is neutral in the coronal plane. 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. This activity will review the pathophysiology, classification, and treatment options for SLAP lesions and examine the role of physicians, physician assistants, nurses, physical therapy teams, and medical assistants in optimizing collaboration to ensure patients receive high-quality care, which will lead to enhanced outcomes. 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). Schultz KA, Nelson R. Superior Labrum Lesions. Arthroscopic all-intra-articular decompression and labral repair of paralabral cyst in the shoulder. Type II is the most common type and represents a detachment of the superior labrum and biceps from the glenoid rim. Tenodesis patients are protected for four weeks, and avoidance of supination and flexion of the elbow is recommended. Alleviation of pain and return of range of motion may result in treatment success for some; however, in overhead athletes, many patients are unable to return to their prior level of sport or performance. Anteroinferior labral tears decreased posterior stability and posterosuperior labral tears decreased anterior and anteroinferior stability, largely because of loss of the suction cup effect. 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). Superior labrum is more weakly attached to glenoid than inferior labrum. [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. http://creativecommons.org/licenses/by-nc-nd/4.0/. 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. 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. Brockmeier SF, Voos JE, Williams RJ, Altchek DW, Cordasco FA, Allen AA., Hospital for Special Surgery Sports Medicine and Shoulder Service. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). 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. [3] The biceps has also been implicated in the follow-through phase of throwing as an eccentric contraction of the biceps transmits an extensive pull on the superior labrum. 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. [Updated 2022 Sep 4]. Finally, SLAP tears can occur in a degenerative setting for the aging population. [12]They may also report a loss of velocity and accuracy along with discomfort in the shoulder. The possibility of generalized hyperlaxity of tissues in all patients with instability should also be considered, and a Beighton score can easily be obtained. A detailed neurovascular examination is performed and documented, complete with muscle strength testing. SLAP lesions first gained recognition in the 1980s. II. Patel KV, Bravman J, Vidal A, Chrisman A, McCarty E. Biceps Tenotomy Versus Tenodesis. Indeed, Snyder et al found partial-thickness or full-thickness rotator cuff disease in 55 (40%) of 140 patients with SLAP lesions. Several authors have proposed surgical treatment algorithms depending on the specific type of SLAP lesion identified on advanced imaging, clinical exam, and intraoperative arthroscopy. Ilahi OA, Labbe MR, Cosculluela P. Variants of the anterosuperior glenoid labrum and associated pathology. Incidence of SLAP lesions in a military population. [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. StatPearls Publishing, Treasure Island (FL). Yeh ML, Lintner D, Luo ZP. Secondary to fraying related to Internal Shoulder Impingement. [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. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. [36] Functional exercise and light strengthening can be progressively incorporated. Isolated tenotomy patients typically can resume activity within a week. [36] [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%). Cadaveric studies have demonstrated that SLAP tears are more likely to occur with the shoulder in a forward flexed position than positions in extension. SLAP lesions are lesions of the superior labrum in which there are several types described. 2022 Dec . It is important to discuss the patients’ activities such as athletics, profession, and baseline activity level. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. SLAP tears are typically defined as superior labrum fraying/tearing from the glenoid. Zhang AL, Kreulen C, Ngo SS, Hame SL, Wang JC, Gamradt SC. Outcome of the isolated SLAP lesions and analysis of the results according to the injury mechanisms. Las lesiones SLAP ( Superior, Labrum, Anterior, Posterior ) son lesiones que comprometen al Labrum Superior y la Inserción del Tendón del Bíceps en el mismo. Am J Sports Med., 2013;41:880–886, ALPERT J.M. [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. Understanding the rigorous rehabilitation required from advanced procedures helps the patient understand what is expected on their road to recovery. Patients presenting with concerns over a potential SLAP tear should receive education regarding the contemporary clinical knowledge we now have regarding these injuries. It contains the coracohumeral and the superior glenohumeral ligament, the biceps tendon and the anterior joint capsule. 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. Fraying occurs at the free edge of the labrum. J. Ther., 2013; 8(5): 579-600, HURI G. et al, Treatment of superior labrum anterior posterior lesions: a literature review. [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. A detailed sensory examination should take place in all acute and chronic instability patients. There is an increasing body of literature evidence now recognizing that appropriate patient selection is critical. Resisted elbow flexion, resisted forearm supination. Care must be taken to avoid iatrogenic nerve injury during decompression. 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. Weber et al. In the setting of chronic anterior instability, the clinician may appreciate a palpable anterior fullness. Nonoperative management modalities include: Anti-inflammatory medications, cryotherapy/cooling/ice application, rest and activity modification. 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. A total of four types of superior labral lesions involving the biceps anchor have been identified. Part II candidates. Describe interprofessional team strategies for improving care coordination and communication to advance the treatment of superior labrum lesions (SLAP tears) and improve outcomes. 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 labral anterior posterior (SLAP) tears are injuries of the glenoid labrum, and can often be confused with a sublabral sulcus on MRI. 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. Orthop., 2014; 5(3): 344-350, PAINE R. et al., The role of the scapula. Waterman BR, Cameron KL, Hsiao M, Langston JR, Clark NJ, Owens BD. Weber SC, Martin DF, Seiler JG, Harrast JJ. Thus, we can conclude that there is an age-related effect in which the older the patient is, the more likely he will incur a SLAP lesion, due to age-related changes. 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. [25] later clarified these attachment types and included their relationships with the glenoid attachment of the glenohumeral ligaments. [16] For those with atrophy, weakness, or continued pain, surgical decompression is indicated. J. Nonoperative PT regimens focused on correcting for scapular dyskinesia and glenohumeral internal rotation deficit (GIRD).[49]. 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. Performance of the test on the nonaffected shoulder should not elicit any pain. Charles MD, Christian DR, Cole BJ. Burkhart previously described demonstrating a ‘‘peel-back’’ sign during arthroscopy. Passive and active-assist forward elevation encouraged, may progress limitations depending on surgeon preference. 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. 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. The specific etiology underlying the various SLAP tear presentations is multifactorial and remains a topic of debate and controversy. Etiology [12] These concepts are further realized by the fact that a formal diagnosis code was not available until 2001, and it took until 2003 to institute a separate Current Procedural Terminology (CPT) code: 29807. 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. 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. Three distinct variations occur in over 10% of patients: In the acute setting, they are most frequently seen in falls onto an outstretched arm or in throwing sports athletes. [6] The former implicates the late-cocking phase of throwing, while the latter would theoretically implicate more traction-based mechanisms. Most of them had a type II SLAP lesion. Horizontal mattress with a knotless anchor to better recreate the normal superior labrum anatomy. The patient is eventually advanced to a strengthening phase, which includes trunk, core, rotator cuff, and scapular musculature. 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. Moreover, patients will often present with an MRI final report stating a SLAP tear was present on imaging. Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction. Am J Sports Med., 2009;37:929–936, OH, J. H. et al., The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion. A structured rehabilitation program and open communication between the interprofessional team, including primary care, sports medicine, orthopedics, physical therapists, and specialty trained nurses, are important to ensure a step-wise approach is followed to achieve maximum patient satisfaction and function. Burkhart SS, Morgan CD. [18] However, in younger patients presenting with shoulder instability, the SLAP injury may be present and contributing to symptoms, especially in the setting of an acute anterior and/or posterior labral tear. The authors noted an increase in the SLAP repair rate to greater than 10% of shoulder cases reported by 2008. Superior Labrum Anterior Posterior Lesions. From the average age of 35, the superior labrum is less firmly attached to the glenoid than in people under the age of 30. Unlike Bankart lesions and ALPSA lesions, they are not usually (20%) associated with shoulder instability.[1]. 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. Pain is typically intermittent and often associated with overhead movements. Given the clinical complexity of SLAP injuries and concomitant shoulder pathologies, early consultation with an orthopedic surgeon is encouraged. [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 deltoid muscle often demonstrates atrophy in chronic dislocators. 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. http://creativecommons.org/licenses/by-nc-nd/4.0/ An initial period of rest following the acute (or acute-on-chronic) injury should be implemented in all patients. [Updated 2022 Jul 6]. A stabilizing role of the glenoid labrum: the suction cup effect J Shoulder Elbow Surg. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. 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. Superior Scapes | Liverpool NY A multifaceted approach to treatment is required for successful outcomes. 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. [4] Other studies have shown rates between 6% and 26% at the time of arthroscopy. The outcome of type II SLAP repair: a systematic review. A paralabral cyst found on MRI is a diagnostic clue for a SLAP tear. 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 … Strength, stability and motion are the components of shoulder function that should be focused on during rehabilitation. The long head of the biceps tendon attaches in the glenoid as part of the labrum at roughly 12:00. [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. [28], Finally, the Buford complex is a congenitally absent anterosuperior labrum plus a thickened cord-like middle glenohumeral ligament. A total of four types of superior labral lesions involving the biceps anchor have been identified. Patients often complain of vague, deep shoulder pain and mechanical clicking with exacerbating activities. Compression-type injuries Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Trends in the diagnosis of SLAP lesions in the US military. Distal pulses should be assessed at the wrist as well. If one were to liken the glenoid to a clock face, these occur in the 10 o’clock to 2 o’clock position. Arthroscopy, 2010. Pertinent elements in history taking to best elucidate the nature of a potential SLAP tear (or other associated shoulder injuries) include:[33][34][35]. Snyder et al. [10][13][14] Multiple tests of the shoulder should be used to gain information collectively towards suspicion for labral pathology. et al., Shoulder rotator strength and torque steadiness in athletes with anterior shoulder instability or SLAP lesion. LIST YOUR PRACTICE ; Dentist ; Pharmacy ; Search . In a labrum SLAP tear, SLAP stands for superior labrum anterior and posterior. Type II is the most common type and represents a detachment of the superior labrum and biceps from the glenoid rim. The arm is released from traction and brought into an abducted/externally rotated position. Additionally, specific biceps testing can be used; however, they are not reliable for SLAP tears as they can be positive with other pathologies. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction. [27], Alpantaki et al. [1], In various patient populations, internal impingement is also a culprit of SLAP tears. Initially rest post the acute (or acute-on-chronic) injury should be implemented. Background:Superior labral anterior and posterior (SLAP) lesions are common injuries in overhead athletes. [10], For the vast majority of SLAP injuries, the initial management is nonoperative. Read more, © Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. [15] Additionally, we now recognize that SLAP lesions commonly occur in asymptomatic overhead athletes. [20], Erickson et al. Find a doctor near you. Para ayudar a estabilizar el hombro, hay un anillo de tejido firme, llamado labrum, alrededor de la cavidad del hombro. In: StatPearls [Internet]. A systematic approach to diagnosis is essential to exclude life-threatening presentations of shoulder pain such as myocardial infarction or aortic dissection. Maffet MW, Gartsman GM, Moseley B. 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. Moreover, the macroscopic attachment types correlated to the specimen histologic sectioning observed in the sagittal section. 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. They can extend into the tendon, involve the glenohumeral ligamentsor extend into other quadrants of the labrum. A positive test includes a reproduction of the pain and/or a painful click or catch in the joint line along the posterior joint line between 120 and 90 degrees of abduction, Surgical treatment: arthroscopic debridement, Surgical treatment: SLAP repair versus biceps tenotomy/tenodesis. Book an appointment today! [2], After surgery, for 3 to 4 weeks, the shoulder of the patient is placed in a sling, which immobilises the shoulder in internal rotation and leads to general loss of motion and stiffness. 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. If necessary, NSAID’s and intra-articular corticosteroid injections can be applied to help diminish complaints. Superior labral anterior to posterior (SLAP) lesions constitute a recognized clinical subset of complex shoulder pain pathologies. This rotator interval has a triangular shape in which the supraspinatus is superiorly located, the subscapularis inferiorly and the processus coracoideus medially. [19][20][4] Subsequently, as the understanding of the injury continued to unfold, rates of repair have steadily declined. Hill L, Collins M, Posthumus M. Risk factors for shoulder pain and injury in swimmers: A critical systematic review. 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. Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography. [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. [15], SLAP tear itself accounts for 80–90% of labral pathology in stable shoulder but it’s only found in 6% on arthroscopy. 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. World J. Type I concerns degenerative fraying with no detachment of the biceps insertion. That is usually the journal article where the information was first stated. [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. 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