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SLAP Tear Notes
SLAP Lesion
| Question | Answer |
|---|---|
| What is the labrum? | Fibrous ring attached to the rim of the glenoid |
| Labrum Functions | Expands size & depth of glenoid Increases sup/inf diameter 75% & ant/post diameter 50% Primary attachment of capsule & GH ligs Sup. aspect attachment site for LHB (where tear typically occurs) |
| LHB Tendon | Blends with superior labrum Inserts into supraglenoid tubercle of scapula |
| Labrum Attachment | Meniscoid & has free edge extending over rim of glenoid onto articular surface May naturally be loose LHB tendon important for anterior stability Some biceps loading is good for joint stability |
| Bankart Lesion | Dislocation anterior-inferior & tear anterior-inferior labrum |
| Causes of SLAP | Biceps contracting eccentrically to decelerate extending elbow during follow-thru of throw Disruption of sup labrum-LHB complex involving tearing/separating sup labrum starting post to biceps tendon & extending anteriorly |
| Classic description of labral tear patient | Shoulder pain with throwing activities & palpable clicking Labral tears rarely seen w/o presence of instability |
| SLAP MOI | Forceful abd, ext, & ER Post. damage with force applied to humerus in direction of longitudinal axis with shoulder in 90 deg fwd flex Superior labrum with biceps tendon/traction or fall on outstretched, abd & fwd flexed arm |
| SLAP S/sx | Pain- greater with OH activity; "catching & popping" Strength > RTC injury but painful with resistance Pt. population of SLAP younger than RTC, OH athlete |
| SLAP Tests- what should you put together? | Combine 2 sensitive tests with 1 specific test 70% sensitive & 95% specific |
| What are 3 sensitive tests for SLAP? | O'Brien Apprehension Compression Rotation |
| What are 3 specific tests for SLAP? | Speed's Yergason's Biceps load II |
| Type I SLAP Lesion | SLAP degenerated Marked fraying with degenerative appearance Periphery attached Biceps firmly attached |
| Type 2 SLAP Lesion | Degenerated & fraying Sup. labrum & biceps tendon stripped off glenoid Labral-biceps anchor unstable & pulled off glenoid Most common SLAP tear Posterior 3x more common in throwers Anterior 3x more common in traumatic injuries |
| Type 3 SLAP Lesion | Bucket Handle tear Central (Superior) portion displaced into joint while periphery firmly attached to glenoid |
| Type 4 SLAP Lesion | Bucket handle tear with extension into biceps Labral flap tends to displace into joint |
| What is seen as a result of tight posterior-inferior shoulder capsule? | Hyper ER Hyper horizontal abd Dropped elbow Premature trunk rotation *All classic derangements of pitching mechanics* |
| SLAP Lesions in Throwers | Anterosuperior type 2 Posterosuperior type 2 COmbined anterior & posterior type 2 SLAP lesion Posteiror & combined type 2 SLAP are frequently observed in OH athlete & have unique dx & tx challenges separating them from anterosuperior type 2 |
| Peel-Back Mechanism | When a torsional force "peels back" the biceps & posterior labrum as the shoulder goes into extreme abd & ER during cocking phase of throwing LHB force shifts vertically & posteriorly (abd/ER) If initiated, peel back will repeat each time |
| Peel-Back Mechanism | Once it occurs, it causes progressive failure over time, with gradual enlargement of lesion Arm brought into abd/ER, LHB assumes vertical/posterior angle Angle produces twist at base of biceps, transmits torsional force to post/sup labrum |
| Clinical Implications of Peel-Back Mechanism | Has to be neutralized to surgically repair posterior SLAP lesion Requires at least 1 suture anchor stabilizing labrum posterior to biceps to effectively counter torsion Avoid PROM past 0 Wait 3 wks before allowing ER >0 |
| Treatment of Type 1 Tear | Torn & frayed debrided back to intact labrum Careful preservation of attachment of labrum & biceps tendon to glenoid More common than type 3 or 4 |
| Treatment of Type 2 Tear | Attention to torn labrum/LHP but also re-attachment of biceps anchro to superior glenoid neck Superor glenoid neck abraded to promote healing of detached labrum Creates a bleeding bond surface |
| Treatment of Type 3 Tear | Excision of bucket handle |
| Treatment of Type 4 Tear | Excision of bucket-handle, with resection continuing into the split portion of the biceps tendon Sometimes the split in the biceps tendon & the labrum can be repaired with sutures |
| Type 1 Post-Op Treatment | ROM as tolerated, no restrictions Protect biceps 7-10 days Return to sport in 2-4 wks |
| Type 2 Post-Op Treatment | Sling x4 weeks Full ROM by 6 wks Avoid biceps resistance x10-12 wks, no ER past neutral x4 wks, 40 deg x6 wks Interval throwing @4 months Throw from mound @6 months Full-velocity from mound @7 months Be sure to stretch post. capsule! |
| GIRD | Loss of GH IR of dominant shoulder compared to non-dominant Those with GIRD >20 deg or >10% total rotation in non-dominant shoulder may be at risk for SLAP lesions |
| Posterior Capsule | Contracture in posteroinferior quadrant of capsule in zone of posterior band of IGHL complex Stretch capsulotomy pt more aggressively so capsule doesn't scar back down |
| Moseley Core Scapular Exercises | Press-Ups from seated Rows Scapular Protraction/Push Up (+) Elevation in Scapular Plane |
| Type 3 Post-Op Treatment | ROM similar to type 1 but a couple weeks slower Protection same as type 1 Return to activity 2-4 wks |
| Type 4 Post-Op Treatment | Sling x3 wks, full ROM at 6 weeks Avoid biceps resistance x6 weeks if tenodesis or 10 wks if repaired Return to sport at 8-10 wks with excision & tenodesis Return to throwing at 3-4 months |
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