SLAP Lesion
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| What is the labrum? | Fibrous ring attached to the rim of the glenoid
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| 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)
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| LHB Tendon | Blends with superior labrum
Inserts into supraglenoid tubercle of scapula
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| 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
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| Bankart Lesion | Dislocation anterior-inferior & tear anterior-inferior labrum
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| 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
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| Classic description of labral tear patient | Shoulder pain with throwing activities & palpable clicking
Labral tears rarely seen w/o presence of instability
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| 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
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| 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
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| SLAP Tests- what should you put together? | Combine 2 sensitive tests with 1 specific test
70% sensitive & 95% specific
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| What are 3 sensitive tests for SLAP? | O'Brien
Apprehension
Compression Rotation
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| What are 3 specific tests for SLAP? | Speed's
Yergason's
Biceps load II
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| Type I SLAP Lesion | SLAP degenerated
Marked fraying with degenerative appearance
Periphery attached
Biceps firmly attached
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| 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
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| Type 3 SLAP Lesion | Bucket Handle tear
Central (Superior) portion displaced into joint while periphery firmly attached to glenoid
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| Type 4 SLAP Lesion | Bucket handle tear with extension into biceps
Labral flap tends to displace into joint
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| 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*
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| Treatment of Type 3 Tear | Excision of bucket handle
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| 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
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| Type 1 Post-Op Treatment | ROM as tolerated, no restrictions
Protect biceps 7-10 days
Return to sport in 2-4 wks
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| 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!
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| 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
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| 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
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| Moseley Core Scapular Exercises | Press-Ups from seated
Rows
Scapular Protraction/Push Up (+)
Elevation in Scapular Plane
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| 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
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| 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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