At first the clinician can test the tenderness to palpation at the rotator interval which can be helpful in the diagnostic procedure. [46]. Smith R, Lombardo DJ, Petersen-Fitts GR, Frank C, Tenbrunsel T, Curtis G, Whaley J, Sabesan VJ. [53][54][55] A number of authors report good results in athletes, including those with sport-specific overhead demand requirements. Un desgarro del labrum superior del hombro (SLAP, por sus siglas en inglés) es un tipo específico de lesión en el hombro. 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. 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. Glenoid labrum tears related to the long head of the biceps. A detailed sensory examination should take place in all acute and chronic instability patients. [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%). Intervention and outcome: A conservative chiropractic treatment plan in addition to physical therapy was initiated. The resulting tear of the labrum can then be debrided or fixed depending upon the severity of the tear. 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. lesión SLAP (Superior Labrum Anterior to Posterior) es una lesión de la parte superior del labrum glenoideo del hombro, generalmente centrada en la inserción del tendón de la cabeza larga del músculo bíceps braquial, aunque puede extenderse e involucrar al labrum anterior y posterior, así como estructuras circundantes. A systematic approach to diagnosis is essential to exclude life-threatening presentations of shoulder pain such as myocardial infarction or aortic dissection. [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. CORR 2012. Nonoperative management modalities include: Anti-inflammatory medications, cryotherapy/cooling/ice application, rest and activity modification. If you know where these structures are situated, you can try to palpate the rotator interval.[20]. [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. Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes. The involved shoulder is positioned at neutral, the elbow is flexed to 90 degrees, the forearm is supinated, and the patient makes a fist. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Chronic instability patients will almost always exhibit at least a mild degree of asymmetry. The ultimate goal of fixation for all repair techniques is to provide a robust and stable fixation, promoting the stability of the glenohumeral joint and allowing for adequate rehabilitation without failure of repair.[9]. Athletes and overhead laborers should also be placed on a restricted sport-specific timeline protocol, and manual laborers should receive appropriate occupational modifications. Burkhart SS, Morgan CD. previously demonstrated that the tendon of the long head of the biceps contains a complex network of sensory and sympathetic nerve fibers. Glenoid labrum tears related to the long head of the biceps. The physical requirements of military service may contribute to an increased. The findings can be rather subtle, especially in obese patients. Describe treatment considerations for patients with superior labral anterior to posterior (SLAP) lesions. By weeks five to six, strengthening exercises are started, and active external rotation and abduction motions are allowed. In these situations, evaluating the patient’s history of repetitive overhead activity or general functional history will help isolate suspicion towards the superior labrum. Varacallo M, Tapscott DC, Mair SD. The patient reported 75% . 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. SLAP tears involve the superior glenoid labrum, where the long head of bicepstendon inserts. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) Superior labral anterior to posterior (SLAP) lesions constitute a recognized clinical subset of complex shoulder pain pathologies. In 2005, an MRI analysis of professional handball players demonstrated abnormalities in 93% of shoulders, with only 37% being symptomatic.[48]. Please enter a valid 5-digit Zip Code. Park JY, Chung SW, Jeon SH, Lee JG, Oh KS. The odds ratio for revision surgery was 3.5 in the setting of LHBT tendinitis alone. et al., Rehabilitation Exercises for Athletes With Biceps Disorders and SLAP Lesions: A Continuum of Exercises With Increasing Loads on the Biceps. Superior Scapes, Liverpool, New York. When refering to evidence in academic writing, you should always try to reference the primary (original) source. The beam can otherwise be rotated while the patient is neutral in the coronal plane. El labrum glenoideo, recordemos, es un anillo de fibrocartílago que aumenta el diámetro efectivo de la glenoides respecto a la cabeza humeral. [26], In contrast, a sublabral hole or sublabral foramen is typically located at the 12 to 2 o’clock position. Indeed, Snyder et al found partial-thickness or full-thickness rotator cuff disease in 55 (40%) of 140 patients with SLAP lesions. SLAP Lesions: Trends in Treatment. Athletes and overhead laborers should also be placed on restricted sport-specific timeline protocol, and manual laborers should receive appropriate occupational modifications. [27], Alpantaki et al. [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. 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%). Adolescent Posterior-Superior Glenoid Labral Pathology: Does Involvement of the Biceps Anchor Make a Difference? Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. [31], When conservative treatment fails, a surgical approach is in order. Any evidence of significant muscular weakness may hint at an underlying associated neurologic deficit. Scapulothoracic motion and scapular winging should also be evaluated during active and passive motion. Onyekwelu I, Khatib O, Zuckerman JD, Rokito AS, Kwon YW. 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. advertisement. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. SLAP lesions are difficult to diagnose as they are very similar to those of instability and rotator cuff disorders. Clinicians should inquire regarding certain history elements that may help differentiate SLAP tears from other shoulder injuries. Moreover, the macroscopic attachment types correlated to the specimen histologic sectioning observed in the sagittal section. 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. 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. SLAP stands for "superior labrum, anterior to posterior"—in other words, "the top part of the labrum, from the front to the back." It refers to the part of the labrum that is injured, or torn, in a SLAP injury. Specific attention should be paid to scapulothoracic motion, as altered mechanics of the global shoulder complex can be the result of or a contributing factor to SLAP tears. NSAIDs and cryotherapy device/ice pack application can be beneficial for pain control. Clinicians should obtain a true anteroposterior (AP) image of the glenohumeral joint (also known as the “Grashey” view). Additionally, specific biceps testing can be used; however, they are not reliable for SLAP tears as they can be positive with other pathologies. 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. Aflatooni JO, Meeks BD, Froehle AW, Bonner KF. This means your labrum is. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) Initially rest post the acute (or acute-on-chronic) injury should be implemented. The Journal Of Orthopaedic And Sports Physical Therapy, 1985;6(4):225-228, KOZIAK A. et al, Magnetic resonance arthrography assessment of the superior labrum using the BLC system: age-related changes mimicking SLAP-2 lesions. Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography. et al, The recognition and treatment of superior labral (SLAP) lesions in the overhead athlete. National trends in the diagnosis and repair of SLAP lesions in the United States. In throwing athletes, a progressive throwing program that is directed toward the patients' specific sport and position can be initiated after 3 months.[2]. Their findings show no difference between the two age groups. Rehabilitation after surgery is dependent upon several factors. [36], Mayo Shear Test (also known as the Modified O’Driscoll Test or the Modified Dynamic Labral Shear Test: Int. [11], It is important to keep in mind that the scapula is an important factor during shoulder movements. [1], In various patient populations, internal impingement is also a culprit of SLAP tears. [2][9][6][12], Non-operative management focuses on the initial restriction of provoking maneuvers. Erickson BJ, Jain A, Abrams GD, Nicholson GP, Cole BJ, Romeo AA, Verma NN. A sublabral recess or foramen can be misread as a labral tear. [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]. The long head of the biceps tendon attaches in the glenoid as part of the labrum at roughly 12:00. et al., A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. The Journal of Manual & Manipulative Therapy, 2001;9(2):71 – 83, WILK K.E. However, the study acknowledges that more than half of the treatment of patients who were initially prescribed non operative management failed and these patients went on to undergo arthroscopic surgery. Often seen in association with shoulder instability and anterior labral tears. There is a wide variety of pathology, and patient-specific characteristics and goals heavily influence treatment options. Guanche CA, Jones DC. Holtby R, Razmjou H. Accuracy of the Speed's and Yergason's tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes. This can lead to instability and, ultimately, impingement of the superior labrum with degenerative tearing. Rowbotham EL, Grainger AJ. 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. Superior labrum is more weakly attached to glenoid than inferior labrum. Search doctors, conditions, or procedures . SLAP lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization. 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., 2012;40(9):2105-2112, COOLS A .M. Risk Factors for Revision Surgery After Superior Labral Anterior-Posterior Repair: A National Perspective. Sports. [36] 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%. An anatomical study of 100 shoulders. ), which permits others to distribute the work, provided that the article is not altered or used commercially. The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs. [Updated 2022 Jul 6]. In the age category 60 years or older, circumferential lesions have been identified. Am J Sports Med., 2010;38:1456–1461, SACCOL M.F. Common SLAP-provoking sports include but are not limited to: Overhead sports (volleyball, baseball pitchers, javelin, swimming), History or current manual/physical laborer occupations, Atraumatic, insidious onset of anterior shoulder pain, Symptom exacerbation with overhead activities, Pain radiating down the anterior arm from the shoulder, Clicking or audible popping reported in the setting of proximal biceps instability. Oper Tech Sports Med, 2012;20 (1):46 – 56, MYERS J.B. et al., Sensorimotor deficits contributing to glenohumeral instability. [13][14], The highest incidence rates of SLAP lesions present in the 20- to 29-year-old and 40- to 49-year-old age groups. Determining the onset of symptoms and mechanism (trauma, dislocation, or exacerbating maneuvers with overhead activity) can clue an examiner into labral pathology. The examiner then applies terminal external rotation until resistance is appreciated. [16] For those with atrophy, weakness, or continued pain, surgical decompression is indicated. Brockmeier SF, Voos JE, Williams RJ, Altchek DW, Cordasco FA, Allen AA., Hospital for Special Surgery Sports Medicine and Shoulder Service. http://creativecommons.org/licenses/by-nc-nd/4.0/. While elite athletes and young patients typically undergo repair, these techniques provide satisfactory results for a wide variety of patients. 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. Tenodesis can be performed by subpectoral, all-arthroscopic, and mini-open techniques. Surgical treatment: SLAP repair versus resection. The examiner initially supports the elbow, and a positive test occurs if the elbow does not maintain this position upon the examiner removing the supportive force. SLAP tears involve the superior glenoid labrum, where the long head of biceps tendon inserts. For the treatment of SLAP lesion one uses often a medical treatment where the surgeon uses advanced arthroscopic techniques. Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction. If necessary, NSAID’s and intra-articular corticosteroid injections can be applied to help diminish complaints. 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. Type VII: a superior labrum and biceps tendon separation that extends anteriorly, inferior to the middle glenohumeral ligament. The rotator interval is an anatomic space between the Supraspinatus tendon, the Subscapularis tendon and the processus coracoideus. SLAP lesions demonstrate a predilection for young laborers, overhead athletes, and middle-aged manual laborers. Superior labrum anterior posterior lesions.Available: PROVENCHER M.T. The upper, or superior, part of your labrum attaches to your biceps tendon. [9]Isolated SLAP lesions are uncommon. Focus on stretching the posterior capsule is also a focus of rehabilitation. Superior labrum anterior to posterior lesions and the superior labrum. The study was a one year follow-up study of with 19 patients. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Patients often complain of vague, deep shoulder pain and mechanical clicking with exacerbating activities. A physical exam led to differential diagnoses of a Superior Labrum Anterior to Posterior (SLAP) lesion, Bankart lesion, and bicipital tendinopathy. In the setting of chronic anterior instability, the clinician may appreciate a palpable anterior fullness. As symptoms diminish, a structured rehabilitation protocol focusing on rotator cuff and pericapsular strengthening exercises are utilized. The avulsed area is now devoid of cartilage in the zone of injury. SLAP lesions are considered as separate entities from other labral tears because the superior labrum is the attachment site of the long head biceps tendon. [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. Chang D, Mohana-Borges A, Borso M, Chung CB. Dougherty MC, Kulenkamp JE, Boyajian H, Koh JL, Lee MJ, Shi LL. 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]. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. It is associated with pain and instability and an inability of the patient to perform overhead movements. Tennent D, Pearse E. A Percutaneous Knotless Technique for SLAP Repair. 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. This factor may have a potential impact on patients experiencing persistent pain following various types of SLAP repairs. Snyder et al. Also, a wide array of implant options are available depending on surgeon preference. Access free multiple choice questions on this topic. IF < 50% of the biceps tendon is affected, consider SLAP repair/resection. 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 … 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. Trends in the early 2000s showed an increase in SLAP repairs. Between week 4 and 8, internal and external rotation ROM are progressively increased to 90° of shoulder abduction. A stabilizing role of the glenoid labrum: the suction cup effect J Shoulder Elbow Surg. The incidence of SLAP tears is a controversial topic in the current literature. Active strengthening of the biceps is still avoided. Initial reported performance of these tests has not been reproduced by independent investigat … Zhang AL, Kreulen C, Ngo SS, Hame SL, Wang JC, Gamradt SC. Rossy W, Sanchez G, Sanchez A, Provencher MT. A tear of the labrum below the middle of the glenoid socket that also involves the inferior glenohumeral ligament is called a Bankart lesion. [13][14], The glenoid labrum is often involved in shoulder pathology. [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%). [1][2]  Snyder developed the initial 4-subtype classification of these lesions. In: StatPearls [Internet]. 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]. It also becomes more brittle with age, and can fray and tear as part of the aging process. [24]  These four types were described based on macroscopic observation of 105 cadaveric shoulder specimens: Tuoheti et al. [19][21] The recent overlying trend appears to favor tenodesis rather than repair; however, the decision for the type of intervention remains patient-specific. AJSM 2013. Care must be taken to avoid exercises activating the biceps. Glenohumeral internal rotation deficit (GIRD) is a common associated finding in throwing athletes. [12]They may also report a loss of velocity and accuracy along with discomfort in the shoulder. Phys Ther., 1986;66:1855-1865, CARMICHAEL S.W. SLAP (superior labrum anterior and posterior) tears are injuries to the uppermost part of the labrum, where the biceps tendon attaches to the shoulder. 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. Ek ET, Shi LL, Tompson JD, Freehill MT, Warner JJ. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. Weber et al. Initial physical examination includes visual inspection for gross asymmetry and muscle atrophy. 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]. Examiners should observe and compare bilateral shoulder girdles for any notable asymmetry, scapular posturing, muscle bulk comparison, or any atrophic changes. Typically, an MR arthrogram (MRA) is performed to evaluate the shoulder labrum. Superior Labrum Anterior to Posterior Tear (SLAP Lesions) Associated with Biceps Tenosynovitis. [15], SLAP tear itself accounts for 80–90% of labral pathology in stable shoulder but it’s only found in 6% on arthroscopy. SLAP lesions demonstrate a predilection for young laborers, overhead athletes, and middle-aged manual laborers. [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. Strength, stability and motion are the components of shoulder function that should be focused on during rehabilitation. Type I concerns degenerative fraying with no detachment of the biceps insertion. A positive test is noted if the patient reports pain over the bicipital groove and/or subluxation of the LHB tendon. [5], There remains debate regarding whether the so-called peel-back mechanism versus the deceleration phase of throwing is most responsible for the pathologic forces driving SLAP tears in overhead athletes. Several authors recommend against repair in these populations.[23][31]. Healing time constraints are critical. Taylor SA, Degen RM, White AE, McCarthy MM, Gulotta LV, O'Brien SJ, Werner BC. [57] Professional baseball pitchers demonstrate relatively inferior outcomes regarding return to play and return to prior performance level. [6] The former implicates the late-cocking phase of throwing, while the latter would theoretically implicate more traction-based mechanisms. Outcome of the isolated SLAP lesions and analysis of the results according to the injury mechanisms. Return to play after Type II superior labral anterior-posterior lesion repairs in athletes: a systematic review. [18][23], Operative intervention in adults has been reported to be successful between 80 and 97% of patients in several populations. Read more, © Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. Unlike Bankart lesions and ALPSA lesions, they are uncommonly (20%) associated with shoulder instability 5. et al., Non operative treatment of superior labrum anterior posterior tears - improvements in pain function and quality of life. 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. 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 typical symptom is intermittent pain that also occurs in overhead movements. [28], Finally, the Buford complex is a congenitally absent anterosuperior labrum plus a thickened cord-like middle glenohumeral ligament. 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. Poor outcomes after SLAP repair: descriptive analysis and prognosis. The patient places their hand on the contralateral (normal) shoulder in a “self-hug” position. 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. However, the achievement of adequate shoulder mobility is an important condition to begin resistance training. 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. [23][26][27][28][29][30] Non-overhead athletes return to sport at a consistently higher rate, although some patients inevitably are unable to return to participation. What causes it? Patterson BM, Creighton RA, Spang JT, Roberson JR, Kamath GV. It contains the coracohumeral and the superior glenohumeral ligament, the biceps tendon and the anterior joint capsule. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. The rotator cuff muscles are important as well to anchor the scapula and guide the movement. SLAP tears are typically defined as superior labrum fraying/tearing from the glenoid. Original Editor - Kristin Sartore, Venugopal Pawar, Top Contributors - Venugopal Pawar, Lucinda hampton, Fasuba Ayobami, Kim Jackson, Rachael Lowe, Claire Knott, Amrita Patro, Wanda van Niekerk, Vasileios Tyros, Admin and WikiSysop. A total of four types of superior labral lesions involving the biceps anchor have been identified. Depending on location, it can lead to combined supraspinatus and infraspinatus weakness (suprascapular notch) or isolated infraspinatus atrophy (spinoglenoid notch).[15][16]. Outline the appropriate evaluation of superior labrum lesions (SLAP tears). Resisted elbow flexion, resisted forearm supination. Clinicians should focus on the potential relevance of the SLAP lesion as it attributes to the specific patient’s pain and dysfunction. They can extend into the tendon, involve the glenohumeral ligamentsor extend into other quadrants of the labrum. Summarize interprofessional team strategies for improving care coordination and communication to enhance outcomes for patients affected by superior labral anterior to posterior (SLAP) lesions. Also, posterior shoulder joint capsular contractures should be addressed with various stretching and strengthening programs. Find top doctors who treat Labral tears near you in Liverpool, NY. StatPearls Publishing, Treasure Island (FL). Additionally, classification and severity of the SLAP tear, in combination with concomitant pathology, affects the type of operative management selected. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. [24][25] Several of these studies, however, are heterogeneous and successful treatment is a matter of definition. Special tests that are helpful in this regard include the Spurling maneuver, myelopathic testing, reflex testing, and a comprehensive neurovascular exam. Initial evaluation of the shoulder typically starts with x-rays to rule out osseous pathology. Kwak SM, Brown RR, Resnick D, Trudell D, Applegate GR, Haghighi P. Anatomy, anatomic variations, and pathology of the 11- to 3-o'clock position of the glenoid labrum: findings on MR arthrography and anatomic sections. Sometimes morphological varieties can be confused with pathological aspects and therefore diagnosis should be established following careful analysis of the case history and a physical examination. There is increasing evidence that SLAP tears are frequently present on MRI in asymptomatic overhead athletes. Find a doctor near you. SLAP lesions first gained recognition in the 1980s. Arthroscopic all-intra-articular decompression and labral repair of paralabral cyst in the shoulder. Moreover, clinicians began reporting on the critical importance of differentiating younger, active patient populations (e.g., under 40 years old) and overhead athletes from the older patients (e.g., over 40 years old) with degenerative SLAP tears secondary to repetitive overhead manual laborer occupations. [38] 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. Stress distribution in the superior labrum during throwing motion. Type VI: an unstable flap tear of the labrum in conjunction with a biceps tendon separation. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. So there are conflicting views in the literature about the repairs in the older patients.[27]. Outcomes after arthroscopic repair of type-II SLAP lesions. [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. Other standard views include the axillary lateral view and “scapular Y”/outlet views. 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. Katz LM, Hsu S, Miller SL, Richmond JC, Khetia E, Kohli N, Curtis AS. Until now only one study looked at results from physical management on SLAP lesion. 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]. Am J Sports Med.,2014 ;42(6):1315-1322, WEBER S.C., Surgical management of the failed SLAP repair. 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. Results are widely varied in these athletes, demonstrating the return to the prior level of sport between 7% and 84%. SLAP lesions: a treatment algorithm. Previous studies have demonstrated non-operative management successful for 22 to 85% of patients. Popp D, Schöffl V. Superior labral anterior posterior lesions of the shoulder: Current diagnostic and therapeutic standards. Resistance exercises can be initiated at approximately 8 weeks post-operative, in which scapular strengthening should be emphasized. IF > 50% of the biceps tendon is affected, perform tenotomy/tenodesis, Surgical treatment: Bankart repair plus SLAP repair, Surgical treatment: Suture/anchor fixation of anterosuperior labrum plus SLAP repair, Surgical treatment: SLAP repair versus biceps tenotomy/tenodesis; gentle debridement of any cartilage/chondral unstable flap, Internal (including SLAP lesions, GIRD, little league shoulder, posterior labral tears), Partial- versus full-thickness tears (PTTs versus FTTs), Subluxation–often seen in association with SubSc injuries, Unidirectional instability–seen in association with an inciting event/dislocation (anterior, posterior, inferior), Suprascapular neuropathy–can be associated with a paralabral cyst at the spinoglenoid notch, Muscle ruptures (pectoralis major, deltoid, latissimus dorsi), Fracture (acute injury or pain resulting from long-standing deformity, malunion, or nonunion). Hippensteel KJ, Brophy R, Smith MV, Wright RW. 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. A shoulder SLAP tear is when the labrum frays or tears because of an injury. Erickson BJ, Jain A, Abrams GD, Nicholson GP, Cole BJ, Romeo AA, Verma NN. A total of four types of superior labral lesions involving the biceps anchor have been identified. Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum, and can often be confused with a sublabral sulcus on MRI. In the appropriate patient, NSAIDs and cryotherapy device/ice pack application can be beneficial for pain control. [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. Provocative Examination Testing/Maneuver: [40]. Additionally, adolescents also demonstrated successful outcomes with operative repair in regards to pain and function; however, there remain similar considerations regarding return to sport. [22] Tenotomy can lead to a cosmetic deformity with retraction of the biceps muscle. [15] Additionally, we now recognize that SLAP lesions commonly occur in asymptomatic overhead athletes. Zhang AL, Kreulen C, Ngo SS, Hame SL, Wang JC, Gamradt SC. It is important to discuss the patients’ activities such as athletics, profession, and baseline activity level. Weber SC, Martin DF, Seiler JG, Harrast JJ. It is essential to understand that not all SLAP tears are created equal. The patient is standing, and the arm of interest is positioned at 90 degrees of forward flexion, 10 degrees of adduction, and internally rotated so the thumb points toward the floor. [Updated 2022 Sep 4]. The examiner places his or her hand over the patient’s elbow while instructing the patient to resist the examiner’s downward force applied to the arm. Immediately post operative Patient will remain in an immobilizer for four weeks. Additional subtypes for type II tears, as well as additional tear patterns, were described in subsequent years. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Superior Labrum Anterior Posterior Lesions. [25], Another potential nidus predisposing certain patients to SLAP tears is the presence of a sublabral recess (or sublabral sulcus). SLAP - Superior Labrum Anterior to Posterior InjuryReparación Quirúrgica, por medio de Artroscopía de la Lesión de SLAP, que consiste en una lesión del Rodet. Increasing age, activity level, obesity, female sex, smoking, and concomitant shoulder pathology are risk factors for failure. Typically, SLAP lesions are from about 10:00 - 2:00 if you were to visualize a clock face. As pain recedes and range of motion is returned, dynamic strengthening exercises and sport-specific protocols are initiated. OK to begin biceps resistance exercises beyond 6 to 8 weeks postoperative. SLAP tear patients typically admit to resolution or reduction of symptoms at rest. Occur secondary to sudden jerking movements or after lifting heavy objects, Can occur after an unexpected pull on the arm. This decreases the normal shoulder function. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. Superior labrum anterior to posterior (SLAP) tears are a subset of labral pathology in acute and chronic/degenerative settings. Specific physical examination of SLAP tears is difficult as they typically present with other pathology in the shoulder. Thus, clinicians should remain cognizant of the known clinical ambiguity that may present with SLAP lesions recognized in isolation or association with other shoulder pathology. American journal of sports medicine,2009;37:2252-2258. What this means is that the labrum is torn at the superior (top) of the glenoid. Burkhart SS, Morgan CD, Kibler WB. 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. [Level 2-3]. Pathophysiology. If one were to liken the glenoid to a clock face, these occur in the 10 o’clock to 2 o’clock position. The true AP image is taken with the patient rotated between 30 and 45 degrees offset the cassette in the coronal plane. Presence of concomitant LHBT tendinitis or tendinosis: The odds ratio for revision surgery was 5.1 in the setting of LHBT tearing/fraying. That is usually the journal article where the information was first stated. These tears are common in overhead throwing athletes and laborers involved in overhead activities. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. [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. A sling with an abduction pillow is typically utilized with avoidance of external rotation and abduction. Tears of the glenoid labrum Waterman BR, Cameron KL, Hsiao M, Langston JR, Clark NJ, Owens BD. They may extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. Clinical testing for tears of the glenoid labrum. A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. [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. Alternatively, the biceps anchor may be sacrificed, and a biceps tenotomy or tenodesis performed. 163 likes. Specific testing of the supraspinatus muscle can be difficult when passive ROM is limited.

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