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CLINICAL
Pathology of the superior aspect of the glenoid labrum (SLAP lesion) poses a significant challenge the superior labrum in a subset of
to the rehabilitation specialist due to the complex nature and wide variety of etiological factors throwing athletes in 1985. Later
associated with these lesions. A thorough clinical evaluation and proper identification of the extent Snyder et al49 introduced the term
of labral injury is important to determine the most appropriate nonoperative and/or surgical
SLAP lesion, indicating an injury
management. Postoperative rehabilitation is based on the specific surgical procedure as well as the
extent, location, and mechanism of labral pathology and associated lesions. Emphasis is placed on
located within the superior labrum
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protecting the healing labrum, while gradually restoring range of motion, strength, and dynamic extending anterior to posterior.
They originally classified these le-
COMMENTARY
stability of the glenohumeral joint. The purpose of this paper is to provide an overview of the
anatomy and pathomechanics of SLAP lesions and review specific clinical examination techniques sions into 4 distinct categories
used to identify these lesions, including 3 newly described tests. Furthermore, a review of the based on the type of lesion
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
current surgical management and postoperative rehabilitation guidelines is provided. J Orthop present, emphasizing that this le-
Sports Phys Ther 2005;35:273-291. sion may disrupt the origin of the
Key Words: dynamic stability, glenohumeral, rehabilitation, shoulder long head of the biceps brachii49
(Figure 1). Subsequent authors
have added additional classifica-
T
he inherently complicated nature of injuries involving the tion categories and specific sub-
superior aspect of the glenoid labrum can present a types, further expanding on the 4
substantial clinical challenge. Successful return to unre- originally described catego-
stricted function requires integrating the appropriate diag- ries.15,29,33 Based on these subtle
Journal of Orthopaedic & Sports Physical Therapy®
and numerous published materials. Vascularity of the labrum decreases with increasing
age.10 No mechanoreceptors have been identified
Normal Anatomy and Biomechanics of the Glenoid within the glenoid labrum.53 However, free nerve
Labrum endings have been isolated in the fibrocartilagenous
The total surface of the humeral head is approxi- tissue of the labrum, the biceps-labrum complex, and
mately 4 times larger than that of the glenoid, the connective tissue surrounding the labrum.19,53
The glenoid labrum enhances shoulder stability in
contributing to the tremendous joint mobility avail-
4 distinct ways: (1) it produces a ‘‘chock-block’’ effect
able at the glenohumeral joint. Glenohumeral stabil-
between the glenoid and the humeral head that
Journal of Orthopaedic & Sports Physical Therapy®
CLINICAL
showed that 7 of 8 of the in-line loading group failed
cord-like middle glenohumeral ligament that blended in the midsubstance of the biceps tendon, with 1 of 8
with the anterior superior labrum, with the absence fracturing at the supraglenoid tubercle. However, all
of any anterior superior labrum from the 12- to the 8 of the simulated peel-back group failures resulted
3-o’clock position (in a right shoulder) on the in a type II SLAP lesion. The ultimate strength of the
glenoid. The authors recommended not treating this biceps anchor was significantly different when the 2
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variation surgically as it does not appear to lead to loading techniques were compared. The biceps an-
instability and/or pain when present in isolation. chor demonstrated significantly higher ultimate
COMMENTARY
strength with the in-line loading (508 N) as opposed
Pathomechanics of SLAP Lesions to the ultimate strength seen during the peel-back
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
There are several injury mechanisms that are loading mechanism (202 N).
speculated to be responsible for creating SLAP le- A subsequent follow-up study at our center evalu-
sions. These mechanisms range from single traumatic ated the same mechanisms of injury pattern (peel-
events to repetitive microtraumatic injuries. Trau- back versus in-line loading) in 7 paired cadaveric
matic events, such as falling on an outstretched arm models following repair of a SLAP II lesion.12 The
or bracing oneself during a motor vehicle accident, results were similar to those published by Sheppard
may result in SLAP lesions due to compression of the et al on intact structures,47 with a 51% lower load to
superior joint surfaces superimposed with subluxation failure in the peel-back group compared to the
of the humeral head. Snyder et al49 referred to this
Journal of Orthopaedic & Sports Physical Therapy®
130 overhead athletes with symptomatic hyper laxity bucket-handle tear of the labrum with an intact
undergoing thermal-assisted capsular shrinkage of the biceps insertion is the characteristic presentation of a
glenohumeral joint (TACS), 69% exhibited superior type III SLAP lesion. Type IV SLAP lesions have a
labral degeneration, while 35% had type II SLAP bucket-handle tear of the labrum that extends into
lesions. Furthermore, Pagnani et al38 reported that
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
anterior instability. Because this position is remark- descriptions for types V through VII.29 Type V SLAP
ably similar to the cocking position of the overhand lesions are characterized by the presence of a Bankart
throwing motion, the finding of instability may cause lesion of the anterior capsule that extends into the
or facilitate the progression of internal impingement anterior superior labrum. Disruption of the biceps
(impingement of the infraspinatus on the tendon anchor with an anterior or posterior superior
posterosuperior glenoid rim) in the overhead athlete. labral flap tear is indicative of a type VI SLAP lesion.
Type VII SLAP lesions are described as the extension
of a SLAP lesion anteriorly to involve the area
CLASSIFICATION OF SLAP LESIONS inferior to the middle glenohumeral ligament. These
3 types typically involve a concomitant pathology in
Because the glenoid labrum is involved in the
stability of the glenohumeral joint, pathological con- conjunction with a SLAP lesion. Thus, the surgical
ditions of the labrum appear in cases of instability, treatment and rehabilitation will vary based on these
whether due to repetitive loads or frank traumatic concomitant pathologies. A detailed description of
injury.6,29,31,34 Clinically these instabilities may be these variations is beyond the scope of the current
either gross or subtle. Although instability may occur, paper.
SLAP lesions most often result in symptoms of Three distinct subcategories of type II SLAP lesions
mechanical pain and dysfunction, rather than insta- have been further identified by Morgan et al.33 They
bility. reported that in a series of 102 patients undergoing
CLINICAL
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C D
COMMENTARY
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®
FIGURE 3. Illustration of type I-IV SLAP lesions. Type I represents a frayed and/or degenerative labrum with a firm attachment of the labrum
to the glenoid (Figure 3A). Type II represents a detachment of the superior labrum and biceps attachment from the glenoid rim (Figure 3B).
Type III represents a bucket-handle tear of the labrum with an intact biceps anchor (Figure 3C). Type IV represents a bucket-handle tear of
the labrum that extends into the biceps tendon (Figure 3D). Reproduced with permission from Snyder et al.49
arthroscopic evaluation 37% presented with an present with posterosuperior lesions, while individuals
anterosuperior lesion, 31% presented with a who have traumatic SLAP lesions typically present
posterosuperior lesion, and 31% exhibited a com- with anterosuperior lesions. These variations may
bined anterior and superior lesion.33 These findings become important when selecting which special tests
are consistent with our clinical observations. In the to perform based on the patient’s history and mecha-
authors’ experience, the majority of overhead athletes nism of injury.
CLINICAL
pathology. Pain provocation using this test is com-
mon, which challenges the validity of the results. In
the authors’ experience, the presence of deep and
diffuse glenohumeral joint pain is most indicative of
the presence of a SLAP lesion. Pain localized in the
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COMMENTARY
FIGURE 6. A new test for detecting SLAP lesions, the dynamic
posterior shoulder symptoms are indicative of pro- Speed’s test. The examiner resists forward shoulder elevation and
vocative strain on the rotator cuff musculature when elbow flexion simultaneously as the arm is elevated overhead in an
attempt to provide tension on the superior labrum. (Video available
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
simultaneously rotating the humerus externally with to increase tension on the biceps and subsequently
the hand holding the elbow (Figure 7). The mecha- the labral attachment. When maximal ER is achieved,
nism of this test is similar to that of a McMurray’s test the patient is instructed to perform a resisted isomet-
of the knee menisci, where the examiner attempts to ric contraction of the biceps to simulate the peel-back
mechanism (Figure 9). This test combines the active
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
CLINICAL
McFarland et al30 evaluated the ability of 3 clinical
tests to predict the presence of labral pathology. In
this investigation 3 tests (active-compression test,
anterior-slide test, and compression-rotation test)
FIGURE 10. A new test for detecting SLAP lesions, the resisted
were performed on 426 patients who subsequently
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supination external-rotation test. The patient is passively positioned underwent arthroscopic examination. Of these pa-
at 90° of abduction, 65° to 70° of elbow flexion, and neutral tients, 39 had type II through IV SLAP lesions, while
COMMENTARY
rotation. The examiner simultaneously resists forearm supination 387 had type I lesions. The active-compression test
during passive shoulder external rotation in an attempt to peel back was found to be the most sensitive and have the
the labrum. (Video available at www.jospt.org.)
highest predictive value, although both values were
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
bicipital contraction of the biceps load test with the low (47% sensitivity, 10% positive predictive value).
passive ER in the pronated position similar to the The anterior-slide test was the most specific maneu-
pain provocation test. ver, with an 84% specificity. All 3 tests were found to
SURGICAL MANAGEMENT
have high associated accuracy, although the majority
Conservative management of SLAP lesions is often
of patients presented with only type I lesions. It is
unsuccessful, particularly of type II and IV lesions
also interesting to note that the presence of clicking
with labral instability and underlying shoulder insta-
and the location of pain was not a reliable predictor
bility. Therefore, surgical intervention is most often
of the presence or severity of labral involvement.
warranted to repair the labral lesion while addressing
Stetson et al51 similarly examined the reliability and
any concomitant pathology. In the event that an
validity of the crank test, active-compression test, and
athlete does undergo conservative rehabilitation,
enhanced MRI. MRI was determined to have the
many of the same principles discussed in the upcom-
greatest specificity (92%), positive predictive value
ing sections may be applied.
(63%), and negative predictive value (83%). Of the 2
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CLINICAL
reattachment of the superior labrum, is generally cal intervention involving the superior glenoid
performed. However, if the biceps tear is extensive labrum is dependent on the severity of the pathology
enough to substantially alter the biceps origin, a and should specifically match the type of SLAP
biceps tenodesis is more practical than a direct repair. lesion, the exact surgical procedure performed
In addition to the treatment of the SLAP lesion, (debridement versus repair), and other possible con-
comitant procedures performed because of the un-
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COMMENTARY
and treated at the time of surgery. present. Overall, emphasis should be placed on
restoring and enhancing dynamic stability of the
Operative SLAP Repair Surgical Technique glenohumeral joint, while at the same time ensuring
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
from approximately the 11- to the 1-o’clock positions injuries should avoid heavy resisted or excessive
of the glenoid (in a right shoulder). The bony area eccentric biceps contractions. Furthermore, patients
of attachment is abraded to create a bleeding bed to with peel-back lesions, such as overhead athletes,
facilitate healing. The repair surface of the labrum is should avoid excessive amounts of shoulder ER while
also gently debrided to stimulate a healing response. the SLAP lesion is healing. Thus the mechanism of
Two suture anchors are usually adequate to secure injury is an important factor to individually assess
the biceps anchor and superior labrum. Our center when determining appropriate rehabilitation guide-
prefers to use bioabsorbable suture anchors with lines for each patient.
number 2 braided nonabsorbable sutures loaded on Although the efficacy of rehabilitation following
the eyelet. The number of anchors utilized is based SLAP repairs has not been documented, the follow-
on the size of the SLAP lesion present. The suture ing sections will overview guidelines based on our
anchors are positioned so that each one splits the clinical experience and basic science studies on the
difference between the biceps and the normal area of mechanics of the glenoid labrum and pathomechan-
labral insertion, usually at the 11:30 and 12:30 ics of SLAP lesions.2,7,10,11,35,36,38,43,44,46,47,53,60,62
positions on a clock face. The suture anchors are
placed at the junction of the articular cartilage and
Debridement of Type I and III SLAP Lesions
cortical bone. The security of anchor fixation is
tested with a firm pull on the sutures. Once the Type I and type III SLAP lesions normally undergo
suture anchors are in place, one end of each suture is a simple arthroscopic debridement of the frayed
Week 2
Exercises
• Initiate isotonic program with dumbbells
- Shoulder musculature
- Scapulothoracic
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Decrease pain/inflammation
• Continue use of modalities, ice, as needed
Week 3
Exercises
• Thrower’s ten program
• Emphasis rotator cuff and scapular strengthening
• Dynamic stabilization drills
III. Phase 3: dynamic-strengthening phase, advanced-strengthening phase (weeks 4-6)
Goals
• Improve strength, power, and endurance
• Improve neuromuscular control
• Prepare athlete to begin to throw, etc
Criteria to enter phase 3
• Full nonpainful AROM and PROM
• No pain or tenderness
• Strength 70% compared to contralateral side
Exercises
• Continue thrower’s ten program
• Continue dumbbell strengthening (supraspinatus, deltoid)
• Initiate tubing exercises in the 90°/90° position for ER/IR (slow/fast sets)
CLINICAL
Abbreviations: AB, abduction; AAROM, active assisted range of motion; ER, external rotation; IR, internal rotation; LE, lower extremity; MMT,
manual muscle test; NSAIDS, nonsteroidal anti-inflammatory drugs; PNF, proprioceptive neuromuscular facilitation; PROM, passive range of
motion; ROM, range of motion; UE, upper extremity.
labrum without an anatomic repair. Table 3 outlines raises, are also included. Weighted resistance begins
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the rehabilitation program following this type of at 0.45 kg (1 lb) and advances by 0.45 kg per week in
a gradual, controlled, progressive-resistance fashion.
COMMENTARY
procedure. This program can be somewhat aggressive
in restoring motion and function because the biceps- This progression is used to gradually challenge the
labral anchor is stable and intact. The rate of musculature. Light biceps resistance is usually not
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
progression during the course of postoperative reha- initiated until 2 weeks following surgery in an at-
bilitation is based on the presence and extent of tempt to prevent debridement site irritation. Further-
concomitant lesions. If, for example, significant rota- more, caution should be placed on early over-
tor cuff fraying (partial thickness tear) is present and aggressive elbow flexion and forearm supination exer-
treated with arthroscopic debridement, the rehabilita- cises, particularly eccentric exercises.
As the strengthening program progresses after this
tive program must be appropriately adapted. Gener-
type of surgical procedure, the emphasis of rehabilita-
ally, a sling is worn for comfort during the first 3 to 4
tive interventions should be on obtaining muscular
days following surgery. Active-assistive range of mo-
balance and promoting dynamic shoulder stability.
tion (AAROM) and passive range of motion (PROM)
Journal of Orthopaedic & Sports Physical Therapy®
believe that it is important to determine the extent of first 8 weeks to protect healing of the biceps anchor.
the lesion and understand its exact location and Neuromuscular control drills are integrated, as toler-
number of suture anchors in constructing an appro- ated, to enhance dynamic stability of the shoulder.
priate rehabilitation program. For instance, the rate These include rhythmic stabilization and perturbation
of rehabilitation progression would be slower for a drills incorporated into manual-resistance and exer-
SLAP repair completed with 3 anchors than for a cise tubing exercises (Figures 13 and 14).
1-anchor repair, based on the extent of the pathology Aggressive strengthening of the biceps is avoided
and tissue involvement. Postoperative rehabilitation is for 12 weeks following surgery. Furthermore, weight-
delayed to allow healing of the more extensive bearing exercises are typically not performed for at
anatomical repair required to reattach the biceps least 8 weeks to avoid compression and shearing
tendon anchor in a type II lesion, in comparison to forces on the healing labrum. Two-hand plyometrics,
type I and III lesions (Table 4). as well as more advanced strengthening activities, are
The patient is instructed to sleep in a shoulder allowed between 10 and 12 weeks, progressing to the
immobilizer and wear a sling during the daytime for initiation of an interval sport program at postopera-
the first 4 weeks following surgery to protect the tive week 16. The same criteria described previously
healing structures from excessive motion. Gradual are utilized to determine if an interval sport program
ROM in a protective range is performed for the first is initiated. Return to play following the surgical
4 weeks below 90° of elevation to avoid strain on the repair of a type II SLAP lesion typically occurs at
labral repair.60 During the first 2 weeks, internal and approximately 9 to 12 months following surgery.
CLINICAL
Week 3-4
• Discontinue use of sling at 4 weeks
• Sleep in immobilizer until week 4
• Continue gentle ROM exercises (PROM and AAROM)
- Flexion to 90°
- Abduction to 75°-85°
- ER in scapular plane to 25°-30°
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COMMENTARY
• No active ER, extension, or elevation
• Initiate rhythmic stabilization drills
• Initiate proprioception training
• Tubing ER/IR at 0° abduction
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
• Continue isometrics
• Continue use of cryotherapy
Week 5-6
• Gradually improve ROM
- Flexion to 145°
- ER at 45° abduction: 45°-50°
- IR at 45° abduction: 55°-60°
• May initiate stretching exercises
• May initiate light (easy) ROM at 90° abduction
• Continue tubing ER/IR (arm at side)
Journal of Orthopaedic & Sports Physical Therapy®
• No pain or tenderness
Weeks 20-26
• Continue flexibility exercises
• Continue isotonic strengthening program
• PNF manual-resistance patterns
• Plyometric strengthening
• Progress interval sport programs
V. Phase 5: return-to-activity phase (months 6 to 9)
Goals
• Gradual return to sport activities
• Maintain strength, mobility and stability
Criteria to enter phase V
• Full functional ROM
• Muscular performance isokinetic (fulfills criteria)
• Satisfactory shoulder stability
• No pain or tenderness
Exercises
• Gradually progress sport activities to unrestrictive participation
• Continue stretching and strengthening program
Abbreviations: ROM, range of motion; ER, external rotation; IR, internal rotation; PROM, passive range of motion; AAROM, active assisted range
of motion; PNF, proprioceptive neuromuscular facilitation.
FIGURE 12: Sidelying manual resistance external rotation. The clinician may resist external rotation as well as scapular retraction with the
proximal hand (A). End range rhythmic stabilizations and perturbations may be incorporated to enhance neuromusclar control (B).
CLINICAL
authors to learn more about these ap-
proaches.56,61,62,63
COMMENTARY
or tenodesis follows much the same postoperative
rehabilitation course as that outlined for a type II
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
SUMMARY
FIGURE 14. Perturbation and rhythmic stabilization drills incorpo- A wide variety of pathology may affect the superior
rated into external rotation at 90° abduction with exercise tubing. aspect of the labrum. Clinical examination is often
difficult due to the numerous injury mechanisms and
Often a type II SLAP repair may be performed various extent of labral pathology. Proper identifica-
with a concomitant glenohumeral stabilization proce- tion of the exact mechanism and specific severity of
dure, such as a thermal capsular shrinkage, pathology is vital to accurately diagnose and manage
arthroscopic plication, or Bankart repair. In these these injuries. Surgical procedures to address SLAP
WG, eds. Injuries to the Throwing Athlete. Philadelphia, labral tears. Arthroscopy. 1995;11:296-300.
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arthrography of the shoulder. Radiology. 2000;214:267- 26. Kim SH, Ha KI, Han KY. Biceps load test: a clinical test
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
CLINICAL
deltoid musculature during common shoulder external tion of the glenohumeral joint: emphasis on the stabiliz-
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COMMENTARY
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Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
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Journal of Orthopaedic & Sports Physical Therapy®