This article will focus on SLAP tears, which are one of the most common form of labral tear. Another common labral pathology is a Bankhardt lesion.
The acronym “SLAP” stands for Superior Labrum Anterior-Posterior, and is used to describe a tear or detachment of the shoulder’s labrum; generally originating at the anchor site for the long head of the biceps tendon and extending into anterior or posterior portions of the labrum. (1) This pathology is fairly common, in fact up to 1/4 of patients undergoing shoulder arthroscopy for any diagnosis will demonstrate a SLAP lesion (2,3). The labrum of the shoulder is a circumferential rim of fibrocartilage that surrounds the entire perimeter of the glenoid fossa (on the scapula) (4-6). The labrum shares some similar characteristics with the knee’s meniscus. (7) The inferior labrum is typically tightly attached to the bony glenoid rim, while the superior labrum is more “meniscus like” with a less secure union. (8)
The labrum serves as an attachment for tendons and ligaments and also deepens the glenoid fossa by 5-9 mm (4,10). Fifty percent of the glenoid depth is attributable to the labrum (11).
How do labral tears occur?
Labral tears may occur abruptly from injury or develop more slowly from repetitive microtrauma. (14) The forces associated with a labral injury typically include either superior compression or sudden inferior traction (14). Traumatic onsets, including a fall or direct blow to the shoulder, are responsible for almost 1/3 of all SLAP lesions. (14) The most common mechanism of acute injury involves a fall onto an outstretched arm. (14) SLAP lesions are common in athletic populations, particularly those requiring overhead motions that encourage the biceps to “pull” the labrum from its underlying bony attachment (1,15). In healthy shoulders, the long head of the biceps stabilizes the shoulder by generating compressive forces that limit translation, thereby, protecting the shoulde (16). The biceps also depresses the humeral head to protect the labrum and subacromial contents during arm lifting. Conversely, repetitive contraction of the biceps may trigger avulsion of its labral anchor – becoming progressively more problematic as the tear progresses (15). Chronic SLAP lesions do not typically occur in the absence of othershoulder problems; in fact, only 28% of SLAP tears are isolated problems (17). Chronic labrum issues are often associated with rotator cuff dysfunction. Weakened and irritated rotator cuff tendons lose their ability to hold the humeral head down within the glenoid cavity during arm lifting. Loss of this protective mechanism allows unchecked superior migration of the humeral head, and over time has the ability to “lift” the labrum from its attachment (14). Not surprisingly, a high percentage (29-45%) of patients with SLAP lesions also demonstrate rotator cuff pathology (17-19).
SLAP lesions commonly occur in young active males. (20) Throwers may be particularly vulnerable as this activity subjects the biceps tendon and its labral attachment to significant strain (15,21). A history of trauma or instability increases the likelihood of SLAP lesion (3,21). However, in many cases, patients present without a history of trauma or predisposing activity. (21)
Symptoms of SLAP lesions:
SLAP lesion complaints can vary from asymptomatic to disabling. Symptomatic patients often describe a deep, vague, non-specific shoulder pain that is provoked by overhead and cross-body activity (20,21). Weakness and stiffness often accompany the disorder. Discomfort may limit athletic performance, particularly in overhead athletes who may complain of a “dead arm” (20,21). Complaints of popping, clicking, grinding or catching are common (20,21) Patients with more advanced lesions are likely to report symptoms associated with instability; i.e. (pinching, slipping, apprehension or “looseness”- especially during overhead activity). The Biceps Load II Test has shown relatively high sensitivity and specificity in identifying isolated SLAP lesions. (26,34) The test is performed with the patient’s shoulder abducted to 120 degrees and externally rotated. The clinician stabilizes the patient’s arm while passively externally rotating until end range or patient apprehension. The patient then attempts to flex their elbow against the clinician’s resistance. An increase in pain suggests a SLAP lesion, while a decrease in apprehension or pain makes a SLAP lesion unlikely.
Is imaging necessary for a SLAP lesion?
Because the clinical assessment of SLAP lesion is difficult, imaging is the mainstay of diagnosis (41). X-rays cannot identify the presence of a SLAP lesion; however, these studies may be useful to rule out differential considerations, including degeneration, dislocation, fracture, or pathology. Diagnostic ultrasound is a useful modality for imaging SLAP tears with an added benefit of receiving patient feedback while evaluating their injury. MRI is typically included in the initial workup for patients with suspected labral pathology (42). MR arthrography provides the highest sensitivity and specificity for detecting SLAP lesions (42-47,61).
Moreover, the significance of a confirmed labral tear is debatable since this finding is present in more than half of asymptomatic, middle-aged patients (48) .
Treatment options for SLAP tears:
Conservative management of SLAP lesions is frequently unsuccessful. (49-51). However, the presence of a SLAP lesion does not automatically necessitate surgical intervention. However, the imaged defect is not necessarily the primary contributor to the patient’s complaint. Most experts, including the American Academy of Orthopedic Surgeons, recommends a 6-12 week course of conservative management prior to considering surgical intervention (50-52). Non-surgical treatment correcting scapular dyskinesis and deficits in internal rotation has a reasonable success rate in MLB players with a documented SLAP lesion (64). Conservative treatment goals include pain reduction, enhancing mobility, and restoration of strength (51). Initial management includes anti-inflammatory medications/ modalities and cessation of provocative activities (i.e. throwing) (51). Flexibility programs are incorporated as symptoms allow.
Progressive strengthening of the scapular and rotator cuff musculature is implemented as tolerated. Strengthening exercises should focus on re-balancing strength between anterior (pec, upper traps) and posterior muscle groups (lower traps, serratus anterior, rhomboid).
Rehabilitation must restore serratus anterior strength and proper scapular function- thoroughly addressing regional biomechanical deficits including scapular dyskinesis and upper crossed syndrome, as well as more distant sites of dysfunction including the hip and trunk. Myofascial release may be directed at the subscapularis, infraspinatus, anterior shoulder musculature and the posterior capsule (53). Manipulation may be helpful to restore mobility to restricted cervical or thoracic segments.
Only 7-57% of elite overhead athletes are able to return to pre-injury level of competition following surgical SLAP repair. (63,64) The co-existence of a partial-thickness rotator cuff tear correlates with inability to return to this level of competition (63) Surgeons may elect to perform debridement, suturing, or excision based upon the type of lesion (54). Surgical intervention should address concurrent shoulder pathology; i.e. rotator cuff lesions, degeneration, instability, etc. (54). Surgical repair typically entails a four to six-month post-operative rehab (55).
At Creekside Chiropractic & Performance Center, we are highly trained to treat this condition. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
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