Introduction
• SLAP tears is Superior Labrum anterior posterior tears.
• an abnormality of the superior labrum usually centered on the attachment of the long head of the biceps tendon.
• lesion originates behind the biceps muscle tendon anchor and extends anteriorly to half of glenoid.
•
ETIOLOGY
The most common mechanism:
• fall on outstretched hand or direct blow to the shoulder.
• due to traction with sudden pull on the arm.
• Repetitive impacts or repetitive biceps tension from either throwing or overhead sports motion.
(Pecina & Bojanic, 2004)
PATHOLOGY
CLASSIFICATION OF SLAP LESION
Type I
: – demonstrates fraying and degeneration.
– attachment of the labrum to the glenoid: intact.
– biceps anchor : intact.
Type II
– superior labrum, biceps anchor detached from the
insertion on the superior glenoid
– Allow the complex to arch away from glenoid neck.
Type III
– a bucket-handle tear of the meniscoid superior
labrum.
– The remaining biceps tendon and labral rim
attachment : intact.
– similar to a bucket-handle tear of the knee
meniscus.
Type IV
– bucket-handle tear of the superior labrum with ex
tension into the biceps ancor.
– torn biceps tendon and the labral flap : displaced
into joint.
COMPLEX – combination of two or more SLAP
types most
– most commonly : types II and III/ types II and IV.
(Pecina & Bojanic, 2004)
CLINICAL FEATURES
• Pain around the shoulder when overhead or cross-body motion
• Mechanical symptom such as catching, locking, popping, or grinding.
• Weakness, stiffness and instability (Pecina & Bojanic, 2004)
(Manske & Prohaska, 2010)
DIAGNOSIS
• MR imaging
• Arthroscopy
(Pecina & Bojanic, 2004)
ASSESSMENT
• Observation general and local
• ROM: -reduce in ROM
– pain with passive external rotation at 90° of
shoulder abduction.
• MMT –rotator cuff muscles
(Dodson & Altchek, 2009)
DIFFERENTIAL DIAGNOSE
• Bursitis (Bursitis sign)
• Rotator cuff tear (Empty can test/ Codman’s sign)
TEST
1. reproduce a torsional traction force to the superior labrum (active tests): O'Brien's Test, Biceps Load Test 2.
2. reproduce a compressive force to the superior labrum (passive tests): Compression Rotation Test (Crank Test).
(Funk, 2009)
TEST EXPLAINATION
O’Brien’s test (high specificity)
(Manske & Prohaska, 2010)
• Sh. 90° flexion, 20° of adduction, and full internal rotation.
• Resistance against elevation by therapist.
• Positive: pain is elicited with the forearm in pronation, relieved when the forearm is supinated.
(Funk, 2009)
Compression Rotation Test/ Crank test (high sensitivity)
(Funk, 2009)
• Sh. abducted to 90 degrees
• slowly internally and externally rotated
• apply an axial compressive load through GH joint.
• Positive: pain and/ or catching deep in the shoulder joint.
(Funk, 2009)
Biceps Load Test 2 in equivocal cases
• supine, Sh. abducted to 120°, externally rotated maximally, elbow in 90° flexion and forearm supinated.
• Resist elbow flexion.
• Positive: increased pain during resisted elbow flexion.
(Kenyon & Kenyon, 2009)
TREATMENT
CONSERVATIVE
(Non-operative)
GOALS: to reduced pain, improve motion, restore strength
in pt. who do not wish to proceed to operative management.
• Usually for type I but there is only a few that success
• abstain aggravating activities to relief pain and inflammation.
• If necessary: NSAID’s and intra-articular corticosteroid injections
After pain has subsided,
PHYSIOTHERAPY MANAGEMENT:
• Restoring normal Sh. Motion
• Strengthening of Sh. Muscles
• Stretching posterior capsule
(Dodson & Altchek, 2009)
(OPERATIVE)
DOCTOR’S MANAGEMENT:
• Type I: The superior labrum is debrided back only to the stable rim.
• Type II: The labrum and the anchor of the caput longum of the biceps
muscles are fixated.
• Type III: with bucket-handle tear, the torn fragment is resected.
• Type IV: 1) In younger patients: an attempt to reconstruct the biceps-
labrum complex is recommended.
2) In older patients: resection and tenodesis of the caput
longum of the biceps muscle is performed.
(Pecina & Bojanic, 2004)
(POST-OPERATIVE REHABILITATION)
• Pt’s Sh. immobilized in internal rotation in a sling.
PHYSIOTHERAPY MANAGEMENT:
Phase 1 (week 1-3)
GOALS: – Promote tissue healing
– Control pain, inflammation
– increase ROM gradually
– muscle contraction initiation
• External rotation: prohibited.
• Limited abduction (60°)
(Dodson & Altchek, 2009)
Plan of treatment Intervention
Pain and swelling management Put ice pack, 15 min
Mobilizing
Exercise
Pendulum exercise for Sh. ,10x, 3 sets
(Lowe, n.d.)
Passive movement exercise Sh. Flexion, extension, abduction (within 60°), internal rotation.
Flexion
Abduction int. rot.
Active movement exercise Elbow flexion, extension, supination,
pronation.
10x, 3 sets
Flexion Extension
Supination Pronation
(Dodson & Altchek, 2009)
(Lowe, n.d.)
Phase II (4- 6 weeks)
GOALS: – to control pain, inflammation
– regain muscle strength
– increase ROM
• External rotation: only 30°
• Progression abduction (90°)
• Active flexion (90°)
(Dodson & Altchek, 2009)
(Powell, Nord, & Ryu, 2004)
Plan of treatment Intervention
Pain and swelling management Put ice pack, 15 min
Mobilizing exercise Pendulum exercise, 10x, 3sets
(Lowe, n.d.)
Active movement exercise Sh. flexion, abduction (90°), internal rotation, external rotation (30°)
Flexion abduction
Int. rot.
Posterior capsule stretching 15 s hold, 10x
Isometric exercise
Extension, flexion, abduction, int. rot. , ext. rot.
Hold 10s
Extension Flexion Abduction
Int. rot. Ext. rot.
(Lowe, n.d.)
(Powell et al., 2004)
Strengthening exercise Scapular stabilizer :
10s hold, 10x, 3 sets
T, Y, I exercise
After 2 months:
• Achieved external rotation: 115°-120°
• Continue exercise before
• Add on strengthening exercise
Strengthening exercise External rotation using theraband
Hold 10s, 10x
Active ressisted exercise Use gym ball, hold 10s, 10x
(Dodson & Altchek, 2009)
(Lowe, n.d.)
Conclusion
To conclude, SLAP lesions is injury to the labrum at shoulder joint. Physiotherapist plays important role either in conservative or operative patients to help patients improving their quality of life. Post-operative rehabilitation must be conduct properly in order to get the good results.
References
Dodson, C. C., & Altchek, D. W. (2009). SLAP Lesions: An Update on Recognition and Treatment. Journal of Orthopaedic & Sports Physical Therapy, 39(2), 71–80. http://doi.org/10.2519/jospt.2009.2850
Funk, L. (2009). Clinical Examination of Biceps , SLAP and Pulley Lesions. Pain.
Kenyon, K., & Kenyon, J. (2009). The Physiotherapist’s Pocketbook.
Lowe, W. R. (n.d.). Slap lesion repair protocol.
Manske, R., & Prohaska, D. (2010). Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete. Physical Therapy in Sport, 11(4), 110–121. http://doi.org/10.1016/j.ptsp.2010.06.004
Pecina, M. M., & Bojanic, I. (2004). Overuse Injuries of the musculoskeletal System.
Powell, S. E., Nord, K. D., & Ryu, R. K. N. (2004). The diagnosis, classification, and treatment of SLAP lesions. Operative Techniques in Sports Medicine, 12(2), 99–110. http://doi.org/10.1053/j.otsm.2004.07.001