SLAP – Hayden's Comprehensive Guide to SLAP Tears, For Shannon

7/23/2019 SLAP Hayden's Comprehensive Guide to SLAP Tears, For Shannon

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UpToDate articles and Haydens summary ofSLAP (Superior labrum anterior posterior)

tears and shoulder stability rehab

Contents of this document:

Haydens handwritten notes on SLAP tears

Full UpToDate article on SLAP Pa!e "# Full UpToDate article on S$S% for shoulder reha& e'ercises Pa!e ()#

Hayden Lee 1

Written 11 July 2015 for Shannon Denley


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Hayden Lee 2



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Hayden Lee 3



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the &iceps tendon has some de!ree of in+ury or su&lu'ation or the anterior la&rum shows any

si!nificant de!enerati,e tearin!% the anterior shear forces of the humeral head increase- $n

addition% constraints a!ainst posterior motion of the humeral head are diminished- The

increase in shear forces leads to increased motion of the humeral head posteriorly whene,er

the humeral head returns to a neutral position from action of rotator cuff muscles and

!lenohumeral li!aments tryin! to reset the humeral head within the !lenoid- This increased

translational force e'erted on the posterior !lenohumeral +oint causes microtrauma and some

fi&rosis of the posterior capsule- $f this &ecomes si!nificant% the result is posterior shoulder

capsule ti!htness and a !reater de!ree of !lenohumeral internal rotation deficit 1$0D#-

Com&ined shoulder a&duction and e'ternal rotation causes the &iceps tendon to twist%

increasin! the stress placed on the tendon and its attachment% and there&y increasin! the ris7

of a la&ral tear- 9hen powerful traction forces are applied throu!h the &iceps tendon to the

superior la&rum durin! the coc7in! phase of throwin!% the tendons attachment can tear the

la&rum from the !lenoid- The different stresses placed on the shoulder +oint durin! different

acti,ities li7ely account for the different types of SLAP lesions sustained-

EPIDEMIOLOGY, CLASSIFICATION, AND RISK FACTORS* The term SLAP .superior

la&rum anterior posterior.# was initially coined &y Snyder and his collea!ues while performin!

a retrospecti,e re,iew of a lar!e sample of shoulder arthroscopies =)>- 9hile the true o,erall

incidence of SLAP tears is un7nown% the incidence amon! patients under!oin! arthroscopy is

reported to &e &etween ? and (? percent =)- Four types ofSLAP in+uries were descri&ed

initially:

Type $ demonstrated de!enerati,e frayin! with intact &iceps insertion

Type $$% detachment of the &iceps insertion

Type $$$% a &uc7et


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Accordin! to some researchers% the .peel- $n this mechanism% e'cessi,e stress on the &iceps tendon attachment when the

shoulder is placed in a&duction and ma'imal e'ternal rotation leads to separation and tearin!

of the superior posterior la&rum from the !lenoid- 6,erhead throwin! athletes e!% &ase&all

pitchers% cric7et &owlers# and la&orers who swin! tools o,erhead freBuently assume this

position-

Durin! repetiti,e o,erhead motions that in,ol,e a&duction to ; de!rees and ma'imal

e'ternal rotation% increases in e'ternal rotation ran!e can &e seen o,er time- 6ften% this

increase is associated with a loss of internal rotation% a pattern termed !lenohumeral internal

rotation deficit 1$0D# =">- 9hile it remains unclear how 1$0D de,elops% it can lead to

ti!htenin! of the posterior capsule% which in turn chan!es the translational mechanics of the

humeral head within the !lenoid- These chan!es can lead to internal impin!ement and

posterior la&ral in+ury-

CLINICAL FEATURES

History* The history pro,ided &y the patient ultimately dia!nosed with a SLAP lesion is

often ,a!ue- SLAP tears may stem from chronic o,eruse or acute in+ury- Typically in cases of

repetiti,e o,eruse% the patient complains of anterior shoulder pain- The athlete or la&orer may

complain of episodic clic7in! or compara&le mechanical symptoms% particularly when their

arm is placed in the coc7in! position of throwin! ie% a&duction and e'ternal rotation# fi!ure ?#

=?>- $n patients with a history of !lenohumeral dislocation% su&lu'ation% or a shoulder sprain%

persistent anterior shoulder pain after returnin! to normal acti,ities should raise suspicion for

a SLAP tear and prompt an assessment of la&ral sta&ility- Howe,er% no particular acti,ity of

daily li,in! consistently elicits pain in the patient with a SLAP lesion- Ei!ht pain is an

uncommon symptom and su!!ests a rotator cuff tear or other patholo!y- Shoulder insta&ility

with normal acti,ity is not common% nor is swellin! or paresthesias% which can occur with

multidirectional shoulder insta&ility =4>- See .Presentation and dia!nosis of rotator cuff

tears.and .8ultidirectional insta&ility of the shoulder.-#

6,erhead athletes% such as tennis% &ase&all% and ,olley&all players% may complain of a

decline in function or throwin! ,elocity =>- A classic complaint of &ase&all pitchers with an

acute la&ral tear is that their arm feels li7e it went dead- $nitially% pitchers are often a&le to

continue throwin! in spite of the pain- Some researchers descri&e throwers or o,erhead

wor7ers initially e'periencin! dull shoulder ti!htness% which then pro!resses to pain and

mechanical symptoms as tears de,elop in those who play or wor7 throu!h the initial ti!htness

=">- The dia!nosis should &e entertained in la&orers who routinely swin! a hammer o,erheadand complain of anterior shoulder painand/ormechanical symptoms such as clic7in! or

catchin!- See .Throwin! in+uries: Giomechanics and mechanism of in+ury.and .Throwin!

in+uries of the upper e'tremity: Clinical presentation and dia!nostic approach.-#

$n a patient complainin! of new onset shoulder symptoms after an acute e,ent% the clinician

should re,iew the history to see if the mechanism is consistent with the traumatic SLAP in+ury-

Typically% this in,ol,es patients who recei,e a direct &low to the shoulder or fall onto an

outstretched hand and complain of anterior shoulder pain immediately followin! the trauma-

$n+uries in,ol,in! sudden traction of the arm% which may occur while liftin! a hea,y o&+ect with

a sudden +er7in! motion% also su!!est la&ral in+ury- SLAP tears are typically not associated

with acute anterior shoulder dislocations% althou!h they may &e present in patients with a

history of shoulder dislocation and su&seBuent insta&ility-

Hayden Lee 6

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Concomitnt in!"ry* SLAP tears are freBuently accompanied &y other shoulder patholo!y-

0otator cuff impin!ement or tears% Gan7art lesions% &iceps tendon in+ury% and !lenohumeral

osteoarthritis are common findin!s durin! arthroscopic e,aluation of patients with SLAP tears-

$f a SLAP tear is suspected% clinicians should assess for other shoulder patholo!y-

See .Shoulder impin!ement syndrome.and .Presentation and dia!nosis of rotator cuff

tears.and .Giceps tendinopathy and tendon rupture.and.8ultidirectional insta&ility of the

shoulder.and .1lenohumeral osteoarthritis.-#

E#mintion

O$%r&& ''roc(* Asnoted a&o,e% patients with SLAP lesions often ha,e sustained

additional shoulder and upper e'tremity in+uries% and thus a careful e'amination of the

in,ol,ed shoulder and upper e'tremity should &e performed% includin! assessments of

motion% stren!th% and &asic neuro,ascular function- To a lar!e e'tent% the e'amination is

!uided &y the differential dia!nosis that is !enerated throu!h the history- Assessment of the

rotator cuff and &iceps tendon are often indicated- 6ur approach to the adult with shoulder

pain and a re,iew of the shoulder e'amination are pro,ided separately- See ./,aluation ofthe patient with shoulder complaints.and .Physical e'amination of the shoulder.-#

/'amination &e!ins with o&ser,ation- Posture and shoulder position should &e assessed- $n

throwin! athletes% it is helpful to loo7 for asymmetries in the upper e'tremities- 8any athletes

ha,e hypertrophy of the throwin! arm and malposition of the shoulder of the dominant arm- $n

particular% im&alances in muscle stren!th may lead to scapular protraction and a rolled

forward shoulder appearance- Si!nificant muscular atrophy is unusual in patients with SLAP

tears and su!!ests neurolo!ic pro&lems or other in+uries leadin! to disuse-

9hene,er possi&le% the e'amination should include an assessment of shoulder motion-

Clinicians should loo7 for scapular dys7inesis as well as any hesitancy or catch as the patient

mo,es their shoulder in normal arcsof a&duction and ele,ation or forward fle'ion and

ele,ation- Symptoms or a&normal motion that manifests durin! &asic mo&ility testin! su!!ests

some underlyin! patholo!y and the need for more careful e'amination of the scapular

sta&iliers and rotator cuff- The portions of the e'amination of particular rele,ance to SLAP

patholo!y are discussed &elow-

$n addition to specific tests for SLAP lesions descri&ed &elow#% we su!!est clinicians perform

the followin! maneu,ers:

Palpate the pro'imal &iceps tendon- The presence of focal tenderness su!!eststendon in+ury-

Assess the !lenohumeral +oint for restricted internal rotation and e'cessi,e e'ternal

rotation- 9ith the patient supine% the shoulder in ; de!rees of a&duction% and the el&ow

in ; de!rees of fle'ion% !ently determine the de!ree of ma'imal e'ternal and internal

shoulder rotation compared to &oth standard measures of the !lenohumeral arc and to

the unaffected shoulder- See .Physical e'amination of the shoulder.% section on 30an!e

of motion3-#

Assess scapular motion- 8any patients with a SLAP tear ha,e some de!ree of

unilateral scapulothoracic dysfunction- See .Physical e'amination of the shoulder.%

section on 3Scapulothoracic motion and stren!th3-#

Hayden Lee 7

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SLAP)s'%ci*ic t%stin+ S"++%st%- ''roc(* Eo sin!le e'amination maneu,er or

com&ination of tests has &een shown to identify superior la&ral lesions with hi!h sensiti,ity

and specificity =- $n addition% the plethora of a,aila&le tests for SLAP lesions can &e

o,erwhelmin! for the clinician% not to mention the patient who has a painful shoulder and may

&ecome annoyed &y all the manipulation- Thus% we limit the num&er of tests we perform-

Ultimately% thedia!nosis of a SLAP lesion ismade usin! the history% ima!in! studies% and

sometimes arthroscopy in addition to the physical e'amination- The specific e'amination

maneu,ers for detectin! SLAP lesions should &e approached with the intention of determinin!

the need for ad,anced ima!in! or sur!ical inter,ention- Althou!h there are many different

e'amination tests for SLAP tears% they essentially fall into one of a few &asic cate!ories%

includin!: maneu,ers that elicit pain at the site of the tear e!% &y compressin! and rotatin!

the humeral head into the !lenoid#% maneu,ers that place a strain on the pro'imal &iceps

tendon which is often affected with SLAP tears#% and maneu,ers that demonstrate shoulder

insta&ility- Gased upon the a,aila&le e,idence and our clinical e'perience% we perform the

followin! e'amination maneu,ers in the followin! order to assess for SLAP in+uries:

Anterior !lide test

Compression rotation test

Acti,e compression 6Griens# test

Cran7 test

Speeds test

Performance of these tests is descri&ed &elow- See 3SLAP- Additional tests for detectin! SLAP lesions may &e performed for difficult cases that

remain unclear after these tests are performed-

1i,en the limitations of the a,aila&le research% it is not surprisin! that a num&er of

approaches to the clinical dia!nosis of SLAP lesions ha,e &een ad,ocated- A prospecti,e

study of se,eral e'amination tests in a population of o,erhead throwin! athletes with ane'pected hi!h pre,alence of SLAP lesions concluded that earlier studies of indi,idual tests

were e'ceedin!ly optimistic =)4>- $ts authors su!!est that the &est approach to the clinical

dia!nosis of SLAP lesions would include a com&ination of tests desi!ned to detect SLAP

lesions and &iceps tendon in+uries-

6ne research !roup su!!ests that com&inin! two of three sensiti,e tests acti,e compression

test% apprehension test% compression


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slide and acti,e compression tests =)">- Howe,er% another !roup re,iewed fi,e selected

clinical maneu,ers for dia!nosin! SLAP tears and found that com&inations of tests did not

impro,e dia!nostic accuracy compared to stand-

SLAP)s'%ci*ic t%stin+ O$%r$i%. n- t%st -%scri'tions* 8any e'amination tests for

detectin! superior la&rum anterior posterior SLAP# lesions ha,e &een descri&ed% &ut studies

of indi,idual techniBues are e'tremely limited &y methodolo!y% ,ariations amon! patient

populations% and other factors- Se,eral meta- Layin! supine with the &ac7 a!ainst the e'amination ta&le

sta&ilies the scapula- The e'aminer pushes the humerus into the !lenoid &y applyin!

an a'ial load and then rotates the humerus internally and e'ternally- A positi,e testproduces discomfort and a catchin!% poppin!% or snappin! sensation- This test is

analo!ous to the 8c8urrays test for meniscus lesions of the 7nee-

S'%%-s n- Y%r+son3s t%stsJ 1i,en the freBuent association &etween &iceps

patholo!y and SLAP tears% performin! these two tests can &e helpful in a patient with a

suspected SLAP tear- $n Speeds test% the patients el&ow is e'tended and their forearm

fully supinated with the shoulder sli!htly fle'ed- $n this position% the patient is as7ed to

ele,ate the arm a!ainst a resisted isometric force applied &y the e'aminer picture

(and mo,ie 4# =)>- Atest that elicits pain in the anterior shoulder is considered positi,e-

Ier!ason3s test is performed with the patient3s forearm pronated and el&ow fle'ed to ;

de!rees picture (#- The patient then attempts to supinate their arm a!ainst a resisted

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isometric force applied &y the e'aminer mo,ie 5#- Pain localied to the lon! &iceps

tendon mar7s a positi,e test- Ier!ason reasoned this test would isolate &iceps tendon

in+ury from rotator cuff patholo!y- A study of "; patients% usin! arthroscopy as the !old

standard% found Ier!ason3s test to ha,e a sensiti,ity of 54 percent% specificity of

percent% and positi,e li7elihood ratio of (-;" =(;>-

The studies descri&ed here reflect the !eneral sur!ical literature% which su!!ests that

neither Speeds test nor Ier!ason3s test pro,ide much help in distin!uishin! &iceps

tendon patholo!y from other causes of anterior shoulder pain = (;%()>- $n other words%

these tests increase the post- The patient and e'aminer positions are the same as

for the first &iceps load test- Howe,er% in the second test% the shoulder is a&ducted )(;de!rees &efore the shoulder is ma'imally e'ternally rotated% a!ain with the el&ow fle'ed

to ; de!rees% and the arm is supinated- The patient is then as7ed to fle' the el&ow

while the e'aminer resists mo,ie "#- The test is positi,e if pain de,elops when the

patient fle'es their el&ow or if pain increases when the e'aminer applies resistance-

Pin 'ro$oction t%stJ This test is similar to the &iceps load tests mo,ie ?# =(">- The

patient sits with the e'aminer standin! &ehind them- The e'aminer holds the patients

wrist with their ipsilateral hand while the contralateral hand !ently &races the patients

shoulder- The shoulder is a&ducted ; to );; de!rees directly to the side with the el&ow

fle'ed ; de!rees- The arm is then ma'imally e'ternally rotated and% while maintainin!

this position% the arm is then ma'imally pronated and supinated- The test is positi,e if

ma'imal pronationelicits or worsens pain-

Hayden Lee 10

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Ant%rior +&i-% t%stJ For the anterior !lide test%the patient lies supine and their arm is

a&ducted a &it less than ; de!rees mo,ie #- The e'aminer stands ne't to the patient

&etween their torso and the affected upper e'tremity- Ee't% the e'aminer wraps the hand

closest to the patient around the patients superior trapeius and cla,icle to pro,ide

sta&ility- 9ith the other hand% the e'aminer !rasps +ust distal to the patients humeral

head% with the thum& anterior and the remainin! fin!ers wrapped around the pro'imal

humerus- Ee't% the e'aminer distracts the humerus sli!htly and then translates the

humeral head anteriorly- A positi,e test produces nota&le anterior la'ity when compared

to the unaffected side-

DIAGNOSTIC IMAGING

O$%r$i%.* All ima!in! techniBues used to dia!nose superior la&rum anterior posterior

SLAP# tears ha,e limitations% ma7in! definiti,e dia!nosis of these in+uries challen!in!

=(?%(>- $n addition% dependin! upon the clinical scenario and prospecti,e treatment% it may

not &e necessary to o&tain ad,anced ima!in! studies to esta&lish the dia!nosis- As one

important e'ample% since patients older than 4" are often poor sur!ical candidates% it is!enerally &est to o&tain consultation with an e'perienced shoulder sur!eon &efore orderin!

ad,anced ima!in! studies for such patients% who are unli7ely to need them- See 3$ndications

for orthopedic consult or referral3&elow-#

Currently% ma!netic resonance arthro!ram 80A# is the most accurate ima!in! study for

dia!nosin! SLAP tears- Plain radio!raphs cannot delineate soft tissue in+uries such as SLAP

tears &ut remain important for identifyin! concomitant in+uries and are o&tained in most

patients- Computed tomo!raphy CT# arthro!raphy can help to dia!nose SLAP tears &ut is

typically reser,ed for patients with contraindications to 80$-

P&in r-io+r'(y* 9hen a SLAP tear is suspected% plain radio!raphs of the shoulder are

used to assess other potential causes of shoulder pain- 1i,en how freBuently SLAP tears are

associated with other in+uries% plain radio!raphs are typically the first studies performed-

Anteroposterior% scapular I% and a'illary ,iews are !enerally o&tained- Acromiocla,icular AC#

and !lenohumeral 1H# +oint osteoarthritis% calcific tendinopathy% osteochondral lesions of the

!lenoid or humerus% fractures% dislocations% and &ony tumors can &e seen usin! plain

radio!raphs-

Com'"t%- tomo+r'(y* $n patients who are una&le to o&tain a 80$ due to implanted

medical de,ices e!% Pacema7er# or other reasons% CT arthro!raphy may &e used to assess

possi&le SLAP tears- Accordin! to a retrospecti,e re,iew that included )?) ima!in! studies%CT demonstrated a sensiti,ity and specificity of 5 to percent and ( to ? percent%

respecti,ely% compared to arthroscopy =(>-

M"sc"&os2%&%t& "&trso"n-* Althou!h useful for identifyin! some shoulder patholo!y

such as supraspinatus tear% musculos7eletal ultrasound 8SK US# is not useful for e'aminin!

SLAP tears =(>- The la&rum is surrounded &y multiple osseous structures% which ma7esit

difficult to assess usin! ultrasound- La&ral tears may &e associated with parala&ral cysts or

&iceps tendon a&normalities that can &e e,aluated relia&ly usin! ultrasound- Giceps tendon

su&lu'ation can &e demonstrated on dynamic US and this findin! may raise suspicion of a

Type $$ SLAP lesion-

Hayden Lee 11

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M+n%tic r%sonnc% im+in+* 8a!netic resonance arthro!ram 80A# is the most

accurate a,aila&le ima!in! techniBue for dia!nosin! SLAP tears% &ut has limitations and is

most useful in patients youn!er than 4" years- $n addition% Buality ,aries !reatly with these

studies and the orderin! physician usually the shoulder sur!eon assumin! care# should

ma7e certain that the ima!in! facility can pro,ide the appropriate% hi!h Buality study-

Accordin! to se,eral o&ser,ational studies that used findin!s at arthroscopy or open sur!ery

as the !old standard% the sensiti,ity of 80A falls &etween and " percent = 4;- The

specificity of 80A reported in these studies was &etween "; and ) percent- A meta- 6ne

li7ely reason for the limitations of 80$ is the relati,ely wide ,ariation of the normal

appearance of the !lenoid la&rum-

Since patients older than 4" are often poor sur!ical candidates% 80$ and 80A studies

!enerally should not &e ordered &y the primary care physician- As descri&ed a&o,e% 80A and

80$ show a ran!e of sensiti,ity and specificity and most li7ely will &e a&normal in patients

older than 4"- These studies rarely chan!e mana!ement in this a!e !roup so it is !enerally

&est to o&tain consultation with an e'perienced shoulder sur!eon &efore orderin! ad,anced

ima!in! studies for such patients- See 3$ndications for orthopedic consult or referral3&elow-#

Im+in+ n- intr)rtic"&r in!%ction* 1uided intra


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Ultimately% a definiti,e dia!nosis of SLAP tear is made usin! either ad,anced ima!in!%

prefera&ly 80A% or &y performin! dia!nostic arthroscopy- Arthroscopy is the !old standard for

SLAP tear dia!nosis !i,en the occasional limitations of 80A- 8usculos7eletal ultrasound

8SK US# can &e useful for e,aluatin! concomitant rotator cuff or &iceps tendon patholo!y- $n

the authors e'perience% the dia!nosis of SLAP tear is li7ely in patients with a su!!esti,e

history and anterior shoulder pain without e,idence of rotator cuff patholo!y on e'amination

and 8SK US- $t is important to note that the effecti,eness of sur!ical treatment is limited%

particularly in patients 4" years or older% and therefore% many patients do not need ad,anced

ima!in! to esta&lish a definiti,e dia!nosis of SLAP tear if the dia!nosis is li7ely &ased upon

the clinical e,aluation and common alternati,e dia!noses ha,e &een ruled out- $n most cases%

only !ood sur!ical candidates warrant ad,anced ima!in! e!% 80A#% and this determination is

&est made &y an orthopedist with ad,anced trainin! in shoulder sur!ery-

INDICATIONS FOR ORTHOPEDIC CONSULT OR REFERRAL* SLAP tears can &e difficult

to dia!nose definiti,ely &y history and physical e'amination- /,en ma!netic resonance

arthro!ram 80A# has limitations and is often unnecessary in patients o,er 4" years and

others who may &e poor sur!ical candidates- 1i,en the comple'ities of esta&lishin! thedia!nosis of SLAP tear and determinin! the &est approach to mana!ement% in most cases we

su!!est o&tainin! orthopedic referral prior to performin! ad,anced ima!in! studies e!% 80A#

when a SLAP in+ury is suspected- $deally% the consultin! sur!eon should &e an orthopedist

with ad,anced trainin! in shoulder sur!ery-

0efrainin! from o&tainin! ad,anced ima!in! is particularly important in patients who are

unli7ely to &e suita&le sur!ical candidates- This approach minimies unnecessary studies and

the possi&ility of false


14/34

confused with SLAP tears include the followin!% listed in order of decreasin! li7elihood% alon!

with important features to differentiate them from SLAP tears- Key historical and e'amination

features that su!!est a SLAP tear rather than other shoulder patholo!y include participation in

a sport or occupation that in,ol,es e'tensi,e o,erhead acti,ity% pain that is worst in the

coc7in! phase of shoulder motion% and intra


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G&%no("m%r& ost%ort(ritisJ SLAP tears and !lenohumeral osteoarthritis can &oth

cause anterior shoulder pain- Patients with either condition may e'perience reduced

shoulder motion and pain with o,erhead acti,ities- Ei!ht time pain is common with

osteoarthritis &ut not SLAP lesions- 1lenohumeral osteoarthritis is easily identified on

plain radio!raphs of the shoulder ima!e )and ima!e (#% whereas patients with an

isolated SLAP tear typically ha,e normal radio!raphs- See.1lenohumeral

osteoarthritis.-#

M"&ti-ir%ction& s(o"&-%r inst6i&ityJ A SLAP tear can cause symptoms of shoulder

insta&ility% particularly after a traumatic dislocation- Howe,er% in !eneral patients with

SLAP tears do not complain of shoulder insta&ility symptoms or transient neurolo!ic

symptoms- 8ultidirectional insta&ility in,ol,es la'ity in all directions of humeral motion

anterior% inferior% and posterior# whereas SLAP tears may in rare instances &e

associated with anterior la'ity only- See .8ultidirectional insta&ility of the shoulder.-#

MANAGEMENT

Pti%nt ct%+ori%s n- o$%r$i%. o* mn+%m%nt* Appropriate classification of patients

and the demands they place on their shoulder +oint help to determinethe &est approach to the

mana!ement of superior la&rum anterior posterior SLAP# tears- $n our e'perience% the

cate!ories listed &elow pro,ide a useful framewor7-

Hi+()&%$%& t(ro.in+ or o$%r(%- t(&%t%sJ These patients are typically referred to

an orthopedic sur!eon e'perienced in treatin! athletes with SLAP lesions- 9hen referral

poses difficulty% dia!nostic testin! with 80A preferred# or 80$% dependin! upon

institutional e'perience% is warranted- 9hile awaitin! sur!ical e,aluation% the patient can

&e!in a home e'ercise pro!ram- /'ercises that emphasie &iceps and rotator cuff

stren!thenin! performed with li!ht wei!hts may &e performed within a pain free ran!e of

motion-

Pti%nts .it( (i+( occ"'tion& -%mn-s in$o&$in+ *r%7"%nt o$%r(%- cti$ity J

For patients youn!er than 4" years who fall into this cate!ory% we follow the same

approach used for hi!h le,el athletes- 9e refer patients o,er 4" years to physical

therapy for a comprehensi,e reha&ilitation pro!ram and see them periodically in follow- Althou!h studies are

limited primarily to retrospecti,e case series% e,idence su!!ests that most patients are a&le toresume pre


17/34

SLAP tears are often accompanied &y other patholo!y% such as rotator cuff or &iceps

tendinopathy- $n such cases% treatment of these associated conditions should &e performed% in

part to determine the e'tent to which the SLAP tear is contri&utin! to the patients symptoms-

8any times resol,in! rotatorcuff or &iceps tendon


18/34

randomied trial of ?4 patients o,er "; years of a!e reported no difference in outcome in

patients whose SLAP and rotator cuff tears were repaired compared to those treated with

rotator cuff repair and &iceps tenotomy =";%")>- $n patients with concomitant rotator cuff in+ury%

la&ral de&ridement or &iceps tenotomy may &e prefera&le to la&ral repair = 55>-

Posto'%rti$% tr%tm%nt n- r%s"&ts* $t typically reBuires si' months and often as lon! as

)( months to return to throwin! after sur!ical repair of a SLAP lesion- Healin! must not &e

rushed- The patient should wor7 throu!h the appropriate sta!es of reha&ilitation !radually and

clinicians must !uard a!ainst the patient pro!ressin! prematurely- 1i,en the comple'ity and

importance of post


19/34

who completed the repair- Similarly% if the patient de,elops une'pected pain or dysfunction

durin! the post- Howe,er% only 4 percent of patients returned to their prior le,el of

function% while only ?4 percent of o,erhead throwin! athletes returned to their pre,ious le,el

of play- Should primary repair fail% &iceps tenodesis often relie,es pain- A&out 5; percent of

patients report an e'cellent outcome with this sur!ery% while appro'imately 5 percent

e'perience si!nificant complications =5>- Common lon!


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Cran7 test

Speeds test see 3/'amination3a&o,e#

All ima!in! techniBues used to dia!nose SLAP tears ha,e limitations% ma7in! definiti,e

dia!nosis challen!in!- Dependin! upon the clinical scenario and prospecti,e treatment%

it may not &e necessary to o&tain ad,anced ima!in! studies to esta&lish the dia!nosis-

Currently% ma!netic resonance arthro!ram 80A# is the most accurate ima!in! study for

dia!nosin! SLAP tears- Plain radio!raphs cannot dia!nose SLAP tears &ut remain

important for identifyin! concomitant in+uries and are o&tained in most patients-

See 3Dia!nostic ima!in!3a&o,e-#

Definiti,e dia!nosis of a SLAP tear reBuires arthroscopy or 80A% &ut these are often

unnecessary and a clinical dia!nosis is adeBuate if the patient is not a !ood sur!ical

candidate% the history and clinical findin!s stron!ly su!!est the dia!nosis% and other

important alternati,e dia!noses such as rotator cuff tear can &e ruled out &y e'amination

and ultrasound- See 3Dia!nosis3a&o,e-#

1i,en the comple'ities of esta&lishin! the dia!nosis of SLAP tear and determinin! the

&est approach to mana!ement% in most cases we su!!est o&tainin! orthopedic referral

prior to performin! ad,anced ima!in! studies e!% 80A# when a SLAP in+ury is

suspected- $deally% the consultin! sur!eon should &e an orthopedist with ad,anced

trainin! in shoulder sur!ery- 0efrainin! from o&tainin! ad,anced ima!in! is particularly

important in patients who are unli7ely to &e suita&lesur!ical candidates-

See 3$ndications for orthopedic consult or referral3a&o,e-#

SLAP tears are freBuently associated with other shoulder patholo!y% which can ma7e

identifyin! SLAP tears difficult- A few common shoulder dia!noses that may &e confused

with SLAP tears are discussed in the te't% alon! with important features to differentiate

them from SLAP tears- These dia!noses include rotator cuff tear or tendinopathy%

shoulder impin!ement% and &iceps tendinopathy or tear- See 3Differential

dia!nosis3a&o,e-#

The mana!ement of SLAP tears depends upon patient a!e and acti,ity% and the type of

tear- Eonoperati,e mana!ement of SLAP tears is preferred whene,er possi&le !i,en the

lon! reco,ery reBuired followin! sur!ical repair typically ? to )( months# and the

limitations of sur!ical treatment% particularly in older patients- Hi!h


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Eercises!rehab for shoulder

INTRODUCTION* Shoulder impin!ement syndrome S$S# refers to a com&ination of

shoulder symptoms% e'amination findin!s% and radiolo!ic si!ns attri&uta&le to the

compression of structures around the !lenohumeral +oint that occurs durin! shoulderele,ation- Such compression causes persistent pain and dysfunction- S$S is a common cause

of shoulder pain amon! patients presentin! to primary care clinics-

The principles of reha&ilitation and a physical therapy pro!ram for the treatment of S$S are

discussed here- The ris7 factors% pathophysiolo!y% dia!nosis% and !eneral mana!ement of S$S

and other shoulder pro&lems are re,iewed separately- See .Shoulder impin!ement

syndrome.and .0otator cuff tendinopathy.and .Presentation and dia!nosis of rotator cuff

tears.and .Froen shoulder adhesi,e capsulitis#.and ./,aluation of the patient with shoulder

complaints.and .Physical e'amination of the shoulder.-#

DEFINITION AND CLASSIFICATION* 1lenohumeral or shoulder impin!ement syndrome

S$S# is a chronic condition that de,elops when soft tissues are repeatedly compressed

&etween the humeral head and the acromion when the arm is acti,ely raised- S$S refers to a

com&ination of shoulder symptoms% e'amination findin!s% and radiolo!ic si!ns% rather than

in+ury to a specific structure- Howe,er% shoulder impin!ement predisposes to rotator cuff

tendinopathy and tears-

8ost oftenS$S results from o,eruse in middle


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understand and reha&ilitate in+uries properly we need to understand the reBuirements of the

in,ol,ed +oint comple' and how im&alances in stren!th and fle'i&ility affect its function- 6nce

the fundamental pro&lems are reco!nied% a pro!ressi,e pro!ram can &e desi!ned to

address them-

Proper reha&ilitation ma7es use of the o,erload principle% which in,ol,es pro,idin! a

pro!ressi,e stimulus or stress# to which the &ody must adapt =?>- Accordin! to this principle% a

muscle will only &ecome stron!er if resistance is increased- /ach e'ercise pro!ram starts with

simple mo,ements in,ol,in! li!ht resistance- 6,er time% dependin! upon the muscle !roup

in,ol,ed% more comple' e'ercises usin! !reater resistance are added% as the patient can

tolerate them- $n other words% as soon as the patient can perform an e'ercise without

difficulty% the amount of wei!ht or the tu&e tension &ein! used should &e increased- Such

increases in resistance should &e !radual &ut steady-

$t is important tomaintain the patients confidence durin! reha&ilitation- $f a pro!ram is too

easy and pro,ides little &enefit% patient compliance may fall2 if a pro!ram is too difficult% pain

may increase and the patient may Buit reha&ilitation- $ncreasin! the stimulus &y anappropriate amount and at an appropriate rate leads to steady impro,ement-

All therapeutic e'ercise pro!rams follow the &asic steps of reha&ilitation:

Decrease pain and inflammation

0estore normal ran!e of motion 068#

$mpro,e indi,idual muscle function

0estore o,erall functional capacity

/ducate and direct in+ury pre,ention e'ercises to a,oid re


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scapular sta&ility% the ma+or mo,ements are retraction% ele,ation% and depression- Postural% or tonic% muscles are

primarily in,ol,ed in endurance functions and contract o,er lon!er periods while phasic

muscles primarily perform in short &ursts of acti,ity and e'ert !reater power- The num&er of

repetitions used for a particular e'ercise will ,ary dependin! upon the muscle type- As an

e'ample% a hi!h num&er of repetitions "; to );;# is necessary to impro,e the endurance of

postural muscles% while phasic muscles &ecome stron!er when performin! fewer repetitions

); to (;# usin! !reater resistance-

Proper e'ercise techniBue and posture are essential for effecti,e physical therapy- Durin!

reha&ilitation% e'ercises for the shoulder comple' should &e performed in a deli&erate%

controlled manner2 patients must a,oid usin! momentum to ma7e e'ercises easier- The

muscles in,ol,ed in e'ecutin! a particular mo,ement should mo,e smoothly- $f a patient is

una&le to complete the prescri&ed num&er of repetitions in a controlled manner% it is &etter tostop as soon as the form starts to &rea7 down% rather than ris7 in+ury% and &uild up to the

desired num&er o,er time- 6ur !oal is to impro,e muscle function% not +ust to complete the

sets and repetitions-

Appropriate e'ercise techniBue depends in part on whether a muscle is contractin!

concentrically or eccentrically- 9hen a muscle is contractin! and the le,er arm is shortenin!%

this is called a concentric contraction- 6ne e'ample is the &iceps muscle when a person is

pullin! their &ody up to the &ar durin! a chin up- Concentric e'ercises durin! physical therapy

are !enerally performed to a ( second count- 9hen a muscle is contractin! and the le,er arm

is len!thenin!% this is called an eccentric contraction sometimes referred to as a ne!ati,e

repetition &y wei!htlifters#- An e'ample would &e the &iceps muscle when a person is lowerin!

their &ody down from the &ar durin! a chin up- /ccentric e'ercises durin! physical therapy

are !enerally performed to a 5 second count-

These second counts reflect the importance of usin! controlled deli&erate mo,ements to

perform resisted reha&ilitation e'ercises and the relati,e stren!th of eccentric mo,ement

!enerally- This approach ensures that the appropriate muscles are doin! the wor7 and the

role of momentum is minimied- $n addition% an eccentric contraction can !enerate forces up

to one and a third times that of a concentric contraction in,ol,in! the same muscle- Gy

increasin! the duration of the eccentric contraction% a suita&le challen!e is created for the

muscle without chan!in! the load-

6f note% eccentric contraction in,ol,es the &rea7in! actin


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6nce reha&ilitation is completed and healthy shoulder function is achie,ed% it is crucial that

patients not resume the postures and practices that predispose to disa&ility- Therefore% it is

important that patients continue to perform a few times each wee7 a su&set of e'ercises

prescri&ed &y the physical therapist that will maintain the stren!th of the scapular sta&iliers

and rotator cuff muscles and o,erall shoulder function- $n addition% proper posture and

er!onomics at home% wor7% and play are essential to a,oidin! a recurrence of shoulder

impin!ement- TechniBues for impro,in! and maintainin! proper posture and er!onomics are

re,iewed separately- See .6,er,iew of +oint protection.% section on 3The principles of +oint

protection3-#

REHABILITATION PROGRAM

O$%r$i%.* 0eha&ilitation of any in+ury reBuires a specific plan and e'ercise pro!ression-

9ith shoulder impin!ement syndrome S$S#% there are three primary !oals of reha&ilitation

=4%)(%)4>:

Stren!then the muscles that sta&ilie the scapula: Gy stren!thenin! the scapularsta&iliers% !reater sta&ility is pro,ided for the rotator cuff muscles% which ori!inate on

the scapula- This sta&ility allows for !reater efficiency and muscular endurance of the

rotator cuff% and impro,ed o,erall shoulder function- This is a critical first step in

reha&ilitation-

Correct im&alances in stren!th amon! the rotator cuff muscles: Typically% &efore

reha&ilitation% the muscles at the front of the shoulder comple' anterior deltoid% internal

rotator ie% su&scapularis## are )-" to ( times stron!er than those at the posterior

posterior deltoid% e'ternal rotators#-

Sta&ilie the secondary mo,ers of the shoulder comple': 6nce the primary muscles of

the shoulder are stron! and functional% the ne't step is to reha&ilitate the secondary

shoulder muscles in order to impro,e coordination of the entire shoulder comple'-

$n addition to these three primary !oals% a fourth !oal for many athletes is to impro,e sport- The mean

chan!e in the Constant


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posterior posterior deltoid% e'ternal rotators#- See 3Step two: Stren!then the

rotator cuff3a&o,e-#

Sta&ilie the secondary mo,ers of the shoulder comple': 6nce the primary

muscles of the shoulder are stron! and functional% the ne't step is to reha&ilitate

the secondary shoulder muscles in order to impro,e coordination of the entire

shoulder comple'- See 3Step three: $mpro,e o,erall stren!thand coordination of

shoulder comple'3a&o,e-#

Appropriate stretchin! is another important element of the reha&ilitation pro!ram-

Su!!ested stretches are descri&ed in the te't- See 3Stretchin!3a&o,e-#

Successful completion of the S$S reha&ilitation pro!ram !enerally reBuires from to )?

wee7s% &ut some impro,ement is usually noted within the first three to four wee7s- A

patient who has successfully completed a reha&ilitation pro!ram for S$S should ha,e

complete% pain


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