A SLAP Lesion, shortened forSuperior Labrum Anterior to Posterior, describes a Tear of the Glenoid Labrum specific to this region. There are several types of SLAP lesions that are categorised by their onset (SOURCE-1+2+3+11+12):
Type I- a degenerative lesion with an insidious onset. Marked by fraying of the superior Labral attachment while the insertion to the edge of the Glenoid Cavity is unaffected
Type II- derived from a traumatic event where the proximal Long Head of Biceps Tendon and SLAP are torn from the Glenoid Cavity. These types are reported to be the most common
a - detachment extends anteriorly
b - detachment extends posteriorly
c - detachment extends both anteriorly and posteriorly
Type III- a rare “bucket-handle” tear of the superior Labrum that displaces it into the articular surface. No damage to the proximal Long Head of Biceps Tendon
Type IV- similar to Type III; however, the tear extends to the proximal Long Head of Biceps Tendon , partially displacing it into the articular surface
Type V- occurs when an (anteroinferior) Bankart Lesion extends superiorly to include the proximal Long Head of Biceps Tendon
Type VI- large superior Labral flaps without detachment of the proximal Long Head of Biceps Tendon
Type VII- tear of the superior Labrum that extends to the Middle Glenohumeral Ligament
Type VIII- tear of the superior Labrum that extends posteriorly towards the inferior Labrum (6 o’clock)
Type IX- a “pan-labral” tear which extends the full 360º of the Labrum
Type X- a reverse Bankart Lesion which reaches the superior Labrum
There are several structural elements of the Superior Glenoid Labrum that leave it particularly vulnerable and may reflect the disproportionate amount of Labral Tears in this region (SOURCE-9):
Mobility - the Superior Labrum is the most mobile portion due to its unique attachment on the Glenoid Rim and receiving of the Long Head of Biceps Tendon attachment. Unlike other portions of the Rim, the superior portion extends slightly and often eclipses the Superior Labrum, forming a space known as theSubsynovial Recess, where the labral attachment is medial on the articular cartilage rather than directly on the Rim
Composition - comprised of a lower proportion of Elastin Fibres and a larger fibrocartilaginous transition zone between the Hyaline Cartilage of the Glenoid and Fibrous Labrum which may represent a biomechanical weak point. Additionally the anterosuperior portion receives the poorest blood supply, which impairs its ability to heal and repair
Congenital or degenerative morphologies, concomitant injury or repetitive strain are all described to predispose SLAP lesions and may have distinct associations with lesion sub-types. Inferior traction of the Long Head of Biceps , for example, are associated with Type-II SLAP lesions (SOURCE-9+10). The array of mechanisms behind SLAP lesions includes traction to the arm, compression loads (such as the axial loading during FOOSH ), repetitive overhead activities (such as throwing) or direct injury to the Biceps Tendon (SOURCE-3+4+9+10).
Of particular relevance to underlying SLAP lesion mechanisms is overhead throwing. The Bicipital-Labral complex serves as a crucial secondary stabiliser during the combined GH Joint - Abduction and GH Joint - External Rotation of overhead throwing (SOURCE-9). Hyperabduction with External Rotation increases both shear and compressive forces on the Glenohumeral Joint , leading to Strain of the Rotator Cuff and capsulolabroligamentous structures (SOURCE-9). Athletes display an increase in External Rotation orGlenohumeral Internal Rotation Deficit (GIRD)and consequently bony or capsular adaptations associated with an increased risk of pathology (SOURCE-9). The most vulnerable portion of the throwing movement is generally thought to be the late-cocking phase as Long Head of Biceps Tendon Strength may be disadvantaged by ~20%, while simultaneously the strain on the Superior Glenoid Labrum is most significant (SOURCE-9). The late-cocking phase is thought to provoke a SLAP lesion in one of two ways (SOURCE-9+10):
“Peel-Back” mechanism- maximal GH Joint - External Rotation significantly increases sheer forces on the Superoposterior Labrum. Contractures of the Posterior and Inferior Glenohumeral Capsular Ligaments may exacerbate this processes as it leads to posterosuperior translation of the Head of Humerus during cocking and the accumulation of micro-trauma. Posteriorly directed forces may have a particular association with Type-II lesions
Internal Impingement mechanism- the Superior Labrum may not only be subject to detrimental shear forces but direct contact stresses in the late-cocking position. Previously discussed capsular contractures or fatigue/ injury-derived anterior Glenohumeral Instability causes the Humeral Head to migrate anteriorly, mechanically impinging the Posterosuperior Labrum and Rotator Cuff between the bony Humerus and Glenoid Rim
The other portion of the overhead throwing movement thought to play a part in SLAP lesion pathogenesis is the Deceleration Phase (SOURCE-9+10):
“Weed-Puller” mechanism- torsion produced by the Long Head of Biceps during the Deceleration phase of throwing may Tear the Glenoid Labrum from the Glenoid Rim. This notion is supported by the most significant stressors for the top 50% of the Labrum were displayed during deceleration. Similarly, peak activity of the Biceps Brachii is achieved during this phase
In pathologic states, both the superior glenoid labrum and proximal long head of biceps tendon (PLHBT) are notable sources of Pain for The Shoulder Girdle . From a neuro-anatomical perspective, the Anterosuperior Labrum and Bicipital-Labral complex have a particularly high density of nerve endings, suggesting they are highly sensitive pain generators (SOURCe-18+23).Within this complex, distinct nerve distributions contribute to different types of pain and function (SOURCE-22):
Fine Nerve Fibers - independent of vascular structures and located primarily in the PLHBT, are thought to carry signals for the dull, aching pain often felt at rest
Thicker Nerve Bundles - found at the transition from the PLHBT to the Glenoid Labrum and accompanied by arterial blood vessels, likely transmit the sharp, immediate pain triggered by movement
Complex Nerve Endings - the Labrum contains complex nerve endings with oval, conical, and fusiform structures, which are implicated in both pain and Proprioception
This high concentration of pain-sensing nerves offers a clear explanation for why patients experience significant pain relief following a biceps tenotomy or tenodesis (SOURCe-23). By surgically compromising the natural attachment, the procedure effectively severs a major neural pathway for both sharp and aching pain signals.The pain associated with SLAP lesions is not exclusively derived from mechanical compromise. Nerve endings within the labrum and capsule perform both Nociception and Proprioception functions. A weakening of the proprioceptive reflex is a plausible mechanism behind glenohumeral instability and the sensation of joint locking (SOURCE-22).Further evidence for a neuro-anatomical cause of pain comes from a preliminary study that reported a 3-4 fold increase in the concentration of neurofilament-expressing cells (a marker for new nerve growth) at the site of SLAP and anterior labral lesions (SOURCE-24). Bearing a resemblance to Adhesive Capsulitis , the influx of new neurons in response to injury suggests an increased capacity for the tissue to perceive pain (SOURCE-24).The inflammatory cascade that follows SLAP lesions is also believed to play a role in pain generation through sensitisation of the Nociceptors . In rodents, Glenoid Labrum Tears trigger an immediate and widespread activation of Mast Cells in the Synovium which prompts degranulation (release of inflammatory contents) and consequently the recruitment of inflammatory cells from the blood to the joint (SOURCE-26). These inflammatory cells release chemical mediators that directly degrade labral tissue and sensitise local nerve endings by lowering their activation threshold, potentially causing typically innocuous stimulus to be painful (SOURCE-26). Both pain and a delayed recovery process following repair have been associated with increased vascularity of the Glenohumeral Joint Capsule and Synovium, which has been attributed to Inflammation (SOURCE-25).
SLAP lesions are reported to account for 4-8% of all pathologies of The Shoulder Girdle and are accompanied by concomitant injury in the vast majoirty of cases (SOURCE-3). The prevalence of SLAP lesions has notable variation depending on the stability of the patients shoulder. In the absence of Glenohumeral Instability , SLAP lesions are reported to account for 80-90% of all Glenoid Labrum Tears (SOURCE-1). Conversely, when associated with traumatic Anteiror Glenohumeral Dislocation , SLAP lesions (~23%) are the third most common soft-tissue lesion behind Bankart Lesions (~67%) and Posterior Bankart (~23%) (SOURCE-28). This type of lesion disproportionately affects the young overhead athlete, with one study reporting 83% of Labral Tears in overhead throwers involved some portion of the Anterosuperior Labrum at the confluence of the Proximal Long Head of Biceps Tendon (SOURCE-4+21).
SLAP lesions rarely occur in isolation and may serve as a predisposing or maintaing factor to other pathologies, including those listed below. The specific mechanism of injury not only bares implications for the type of SLAP lesion but concomitant injury to other tissues. For example, SLAP lesions that result from an acute traumatic event often result in concomitant Bankart Lesions (SOURCE-27).
Rotator Cuff Tear - are a common co-occurrence with SLAP lesions as the underlying mechanisms may be similarly compromising. Studies have reported a high prevalence of concomitant Rotator Cuff damage, with one study finding 29% to have partial-thickness tears while 11% had a complete rupture (SOURCE-27). This co-occurence is more pronounced in specific populations, with another study reporting a concomitant partial-thickness Supraspinatus Tear in 45% of patients with a SLAP lesion, a number that nearly doubled in baseball pitchers (73%) (SOURCE-27). Conversely, 74% of those with a full-thickness Rotator Cuff tear were found to have associated intra-articular lesions (SOURCE-31). A common pathological mechanism these two structures share is degeneration by proxy of age (SOURCE-30-31).
Anterior Glenohumeral Instability - shares a bidirecitonal relationship with SLAP lesions where either may predispose the other or are derived from the same mechanism of injury. Firstly, SLAP lesions may lead to anterior instability. Disturbance of the Superior Glenoid Labrum results in a significant increase in Glenohumeral translation and disturbance of the Long Head of Biceps may (i) impede its inferior distraction bias on the Head of Humerus , compromising its stabilising role and (ii) weaken the Proprioception reflex which may lead to instability and the sensation of joint locking (SOURCE-22+27+28). In the inverse direction, both acute and chronic instability are thought to predispose SLAP lesions (SOURCE-33). SLAP lesions are reported to be the third-most common soft-tissue lesion that occurs following traumatic anterior Glenohumeral Dislocation , accounting for roughly a quarter (23%) (SOURCE-28).
Long Head of Biceps - several SLAP lesion subtypes involve the Long Head of Biceps to varying extents that may compromise the Muscles function and/ or serve as a significant Pain generating tissue.
Glenoid Labrum Tear - SLAP lesions are a specific type of labral tear that accounts for the vast majority (80-90%) when no Glenohumeral Instability is present and roughly a quater (23%) of labral tears derived from traumatic anterior Glenohumeral Dislocation (SOURCE-1+28). SLAP lesions often occur with concomitant injury to to neighbouring osseous and capsulolabroligamentous structures. A notable portion of SLAP lesions are accompanied by a Bankart Lesion (SOURCE-27)
Scapular Dyskinesis - shares a bidirectional relationship with SLAP lesions where abnormal Scapula patterns may increase labral stress; while Dyskinesis is described as a non-specific response to shoulder Pain , of which SLAP lesions are a common cause (SOURCE-8+9+20).
Glenohumeral Internal Rotation Deficit (GIRD)- a pathologic adapation that typically follows reptitive overhead motions such as throwing where the posterior shoulder ( Glenohumeral Joint Capsule and Rotator Cuff ) is left restricted (SOURCE-34). GIRD is descried as a predisposing factor for SLAP lesions (SOURCE-34).
Humeral Retroversion - as Posterior Glenohumeral Joint Capsule thickening is an adaptive response to increased retroversion, it may increase the risk of SLAP Lesion (SOURCE-6)
Acromioclavicular Joint Dislocation - SLAP lesions represent the most common type of Glenoid Labrum Tear associated with Acromioclavicular Joint Dislocations, with a higher prevalance in more severe instances (SOURCE-35).
The following pathologies may be relevant to the differential diagnosis of a SLAP lesions (SOURCE-9+18):
Rotator Cuff Pathology
Other Glenoid Labrum Tear s
Degenerative Joint Disease
The following observations are often found with SLAP lesions (SOURCE-8+9):
Pain - most commonly associated complaint with SLAP lesions, typically felt anteriorly or on palpation of the Bicipital Groove
Mechanical Symptoms - Glenohumeral Instability and sensations of catching, popping or clicking associated with shoulder movement, in particular rotation. This often results in impaired throwing/ overhead capacity
Scapular Winging often observed at rest or through arm elevation, a finding that is not necessarily pathological in the throwing shoulder
Pain revealed on palpation of the Bicipital Groove has a sensitivity of 0.25 and specificity of 0.80 for SLAP Lesions (SOURCE-5)
Range of Motion assessment of The Shoulder Girdle may reveal findings relevant to SLAP lesions, in particular of the Glenohumeral Joint and Scapulothoracic Joint (SOURCE-9). Glenohumeral motion may also be evaluated with the Scapula stabilised (either by the pracitioner or in supine) (SOURCE-9). GIRD (>20º reduction in GH Joint - Internal Rotation ) and replication of Pain on resistance of a throwing motion are common findings (SOURCE-8+9). Range of motion for the Cervical Spine may also be relevant to rule out suspected Radiculopathy (SOURCE-18). Reference should always be made to the asymptomatic side.
There are many orthopaedic Special Tests that may be conducted to evaluate the integrity of the Bicipital-Labral complex, with positive findings from multiple tests representing a higher confidence in diagnosis (SOURCE-9). A comprehensive examination may also encorporate Shoulder - Special Tests that evaluate for other Glenoid Labrum Tears and Glenohumeral Instability as guided by the patients presenting complaints (SOURCE-9+12). The mechanism of injury may also indicate some tests moreso than others as indicated below (SOURCE-12). The following tests have clinical merit for the evaluation of a SLAP lesion (SOURCE-1+9+12+18+19):Compression Injury
Modified O’Brien’s Test - sensitivity: 0.47-0.99, specificity: 0.11-0.98
Humeral Compression with Rotation - without Rotation can be used to implicate intra-articular structures through provocation/ compression
Clunk Test - sensitivity 0.44, specificity 0.68
Anterior Slide Test - sensitivity: 0.05-0.78, specificity: 0.82-0.93
Traction Injury
Speed’s - sensitivity 0.32, specificity 0.61
Dynamic Speed’s
Modified O’Brien’s Test - sensitivity: 0.47-0.99, specificity: 0.11-0.98
“Peel-Back” Mechanism
Pronated Load Test?
Resisted Elbow - Supination with GH Joint - External Rotation
Biceps Load Test I&II - sensitivity 0.90-0.91, specificity 0.97
Crank Test - sensitivity 0.13-0.81, specificity 0.67-0.88
All Other SLAP Tests
Dynamic Labral Shear - sensitivity 0.57-0.78, specificity 0.51-0.52
Forced Shoulder Abduction and Elbow Flexion Test - sensitivity 0.67, specificity 0.67
Bicipital Groove Palpation - sensitivity 0.25, specificity 0.80
There are a few imaging modalities that may be relevant for the evaluation of SLAP lesions and their common concomitant injuries. Determining the most appropriate modaility depends on the suspected pathology:
Magnetic Resonance Imaging (MRI)- with or without arthrography (contrast dye) is considered the gold standard suspected SLAP lesions and other concomitant soft-tissue pathologies (SOURCE-8+9). For small/ difficult to distinguish lesions arthrography (MRA) may better highlight tissue compromise to improve imaging sensivity (SOURCE-8). In the acute phase of injury, joint effusion may serve as an effective contrasting agent (SOURCE-8). Multiplanar images in the Axial, Coronal and Parasagittal planes are recommended, with a position of GH Joint - Abduction and GH Joint - External Rotation thought to improve diagnostic accuracy as it exacerbates the “peel-back” mechanism (SOURCE-8+9). The following findings may be indicative of a SLAP lesion:
Bicipital-Labral Complex - high signal intensity/ contrast extenstion under the complex
Deep Cleft - between Superior Labrum and Glenoid, a laterally curving high signal intensity may be apparent
Labral Fragments - indicated by fluid extravastion
Long Head of Biceps Tendon - high intensity anteroposterior line that extends at the muscles attachment on the labrum
Computed Tomograpgy (CT-Scan)- this modality allows for superior visualisation of Bone , with2-dimensionally and 3-dimensionally reconstructed computed tomography (2DCT and 3DCT)providing information not limited to the quantification of Glenoid bone-loss (SOURCE-1+36). These scans may evalaute for the presence of morphology such as the inverse pear-shaped Glenoid Rim which may be crucial to preoverative planning (SOURCE-36). By injecting contrast dye into the joint space, aCT-arthrographyeffectively outlines soft-tissue structures and reveals any tears or defects. A patient position of GH Joint - Abduction and GH Joint - External Rotation may enhance image sensitivity by tensioning the Inferior Glenohumeral Ligament (SOURCE-1).
Radiography (X-Ray)- is often considered a necessary first step for patients with acute or chronic Pain in The Shoulder Girdle , despite revealing no specific finding to SLAP lesions (SOURCE-9+18). X-Rays may however effectively evaluate for the presence of concomitant osseous pathologies including Acromioclavicular Joint abnormalities, outlet impingement and Bennett’s lesion (SOURCE-9). Less frequently, X-Rays may be sufficent for the evaluation of Hill-Sachs Lesions or other bony disturances to the Glenoid Rim, although more often a lack of image clarity and obstruction from superimposed structures makes quantifying bone loss and determing the rim’s shape difficult (SOURCE-36). The following views may be relevant (SOURCE-9+18):
True AP of Glenohumeral Joint (Grasheys) View - patients torso is rotated 30-45º forward on the affected side to align the joint space with the cassette
Scapula AP View
Axillary View
Outlet View
SLAP Lesions do not necessarily lead to shoulder degeneration which supports the notion that conservative treatment should be attempted before surgical intervention is considered (SOURCE-10). Particularly in young active patients, non-operative strategies have been shown to relieve Pain and improve clinical outcomes associated with SLAP lesions (SOURCE-10). Intuitively, those with a history of trauma, mechanical symptoms or high overhead demands are less likely to respond to conservative management. Rehabilitation protocol following injury or various surgical procedures is for the most part comparable, although time frames and the emphasis of specific tissues deviate (SOURCE-7+8+9+12). For example, following a Debridement no immobilisation is necessary, movement may be commenced immediately, strength progressed from 4 weeks, with a return to sport possible from 7 weeks (SOURCE-12). Conversely, following arthroscopic repair of the Glenoid Labrum or Biceps Brachii immobilisation is recommended for 4 weeks with minimal/ restricted movement permitted within the first 2 weeks (SOURCE-12). For these more intensive procedures, muscular strength may not be emphasised until beyond the 20 week mark and a return to sport is expected between 6-9 months (SOURCE-12). Additionally, the precise mechanism of injury bares implications for the initial healing/ protection phase of treatment (SOURCE-12):
Compression Mechanism - exercise which has the capacity to perpetuate compression or shear on the Glenoid Labrum should be avoided while healing
Traction Mechanism - heavy resisted or eccentric Muscle Contraction of the Biceps Brachii should be avoided while the tissue is recovering
“Peel-Back” Mechanism - while the tissue is recovering excessive GH Joint - External Rotation should be avoided
Stretching may alleviate SLAP lesion symptoms of Pain and shoulder restriction (SOURCE-19). The posterior shoulder is often the chief concern as Contractures of the posterior Glenohumeral Joint Capsule and/ or an GH Joint - Internal Rotation deficit are commonly associated with SLAP lesions and may be ameliorated through stretching (SOURCE-8+9+19). While stretching may be relevant to any treatment approach, the ideal timing for its introduction varies. With a conservative approach stretching as tolerated by the patient may be indicated immediately following subsidence of Inflammation (SOURCE-19). Conversely, stretching is typically delayed for 5-6 weeks following arthroscopic repair to allow adequate time for tissues to heal (SOURCE-10). The following lists stretches that may be relevant in the treatment of SLAP lesions (8+9+10+13+19):Initial Phase
Quadruped Thoracic Rotation - reduce the need for the shoulder to compensate for a lack of Thoracic Spine Mobility
Seated Thoracic Rotation with Breathing - large lateral flexion and rotation range coupled with breathing
Forward Elevation Stretch - rudimentary passive stretch with moderate GH Joint - Flexion range
Genie Stretch - rudimentary horizontal adduction stretch
Shoulder External Rotation Stretch - rudimentary active stretch with large GH Joint - External Rotation range and several variations
Mid-Phase
Door Frame Shoulder Stretch - self-guided anterior shoulder stretch with large Horizontal GH Joint - Abduction range
Dowel External Rotation Stretch - self-guided GH Joint - External Rotation stretch with overpressure
Late Phase
Banded Capsule Rolls - split stance biceps variation that emphasises shoulder rotation
Shoulder Dislocates - mobility exercise that emphasises the greatest circumduction range possible
Split Stance Biceps Stretch - self-guided anterior shoulder stretch with large GH Joint - Extension range
Controversial - the following stretches effectively lengthen the External Rotators and Posterior Capsule; however, they may provoke a SLAP repair site through the “peel-back” mechanism:
Sleeper Stretch - greater emphasis on GH Joint - Internal Rotation
Sleeper Stretch MWM - internal rotation stretch combined with Humerus Mobilisation
Despite deviations between SLAP lesion severity, presence of concomitant pathology and/ or surgical procedure(s) used, Strength training forms an integral part of rehabilitation. Generally this is split into distinct phases that address tissue healing/ protection, restoration of Pain -free Range of Motion and development of Muscle capacity and the functional patterns they belong to. Training should endeavour to improve dynamic stability of the Glenohumeral Joint and ameliorate Scapular Dyskinesis if present (SOURCE-8+12). The following details a comprehensive list of exercises relevant to conservative or surgical management, in rough descending order (SOURCE-7+8+12+13+14+15+19):
Initial Phase - following arthroscopic repair tissues are typically protected via immobilisation for a period of four weeks (SOURCE-10+12). During this period limited movement is permitted within restricted ranges that are contingent on the implicated soft-tissue. Over the first 6 weeks following repair, movements are progressed from passive and active-assisted Range of Motion to Active range of motion and sub-maximal isometrics. Irrespective of the repair site, activity of the Biceps Brachii , active GH Joint - External Rotation , GH Joint - Extension and GH Joint - Abduction should be avoided for at minimum the immobilisation period (SOURCE-7+8+12):
GH Joint - Flexion - 60-75º is permitted within first two weeks. PROM and AAROM to 90º at four weeks and 145º at six weeks
Elevation in Scapular Plane - 60º within first two weeks
GH Joint - External Rotation - 10-15º within first two weeks through motion only. Active assisted External Rotation in the Scapular Plane permitted to 25-30º at four weeks and External Rotation at 45º GH Joint - Abduction to 45-50º at six weeks
GH Joint - Internal Rotation - in the Scapular Plane 25-30º permitted after four weeks as PROM or AAROM. Internal Rotation in 45º GH Joint - Abduction to 55-60º at six weeks
GH Joint - Abduction - PROM and AAROM to 75-85º permitted after immobilisation. At 6 weeks active abduction may be permitted
External/ Internal Rotation in Scapular Plane - permitted within first two weeks
Elbow - Flexion - activation of the biceps should be avoided for the first 6 weeks following a labral repair and 3 months following a Biceps Tenodesis
Isometric Exercises - used to promote dynamic stability and coordination of the Rotator Cuff / shoulder Muscles . Rhythmic stabilisation drills may be commenced immediately following arthroscopic repair where the patient statically holds a position and the practitioner applies gentle resistance from different directions:
Side-Lying Shoulder External Rotations - within permitted range, against manual resistance of the practitioner
Side-Lying Shoulder Internal Rotations - within permitted range, against manual resistance of the practitioner
Side-Lying Scapulothoracic Joint - Retraction - against manual resistance of the practitioner
Side-Lying GH Joint - Flexion - within permitted range, against manual resistance of the practitioner
Side-Lying GH Joint - Extension - within permitted range, against manual resistance of the practitioner
Isotonic Exercises - from roughly week three following arthroscopic repair, light resistance through the use of resistance bands may be added. Once again, within the permitted range/ time frames:
By week six:
Banded Side Raises
Banded Full Can position
Banded Prone Rows
Mid-Phase - this phase is progressed from isotonic strength exercises and Proprioceptive Neuromuscular Facilitation with manual resistance (SOURCE-8+12). At week ten full Range of Motion should be possible and Pain -free, activity of the Biceps Brachii may be commenced and throwing motions soon after (SOURCE-12). Early Biceps activity should be closely monitored and mindful of incidentally provocative exercises (SOURCE-7). Trapezius exercises for example, appear to activate the Biceps less than Serratus Anterior exercises and may be more appropriate for the muscles reintroduction (SOURCE-7). Additionally, GH Joint - Internal Rotation appears to inhibit biceps activity (SOURCE-7).
Isotonic Exercises - the following lists exercises in rough descending order from those that are likely tolerated at week seven to those that are likely relevant beyond week twelve:
Band Pull-Apart - can progress toCheerleader Variationas tolerated by patient
Proprioceptive Neuromuscular Facilitation with manual resistance from practitioner for motions such as:
Bird-Dog - bodyweight isotonic exercise that emphasises Posterior Sling / Core
Push-Up Plus - starting with the support of a wall and progressing to the ground
Prone Cobra - isometric exercise that emphasies Middle and Lower Trapezius
Y-Raise - low load, restrict range till week ten
Prone Row into GH Joint - External Rotation
Bilateral GH Joint - External Rotation with Scapulothoracic Joint - Retraction
Bilateral Banded Full Can in a Split Stance
Bilateral Banded GH Joint - Abduction in Split Stance
Side-Lying Shoulder External Rotations in Half Side Plank - using a resistance band, half side-plank on knees
Banded Horizontal Adduction - low load isotonic horizontal adduction exercise
Scapular Punches - isotonic exercise that emphasises Scapulothoracic Joint - Protraction
Pallof Press - low load horizontal push exercise that emphasises anti-rotation of Core
Standard Resistance exercises that may be commenced with a low load:
Push-Up - bodyweight isotonic horizontal push exercise
Chest Press Machine - rudimentary horizontal push machine
One Arm Row - unilateral DB version of Seated Row
DB Shoulder Press - unilaterally loaded overhead press variation
Lat Pulldown - rudimentary weighted isotonic vertical pull movement with a high range of motion
Overhead Press - isotonic vertical push exercise with large overhead range
Seated Row - rudimentary weighted isotonic horizontal pull movement
Banded Unilateral Lat Activations - activate lat, posteroinferior drawer on Humerus
Circumduction Row - isotonic exercise with variable load used to emphasise mid-to-lower Trapezius
Elbow - Flexion - AROM may be permitted by week seven to nine with resistance Flexion or Elbow - Supination commenced between weeks twelve to sixteen.
Throwing - GH Joint - External Rotation may be progressed to the throwing motion from weeks ten to twelve
Throwers Ten Program - a throwers rehabilitation sequence which should be appropriate from week seven-to-nine, although certain exercises (such as the Biceps Curl) may need to be delayed
Late Cocking Medball Throws - a light ball is thrown against a wall in a controlled manner from a the late cocking phase of overhead throwing (~90º GH Joint - Abduction and end-range GH Joint - External Rotation
Plyometrics - light movements may be commenced as early as week twelve and progressed to higher-load plyometrics in the late phase:
Two-handed Medicine Ball Chest Press
Two-handed Medball Overhead “soccer” throw
Two-handed Medball Side Throw - using lower body to facilitate trunk rotation
Late Phase - from week 20 through to a return to sport ~6-9 months following arthroscopic repair Muscle parameters such as strength, power and endurance are emphasised (SOURCE-12). Exercise selection and intensity should progressively reflect the functional demands of their sport or activities of daily living. Sport specific exercises may include eccentric (rotation) deceleration for throwers or Pull-Ups for climbers (SOURCE-7)
Isotonic Exercises
On an Exercise Ball - unstable position forces patient to engage Core :
GH Joint - External Rotation / GH Joint - Internal Rotation on Exercise Ball - at 0º GH Joint - Abduction , using a cable pulley
Unilateral or alternating Full Can on Exercise Ball - using dumbbells
Prone Row into GH Joint - External Rotation - at 90º GH Joint - Abduction with same sustained hold at top position
Prone Row into GH Joint - Internal Rotation - at 90º GH Joint - Abduction
GH Joint - Extension with arm in GH Joint - External Rotation
Y-Raise - using dumbbells
Prone Horizontal Abduction - using dumbbells
Side-Lying Shoulder External Rotations in Side Plank - using a resistance band, full side-plank on feet
“Lawnmower” - from a quarter squat position, row a resistance band or cable pulley from roughly the height of the opposing knee, across the torso until a high row position ( GH Joint - Extension and Elbow - Flexion ) is achieved
Standard Resistance exercises - in rough descending order:
Bench Press - isotonic horizontal push exercise with capacity for high loads
Incline DB Bench Press - unilaterally loaded Bench variation on variable incline
Prone Lat Pulldown - Lat Pulldown variation that emphasises Thoracic - Extension
Dips - bodyweight isotonic push exercise with large GH Joint - Extension range
Face Pulls - bilateral isonotic horizontal pull exercise that emphasises GH Joint - External Rotation
Inverted Rows - bodyweight Horizontal Pull that emphasises Biceps Brachii and Scapulothoracic Joint - Retraction
Push Press - wholebody, explosive variation of the Overhead Press
Bent Over Row - weighted isotonic horizontal pull exercise that emphasises entire posterior chain
Upright Row - weighted isotonic vertical pull exercise that emphasises Upper Trapezius and Deltoid
DB Pullover - moderate isotonic movement with large overhead and Thoracic - Extension range
Kneeling Landmine Press - wholebody, explosive vertical pressing exercise with large overhead range
Pull-Up - bodyweight or greater load through large overhead motion
Split Stance Landmine Press - crossbody, standing variation of the Kneeling Landmine Press
Rope Climb - pull-up variation with entire load bestowed on alternating arm
Half DB Bench Press - unilateral isotonic horizontal pressing motion that emphasises the Anterior Sling
Bird-Dog Row - One Arm Row variation that emphasises Posterior Sling
Proprioception Exercises
Push-Up on Medball - patient holds a Push-Up position at mid-range while the practitioner applies gentle resistance from different directions. Medball should first be positioned at roughly hip height and progressed to the ground as tolerated by the patient
Standing Shoulder External Rotations in 90º GH Joint - Abduction - with gentle perturbation from practitioner
Plyometrics - training loads should be progressed and intensity should begin to reflect that of their sport:
One-handed Overhead “baseball” throw
Medicine Ball Chest Press - plyometric horizontal pressing motion, often sports relevant
Medball Pullover Throw - plyometric Pullover variation
As SLAP Lesions do not necessarily lead to degeneration of The Shoulder Girdle , surgical intervention is typically reserved for when non-operative management is insufficient (SOURCE-10). Indications for surgery include a traumatic onset, concomitant injury, mechanical symptoms and/ or a high demand for overhead activity (SOURCE-10). There are several common surgical procedures used to treat SLAP Lesions, including (SOURCE-2+11+12+16+17+18):
Labral Debridement - also known as aLabral Resection, involves the removal of the torn or frayed portion of the Glenoid Labrum back to the stable labral rim with aims of eliminating the source of mechanical symptoms. In isolation, this procedure does not restore normal anatomy or stability to the shoulder and consequently has not displayed a reliable relief of long term symptoms. As such this is typically reserved for sedentary persons without concomitant injury
SLAP Repair - also known as aLabral Fixation, utilises suture anchors to secure the Superior Glenoid Labrum and/ or Biceps Anchor to the junction of the articular cartilage and Cortical Bone of the Glenoid Rim. The number of anchors used is based on the size of the lesion. This approach aims to restore natural attachment of the impaired soft-tissue making it suitable for young, active patients. Knotless fixation devices also minimise the risk of post-operative symptoms as there is less bulky disturbance
Biceps Tenotomy - a relatively simple and quick procedure when compared to Tenodesis that involves the surgical release (severing) of the Long Head of Biceps attachment on the Glenoid Labrum . As this procedure impairs the Muscles function, it is typically reserved for elderly patients or those with concomitant injuries such as Rotator Cuff Tears . This procedure also poses the risk of a “Popeye” deformity that may be mitigated with a “loop” biceps tenotomy technique
Biceps Tenodesis - also involves detachment of the Long Head of Biceps Tendon from the Supraglenoid Tubercle but unlike a Tenotomy, reattaches the tendon to one of a few sites on the Proximal Humerus . Tenodesis may be performed through open or arthroscopic means and fixes the tendon to either soft-tissue or Bone with anchors or bone tunnels. While this procedure may better maintain Muscle Strength and appearance when compared to a Tenotomy, the relocation of a significant attachment is not without compromise, making it more suitable for those over the age of 35 with less functional demand. This procedure may also be indicated for patients with a high physical demand with signs of tendinous degeneration
Determining which procedure(s) lead to the most favourable outcomes is influenced by the patients circumstances (age, activity level and size) and nature of injury (type) (SOURCE-8+10). Arthroscopic repair alone may be insufficient for throwing athletes as a notable proportion do not regain their pre-injury level of performance (SOURCE-8). This procedure also has higher revision rates for middle-aged (roughly >40yrs) patients, for whom tenotomy or tenodesis procedures may provide better outcomes (SOURCE-8). The following treatment algorithm has been proposed for the surgical management of SLAP Lesions (SOURCE-8+10+11):
Type I - conservative management alone or arthroscopic debridement of the Superior Labrum may be sufficient
Type II - may be managed with SLAP repair or Tenotomy or Tenodesis of Long Head of Biceps Tendon , depending on patients circumstances. In young active patients, particularly with a traumatic onset, 1-2 suture anchors may be used to fix the damaged Superior Labrum to the Glenoid Rim. One is used to fix the anterosuperior portion and two are used if the posterosuperior portion is also detached. Conversely, for those over 40 yrs, inactive or with concomitant intra-articular injury Tenodesis or Tenotomy may be more suitable
Type III - as the Biceps anchor remains stable, the bucket-handle lesion is simply removed through resection/ debridement
Type IV - surgical pathway determined by the extent of damage to the Long Head of Biceps Tendon . If <50% is compromised, both a SLAP repair and resection of the bucket-handle lesion are recommended. Where more than 50% of the tendon is compromised, a Tenotomy or Tenodesis may be required
Type V - a Bankart repair is used to address the Bankart Lesion , while an additional SLAP repair is used to reattach the Superior Labrum and Biceps to the Glenoid
Type VI - the freely handing labral tissue is resected/ debribed to prevent mechanical symptoms while an additional SLAP repair is used to reattach the Superior Labrum and Biceps to the Glenoid
Type VII - refixation of the Anterosuperior Labrum and attached Middle Glenohumeral Ligament , in addition to SLAP repair of the Superior Labrum and Biceps to the Glenoid
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