SLAP lesion

Author: Patrick McCulloch

Topic updated on 05/16/13 12:45pm

Introduction

Superior Labrum from Anterior to Posterior tears
May occur as isolated lesion or be associated with
- internal impingement
- rotator cuff tears (usually articular sided)
- instability (may be subtle)
Mechanisms
- repetitive overhead activities (often seen in throwing athletes)
- fall on outstretched arm with tensed biceps
- traction on the arm
Pathophysiology
- in thrower's may be due to tightness of the postero-IGHL which shifts the glenohumeral contact point posterosuperiorly and increases the shear force on the superior labrum
- SLAP lesion increases the strain on the anterior band of the IGHL and thus compromises stability of shoulder

Anatomy

Anatomy of glenohumeral joint
Glenoid labrum
- function
  - chock block to subluxation
- composition
  - composed of fibrocartilagenous tissue
- blood supply
  - from suprascapular, circumflex scapular, posterior humeral circumflex arteries
  - labrum receives blood from capsule and periosteal vessels and not from underlying bone
  - anterior-superior labrum has poorest blood supply
- stability
  - superior labrum
    - anchors biceps tendon (weak link that leads to SLAP lesion)
    - most common pattern of biceps tendon attachment to the superior labrum is posterior to the 12 o'clock position
- anatomic variants
  - sublabral recess
    - can be confused with a tear on MRI
  - meniscoid appearance (1%)

Classification

SLAP Classification
Type	Description	%	Images
I	Labral and biceps fraying, anchor intact	11%
II	Labral fraying with detached biceps tendon anchor	41%
III	Bucket handle tear, intact biceps tendon anchor (biceps separates from bucket handle tear)	33%
IV	Bucket handle tear with detached biceps tendon anchor (remains attached to bucket handle tear)	15%
V	SLAP lesion and anterior labral tear (Bankart lesion)	m	m
VI	Superior flap tear	m	m
VII	SLAP lesion with capsular injury	m	m

Snyder Classification: Original classification which includes Types I-IV
Maffet sub-classification: Includes the original I-IV and adds Types V-VII

Presentation

Symptoms
- vague deep shoulder pain (there is often a lag between the time of injury and the onset of symptoms)
- mechanical symptoms of popping and clicking
- weakness, easy fatigue, and decrease athletic performance
Physical exam
- provocative tests
  - active compression test (O'Brien's test)
  - Crank test
  - Dynamic labral shear test
- biceps tendon tenderness
- patients commonly have GIRD
- apprehension positive in 85% of patients
- physical findings of suprascapular neuropathy secondary to a spinoglenoid cyst

Imaging

Radiographs
- should be normal
MRI
- T2 linear signal intensity between the superior labrum and the glenoid rim
- sensitivity ~50% and specificity ~90% which increases with arthrogram
- may see an associated paralabral ganglion cyst
  - usually in the spinoglenoid notch
  - may result in denervation changes to infraspinatus
Arthroscopy
- diagnosis can only be confirmed with arthroscopy
- look for erythema and tearing under labrum to differentiate from normal recess
- "peel back" test shows "peel back" of the labrum with 90° of external rotation and abduction

Treatment

Nonoperative
- physical therapy, NSAIDs
  - indications
    - first line of treatment
    - address GIRD, scapular dyskinesia, rotator cuff
    - incidental SLAP finding
      - in older patients (>45 years) having arthroscopic rotator cuff repair, it is not necessary to repair a SLAP lesion that is found incidentally. It may actually lead to stiffness if it is repaired.
Operative
- arthroscopic debridement and stabilization of the labrum and biceps tendon
  - indications
    - severe symptoms that have failed nonoperative management

Techniques

Arthroscopic debridement and stabilization of the labrum and biceps tendon
- approach
  - standard arthroscopic approach to the shoulder
- technique
  - Type I - debride labrum
  - Type II - reattach labrum
  - Type III - debridement of flaps
  - Type IV
    - if tendon involvement < 1/3, then excise the bucket
    - if tendon involvement >1/3, same and perform biceps tenodesis or tenotomy.
  - decompress any cysts
- rehabilitation
  - week 1-4
    - sling with passive forward elevation. Avoid extremes of abduction and external rotation
    - passive and active assisted flexion in the scapular plane
  - week 4-6
    - progress to active ROM, isometrics
  - week 6-12
    - functional exercise and light strengthening
  - week 12+
    - advance strength and ROM, sport-specifics
    - typical return to sport around 6 months

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Qbank (6 Questions)

TAG

(OBQ10.37) A 26-year-old outfielder undergoes arthroscopic repair of a right shoulder type 2 SLAP tear with two labral anchors in the 11 and 1 o’clock positions. Postoperative rehabilitation for this SLAP repair should include: Topic

Review Topic

1. Immediate full active range of motion that simulates sport-specific activities
2. Full-time sling wear with no active nor passive motion for at least 6 weeks until labral tissues heal
3. Rotator cuff strengthening by post-operative week two to prevent disuse atrophy and shoulder instability
4. Limited passive motion for 4 weeks then progressive active motion until 8 weeks followed by sport specific strengthening until at least 12 to 16 weeks postoperatively
5. Eccentric open chain biceps contraction exercises beginning at postoperative week 2 to retrain the biceps muscle and stimulate SLAP healing at the biceps anchor on the glenoid

PREFERRED RESPONSE ▶

DISCUSSION: The most common type 2 SLAP repair rehabilitation protocols focus on limited passive range of motion followed by regaining active motion, then finally strengthening and sport specific activities. Specific protocols vary by surgeon, concomitant injuries, and intra-operative findings. The initial passive motion is often limited from 0 to 90 degrees of forward elevation during the first 4 weeks. This helps prevent stiffness, but also avoids stressing the repair site at the extremes of motion. Active motion is then initiated in a limited arc of motion to re-strengthen the shoulder. Finally, sport specific activities are progressively trained from 8 to 16 weeks.

The Ellenbecker OKU reference reviews shoulder rehab and the Ellenbecker et al reference describes therapy focused on early passive motion with progressive active motion for rotator cuff repairs. They describe successful return of near full ROM and strength by 12 weeks postoperatively. The Manske et al article reviews the therapy for all SLAP injuries treated both operatively and non-operatively.

REFERENCES:

1. Ellenbecker TS, Reinold MM, Davies GJ. Rehabilitation principles following rotator cuff and superior labral repair. In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009:217-227

2. Ellenbecker TS, Elmore E, Bailie DS. Descriptive report of shoulder range of motion and rotational strength 6 and 12 weeks following rotator cuff repair using a mini-open deltoid splitting technique. J Orthop Sports Phys Ther. 2006 May;36(5):326-35. PMID:16715833 (Link to Abstract)

3. Manske R, Prohaska D. Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete. Phys Ther Sport. 2010 Nov;11(4):110-21. Epub 2010 Jul 27. PMID:21055704 (Link to Abstract)

Question Authors:

Charles Jobin MD, Patrick McCulloch MD, Michael Hughes MD,

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(OBQ10.46) What percent of shoulders have a posterior or posterior dominant attachment of the long head of the biceps onto the glenoid? Topic

Review Topic

1. 0%
2. 15%
3. 30%
4. 70%
5. 100%

PREFERRED RESPONSE ▶

DISCUSSION: The anatomy of the attachment of the long head of the biceps onto the glenoid has been described as "posterior" or "posterior-dominant" in roughly 70% (55-82%)of patients in studies by Tuoheti et al and Vangsness et al. The most common type is posterior dominant. Only 25% (17-33%) of shoulders have an equal distribution of anterior and posterior attachment to the glenoid, and very rarely ~5% (0-8%) is the attachment anterior only. Histologic examination demonstrate that the structural fibers of the long head of the biceps attach directly to the superior glenoid tubercle in nearly 50% of shoulders while in the other half the biceps tendon inserts predominantly into the posterior glenoid labrum which in turn attaches to the glenoid.

REFERENCES:

1. Vangsness CT Jr, Jorgenson SS, Watson T, Johnson DL. The origin of the long head of the biceps from the scapula and glenoid labrum. An anatomical study of 100 shoulders. J Bone Joint Surg Br. 1994 Nov;76(6):951-4. PMID:7983126 (Link to Abstract)

2. Tuoheti Y, Itoi E, Minagawa H, Yamamoto N, Saito H, Seki N, Okada K, Shimada Y, Abe H. Attachment types of the long head of the biceps tendon to the glenoid labrum and their relationships with the glenohumeral ligaments. Arthroscopy. 2005 Oct;21(10):1242-9. PMID:16226654 (Link to Abstract)

Question Authors:

Charles Jobin MD, Patrick McCulloch MD,

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(OBQ04.40) Which of the following best describes a Buford complex? Topic

Review Topic

1. Normal anatomic variant characterized by a cord-like MGHL and an absent anterosuperior labrum
2. Normal anatomic variant characterized by a cord-like SGHL and an absent posterosuperior labrum
3. Abnormal arthroscopic finding characterized by a cord-like MGHL and an absent anterosuperior labrum
4. Abnormal arthroscopic finding characterized by a cord-like SGHL and an absent posterosuperior labrum
5. Normal anatomic variant characterized by a cord-like MGHL and a sublabral foramen at the anterosuperior labrum

PREFERRED RESPONSE ▶

DISCUSSION: A Buford complex, first described by Buford in 1994, is a normal anatomical variant seen in 1.5% of individuals and consists of a cord-like MGHL and absent anterosuperior labrum complex. The cord-like MGHL should not be repaired down to the glenoid as this will result in decreased postoperative range of motion.

Rao et al demonstrated three distinct variations of the anterosuperior portion of the labrum with sublabral foramen being more prevalent than a Buford complex. These normal variants were in order of decreasing prevalence: (1) sublabral foramen with a cord-like MGHL (8%), (2) sublabral foramen (3%), and (3) Buford complex: an absence of labral tissue at the anterosuperior quadrant with a cord-like MGHL (1.5%).

Steinbeck et al. inspected cadaver shoulders and found an absence of an MGHL occurred in 15% of shoulders and was associated with signs of pathologic instability, either Hill-Sachs or bony Bankart.

Illustration A is an arthroscopic image of a Buford Complex, labeled "cord-like MGHL".
Illustration V is a video that shows a diagnostic arthroscopy with a Buford complex.

Illustrations: A

REFERENCES:

1. Steinbeck J, Liljenqvist U, Jerosch J. The anatomy of the glenohumeral ligamentous complex and its contribution to anterior shoulder stability. J Shoulder Elbow Surg. 1998 Mar-Apr;7(2):122-6. PMID:9593089 (Link to Abstract)

2. Rao AG, Kim TK, Chronopoulos E, McFarland EG. Anatomical variants in the anterosuperior aspect of the glenoid labrum: a statistical analysis of seventy-three cases. J Bone Joint Surg Am. 2003 Apr;85-A(4):653-9. PMID:12672841 (Link to Abstract)

3. Williams MM, Snyder SJ, Buford D Jr. The Buford complex--the "cord-like" middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant. Arthroscopy. 1994 Jun;10(3):241-7. PMID:8086014 (Link to Abstract)

Question Authors:

Charles Jobin MD, Derek Moore, Patrick McCulloch MD, Mark Miller MD,

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(OBQ04.236) A 32-year-old overhead athlete catches himself with his right hand while slipping on ice and injures his right shoulder. He fails to improve with therapy, anti-inflammatory medicines, and rest. His MRI is demonstrated in Figure A. What is the most likely diagnosis? Topic

Review Topic

FIGURES: A

1. HAGL
2. SLAP tear
3. ALPSA
4. Bankart
5. Loose body

PREFERRED RESPONSE ▶

DISCUSSION: The T2 MRI image demonstrates a superior labral anterior to posterior tear (SLAP tear), and also shows a partial articular sided tear of the supraspinatus tendon. The gold standard for diagnosis of a SLAP tear is arthroscopy. A study by Yoneda et al. demonstrated that the presence of a linear, high-to-intermediate intensity area between the superior labrum and the glenoid rim on oblique coronal T2-weighted images had a sensitivity of 41%, a specificity of 86%, and an accuracy of 63% for diagnosing a SLAP tear. However, there have been recent concerns about the overdiagnosis and SLAP repairs, based on increased number of SLAP repairs in ABOS part II case logs, as presented at the AANA 2010 meeting. A HAGL lesion is a humeral avulsion of the anterior inferior glenohumeral ligament (Image in Illustration A). An ALPSA lesion is seen on an axial image and is an anterior labral periosteal sleeve avulsion characterized by the capsulolabral-periosteal complex peeling off the glenoid face and displacing medially on the glenoid neck. A Bankart lesion is an anterioinferior labral tear often caused by an anterior shoulder dislocation.

Illustrations: A

REFERENCES:

1. Yoneda M, Izawa K, Hirooka A, Hayashida K, Wakitani S. Indicators of superior glenoid labral detachment on magnetic resonance imaging and computed tomography arthrography. J Shoulder Elbow Surg. 1998 Jan-Feb;7(1):2-12. PMID:9524335 (Link to Abstract)

Question Authors:

Charles Jobin MD, Eric Shirley MD, Patrick McCulloch MD,

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Videos

	Diagnosis & Treatment of SLAP Tears - Dr. Ben Shaffer, WOSM Sports - Educational Presentation - SLAP lesion This talk reviews the diagnosis and treatment of SLAP tears. Dr. Benjamin S. Sha...	3/17/2013 61 views 4
	Shoulder Exam: Exam to detect a SLAP tear Sports - Physical Exam - SLAP lesion Shoulder Exam: Exam to detect a SLAP tear	3/9/2013 459 views 4
	SLAP Type II Arthroscopic Repair Sports - Surgical Techniques - SLAP lesion Shows one technique for arthroscopic repair of a Type II SLAP lesion using knotl...	9/2/2012 127 views 3
	Shoulder arthroscopy with labral injury Sports - Surgical Technique - SLAP lesion This is a arthroscopic view of labral pathology in a shoulder. The biceps ancho...	12/10/2011 75 views 0

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Posts

Attachment types of the long head of the biceps tendon to the glenoid labrum and their relationships with the glenohumeral ligaments. Includes Poll

Tuoheti Y, Itoi E, Minagawa H, Yamamoto N, Saito H, Seki N, Okada K, Shimada Y, Abe H
Arthroscopy. 2005 Oct;21(10):1242-9. PMID: 16226654 (Link to Pubmed)

Sports - Journal Club - SLAP lesion

4/9/2013

14 responses

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Groups

ABOS II: SLAP lesion

General - Oral Boards Review

7/29/2011

0 responses

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Rao AG, Kim TK, Chronopoulos E, McFarland EG. Anatomical variants in the anterosuperior aspect of the glenoid labrum: a statistical analysis of seventy-three cases. J Bone Joint Surg Am. 2003 Apr;85-A(4):653-9. PMID:12672841 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Shepard MF, Dugas JR, Zeng N, Andrews JR. Differences in the ultimate strength of the biceps anchor and the generation of type II superior labral anterior posterior lesions in a cadaveric model. Am J Sports Med. 2004 Jul-Aug;32(5):1197-201. Epub 2004 May 18. PMID:15262642 (Link to Abstract)
Shepard MF, Dugas JR, Zeng N, Andrews JR. Differences in the ultimate strength of the biceps anchor and the generation of type II superior labral anterior posterior lesions in a cadaveric model. Am J Sports Med. 2004 Jul-Aug;32(5):1197-201. Epub 2004 May 18. PMID:15262642 (Link to Abstract)
Steinbeck J, Liljenqvist U, Jerosch J. The anatomy of the glenohumeral ligamentous complex and its contribution to anterior shoulder stability. J Shoulder Elbow Surg. 1998 Mar-Apr;7(2):122-6. PMID:9593089 (Link to Abstract)
Williams MM, Snyder SJ, Buford D Jr. The Buford complex--the "cord-like" middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant. Arthroscopy. 1994 Jun;10(3):241-7. PMID:8086014 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Wilk KE, Reinold MM. Postsurgical shoulder rehabilitation. In: Galatz LM, ed. Orthopaedic Knowledge Update: Shoulder and Elbow 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:559- 568

Undefined

Ellenbecker TS, Reinold MM, Davies GJ. Rehabilitation principles following rotator cuff and superior labral repair. In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009:217-227
Ellenbecker TS, Elmore E, Bailie DS. Descriptive report of shoulder range of motion and rotational strength 6 and 12 weeks following rotator cuff repair using a mini-open deltoid splitting technique. J Orthop Sports Phys Ther. 2006 May;36(5):326-35. PMID:16715833 (Link to Abstract)
Manske R, Prohaska D. Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete. Phys Ther Sport. 2010 Nov;11(4):110-21. Epub 2010 Jul 27. PMID:21055704 (Link to Abstract)
Vangsness CT Jr, Jorgenson SS, Watson T, Johnson DL. The origin of the long head of the biceps from the scapula and glenoid labrum. An anatomical study of 100 shoulders. J Bone Joint Surg Br. 1994 Nov;76(6):951-4. PMID:7983126 (Link to Abstract)
Tuoheti Y, Itoi E, Minagawa H, Yamamoto N, Saito H, Seki N, Okada K, Shimada Y, Abe H. Attachment types of the long head of the biceps tendon to the glenoid labrum and their relationships with the glenohumeral ligaments. Arthroscopy. 2005 Oct;21(10):1242-9. PMID:16226654 (Link to Abstract)
Yoneda M, Izawa K, Hirooka A, Hayashida K, Wakitani S. Indicators of superior glenoid labral detachment on magnetic resonance imaging and computed tomography arthrography. J Shoulder Elbow Surg. 1998 Jan-Feb;7(1):2-12. PMID:9524335 (Link to Abstract)

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SLAP lesion

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