Updated: 5/21/2018

SLAP Lesion

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https://upload.orthobullets.com/topic/3053/images/sublabral foramen illustration_moved.jpg
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 throwers 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
  • Biceps tendon attachment on glenoid (Tuoheti classification)
    • Type I - completely posterior
    • Type II - predominantly posterior
      • Type I and II together comprise >70%
    • Type III - anterior + posterior (25%)
    • Type IV - anterior (5%) 
  • 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%)
      • Buford complex 
        • cordlike MGHL with associated bare area of the anteriosuperior labrum 
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
Type II + anterointerior labral extension (Bankart lesion)
m
m
VI
Type II + unstable flap
m
m
VII
Type II + MGHL injury
m
m
VIII Type II + posterior extension    
IX Circumferential    
X Type II + posteroinferior extension (reverse Bankart)    
  • 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
      • complications
        • overdrilling the glenoid can injury the suprascapular nerve  
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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Questions (16)
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(SAE07SM.81) Medial dislocation of the long head of the biceps tendon in the shoulder is most commonly caused by a Review Topic

QID: 8743
1

tear of the subscapularis tendon.

72%

(77/107)

2

tear of the supraspinatus tendon.

2%

(2/107)

3

tear of the transverse ligament.

13%

(14/107)

4

type I SLAP tear.

6%

(6/107)

5

congenitally shallow bicipital groove.

7%

(7/107)

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(SAE07SM.12) Which of the following is considered an advantage of arthroscopic distal clavicle excision compared with open distal clavicle excision? Review Topic

QID: 8674
1

Fewer complications

8%

(9/113)

2

Lower infection rate

15%

(17/113)

3

Evaluation of the glenohumeral joint

67%

(76/113)

4

Preservation of the inferior acromioclavicular ligament

7%

(8/113)

5

Decreased surgical time

3%

(3/113)

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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? Review Topic

QID: 3134
1

0%

1%

(34/2723)

2

15%

34%

(930/2723)

3

30%

23%

(628/2723)

4

70%

40%

(1098/2723)

5

100%

1%

(24/2723)

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(OBQ13.101) Figure A is the MR image of the left shoulder of an active 47-year-old painter who has been experiencing shoulder pain for 9 months. In addition to the finding shown in Figure A, MRI examination of the intra-articular portion of the biceps tendon shows fraying greater than 50%. He has not obtained relief from an 8 month course of non-operative management including non-steroidal anti-inflammatory medications, physical therapy and corticosteroid injection. What is the best next step in treatment? Review Topic

QID: 4736
FIGURES:
1

New course of physical therapy

0%

(10/3834)

2

Activity shutdown with 6 weeks sling immobilization

0%

(10/3834)

3

Arthroscopic superior labrum anterior to posterior (SLAP) tear repair

17%

(650/3834)

4

Arthroscopic debridement and possible biceps tenotomy versus tenodesis

81%

(3093/3834)

5

Arthroscopic rotator cuff repair and acromioplasty

1%

(54/3834)

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(OBQ12.110) Which of the following rehabilitation exercises is most appropriate immediately following the repair of the injury seen in figure A? Review Topic

QID: 4470
FIGURES:
1

Passive external rotation at 90 degrees of abduction

11%

(442/4188)

2

Isotonic rotator cuff strengthening

14%

(580/4188)

3

Isokinetic resistive elbow flexion

8%

(352/4188)

4

Passive and active assisted flexion in scapular plane

65%

(2723/4188)

5

Concentric latissimus pull down exercises

2%

(63/4188)

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(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: Review Topic

QID: 3125
1

Immediate full active range of motion that simulates sport-specific activities

0%

(8/2248)

2

Full-time sling wear with no active nor passive motion for at least 6 weeks until labral tissues heal

6%

(125/2248)

3

Rotator cuff strengthening by post-operative week two to prevent disuse atrophy and shoulder instability

3%

(78/2248)

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

88%

(1988/2248)

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

2%

(39/2248)

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(OBQ12.1) Figure A is an arthrosopic image from a right shoulder in the lateral decubitus position as viewed from the posterior portal. Which one of the following rehabilitation techniques should be avoided in the patient that is 2 weeks post-operative from the surgical repair shown in Figure A? Review Topic

QID: 4361
FIGURES:
1

Active assisted elevation in the scapular plane

19%

(1044/5479)

2

Passive forearm pronation

3%

(172/5479)

3

Passive external rotation at 90 degrees of abduction

68%

(3703/5479)

4

Open chain passive elbow flexion

7%

(363/5479)

5

Passive assisted elevation in the scapular plane

2%

(103/5479)

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

QID: 101
1

Normal anatomic variant characterized by a cord-like MGHL and an absent anterosuperior labrum

66%

(701/1061)

2

Normal anatomic variant characterized by a cord-like SGHL and an absent posterosuperior labrum

5%

(52/1061)

3

Abnormal arthroscopic finding characterized by a cord-like MGHL and an absent anterosuperior labrum

6%

(67/1061)

4

Abnormal arthroscopic finding characterized by a cord-like SGHL and an absent posterosuperior labrum

2%

(20/1061)

5

Normal anatomic variant characterized by a cord-like MGHL and a sublabral foramen at the anterosuperior labrum

20%

(216/1061)

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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? Review Topic

QID: 1341
FIGURES:
1

HAGL

23%

(226/970)

2

SLAP tear

65%

(630/970)

3

ALPSA

6%

(58/970)

4

Bankart

5%

(48/970)

5

Loose body

0%

(3/970)

ML 3

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