SLAP Lesion - Shoulder & Elbow

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

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)

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

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