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
Technique Guide CPT Codes: 29807 Arthroscopy, shoulder, surgical; repair of slap lesion Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. SLAP Repair Derek Moore Shoulder & Elbow - SLAP Lesion
QUESTIONS 1 of 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Previous Next (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: A 1 New course of physical therapy 0% (9/3463) 2 Activity shutdown with 6 weeks sling immobilization 0% (10/3463) 3 Arthroscopic superior labrum anterior to posterior (SLAP) tear repair 17% (588/3463) 4 Arthroscopic debridement and possible biceps tenotomy versus tenodesis 81% (2791/3463) 5 Arthroscopic rotator cuff repair and acromioplasty 1% (50/3463) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (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. 71% (75/105) 2 tear of the supraspinatus tendon. 2% (2/105) 3 tear of the transverse ligament. 13% (14/105) 4 type I SLAP tear. 6% (6/105) 5 congenitally shallow bicipital groove. 7% (7/105) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (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% (9/109) 2 Lower infection rate 15% (16/109) 3 Evaluation of the glenohumeral joint 67% (73/109) 4 Preservation of the inferior acromioclavicular ligament 7% (8/109) 5 Decreased surgical time 3% (3/109) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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% (34/2691) 2 15% 34% (924/2691) 3 30% 23% (618/2691) 4 70% 40% (1082/2691) 5 100% 1% (24/2691) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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: A 1 Passive external rotation at 90 degrees of abduction 11% (440/4173) 2 Isotonic rotator cuff strengthening 14% (577/4173) 3 Isokinetic resistive elbow flexion 8% (352/4173) 4 Passive and active assisted flexion in scapular plane 65% (2713/4173) 5 Concentric latissimus pull down exercises 2% (63/4173) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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% (8/2247) 2 Full-time sling wear with no active nor passive motion for at least 6 weeks until labral tissues heal 6% (125/2247) 3 Rotator cuff strengthening by post-operative week two to prevent disuse atrophy and shoulder instability 3% (77/2247) 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% (1988/2247) 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% (39/2247) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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: A 1 Active assisted elevation in the scapular plane 19% (1032/5400) 2 Passive forearm pronation 3% (169/5400) 3 Passive external rotation at 90 degrees of abduction 68% (3648/5400) 4 Open chain passive elbow flexion 7% (361/5400) 5 Passive assisted elevation in the scapular plane 2% (99/5400) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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% (700/1061) 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% (217/1061) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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: A 1 HAGL 23% (213/941) 2 SLAP tear 65% (614/941) 3 ALPSA 6% (57/941) 4 Bankart 5% (49/941) 5 Loose body 0% (3/941) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 2
Login to View Community Videos Login to View Community Videos 2018 Baseball Sports Medicine: Game-Changing Concepts The Management of SLAP & Biceps Tendon Injuries in the Overhead Athlete - Michael G. Ciccotti, MD (BSM 2018, #6) Michael Ciccotti Shoulder & Elbow - SLAP Lesion 12/21/2018 280 views Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery SLAP Lesions: If You Are Going to Fix It, Here Is How - John E. Conway, MD (CSMS #37, 2018) John Conway Shoulder & Elbow - SLAP Lesion 11/14/2018 163 views Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery SLAP Lesions: Pathology or Anatomy - Nikhil N. Verma, MD (CSMS #25, 2018) Nikhil Verma Shoulder & Elbow - SLAP Lesion 11/12/2018 199 views See More See Less