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 9/24/2017 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 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Previous Next 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 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% (33/2572) 2 15% 35% (893/2572) 3 30% 23% (592/2572) 4 70% 40% (1023/2572) 5 100% 1% (22/2572) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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% (434/4118) 2 Isotonic rotator cuff strengthening 14% (569/4118) 3 Isokinetic resistive elbow flexion 8% (350/4118) 4 Passive and active assisted flexion in scapular plane 65% (2674/4118) 5 Concentric latissimus pull down exercises 2% (63/4118) 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% (8/2140) 2 Full-time sling wear with no active nor passive motion for at least 6 weeks until labral tissues heal 6% (120/2140) 3 Rotator cuff strengthening by post-operative week two to prevent disuse atrophy and shoulder instability 3% (71/2140) 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 89% (1894/2140) 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% (37/2140) 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% (1019/5283) 2 Passive forearm pronation 3% (162/5283) 3 Passive external rotation at 90 degrees of abduction 67% (3561/5283) 4 Open chain passive elbow flexion 7% (353/5283) 5 Passive assisted elevation in the scapular plane 2% (98/5283) 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 65% (662/1019) 2 Normal anatomic variant characterized by a cord-like SGHL and an absent posterosuperior labrum 5% (52/1019) 3 Abnormal arthroscopic finding characterized by a cord-like MGHL and an absent anterosuperior labrum 6% (66/1019) 4 Abnormal arthroscopic finding characterized by a cord-like SGHL and an absent posterosuperior labrum 2% (19/1019) 5 Normal anatomic variant characterized by a cord-like MGHL and a sublabral foramen at the anterosuperior labrum 21% (215/1019) 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% (207/904) 2 SLAP tear 65% (587/904) 3 ALPSA 6% (55/904) 4 Bankart 5% (47/904) 5 Loose body 0% (3/904) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 2
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