SLAP Lesion

Introduction

Superior labral anterior-posterior (SLAP) tears are injuries to the glenoid labrum that are often confused with the sublabial groove on MRI.

SLAP tears involve the superior labrum where the long head of the biceps tendon inserts. They may extend to tendons involving the glenohumeral ligament or to other quadrants of the labrum. Unlike Bankart injuries and ALPSA injuries, they are usually (20%) unrelated to the shoulder Unstable[1]

In total, four types of superior labrum injuries involving the biceps anchor were identified.

1. Type I involves degenerative wear with no detachment of the bicep insertion point.
2. Type II is the most common type and represents detachment of the superior labrum and biceps from the glenoid rim.
3. Type III represents a barrel-handle tear of the labrum with intact insertion of the biceps tendon into the bone.
4. Type IV injuries are the least common type and represent intrasubstance tears of the biceps tendon and barrel handle tears of the upper labrum. [2]

Type II SLAP injuries are further divided into three subtypes, depending on whether the labral detachment involves only the anterior labrum, only the posterior labrum, or both. The above classification system has been expanded to include three additional Type: [2]

• Type V: Bankart lesion extends upward to include type II SLAP lesion.
• Type VI: Unstable labral tear with separation of the biceps tendon.
• Type VII: The superior labrum separates from the biceps tendon and extends anteriorly to the middle of the glenohumeral ligament. [2]

Clinically Relevant Anatomy

The main joint of the glenohumeral joint is also called a “ball-and-socket joint” because the humeral head (ball) articulates with the glenoid (the glenoid socket or glenoid socket of the scapula). [3] But the humeral head is larger than the socket, so the socket only covers one quarter of the humeral head. [4][3] The convoluted edges of fibrocartilaginous tissue called the glenoid labrum firmly attach to the glenoid fossa, thereby increasing the articular surface area and the stability of the glenoid joint. [3][5]

The long arm of the biceps inserts directly into the upper lip, which also provides stability to the upper part of the joint. [6][4] In addition, the rotator cuff muscles are critical to ensuring dynamic shoulder stability, as they prevent excessive translation of the shoulder joint in the humeral head. The level of the glenoid fossa. [7]

Important changes in the normal anatomy of the labrum have been identified. Three distinct changes occur in more than 10% of patients:

1. An isolated sublabral foramen,
2. sublabial foramen with cord-like glenohumeral ligament
3. The cord-like glenohumeral ligament without tissue at the anterior upper lip. Recognition of these normal variants can help prevent misdiagnosis of labral lesions. [6]

Epidemiology/Aetiology

In acute cases, they are most commonly seen with outstretched arms or throwing athletes during a fall.

The age of the patient has an effect on the superior labrum. From an average age of 35, the superior labrum is less firmly attached to the glenoid than in people younger than 30. In the 30 to 50 age group, there is a greater likelihood of tears/defects in the superior labrum and anterosuperior region Labrum (noted in cadavers). In the age group 60 years or older, peripheral lesions have been identified. Therefore, we can conclude that there is an age-related effect, i.e. the older the patient is, the more likely he is to develop a SLAP injury due to age-related changes. [5] In one study, half of the The case with a SLAP injury was a 40-year-old patient who presented with signs and symptoms of instability following a history of repetitive injury from acute trauma, falls on an outstretched arm, or injury from weightlifting. Most of them have type II SLAP lesions. They also noted that Type II SLAP Lesions in patients under 40 were associated with Bankart injuries, but not type II SLAP injuries in patients under 40, which were associated with supraspinatus tendon tears and osteoarthritis of the humeral head. [6]

There are many different injury mechanisms that can lead to SLAP injuries. The following causes have been found:

• repetitive throwing,
• hyperextension,
• a fall on an outstretched arm,
• heavy lifting,
• direct trauma.

The two most common mechanisms are a fall on an outstretched arm, in which case an upper compression and an inferior direction of traction injury would result. [6]

Landing on the outstretched arm is acute traumatic overstress on the shoulder. In this case, the shoulders are abducted and slightly bent forward at impact.

A subsequent study found that the most common mechanism of injury was a fall or a direct blow to the shoulder in 31% of patients. Numerous patients with superior glenoid injury with impingement or rotator cuff disease in the absence of trauma Sure. In fact, Snyder et al found that 55 (40%) of 140 patients with SLAP injuries had partial-thickness or full-thickness rotator cuff disease. Excessive displacement of the humeral head may be due to the rotator cuff not effectively performing its role as a humeral head inhibitor. superior Theoretically, the labrum and biceps anchor could be gradually lifted from the glenoid due to chronic repetitive upward translation of the humeral head over the glenoid rim. Other authors support the theory of a lowering mechanism based on a sudden traumatic lowering Arm or repetitive microtrauma from overhead sports activities associated with associated instability. [8]

Throwers may have repeated microtrauma. At the moment of impact, the glenohumeral contact point moves posteriorly and superiorly, and increased shear forces are exerted on the posterosuperior labrum, causing a dissection effect and ultimately a SLAP injury. [6]

Clinical Presentation

The most common complaint of patients with SLAP lesions is pain. Pain is usually intermittent and often associated with overhead movement. [9] Isolated SLAP lesions are uncommon. [10] Most patients with SLAP injuries also complain of:

• Painful clicking and/or popping sensations with shoulder movements
• Loss of glenohumeral internal rotation range of motion
• pain with overhead motions
• Loss of rotator cuff muscle strength and endurance
• Loss of scapular stabilizer strength and endurance
• Inability to lie down on affected shoulder[11]

Athletes who engage in overhead movement, especially pitchers, may develop “dead arm” syndrome, a condition in which they experience shoulder pain when throwing and are no longer able to throw at the speed they were before the injury. [12] They may also report decreased speed and accuracy and discomfort when throwing. this shoulder.[11]

It’s important to remember that the scapula is an important factor in shoulder movement. Scapular misalignment occurs when the shoulder blade does not perform its action properly. This reduces normal shoulder function. [13][12] It alters the activation of the scapular stabilizer muscles. Serratus anterior, rhomboids major, levator scapula minor, and trapezius, respectively. The rotator cuff muscles are also important for immobilizing the scapula and guiding movement. [13] [14]

Differential Diagnosis

Shoulder disease often involves the glenoid labrum. Sometimes morphological changes can be confused with pathological aspects, so the diagnosis should be made after careful analysis of the history and physical examination. [15] There are two anatomical regions Variants may be present: predominantly age-related upper region and sometimes anterosuperior region without labrum (12%) or cord-like ligament continuous with biceps footplate (135%). [15]

SLAP tears by themselves account for 80-90% of labral lesions in stable shoulders, but only 6% during arthroscopy. SLAP injuries often co-occur with other shoulder problems, making diagnosis difficult. [16] SLAP injuries are mainly combined with shoulder joint injuries The proximal head of the biceps brachii as it attaches to the upper part of the labrum. It is associated with pain and instability and the patient’s inability to perform overhead movements. [15]

According to William F.B. there is a 43% correlation between SLAP injury and medial sheath injury. The authors hypothesize that forces affecting the biceps anchor may also damage the pulley system of the biceps sheath, so this anatomy should be evaluated, especially during SLAP There is a lesion. [17]

In addition to biceps tears, other problems such as bursitis and rotator cuff tears are often combined with SLAP injuries [18] according to Morgan CD et al. Rotator cuff tears were present in 31% of patients with SLAP injuries and were found to be lesion site specific. [19]

Suprascapular neuropathy secondary to spinous notch cyst compression may also be associated with SLAP tears.

Diagnostic Procedures

SLAP injuries are difficult to diagnose because they closely resemble instability and rotator cuff disease. First, clinicians can test for tenderness on palpation between the rotator muscles, which aids in the diagnostic procedure. The rotational clearance is between Supraspinatus tendon, subscapularis tendon, and coracoid process. This rotator septum has a triangular shape with the supraspinatus superior, the subscapularis inferior, and the coracoid process medial. It contains the coracoid humerus and superior bones Glenohumeral ligament, biceps tendon, and anterior joint capsule. If you know where these structures are, you can try to palpate the rotational intervals. [20]

• This can be followed by these tests, which were positive when a SLAP lesion was present: positive anterior drawer (53%), positive fear of abduction to 90° and maximal external rotation (86%) and positive relocation test (86%).[ 6]
• In addition, there are special tests that can be used to help identify the presence of a SLAP injury, including the Clunk test, the crank test, the O’ Briens forward slide test, the biceps load I and II test, and the active compression test. [6]

SLAP injury MRI

MR arthrogram

The investigation of choice is MR arthrography, which has been reported to be 75-90% accurate, although distinguishing subtypes may be difficult.

Outcome Measures

See Category: Shoulder – Outcome Measures

This measurement is an example of a useful Western Ontario Rotator Cuff (WORC) Index

Examination

Clinical examination to detect SLAP lesions is an extremely challenging process because the condition is often associated with other shoulder lesions in patients presenting with it. [9][13]

As with most shoulder disorders, a history should be taken, including the exact mechanism of injury. [9][11][13] It is important to remember that although labral lesions are often caused by overuse, patients may also describe a single traumatic event. [9] Physical examination is It is also very important in establishing the correct diagnosis [11] However, the physical examination should not be used in isolation as the literature has not demonstrated that specific tests can accurately identify SLAP lesions.

A number of physical examination procedures are described for detecting SLAP lesions:

1. Biceps load test II[9][11][13]
2. O’Brien test[9][11][13]
3. Anterior apprehension test[11]
4. Speeds Testt[11][13]
5. Yergason’s test[11][21]
6. Compression rotation test[11]
7. Dynamic labral shear test[10][13]

Combining 2 sensitive tests and 1 specific test is more effective in diagnosing SLAP lesions [references needed].

The therapist may choose 2 sensitive tests from the following 3:

• Compression rotation test
• O’Brien test
• Anterior apprehension test

For specific tests, the therapist can choose from 3 options:

• Speed’s test
• Yergason’s test
• Biceps load test II[11][22]

This results in a sensitivity of about 75% if one of the three tests is positive. However, if all three tests are positive, this results in a specificity of approximately 90%. [11]

When we consider some tests individually, it can be considered that Speed test and O’Brien test are helpful in diagnosing anterior lesions, while Jobs relocation test is usually positive in posterior lesions[6][23] According to Meserve et al., O’Brien Trial Most Sensitivity tests (47%-78%) and speed tests are the most specific (67%-99%). [11] Some studies combined few tests, but the data were so variable that it was difficult to draw general conclusions. [11][13][24]

There is a lot of discussion about which test is the most accurate, but most experts agree that arthroscopy is the best way to diagnose SLAP injuries. [10]

Treatment/Management

For the vast majority of SLAP injuries, initial management is nonoperative. Non-surgical management includes: Anti-inflammatory drugs Cryotherapy/cooling/ice Rest and activity modification

Rest should initially follow acute (or chronic acute) injury. NSAIDs and cryotherapy devices/ice pack application may help manage pain. Athletes and workers at heights should also follow restricted sport-specific schedule protocols, and manual workers should Receive appropriate career adjustments.

If nonsurgical treatment modalities fail, surgical management is considered, keeping in mind each patient’s age, concomitant pathology, functional requirements, occupational requirements, and sport-specific goals. [25]

1. Type I tears are usually asymptomatic and do not require treatment
2. Type II tears require surgical reduction
3. Type III tears usually require resection of barrel handle tears

For patients over the age of 36, the likelihood of failure was higher. [26] Due to unsatisfactory results in elderly patients, Boileau et al. Arthroscopic biceps tenodesis is recommended for these patients. They found that tenodesis was superior to repairing type II SLAP tears in the elderly population. Arthroscopic biceps tenodesis can be considered an effective alternative for repairing type II SLAP injuries, allowing patients to return to preoperative levels of activity and sports participation. Results of biceps reinsertion compared to biceps tenodesis have been disappointing. Furthermore, biceps tenodesis may offer a viable alternative to salvage failed SLAP repairs. [21] However, in another study by Alpert et al. Results showed that type II SLAP repair using suture anchors can produce good results in patients older than 40 years and younger than 40 years. Their The findings showed no differences between the two age groups. Consequently, there are conflicting views in the literature regarding prosthetics in elderly patients. [27]

This 2 minute video demonstrates the SLAP repair arthroscopic dual loading anchor Y configuration. Ideal graphic animation to avoid rotator cuff entry with Antero-Sup entry.

Physical Therapy Management

To date, only one study has looked at the outcomes of physical management of SLAP injuries. The study was a one-year follow-up study of 19 patients. It compares good shoulder function to that of patients successfully treated with conservative treatment of the scapular form Stability exercises and posterior capsule stretches. However, the study acknowledged that more than half of the patients who were initially prescribed nonsurgical treatment failed, and these patients went on to undergo arthroscopic surgery. [28] It is generally believed that Most patients with symptomatic SLAP injuries will fail conservative treatment, especially throwers. [2] Given that conservative treatment appears to be successful in only a minority of patients, mainly type I SLAP lesions, it is only practiced in patients with such lesions or in patients with [2] In the first step of conservative management, patients should avoid aggravating activities to relieve pain and inflammation. If necessary, NSAIDs and intra-articular corticosteroid injections can be used to help reduce [2][28] This allows for faster initiation of physical therapy. Strength, stability and movement are integral parts of shoulder function and should be a key focus during rehabilitation. [29] The course of treatment should focus on restoring the strength of the rotator cuff and shoulder girdle trunk core [2] Restoration of the GIRD is an important aspect of SLAP injury rehabilitation. [2] By using posterior capsule stretches such as the sleeper stretch and the crossed adduction stretch [28][30] Restoring internal rotation by stretching the posterior capsule and performing posterior capsule stretching exercises such as the sleeper stretch and cross body adduction stretches and exercises Scapular stabilization Pathological contact between the supraspinatus tendon and the posterior upper lip. [28] [30] Can be prevented. The patient eventually enters the strengthening phase, which includes the trunk core, rotator cuff and scapular musculature. Athlete Progression in Throwing A throwing program for patient-specific movements and positions can be initiated after 3 months. [2]

A selection of 16 commonly used shoulder rehabilitation exercises are available based on multiple EMG studies and clinical recommendations for the rehabilitation of patients with SLAP injuries. These exercises are:

• forward flexion in a side-lying position
• prone extension
• seated rowing
• serratus punch (stretch with elbow extended)

• knee push-up plus

• External rotation and forearm supination
• Absolutely (elevation of the scapular plane during external rotation

• Abduction 20° Internal Rotation
• Abduction 20° External Rotation
• Abduction 90° Internal Rotation
• Abduction 90° External Rotation
• Forearm supination Elbow flexion Forearm supination
• Uppercut (combines forward shoulder flexion and elbow flexion and supination)
• internal rotation diagonal
• external rotation diagonal

These exercises of progressively increasing low to moderate activity can be used in the early and intermediate stages of nonsurgical and postoperative management of patients with proximal biceps tendon disease and SLAP injuries. [31]

When conservative treatment fails, a surgical approach is in order. [2]

Three to four weeks after surgery, the patient’s shoulder is placed in a sling that immobilizes the shoulder from internal rotation and causes a general loss of motion and stiffness. [2][10] Postoperative rehabilitation depends on the type of SLAP injury, the surgical procedure chosen and other [2] Pendulum and elbow range-of-motion exercises are usually permitted during immobilization. External rotation must be absolutely avoided and abduction limited to 60°. Assistive and passive techniques used at 4 weeks Increased shoulder mobility postoperatively. Between weeks 4 and 8, internal and external rotation ROM was gradually increased to 90° of shoulder abduction. Resistance training, which emphasizes the strength of the scapula, can begin approximately 8 weeks after surgery. Since the metabolism of cartilage depends in part on its mechanical environment, resistance training helps to gain mobility. However, achieving adequate shoulder mobility is an important prerequisite for beginning resistance training. 4 to 6 months depending on the type of exercise Practicing patients should be able to begin sport-specific training and gradually return to their previous activity levels. [2]

Repair of SLAP injuries often fails, and biceps tenodesis or tenotomy appears to be acceptable alternative treatments for SLAP injuries. Furthermore, this technique is now the most preferred treatment for failed SLAP repairs. [32] The indications for biceps tenodesis are Symptomatic SLAP lesions depend on:

• the patient’s age
• activity level
• arm dominance
• type of sport.[10]

If biceps tenodesis is performed, at least 10 weeks of biceps inactivity are recommended to allow complete integration of the repaired soft tissue into the bone tunnel. [11]

Clinical bottom line

SLAP lesions are lesions of the superior labrum, of which various types have been described. SLAP injuries are primarily the result of a fall with the arm outstretched, in which there is significant upward pressure on the labrum, resulting in a labrum tear. A typical symptom is intermittent pain, Also occurs in overhead movements. To diagnose this condition, it is important to use a number of different tests, not just one. The physical examination is not easy because SLAP injuries are often associated with other shoulder lesions. For physical exams used by therapists The tests described in “Diagnostic Procedures,” but in addition, he can test the range of motion of the glenohumeral and scapular joints, since SLAP injuries can cause movement impairments. For the treatment of SLAP injuries, people usually use medications given by the surgeon Using advanced arthroscopic technology. But physical therapy is also possible. This includes stretching strengthening and stabilization exercises. It is important to note that each treatment is dependent on the type of SLAP lesion, conservative treatment may fail and is not suitable each patient.