sports medicine newsletter
The Types of SLAP lesions -by Vic Goradia, M.D.
Lesions of the superior labrum of the shoulder occur in high level throwing athletes and are called SLAP lesions. Here are the types of SLAP lesions:
>In Type I SLAP lesion, the labrum is frayed and degenerated but remains intact to the glenoid; the biceps anchor is also intact.
>Type II SLAP lesion have a detachment of the labrum and biceps anchor from the superior glenoid.
>>Type III SLAP lesion are similar to bucket-handle meniscal tears of the knee. The labrum is torn away, however the biceps anchor and remaining labrum are still attached to the glenoid.
>In Type IV SLAP lesion the bucket-handle tear of the labrum extends into the biceps anchor.
Diagnosis and Treatment
The diagnosis can often be very difficult. Unfortunately, there are not any specific physical findings; most described tests are non-specific but can still be helpful. MRI and other radiologic tests have limited diagnostic accuracy which is highly dependent on study quality & expertise of the radiologist. Type I and III tears are treated with debridement alone while Type II and IV tears require surgical repair. This repair is performed arthroscopically with suture anchors and/or tacks.
SLAP=
Superior Labrum Anterior Posterior
Rehabilitation and Recovery
The following is a general guide for the rehabilitation of isolated SLAP Lesion repairs. Patients who undergo something referred to as concomitant procedures require modification of this protocol. Progression through the Phases is individualized for each patient by a doctor or physical therapist and a successful outcome is dependent on adequate communication between the patient, therapist and surgeon. Considering those points, these are just guidelines.
ER=external rotation
IR=internal rotation
PNF=proprioceptive neuromuscular facilitation
ROM=range of motion
UBE=upper body ergometer
PHASE I: Immediate postoperative phase
Goals:
Protect the surgical procedure
Weeks 0-3
Use an Arm Sling for comfort
• Sling for 1 week, then use for comfort as needed
• Elbow/hand ROM & Gripping exercises
• Codman’s pendulum exercises
• PROM and AAROM for flexion and abduction as tolerated and ER to 30 at neutral
• No shoulder extension or Combined Abduction/ER
• Submaximal isometrics (NO BICEPS STRENGTHENING)
• Cryotherapy, modalities as needed to control pain and swelling
• Scapular shrugs, protraction and retraction
Weeks 3-6
• AAROM & PROM
-Full Flexion as tolerated
-ER in scapular plane to 45° & progress to full by 6wks
-IR in scapular plane progress to full as tolerated
-Abduction to full as tolerated
-No shoulder extension or Combined Abduction/ER
• Continue isometrics (NO BICEPS STRENGTHENING)
• Begin submaximal dynamic stabilization
Weeks 6-10
• May begin extension
• Should gain full ROM
• Joint mobilization, stretching, etc.
• Self-capsular stretching
• UBE arm at 90 degrees abduction
• Continue PNF diagonal patterns
(rhythmic stabilization techniques)
• Progressive isotonic strengthening
• Begin biceps isometrics at 6 weeks and progressive isotonics at 8 weeks
Normalize Arthrokinematics
means to normalize
the joint movement.PHASE II: Intermediate phase
Goals:
Weeks 10-14• Continue all stretching exercises
- Joint mobilization, capsular stretching (see right box), passive and active stretching
• Continue strengthening exercises
Posterior Capsule Rear Delt Stretch
1. Sit or Stand in upright position.
2. Pull elbow with opposite hand until a stretch is felt in
rear of shoulder.
3. Hold for 20-30 seconds. Repeat as prescribed.
4. While pulling elbow, be sure that forearm remains
perpendicular to floor (fingers pointing up).-Throwers Ten Program
-Isotonic strengthening for entire shoulder complex
-PNF manual technique
-Neuromuscular control drills
-Isokinetic strengthening
• Begin sports specific exercises
• Initiate progressive plyometric exercises
• May initiate “controlled” swimming, golf swings, etc.
• Progressive isotonic machine weight training
PHASE III: Advanced strengthening phase
Goals:
Criteria to enter Phase III:
1) Full range of motion
2) No pain or tenderness
3) Strength 70-80% of contralateral side
• Continue all flexibility exercises
-Self-capsular stretches (anterior, posterior and inferior)
-Maintain ER flexibility
• Continue isotonic strengthening program
• Emphasize muscular balance (ER/IR)
• Continue PNF manual resistance
• Continue plyometrics
• Interval throwing program
• Functional progression
PHASE IV: Return to sports (unrestricted)
Criteria to enter Phase IV:
1) Full nonpainful ROM (range of motions)
2) Satisfactory strength (isokinetics)
3) No pain or tenderness
4) Satisfactory functional progression
Exercises:
• Continue capsular stretching to maintain mobility
• Continue strengthening program
-Either Thrower’s Ten or fundamental shoulder-exercise program
Bio of Author: Article courtesy of Vic Goradia M.D, a fellowship trained surgeon in Sports Medicine, Arthroscopic Surgery, Knee & Shoulder Reconstructive Surgery with a CAQ (Certificate of Added Qualification). For more information about his qualifications please visit www.GoOrtho.net.