Published on Sunday, 27 September 2009 23:38
Written by Vic Goradia, M.D.
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 has a detachment of the labrum and biceps anchor from the superior glenoid.
- Type III SLAP lesion is 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
SLAP=Superior Labrum Anterior Posterior
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.
Rehabilitation and Recovery
PNF=proprioceptive neuromuscular facilitation
ROM=range of motion
UBE=upper body ergometer
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.
SLAP Phase I: Immediate Post-op Phase
Protect the surgical procedure
Minimize the effects of immobilization
Diminish pain and inflammation
- 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
- 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 Program
- 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
SLAP Phase II: Intermediate phase
|Normalize Arthrokinematics means to normalize the joint movement.|
Improve muscular strength
Enhance neuromuscular control Weeks 10-14
| Posterior Capsule Rear Delt Stretch, Capsular Stretching|
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).
- Continue all stretching exercises
- - Joint mobilization, capsular stretching (see picture), passive and active stretching
- Continue strengthening exercises
- -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
SLAP Phase III: Advanced strengthening phase
Enhance muscular strength, power and endurance
Improve muscular endurance
Maintain mobility Criteria to enter Phase III:
1) Full range of motion Program
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 motion) Exercises:
2) Satisfactory strength (isokinetics)
3) No pain or tenderness
4) Satisfactory functional progression
- Continue capsular stretching to maintain mobility
- Continue strengthening program
- -Either Thrower’s Ten or fundamental shoulder-exercise program