SLAP Lesions Assessment & Treatment Kevin E. Wilk,, PT, DPT Glenoid Labral Lesions Introduction Common injury - difficult to diagnose May occur in isolation or in combination SLAP lesions: Snyder: Arthroscopy 90 Andrews: AJSM 85 Difficult to diagnose» subtle symptoms, pain, popping» can cause disability» prolonged symptoms O Brien: AJSM 98 Glenoid Labral Lesions Introduction Common injury - Can lead to functional limitations Functional disability Can t t perform at a high level Wilk, Reinold: JOSPT 05 Often pain is limiting factor Maffet, Gartsman: : AJSM 95 Mechanical pain alleviated with rest Pain during specific movement Throwing, lifting overhead, etc Wilk, Reinold: : JOSPT 05 Normal Anatomy Mechanisms of SLAP Lesions Glenoid Labral Lesions Traumatic Lesions Fall onto outstretched arms Forceful abduction diving (diving) Weightlifters Pushing heavy objects Blow to the shoulder
Glenoid Labral Lesions Traumatic Lesions Glenoid Labral Lesions Traumatic Lesions Miniaci et al:ajsm 02 Examined 14 asymptomatic professional pitchers Performed MRI & clinical examination 79% exhibited abnormal glenoid labrum 79% exhibited changes of the supraspinatus tendon Humeral head changes were seen in 36% (cystic changes) Andrews, Wilk,, Reed et al: Sprg Trn 00 31 asymptomatic professional baseball pitchers in spring training MRI of glenohumeral joint 28/31 (90 %) abnormal glenoid labrum 27/31 (87 %) abnormal rotator cuff appearance 12/31 (39%) humeral head changes All pitchers were pain-free at time of study SLAP Classification SLAP Classification
Glenoid Labral Lesions Repetitive Lesions Repetitive stresses during throwing (microtraumatic) Anterosuperior lesion, near biceps During follow-through phase *Arthroscopy of 73 throwers 83% exhibited a Labral lesion Andrews, AJSM 85 *Throwers undergoing TCS: 91% labral pathology Wilk,Reinold,Andrews:JOSPT 02 Glenoid Labral Tears SLAP Lesions Type II Peel Back Lesion» Three types of subclasses IIA: Anterior type III IIB: *posterior type II IIC: combined anterior & posterior type II Burkhart, Morgan: Arthroscopy 98 Glenoid Labral Tears SLAP Lesions Type II peel back mechanism Torsional force of biceps labrum as arm abducts & ER Change in biceps vectors from anterior horizontal to vertical & posterior??? Shepard,Dugas,Zheng:AJSM 04 8 fresh frozen cadavers Ultimate strength of biceps labrum complex. SLAP lesion mechanism Two loading patterns:» Eccentric force(force in line)» Late cocking loading (ER in Abd) Ultimate tissue strength: eccentric: 508N cocking : 262N All failures appeared as SLAP type II lesions Maffet, Gartsman: : AJSM 95 SLAP lesions did not fit into classification system described by Snyder 38% of patients had a labral lesion that could not be classified Usually history of impingement or 43% exhibited an increase in translation compared to contralateral shoulder (EUA)» Type V, VI, VII Type V: An anterior-inferior Bankart lesion continues superiorly to include separation of the biceps tendon Maffet: : AJSM 95
Type VI: An unstable flap tear of the labrum is present in addition to biceps tendon separation Maffet: : AJSM 95 Type VII: The superior labrum- biceps tendon separation extends anteriorly beneath the middle GH ligament Maffet: : AJSM 95 360 Type Avulsion of the glenoid labrum around the entire glenoid traumatic mechanism 48 patients thus far Glenoid Labral Tears SLAP Lesions The peel back mechanism Type II SLAP lesions Burkhart, Morgan: Arthroscopy 98
SLAP Lesion Arthroscopic View Overhead Throwing Athlete SLAP Repair with Concomitant Procedures??? Partial Undersurface Infraspinatus Tear Posterior Labral Detachment With Peel-Back Rotator Cuff Tear with Anterior Instability Case Illustration: 18 yr old HS baseball pitcher and football linebacker Arthroscopic Treatment: 7 biodegradable anchors Type IV SLAP Full Thickness RCT Anterior Labral Detachment Repair of SLAP Lesion Arthroscopic Repair of Capsulolabral Lesion 28 yr old professional football quarterback traumatic 360 SLAP with full thickness supraspinatus tear??
Case Study 360 SLAP Injury 12/31/05 Anteroinferior dislocation Surgery 1/5/06-7 anchors in labrum 2 anchors GT RTC repair Total of 9 anchors placed in GH joint Case Study 360 SLAP Rehabilitation Following SLAP Surgery Rehab Overview: Rehab: immediate PROM & RS, scapula ROM Progression: Flexion to 90 first 3-4 wks ER/IR @ 30 deg abd. at 4 wks gradual restore ROM above 90 Week 8: full PROM (ER to 100 deg) Week 12: ER improved to 115-120 deg Goal was to restore throwers motion Rehabilitation Following SLAP Repair Range of Motion Progression Sling for 3-4 weeks» Sleep immobilizer 4 weeks Immediate limited motion» AAROM / PROM flexion to 70 0» Weeks 2-4: flexion to 90 Motion above 90 begins week 4-5 ER/IR @ 90 deg abd.. Week 5 Full normal ROM week 8 Week 8-12: return to throwers motion ER to 115 deg Rehabilitation Following SLAP Repair Range of Motion Progression Sling for 3-4 weeks» Sleep immobilizer 4 weeks Shoulder immobilizer for protection
Rehabilitation Following SLAP Repair Remove ROM restrictions Gradually increase ROM» Flexion to tolerance! ER/IR at 90 0 ABD Full ROM @ week 7-8» ER @90 abd to 95-105» in overhead athletes Progress isotonics» thrower s s ten program ROM Progression Rehabilitation Following SLAP Repair Muscular Training Isometrics immediately sub program!! Active ROM week 3 Light isotonics week 4-6 No isolated biceps for 8 weeks No CKC exercises for 8 weeks Advanced strengthening wk 10-12 Plyometrics week 12-14 Interval throwing week 16 (toss) Interval mound throwing program 5-6mos Interval hitting program week 12-14 Rehabilitation Following SLAP Repair Full ROM by week 6-9! ER to 90 0 by week 6-7! ER to 105 0 by week 7-8! ER to 115 at week 10-12 Plyometrics week 8» 2 hand plyos week 8-10» 1 hand plyos week 12 No CKC drills for 8-10 weeks Isolated biceps: initiate week 8» Light & progress Rehabilitation Following SLAP Repair Functional Activities Initiate throwing program week 16» ITP light toss: week 16» High intensity throwing week 22-26» Competitive throwing: 7-9 months Athletes must continue ROM & strengthening program Return to sports:» Overhead sports: 6.5 months» First game back 6.5 mos post-op Case Study 360 SLAP Starting QB for every game entire season 06 & 07 Lead team NFC Championship game 06 All Pro Team starting QB 06 Lead NFL passing yds 06 Team #1 total offense 06 QB rating 3 rd in NFL 06 Career year 06 2 nd best year 07 2008 leading QB yds passing Rehab Following SLAP Repair with Concomitant Surgical Procedures!SLAP repair with stabilization surgery "Thermal capsular shrinkage "Bankart repair (type V) "Capsular shift or plication!slap repair with cuff repair "Arthroscopic or open repair!slap repair with decompression!slap with debridement
Rehab Following SLAP Repair with Concomitant Surgical Procedures! SLAP repair with stabilization surgery " Thermal capsular shrinkage Wilk, Reinold,, Andrews: JOSPT 05 " Bankart repair (type V) Voos,Pearle, Mattern: : AJSM 07 " Capsular shift or plication! SLAP repair with cuff repair " Arthroscopic or open repair Voos,, Pearle, Mattern: : AJSM 07! SLAP repair with decompression Coleman, Cohen, Drakos: : AJSM 07! SLAP with debridement Beware of SLAP repairs with concomitant procedures Stiffness Monitor Patient closely & adjust appropriately SLAP Lesion Rehab Summary Rehab must match surgery» Repair vs debridement Type I & III, simple debridement» Rehab for functional stability Type II & IV, (V VIII) control stresses» No overhead motion for 4 weeks» Control forces 8-12 weeks» Suture anchors strength Team approach to treatment» Extent & location of SLAP lesion» Concomitant pathologies - Cuff Thank You!!!