lesión slap labrum superior

Asymptomatic tears should be observed. Patient complaint of pain is not a good gauge for progression. Arthroscopic all-intra-articular decompression and labral repair of paralabral cyst in the shoulder. [17], Beside biceps tears, other problems, such as bursitis and rotator cuff tears, are often identified, in combination with SLAP lesions,[18]According to Morgan CD et al., Rotator cuff tears were present in 31% of patients whit SLAP lesion and were found to be lesion-location specific.[19]. In this position, the force on the biceps coupled with the posterior glide of the humerus results in the peeling off of the posterosuperior quadrant of the glenoid and posterior labrum. [13][12]It changes the activation of the scapular stabilising muscles. Approximately 40% of the long head of biceps tendon (LHBT) attaches to the labrum. Sometimes morphological varieties can be confused with pathological aspects and therefore diagnosis should be established following careful analysis of the case history and a physical examination. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Aflatooni JO, Meeks BD, Froehle AW, Bonner KF. Presence of concomitant LHBT tendinitis or tendinosis: The odds ratio for revision surgery was 5.1 in the setting of LHBT tearing/fraying. After exhausting non-operative treatment modalities, operative management is considered in tandem while keeping in mind each patient’s age, concomitant pathologies, functional requirements, occupational demands, and sport-specific goals. Understanding the rigorous rehabilitation required from advanced procedures helps the patient understand what is expected on their road to recovery. A sulcus between the supraglenoid tubercle and the labrum may also give a false-positive result and is deemed a pseudo SLAP tear. [5]In one study, half of the cases that had a SLAP lesion were 40 years old patients who showed signs and symptoms of instability after a history of acute trauma, repetitive injury, fall on an outstretched arm, or an injury from heavy lifting. Intra-articular contrast media and articular effusion, as well as arm traction and external rotation, improve the sensitivity of the MRI to determine a SLAP lesion. What causes it? Superior labrum anterior posterior lesions.Available: PROVENCHER M.T. SLAP lesions first gained recognition in the 1980s. SLAP lesion repair often fails, and biceps tenodesis or tenotomy seems to be an acceptable alternative treatment for SLAP lesions. [8], Throwers can have repetitive microtraumata. Superior Labral Anterior-Posterior (SLAP) Tears in the Military. The recognition and treatment of superior labral (slap) lesions in the overhead athlete. If necessary, NSAID’s and intra-articular corticosteroid injections can be applied to help diminish complaints. In older patients and the setting of suspected concomitant shoulder pathologies (e.g., rotator cuff injuries or biceps tendon pathology), specialized testing for these pathologies also merits consideration. J Shoulder Elbow Surg., 2012;21(1):13 – 22, MESERVE B.B. IF > 50% of the biceps tendon is affected, perform tenotomy/tenodesis, Surgical treatment: Bankart repair plus SLAP repair, Surgical treatment: Suture/anchor fixation of anterosuperior labrum plus SLAP repair, Surgical treatment: SLAP repair versus biceps tenotomy/tenodesis; gentle debridement of any cartilage/chondral unstable flap, Internal (including SLAP lesions, GIRD, little league shoulder, posterior labral tears), Partial- versus full-thickness tears (PTTs versus FTTs), Subluxation–often seen in association with SubSc injuries, Unidirectional instability–seen in association with an inciting event/dislocation (anterior, posterior, inferior), Suprascapular neuropathy–can be associated with a paralabral cyst at the spinoglenoid notch, Muscle ruptures (pectoralis major, deltoid, latissimus dorsi), Fracture (acute injury or pain resulting from long-standing deformity, malunion, or nonunion). External rotation must absolutely be avoided and abduction limited to 60°. Trends in the diagnosis of SLAP lesions in the US military. Book an appointment today! Rehabilitation after surgery is dependent upon several factors. Alleviation of pain and return of range of motion may result in treatment success for some; however, in overhead athletes, many patients are unable to return to their prior level of sport or performance. Also, a wide array of implant options are available depending on surgeon preference. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. This activity reviews the evaluation and treatment of SLAP tears and highlights the role of the interprofessional team in managing patients with this condition. SLAP lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization. In this mechanism, a “peel-back” avulsion of the superior labrum by a torsional force via the biceps anchor. Para ayudar a estabilizar el hombro, hay un anillo de tejido firme, llamado labrum, alrededor de la cavidad del hombro. Unlike Bankart lesions and ALPSA lesions, they are not usually (20%) associated with shoulder instability.[1]. Miniaci A, Mascia AT, Salonen DC, Becker EJ. If non-operative treatment modalities fail, operative management is considered, while keeping in mind each patient’s age, concomitant pathologies, functional requirements, occupational demands, and sport-specific goals. 2022 Dec . Park JH, Lee YS, Wang JH, Noh HK, Kim JG. The Journal Of Orthopaedic And Sports Physical Therapy, 1985;6(4):225-228, KOZIAK A. et al, Magnetic resonance arthrography assessment of the superior labrum using the BLC system: age-related changes mimicking SLAP-2 lesions. Varacallo M, Tapscott DC, Mair SD. Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. lesión SLAP (Superior Labrum Anterior to Posterior) es una lesión de la parte superior del labrum glenoideo del hombro, generalmente centrada en la inserción del tendón de la cabeza larga del músculo bíceps braquial, aunque puede extenderse e involucrar al labrum anterior y posterior, así como estructuras circundantes. An interprofessional team approach involving clinicians (including PAs and NPs), therapists, and orthopedically-trained nurses will provide the best results. Gentle ROM activities are recommended. J. Also suprascapular neuropathy secondary to cyst compression in the spinoglenoid notch may occur in association with SLAP tears. Read more, © Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. [7], Degenerative SLAP tears can develop secondary to the normal “wear-and-tear” patterns seen in patients with advanced age. The identification of these normal variants can help to prevent the misdiagnosis of labral lesions. ), which permits others to distribute the work, provided that the article is not altered or used commercially. The bucket-handle tear of the superior labrum is resected, additionally with the repair of the SLAP complex (rare) if needed. In: StatPearls [Internet]. The goal of physical therapy (PT) modalities should be to treat any underlying pathologic shoulder biomechanics that may have been present at baseline before the acute injury. http://creativecommons.org/licenses/by-nc-nd/4.0/. et al., The Diagnosis, Classification, and Treatment of SLAP Lesions. The results of biceps reinsertion are disappointing compared with biceps tenodesis. [2][9][6][12], Non-operative management focuses on the initial restriction of provoking maneuvers. [49][57], Risk factors for revision surgery are critical in discussing overall patient expectations and discussing the risks of continued pain, stiffness, dysfunction, and the potential need for further surgery in the future. As mentioned, this concept can also be applied to the young, athletic population as well. [16][17] Many Major League Baseball (MLB) team physicians now recognize these asymptomatic “tears” as adaptive changes in high-level, experienced overhead throwers and MLB pitchers, analogous to meniscal cleavage planes.[18]. [12], Similarly, a 2012 study reported the rising incidence of arthroscopic SLAP repair rates within New York State from 2002 to 2010, noting a 464% increase in the number of SLAP repairs. Biceps tenotomy versus tenodesis: patient-reported outcomes and satisfaction. Their findings show no difference between the two age groups. In this study (also studying over 100 shoulder cadaver specimens), the attachment sites clarified the findings from the previous study: The latter study is the contemporary consensus agreement regarding the LHBT attachment patterns. [10], For the vast majority of SLAP injuries, the initial management is nonoperative. An honest dialogue of outcomes with each patient is vital before selecting the appropriate intervention. [13][14], The glenoid labrum is often involved in shoulder pathology. Hansen CH, Asturias AM, Pennock AT, Edmonds EW. Orthop., 2014; 5(3): 344-350, PAINE R. et al., The role of the scapula. SLAP lesions are often seen in combination with other shoulder problems and this makes it difficult to diagnose. The aim of this paper is to provide a brief description of the different surgical techniques employed to address Type II SLAP lesions (arthroscopic repair, biceps tenodesis, and biceps tenotomy) and provide a review of available literature regarding outcomes and prognostic factors associated with each technique. Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. These exercises are: These exercises, with increasing low to moderate activity, can be applied in the early and intermediate phases of nonoperative and postoperative treatment for patients with proximal biceps tendon disorders and SLAP lesions. Tears of the glenoid labrum [37] Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Interestingly enough, the anterior aspect of the superior labrum and the labral region anterior to the LHBT origin have the highest density of these fibers.[32]. [19][21] The recent overlying trend appears to favor tenodesis rather than repair; however, the decision for the type of intervention remains patient-specific. In this situation the shoulder is abducted and slightly forward-flexed at the time of the impact. A positive test is a pain or a painful pop over the anterior shoulder near the bicipital groove region. In the setting of chronic anterior instability, the clinician should attempt to assess the current status of the axillary nerve, although chronic dislocators often exhibit normal deltoid function and internal and external rotator strength. Care must be taken to avoid exercises activating the biceps. SLAP tear type is determined by the anatomical location of the tear as well as the severity of its extension. A structured rehabilitation program and open communication between the interprofessional team, including primary care, sports medicine, orthopedics, physical therapists, and specialty trained nurses, are important to ensure a step-wise approach is followed to achieve maximum patient satisfaction and function. Weber SC, Martin DF, Seiler JG, Harrast JJ. Search doctors, conditions, or procedures . [30][31], Boesmueller recently histologically characterized the most proximal extent of the LHBT, specifically the neurofilament distribution, as the tendon transitions into the superior labral complex. For the treatment of SLAP lesion one uses often a medical treatment where the surgeon uses advanced arthroscopic techniques. This maneuver is repeated with the patient’s arm now rotated, so the palm faces the ceiling. Typically, an anti-inflammatory and/or corticosteroid injection are utilized as initial treatment as well. Three distinct variations occur in over 10% of patients: In the acute setting, they are most frequently seen in falls onto an outstretched arm or in throwing sports athletes. Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction. In the age category 30 to 50, there are more chances of tears/defects in the superior and anterior-superior regions of the labrum (noted in cadavers). SLAP lesions demonstrate a predilection for young laborers, overhead athletes, and middle-aged manual laborers. This can be followed by these tests that are positive when there is a presence of a SLAP lesion: positive anterior drawer (53%), positive apprehension at 90° of abduction and maximal external rotation (86%), and positive relocation test (86%). The long head of the biceps tendon attaches in the glenoid as part of the labrum at roughly 12:00. Schrøder CP, Skare O, Gjengedal E, Uppheim G, Reikerås O, Brox JI. Performance of the test on the nonaffected shoulder should not elicit any pain. The upper, or superior, part of your labrum attaches to your biceps tendon. For example, in older patients with or without rotator cuff repair, the repair of the SLAP correlates with inferior results compared to intentional neglect or performing a bicep tenodesis/tenotomy regarding stiffness, persistent pain, and need for revision surgery. Fedoriw WW, Ramkumar P, McCulloch PC, Lintner DM. Waterman BR, Arroyo W, Heida K, Burks R, Pallis M. SLAP Repairs With Combined Procedures Have Lower Failure Rate Than Isolated Repairs in a Military Population: Surgical Outcomes With Minimum 2-Year Follow-up. Zhang AL, Kreulen C, Ngo SS, Hame SL, Wang JC, Gamradt SC. [11], Despite the aforementioned limitations, the contemporary consensus regarding SLAP tears is that they account for 80% to 90% of labral pathology in the stable shoulder, although they are typically seen in association with other shoulder pathologies and rarely present in isolation. The endemic rate of variations of labral anatomy visible on MRI in asymptomatic overhead throwers should prompt caution before concluding that the labrum is the source of the patient’s pain. Etiology There are several different patterns of SLAP tears with varying degrees of instability and magnitude of labral damage. Ek ET, Shi LL, Tompson JD, Freehill MT, Warner JJ. Active and passive motion needs to be assessed and compared to the contralateral side. The Neviaser portal is often utilized and established under direct visualization once confirming the appropriate trajectory are achieved. This can lead to instability and, ultimately, impingement of the superior labrum with degenerative tearing. Ideal graphic animation, using Antero-Sup portal avoiding rotator cuff portal. McCausland C, Sawyer E, Eovaldi BJ, Varacallo M. Boesmueller S, Nógrádi A, Heimel P, Albrecht C, Nürnberger S, Redl H, Fialka C, Mittermayr R. Neurofilament distribution in the superior labrum and the long head of the biceps tendon. At the moment of the impact the glenohumeral contact point is shifted posterosuperiorly and increased shear forces are placed on the posterior-superior labrum, which results in a peel-back effect and eventually in a SLAP lesion.[6]. Furthermore, biceps tenodesis may provide a viable alternative for the salvage of a failed SLAP repair. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs. Type I concerns degenerative fraying with no detachment of the biceps insertion. Traumatic injuries commonly occur following acute, index events based on one of the following mechanisms:[2], Compared to the acute, traumatic SLAP injuries, the overhead athlete is more likely to present with attritional-based etiologies. [6] The former implicates the late-cocking phase of throwing, while the latter would theoretically implicate more traction-based mechanisms. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. The pathophysiology, diagnosis, and nonsurgical management of SLAP tears are reviewed . Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Outcome of type II superior labral anterior posterior repairs in elite overhead athletes: Effect of concomitant partial-thickness rotator cuff tears. Patel KV, Bravman J, Vidal A, Chrisman A, McCarty E. Biceps Tenotomy Versus Tenodesis. [1] Patient-specific considerations and appropriate utilization of both non-surgical and surgical interventions are of the utmost importance to maximize results while minimizing complications. The authors noted that in cases of a positive peel-back sign (i.e., not present in normal shoulders during an arthroscopic examination), the biceps anchor assumes a more vertical and posterior angle that is dynamically visible. Superior Labral Anterior to Posterior Tear Management in Athletes. In addition, understanding how to treat a SLAP tear in the setting of other concomitant injuries is imperative. Typically, an MR arthrogram (MRA) is performed to evaluate the shoulder labrum. Sling immobilization until 4 weeks postoperative, Early shoulder pendulum exercises, periscapular muscle activation exercises. [11], When we consider some tests individually, one can consider the Speed’s test and O’Brien’s test helpful in the diagnosis of anterior lesions and the Jobes Relocation Test is often positive in a posterior lesion[6][23] According to Meserve et al, the O’Brien test is the most sensitive test (47%-78%) and the Speed’s test the most specific (67%-99%). Incidence of SLAP lesions in a military population. BackgroundPrevious studies have demonstrated increased glenohumeral translations with simulated type II superior labral anterior posterior lesions, which may explain the sensation of instability in. Type VI: an unstable flap tear of the labrum in conjunction with a biceps tendon separation. Additionally, adolescents also demonstrated successful outcomes with operative repair in regards to pain and function; however, there remain similar considerations regarding return to sport. Superior labral anterior posterior (SLAP) lesions of the glenoid have proven difficult to diagnose clinically. This can help avoid stressing the dynamic and static stabilizers of the shoulder in hopes of limiting stress at the glenoid-labrum interface. Part II candidates. Gradually, active strengthening and improvement of neuromuscular control are undertaken from two to four weeks. SLAP tears involve the superior glenoid labrum, where the long head of bicepstendon inserts. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. Describe treatment considerations for patients with superior labral anterior to posterior (SLAP) lesions. [2]By the use of posterior capsule stretching exercises, such as sleeper stretch and cross body adduction stretches, and exercises for scapula stabilisation, redevelopment of the internal rotation can be accomplished. Consultations should include primary care sports medicine specialists experienced in managing SLAP tears nonoperatively. A typical symptom is intermittent pain that also occurs in overhead movements. Isolated type II superior labral anterior posterior lesions: age-related outcome of arthroscopic fixation. There is a wide variety of pathology, and patient-specific characteristics and goals heavily influence treatment options. Upon observation, the posterior shoulder (when viewed from the patient's side) will be relatively flat relative to the anterior fullness. They may extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. [15] Additionally, we now recognize that SLAP lesions commonly occur in asymptomatic overhead athletes. - Clinical Presentation and Follow-up of Isolated SLAP Lesions of the Shoulder (SS-04) - Classification and Treatment: - labrum is assessed, including stability of the biceps labral attachment, as well as biceps tendon; - SLAP tears will show more than 5 mm of exposed superior glenoid bone and often a peel back sign; - peel back sign: Orthop Traumatol Surg Res., 2015;101(1):19-24, STETSON, W. (2010). et al., Anatomy of the Shoulder Joint. [41] It is critical to discern whether the labrum alone is responsible for the patient’s symptoms and whether restoring the labral attachment and biceps root to the glenoid will help. [25][32] Additionally, infection, failure of repair, residual pain, neurovascular injury, and recurrent instability may occur. There is increasing evidence that SLAP tears are frequently present on MRI in asymptomatic overhead athletes. A significant number of patients with superior glenoid lesions and concomitant impingement or rotator cuff disease in the absence of trauma has also been identified. Outcome of the isolated SLAP lesions and analysis of the results according to the injury mechanisms. [8], A 2015 study investigated the adjusted incidence rates of SLAP tears as reported in the Defense Medical Epidemiological Database between 2002 and 2009. Results are widely varied in these athletes, demonstrating the return to the prior level of sport between 7% and 84%. The palm is facing upward. SLAP lesions of the shoulder. This increase translated to a population-based increased incidence rate from 4 per 100000 patients in 2002 to 22.3 per 100000 patients in 2010. It is essential to understand that not all SLAP tears are created equal. Shon MS, Jung SW, Kim JW, Yoo JC. 1173185. et al., A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. A sling with an abduction pillow is typically utilized with avoidance of external rotation and abduction. The skin should also be evaluated for prior surgical incisions or injuries attributed to an acute mechanism. In most cases Physiopedia articles are a secondary source and so should not be used as references. Several authors recommend against repair in these populations.[23][31]. Strength, stability and motion are the components of shoulder function that should be focused on during rehabilitation. Superior Labrum Anterior to Posterior Tear (SLAP Lesions) Associated with Biceps Tenosynovitis. Glenoid labrum tears related to the long head of the biceps. In the chronic setting, degenerative changes within the shoulder may be present, and while testing of the superior labrum may be positive, it may not be the main cause of their symptoms. It contains the coracohumeral and the superior glenohumeral ligament, the biceps tendon and the anterior joint capsule. [Updated 2022 Sep 4]. More research is necessary regarding the histologic characterization of the superior labrum-LHBT complex. [37] [2] This position has also been implicated in a sport-specific traumatic force (hyperabduction or traction) as well as during the cocking phase of throwing. El labrum glenoideo, recordemos, es un anillo de fibrocartílago que aumenta el diámetro efectivo de la glenoides respecto a la cabeza humeral. Increasing age, activity level, obesity, female sex, smoking, and concomitant shoulder pathology are risk factors for failure. Stress distribution in the superior labrum during throwing motion. [2]Given that conservative management only seems to be successful in a few patients, mainly in type I SLAP lesions, it is only implemented in patients with this type of lesion or patients who do not wish to undergo surgery. SLAP tears may present in a relatively nonspecific fashion and association with other shoulder pathologies. Phys Ther Sport., 2010;110-121, KNESEK M. et al., Diagnosis and management of superior labral anterior posterior tears in throwing athlets. 163 likes. The patient stands with his or her involved arm flexed 90 degrees at the elbow and abducts the shoulder in the scapular plane to above 120 degrees. [Level 2-3]. Variability in the anatomy of the biceps anchor and tendinous origin translates to varying levels of strain on the superior labrum. Some tests isolate the tension placed on the superior labrum by the biceps via provocative maneuvers in active and passive forms. It is important to discuss the patients’ activities such as athletics, profession, and baseline activity level. Athletes and overhead laborers should also be placed on a restricted sport-specific timeline protocol, and manual laborers should receive appropriate occupational modifications. [2], After surgery, for 3 to 4 weeks, the shoulder of the patient is placed in a sling, which immobilises the shoulder in internal rotation and leads to general loss of motion and stiffness. Brockmeyer M, Tompkins M, Kohn DM, Lorbach O. Charles MD, Christian DR, Cole BJ. The following algorithm has been previously proposed[41], Multiple SLAP repair techniques have been previously described. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Patients with SLAP lesions complain of. A positive test consists of pain elicited in the bicipital groove when the patient attempts to forward elevate the shoulder against examiner resistance; the elbow is slightly flexed, and the forearm is supinated. [39] The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. [10]The majority of patients with SLAP lesions will also complain of: Athletes performing overhead movements, especially pitchers, may develop “dead arm” syndrome in which they have a painful shoulder with throwing and can no longer throw with pre-injury velocity. “Type II plus anterior shoulder instability.”. Dougherty MC, Kulenkamp JE, Boyajian H, Koh JL, Lee MJ, Shi LL. In the acute setting, traumatic injury can occur in traction/torsion and compressive/subluxation mechanisms. [27] It is the anatomic manifestation of a congenital failure of fusion of the labrum, which attaches to the glenoid with a smooth margin or a medial slip. Superior labrum-biceps tendon complex lesions of the shoulder. For the physical examination the therapist uses the tests described in ‘Diagnostic Procedures’, but apart from that he can also test the glenohumeral and scapulothracic range of motion because there could occur a dyskinesis caused by the SLAP lesion. A SLAP lesion (superior labrum, anterior [front] to posterior [back]) is a tear of the rim above the middle of the socket that may also involve the biceps tendon. Anti-inflammatory medications, cryotherapy/cooling/ice application, rest and activity modification. The palm is on the anterior aspect of the contralateral shoulder, with the elbow flexed to 90 degrees. [9]Isolated SLAP lesions are uncommon. The arthroscopic criterion for a type II SLAP lesion includes the ability to demonstrate (usually with an arthroscopic probe) the definitive separation of the superior labrum from the supraglenoid cartilage rim. In SLAP repairs with unstable patterns, a more gradual approach is taken. [39][38] Thus, the inadvertent focus given to a potential SLAP lesion may be either overappreciated or misdirected. ( Pain is typically intermittent and often associated with overhead movements. If the non-operative therapy fails and symptoms persist that prevent sports activities or activities of daily living, then this would indicate the need for operative treatment. initially described four types of attachment patterns of the long head of the biceps tendon (LHBT) to the superior glenoid rim and the superior labrum. In these clinical scenarios, the recommendation is to reassure the patient and educate them regarding the high incidence rate of “incidental” or “clinically irrelevant” SLAP injuries. [23][26][27][28][29][30] Non-overhead athletes return to sport at a consistently higher rate, although some patients inevitably are unable to return to participation. Demographic trends in arthroscopic SLAP repair in the United States. J. Clinicians should inquire regarding certain history elements that may help differentiate SLAP tears from other shoulder injuries. However, the achievement of adequate shoulder mobility is an important condition to begin resistance training. It can be caused by a forceful overhead motion, or when you try to catch something heavy. The patient stands with his or her hand of the involved arm placed on the ipsilateral hip with the thumb pointing posteriorly. Essential to full recovery from a Type II SLAP ( S uperior L abral tear from A nterior to P osterior) Lesion is protection of the repaired labrum. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. et al., Rehabilitation Exercises for Athletes With Biceps Disorders and SLAP Lesions: A Continuum of Exercises With Increasing Loads on the Biceps. Clinical testing for tears of the glenoid labrum. In 2005, an MRI analysis of professional handball players demonstrated abnormalities in 93% of shoulders, with only 37% being symptomatic.[48]. Identify the population(s) most at risk for superior labral anterior to posterior (SLAP) lesions. Additionally, specific biceps testing can be used; however, they are not reliable for SLAP tears as they can be positive with other pathologies. [10][13][14] Multiple tests of the shoulder should be used to gain information collectively towards suspicion for labral pathology. Tenodesis can be performed by subpectoral, all-arthroscopic, and mini-open techniques. What this means is that the labrum is torn at the superior (top) of the glenoid. [2]In the first step of conservative management, patients should abstain from aggravating activities in order to provide relief to the pain and inflammation. The findings can be rather subtle, especially in obese patients. Until now only one study looked at results from physical management on SLAP lesion. Falling on an outstretched arm is an acute traumatic superior compression force to the shoulder. The avulsed area is now devoid of cartilage in the zone of injury. Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum, and can often be confused with a sublabral sulcus on MRI. A superior labrum anterior and posterior (SLAP) tear involves a tear in the 10 o'clock to 2 o'clock positions on the A SLAP tear can be caused by trauma to the shoulder. Special tests that are helpful in this regard include the Spurling maneuver, myelopathic testing, reflex testing, and a comprehensive neurovascular exam. Kuhn JE, Lindholm SR, Huston LJ, Soslowsky LJ, Blasier RB. There are numerous physical examination procedures described to detect the SLAP lesion: A combination of 2 sensitive tests and 1 specific test is more efficient to diagnose a SLAP lesion [reference needed]. Return to Play and Prior Performance in Major League Baseball Pitchers After Repair of Superior Labral Anterior-Posterior Tears. Sports Phys. Ther., 2013; 8(5): 579-600, HURI G. et al, Treatment of superior labrum anterior posterior lesions: a literature review. [25], Another potential nidus predisposing certain patients to SLAP tears is the presence of a sublabral recess (or sublabral sulcus). Varacallo M, Tapscott DC, Mair SD. SLAP stands for "superior labrum, anterior to posterior"—in other words, "the top part of the labrum, from the front to the back." It refers to the part of the labrum that is injured, or torn, in a SLAP injury. Initial reported performance of these tests has not been reproduced by independent investigat … IF < 50% of the biceps tendon is affected, consider SLAP repair/resection. [28], Finally, the Buford complex is a congenitally absent anterosuperior labrum plus a thickened cord-like middle glenohumeral ligament. A detailed sensory examination should take place in all acute and chronic instability patients. Multiple reports on high-level (i.e., professional) overhead throwers have demonstrated equivalent outcomes regarding return to play and return to play performance in athletes managed with operative versus nonoperative modalities alone. Kampa RJ, Clasper J. Degenerative SLAP tears often affect overhead laborers with increasing degrees of association in patients over 40 years old[8], It is important to appreciate the limitations in our ability to accurately report the definitive epidemiological trends as the contemporary recognition and diagnosis of SLAP injuries remains debated. Often seen in association with shoulder instability and anterior labral tears. Arthroscopic biceps tenodesis can be considered as an effective alternative to the repair of a type II SLAP lesion, allowing patients to return to a pre-surgical level of activity and sports participation. Fealy S, Rodeo SA, Dicarlo EF, O'Brien SJ. The examiner initially supports the elbow, and a positive test occurs if the elbow does not maintain this position upon the examiner removing the supportive force. Healing time constraints are critical. [29] Previous reports have emphasized the LHBT as a potentially dominant source of anterior shoulder pain at clinical presentation. A shoulder SLAP tear is when the labrum frays or tears because of an injury. Provocative Examination Testing/Maneuver: Yeh ML, Lintner D, Luo ZP. The highest incidences of SLAP repairs were found in the 20 to 29 and 40 to 49 decades at 29.1 and 27.8 per 10,000 patients, respectively. The examiner manually resists supination while the patient also externally rotated the arm against resistance. SLAP Lesions: Trends in Treatment. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Important variations in the normal anatomy of the labrum have been identified. The above classification system has been expanded to include an additional three types:[2], The major joint of the Glenohumeral Joint, which is also called the ‘ball in a socket’ joint because of the humeral head (ball) that articulates with the glenoid cavity (glenoid fossa of scapula or socket). Katz LM, Hsu S, Miller SL, Richmond JC, Khetia E, Kohli N, Curtis AS. StatPearls Publishing, Treasure Island (FL). SLAP (superior labrum anterior and posterior) tears are injuries to the uppermost part of the labrum, where the biceps tendon attaches to the shoulder. The involved shoulder is positioned at neutral, the elbow is flexed to 90 degrees, the forearm is supinated, and the patient makes a fist. Smith R, Lombardo DJ, Petersen-Fitts GR, Frank C, Tenbrunsel T, Curtis G, Whaley J, Sabesan VJ. Superior Scapes, Inc. is a locally owned and operated full-service landscape company serving the Central New York area since 1990. A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. Treatment failure and complications are dependent upon intervention, patient adherence to rehabilitation protocols, and patient-specific factors. [2][28]This way, physical treatment can be started sooner. SLAP lesions demonstrate a predilection for young laborers, overhead athletes, and middle-aged manual laborers. Surgical treatment: SLAP repair versus resection. The authors demonstrated via immunohistochemical staining that there is an inhomogeneous distribution of nerve endings and sympathetic nerve fibers throughout the superior labral complex. Focus on stretching the posterior capsule is also a focus of rehabilitation. The possibility of generalized hyperlaxity of tissues in all patients with instability should also be considered, and a Beighton score can easily be obtained. Journal of orthopaedic & sports physical therapy, 2009;39(2): 2009, MORGAN CD et al., Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears, Arthroscopy 1998 Sep;14(6):553-65, GASKILL T.R., The rotator interval: pathology and management, Journal of Arthroscopy and Related Surgery 2011, vol. The arm is released from traction and brought into an abducted/externally rotated position. Dines JS, Elattrache NS. An Age and Activity Algorithm for Treatment of Type II SLAP Tears. [36], Mayo Shear Test (also known as the Modified O’Driscoll Test or the Modified Dynamic Labral Shear Test: This factor may have a potential impact on patients experiencing persistent pain following various types of SLAP repairs. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Chang D, Mohana-Borges A, Borso M, Chung CB. Mathew CJ, Lintner DM. Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. NSAIDs and cryotherapy device/ice pack application can be beneficial for pain control. Alpantaki K, McLaughlin D, Karagogeos D, Hadjipavlou A, Kontakis G. Sympathetic and sensory neural elements in the tendon of the long head of the biceps. In the acute traumatic setting, a fall onto an extended and abducted arm leads to a compressive and superior directed force from the humeral head into the superior labrum. Next, the examiner applies a shear force through the shoulder joint by maintaining external rotation and horizontal abduction and lowering the arm from 120 to 60 degrees abduction. Jost B, Zumstein M, Pfirrmann CW, Zanetti M, Gerber C. MRI findings in throwing shoulders: abnormalities in professional handball players. 2009 Oct-Dec; 43(4): 342–346, WILK K.E. Johannsen AM, Costouros JG. Pandya NK, Colton A, Webner D, Sennett B, Huffman GR. Type II SLAP tear pattern plus middle and inferior IGHL compromise, Tear pattern seen in the setting of complex shoulder instability presentations, Type II SLAP tear pattern plus additional cartilage injury adjacent to the bicipital footplate, Mechanical symptoms: popping, locking, catching with various movements and activity, History of any sudden, jerking force to the shoulder with an associated onset of pain, History of or current episodes of shoulder instability, History of or current sport-specific participation, Including the level of competition (e.g., professional, collegiate, recreational). Sports Med Arthrosc.,2010;18:162-166. The study was a one year follow-up study of with 19 patients. Clinicians should focus on the potential relevance of the SLAP lesion as it attributes to the specific patient’s pain and dysfunction. [17] Anatomical variations such as a Buford complex, a thickened middle glenohumeral ligament (MGHL), and absent anterosuperior labrum may be confused with a SLAP tear as well. First described in the 1980s, extensive study has followed to elucidate appropriate evaluation and management. But a physical treatment is also possible. The patient is standing, and the arm of interest is positioned at 90 degrees of forward flexion, 10 degrees of adduction, and internally rotated so the thumb points toward the floor. Occur secondary to sudden jerking movements or after lifting heavy objects, Can occur after an unexpected pull on the arm. The examiner then applies a downward resistive force just distal to the elbow while asking the patient to perform a throwing motion. An initial period of rest following the acute (or acute-on-chronic) injury should be implemented in all patients. SLAP - Superior Labrum Anterior to Posterior InjuryReparación Quirúrgica, por medio de Artroscopía de la Lesión de SLAP, que consiste en una lesión del Rodet. [31], When conservative treatment fails, a surgical approach is in order. [24][25] Several of these studies, however, are heterogeneous and successful treatment is a matter of definition. Following the observational component of the physical examination, the active and passive ROM are both documented; this may be limited in the setting of initial follow-up in the clinic after an acute instability event or the setting of any complex instability case, especially in the setting of glenoid bone loss. The superior labrum and biceps anchor could theoretically be gradually lifted off the glenoid as a result of chronic repetitive superior translation of the humeral head on the glenoid rim. [18][23], Operative intervention in adults has been reported to be successful between 80 and 97% of patients in several populations. Several authors have proposed surgical treatment algorithms depending on the specific type of SLAP lesion identified on advanced imaging, clinical exam, and intraoperative arthroscopy. World J. Original Editor - Kristin Sartore, Venugopal Pawar, Top Contributors - Venugopal Pawar, Lucinda hampton, Fasuba Ayobami, Kim Jackson, Rachael Lowe, Claire Knott, Amrita Patro, Wanda van Niekerk, Vasileios Tyros, Admin and WikiSysop. The rotator cuff muscles are important as well to anchor the scapula and guide the movement. Thus, we can conclude that there is an age-related effect in which the older the patient is, the more likely he will incur a SLAP lesion, due to age-related changes. Superior migration of the humeral head can result from a rotator cuff that is not effectively performing its role as a humeral head depressor. Am J Sports Med., 2010;38:2299–2303, EDWARDS S.L. Find a doctor near you. Outcomes after arthroscopic repair of type-II SLAP lesions. SLAP lesions represent a specific pattern of injury that involves the partial or complete detachment of the superior labrum and/or the biceps tendon. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes. Initial physical examination includes visual inspection for gross asymmetry and muscle atrophy. While MRA has a sensitivity and specificity of 82% to 100% and 71% to 98%, respectively, there are normal anatomic variants that can be confused with a SLAP tear. It is associated with pain and instability and an inability of the patient to perform overhead movements. The patient reported 75% . The age of the patient has an impact on the superior labrum. Superior labrum is more weakly attached to glenoid than inferior labrum. SLAP Lesions: Trends in Treatment. et al., Schoulder injuries in the overhead athlete. Regardless of the underlying etiology, patients presenting with symptomatic SLAP tears will commonly report the acute onset of deep shoulder pain accompanied by mechanical symptoms such as popping, locking, or catching with various shoulder movements. “Type III plus anterior shoulder instability.”, Type III tear pattern plus extension into the LHBT. Weber SC, Martin DF, Seiler JG, Harrast JJ. Comprehensive Review of Provocative and Instability Physical Examination Tests of the Shoulder. Detailed and focused attention should be given to appropriately delineating the extent of all potential underlying shoulder girdle pathologies. Any evidence of significant muscular weakness may hint at an underlying associated neurologic deficit. Am J Sports Med.,2014 ;42(6):1315-1322, WEBER S.C., Surgical management of the failed SLAP repair. Less common than SLAP Lesions. In a SLAP injury, the top (superior) part of the labrum is injured. [21]However in another study by Alpert et al., it is shown that type II SLAP repairs using suture anchors can yield good to excellent results in patients older and younger than age 40. Previous studies have demonstrated non-operative management successful for 22 to 85% of patients. Most of them had a type II SLAP lesion. But if all three tests are positive this will result in a specificity of about 90%. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Popp D, Schöffl V. Superior labral anterior posterior lesions of the shoulder: Current diagnostic and therapeutic standards. Scapulothoracic motion and scapular winging should also be evaluated during active and passive motion. Additional subtypes for type II tears, as well as additional tear patterns, were described in subsequent years. Onyekwelu I, Khatib O, Zuckerman JD, Rokito AS, Kwon YW. Type I tears are usually asymptomatic and do not require treatment, Type II tears require surgical reattachment, Type III tears usually require resection of the bucket handle tear, serratus punch (protraction with the elbow extended), forward flexion in external rotation and forearm supination, full can (elevation in the scapular plane in external rotation, forearm supination, elbow flexion in forearm supination, uppercut (combined forward flexion of the shoulder and flexion and supination of the elbow). The examiner then applies an axial load in an anterosuperior direction from the elbow to the shoulder. While elite athletes and young patients typically undergo repair, these techniques provide satisfactory results for a wide variety of patients. The shoulder joint is composed of the glenoid (the shallow shoulder "socket") and the head of the upper arm bone known as the humerus (the "ball"). A 2017 level III case-control study highlighted the potential risk factors for revision surgery following SLAP repair, with the inclusion of nearly 5000 patients in the database query[58]. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. SLAP tears are a common coexisting injury in patients with other shoulder pathologies, and they do not always account for the primary cause of symptoms. The patient lies supine on the exam table with his or her arms resting in full elevation with the forearm and hand supported by the table. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. Management of paralabral cysts is dependent upon location and concomitant symptomatic nerve compression. Tear pattern involves larger superior labral flaps without detachment of the LHBT insertion. Superior labrum lesions, or frequently referred to as superior labrum anterior to posterior (SLAP) tears, are a subset of injuries of the labrum in the shoulder that occur in acute and chronic/degenerative settings. Posterosuperior Labral Tears. Specific testing of the supraspinatus muscle can be difficult when passive ROM is limited. They can extend into the tendon, involve the glenohumeral ligamentsor extend into other quadrants of the labrum. When refering to evidence in academic writing, you should always try to reference the primary (original) source. SLAP lesions: a treatment algorithm. Phys Ther., 1986;66:1855-1865, CARMICHAEL S.W. [26]Because of unsatisfactory results in older patients, Boileau et al., suggested arthroscopic biceps tenodesis in these patients. [21] Furthermore, SLAP tears account for approximately 1% to 3% of injuries presenting to sports medicine referral centers, and SLAP tears are present in approximately 6% of shoulder arthroscopy procedures.[2][21][22]. Avoid extremes of abduction and external rotation. Am J Sports Med., 2012;40(9):2105-2112, COOLS A .M. http://creativecommons.org/licenses/by-nc-nd/4.0/ Strengthening exercises can be initiated at six weeks postoperatively.[33]. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. [9] The physical examination is also very important in determining the correct diagnosis[11], however physical examination should not be used in isolation because the literature does not confirm that special tests can accurately identify SLAP lesions. MRI and MR arthrography (MRA) are commonly used imaging modalities to detect a SLAP lesion. Clin Orthop Relat Res,2002; 400:98–104, HUIJBREGTS P.A., SLAP Lesions: Structure, Function, and Physical Therapy Diagnosis and Treatment. Compression-type injuries [53][54][55] A number of authors report good results in athletes, including those with sport-specific overhead demand requirements. [6][4]In addition, the rotator cuff muscles are essential to ensure dynamic shoulder stability as they prevent excessive translations of the humeral head at the level of the glenoid fossa.[7]. Unstable SLAP lesions are typically repaired with anchor fixation, and the extent of the injury typically determines the pattern of repair. [5], There remains debate regarding whether the so-called peel-back mechanism versus the deceleration phase of throwing is most responsible for the pathologic forces driving SLAP tears in overhead athletes. Rowbotham EL, Grainger AJ. Secondary to fraying related to Internal Shoulder Impingement. In fact, superior outcomes have been reported in this particular subset of athletic patients following non-surgical management alone. In the absence of compressive symptoms, a range of non-operative treatments can be considered, including observation, anti-inflammatories, or percutaneous aspiration. A SLAP lesion is mainly caused by a fall on an outstretched arm where there is an important superior compression on the labrum which causes a tear of the labrum. Adolescent Posterior-Superior Glenoid Labral Pathology: Does Involvement of the Biceps Anchor Make a Difference? Part II candidates. Pathophysiology. Common SLAP-provoking sports include but are not limited to: Overhead sports (volleyball, baseball pitchers, javelin, swimming), History or current manual/physical laborer occupations, Atraumatic, insidious onset of anterior shoulder pain, Symptom exacerbation with overhead activities, Pain radiating down the anterior arm from the shoulder, Clicking or audible popping reported in the setting of proximal biceps instability. This increase constituted a jump in case volume reporting from 765 to 4313 annual SLAP repairs. [9][11][13] It is important to keep in mind that while labral pathologies are frequently caused by overuse, the patient may also describe a single traumatic event. The deltoid muscle often demonstrates atrophy in chronic dislocators. The investigation of choice is an MR arthrogram, which is variably reported as having accuracies of 75-90%, although distinguishing between subtypes can be difficult. ( Resisted elbow flexion, resisted forearm supination. The patient places their hand on the contralateral (normal) shoulder in a “self-hug” position. [3] The biceps has also been implicated in the follow-through phase of throwing as an eccentric contraction of the biceps transmits an extensive pull on the superior labrum. [36] Ultimately, nonoperative and operative management yields successful results for many patients; however, treatment success is highly dependent upon the patient's functional level and treatment goals. Phys. ), which permits others to distribute the work, provided that the article is not altered or used commercially. CORR 2012. Etiology Furthermore, this technique has now become the most preferable treatment for failed SLAP repairs. [18], Schwartzberg reported MRI documented SLAP lesions can be present in up to 72% of middle-aged, asymptomatic patients. SLAP tear patients typically admit to resolution or reduction of symptoms at rest. If you know where these structures are situated, you can try to palpate the rotator interval.[20]. , which are the serratus anterior, rhomboid major and minor, levator scapulae and trapezius. The examiner applies a perpendicular external rotational force to try and lift the patient’s handoff of the shoulder. [18] However, in younger patients presenting with shoulder instability, the SLAP injury may be present and contributing to symptoms, especially in the setting of an acute anterior and/or posterior labral tear. [Updated 2022 Jul 6]. Clinicians should keep in mind the utilization of MRA may promote the overdiagnosis of asymptomatic (or clinically irrelevant) SLAP lesions and thus exercise best clinical judgment in ordering specific advanced imaging modalities. Chronic instability patients will almost always exhibit at least a mild degree of asymmetry. Between week 4 and 8, internal and external rotation ROM are progressively increased to 90° of shoulder abduction. [28][30]can be prevented. Resistance exercises can be initiated at approximately 8 weeks post-operative, in which scapular strengthening should be emphasized. Finally, SLAP tears can occur in a degenerative setting for the aging population. Those potentially contributing to patient-reported symptoms may require surgery, and depending on the particular SLAP tear pattern and the presence (or absence) of other associated shoulder pathologies, the recommended surgical technique(s) may vary. [15], According to William F.B., SLAP lesions had an association of 43% with the medial sheath lesion. Taylor SA, Degen RM, White AE, McCarthy MM, Gulotta LV, O'Brien SJ, Werner BC. [13][14], The highest incidence rates of SLAP lesions present in the 20- to 29-year-old and 40- to 49-year-old age groups. Contribution to the study of the pathogenesis of type II superior labrum anterior-posterior lesions: a cadaveric model of a fall on the outstretched hand. There is no gold standard physical exam test that specifically identifies SLAP tears. [28] It is generally recognized that the majority of patients with symptomatic SLAP lesions will fail conservative management, particularly throwers. Pagnani et al29 demonstrated that an isolated lesion of the anterosuperior labrum has 295 no significant effect on anterior-posterior translation, whereas complete lesions of the superior 296 labrum, including both anterior and posterior portions, led to significant increases in anterior-297 posterior translation in a cadaveric testing. ficha médica ocupacional anexo 16, mensaje de la obra yerba santa, horario de atencion estacionamiento los portales, mecánica de maquinaria pesada, la madrastra comparacion, plan de estudios de cálculo diferencial, noticias de hoy cerca de ayaviri, hyundai modelos y precios, identidad nacional mapa conceptual, grindelia boliviana rusby, como redactar un discurso, factores que influyen en el desarrollo, 5 propuestas de emprendimiento, guía para hacer un ensayo pdf, revista peruana de biología, lima polo club lurin direccion, de que departamento es el lomo saltado, gerente financiero organigrama, plan contable general empresarial 2021 excel, fertilizantes orgánicos líquidos, alquiler de departamentos en pueblo libre 800 soles, cuidados de aneurisma cerebral, que necesita un niño para crecer sano y fuerte, emiliano gonzález la madrastra, licencia por maternidad perú, chocolates nestlé multipack, ternos para bebés de 2 años, si lo crees, lo creas resumen por capítulos, sapolio mata moscas por mayor, promociones rokys con tarjeta ripley 2022, bodytech horario el polo, todos los limpiaparabrisas son iguales, tipos de masas enriquecidas, necesidades de la ciberseguridad, como solicitar copias simples de un expediente judicial, hiperemia pulpar definición, guía santillana 6 grado contestada completa 2020 pdf, mini proyectos de emprendimiento, las mejores cremas para xerosis, la exitosa trujillo en vivo, mannucci vs universitario femenino, necesito profesor de matemáticas, comisiongyt_fachse unprg edu pe, indecopi convocatorias, ayahuasca beneficios y contraindicaciones, experiencia de aprendizaje 2021 secundaria, delito de estelionato en el código penal peruano, libro digital derecho romano, cuál es la función de los corchetes, cas hospital cayetano heredia 2022, amuleto bandera de la victoria, terminal terrestre plaza norte teléfono, características de los mantos paracas, alcalde de cerro colorado actual, casa de campo lunahuana airbnb, traslado interno universidad continental, organigrama de la municipalidad provincial de santiago de chuco, extra cash interbank simulador, fundación de tingo maría, ingeniería de minas perú, universidad nacional del santa examen de admisión 2022, tipos de cambio en el comercio internacional, recojo de licencia de conducir, precio ford edge 2022, clínica sanna trujillo ubicación, qué podemos hacer para reducir el uso del plástico, las sanciones se publican en el osce, modelo de plan de reforzamiento escolar, eliminación de barreras burocráticas indecopi, noah schnapp perú precio, electrocardiograma riesgo quirúrgico grado 2, pantalones pionier mujer, políticas económicas en colombia, cefalea tensional crónica, monografías hechas para copiar, plan de cuentas contables, diseño gráfico es rentable, criterios e instrumentos de evaluación en el nivel inicial, ejemplo de una ficha de trabajo para observación, causas y consecuencias de la contaminación del río tumbes,

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