SLAP Tears:

A 2 Pronged Approach to Diagnosis and Treatment

Rebecca Zahniser, PA-S, ATCPhiladelphia University PA Program

Master’s Project: Teaching TrackApril 22, 2010

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Lecture Objectives

At the end of this lecture, first year PA students will be able to: Define the 4 main types of SLAP tears. Name and correctly perform appropriate

special tests to evaluate for a SLAP tear. Order and interpret appropriate diagnostic

imaging to evaluate for a SLAP tear. Discuss with their future patients what to

expect during the arthroscopic surgical repair process, including the pre-operative, operative, and post-operative periods.

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Shoulder Anatomy Review

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What is the Labrum?

Triangular, fibrous structure that is an extension of the glenohumeral ligaments

Peripherally surrounds the glenoid and deepens the socket, increases humeral head contact area, and helps stabilize the GH joint

The biceps tendon fibers blend with both the capsule and labrum at its insertion on the supraglenoid tubercle

The blood supply is from the suprascapular a., posterior circumflex humeral a., and the circumflex scapular branch of the subscapular a.

Vascularity is limited to the periphery, with the inferior and posterior portions being the most vascular

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What is a SLAP Tear?

Superior Labral tear, Anterior to Posterior Classification System:

Type I: Degenerative fraying with intact biceps anchor

Type II: Unstable tear where the superior labrum and biceps anchor are detached from the superior glenoid rim

Type III: Bucket-handle tear of superior labrum with intact biceps anchor

Type IV: Type III lesion with tear extending into biceps anchor

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Types of SLAP Tears

Most Common

A. Type I B. Type II C. Type III

D. Type IV

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Mechanism of Injury

Athletes: Direct blow while tackling Traction injury while water skiing Fall On Outstretched Hand (FOOSH) or fall on tip of

shoulder Weightlifting: traction injury or losing control through

Range Of Motion Overuse in throwers/swimmers Concurrent with shoulder dislocation

Rest of the Population: FOOSH or fall on tip of shoulder Traction injury from losing hold of a heavy object Concurrent with shoulder dislocation Repetitive overhead activity/occupation

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Primary Care Presentation

Common Presenting Symptoms/Complaints: Vague, deep anterior shoulder pain

Often impairs Activities of Daily Living (ADLs) or athletic activities

Intermittent clicking and mechanical symptoms, especially with overhead activities/sports

History: OP4QRST Mechanism of Injury Occupation/Sport Previous Injury

Treatments and Outcomes Affects on ADLs or athletic performance Review Of Systems

Musculoskeletal, Neuro, and Vascular

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Primary Care Presentation, cont.

Physical Exam: Observation

Posture “Typical” Americans have lordotic curve of C-Spine and

kyphotic curve of T-Spine Palpation

Biceps tendon may be painful Range Of Motion (ROM)

Usually normal, but athletes may have excessive External Rotation

External Rotation/Abduction may be painful Strength Testing

Usually normal Special Tests

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O’Brien Test

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Anterior Slide Test

http://www.clinicalsportsmedicine.com/_images/chapters/14/14-2u.jpg

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Biceps Provocation Test

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Orthopedic Office Presentation

Imaging Studies: Shoulder Radiographs Magnetic Resonance Imaging (MRI)

With/Without Contrast Diagnostic Arthroscopy is the only

definitive imaging study!!

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Shoulder Radiograph Views

Normal unless SLAP tear is in conjunction with a shoulder dislocation

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MRI Arthrography Examples

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Orthopedic Office Presentation, cont.

Non-Operative Treatment Not a “cure”

Treatments help decrease symptoms so that the patient can resume ADLs; may/may not be able to resume athletics

Cortisone Injection NSAIDs Physical Therapy

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Orthopedic Office Presentation, cont.

Arthroscopic Repair Anesthesia

General Anesthesia With/without Scalene Nerve Block

Positioning Lateral Decubitus Beach Chair

Technique Examination Under Anesthesia Portal Placement Diagnostic Arthroscopy Suture Anchor Placement

Post-Operative Course

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Patient Positioning

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Portal Placement

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Diagnostic Arthroscopy

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Suture Anchor Placement

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Post-Operative Recovery Immobilized in a sling for 3-4 weeks—depending on

surgeon’s preference Pain relief is important in the immediate post-op period

Narcotic analgesics-->Tylenol®/Motrin® Ice

Phase I-Immediate Post-Operative Weeks 0-2 post-op Goals:

Independent with Home Exercise Program (HEP) Passive ROM to 120 degrees maximum Flexion

(FL)/Scaption Passive ROM to 30 degrees maximum Internal Rotation

(IR)/External Rotation (ER) Full Active ROM wrist, hand, and elbow extension Full Passive ROM elbow flexion Sling compliance NO ACTIVE BICEPS CONTRACTION!!

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Post-Operative Recovery, cont.

Phase II-Graded AROM/Strengthening Weeks 3-6 post-op Goals:

Gradually restore Passive ROM D/C sling at week 3-4 if proximally stable Initiate strengthening at 6wks post-op Restore correct scapulohumeral rhythm Full Active ROM elbow-pain free Able to comb hair Sleep uninterrupted NO LIFTING!! NO ER with ABD > 90 degrees!!!

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Post-Operative Recovery, cont.

Weeks 7-9 post-op Goals:

Active ROM WNL Able to reach behind back for wallet Able to lift to eye level NO LIFTING > 5lbs.!!!!

Weeks 10-11 post-op Goals:

Manual Muscle Testing of elbow and shoulder 4/5 Able to lift 3 lbs. into overhead cabinet Able to tuck in shirt and fasten bra NO UNILATERAL LIFTING OVERHEAD >5lbs.!!!

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Post-Operative Recovery, cont.

Phase III-Advanced Strengthening for Return to Sport Weeks 12-15 post-op

Manual Muscle Testing Shoulder 5/5 Able to place >10lbs. in overhead cabinet May initiate bicep strengthening at 12 wks

post-op Weeks 16-24 post-op

Return to sport/activity of choice Return to Throwing Progression begins at 4

months post-op for baseball players Independent with exercise progression

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VideoSLAP Repair Video

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Questions?

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