Shoulder SLAP Lesion

What is SLAP Lesion?

SLAP Lesion is the abbreviation of Superior Labrum from Anterior to Posterior tears in the shoulder joint labrum.

It may occur as isolated lesion or it can be associated with:

1. Internal impingement of the shoulder.
2. Rotator cuff tears (usually articular sided tears).
3. Shoulder Instability (may be subtle)

Most common occurs in a Throwing Athlete (repetitive overhead activities). It comprise approximately 5% of all shoulder injuries.

See Also: 
- Rotator Cuff of the Shoulder
- Anterior Shoulder Instability

Classification (Expanded Snyder classification)

Type	Description	Treatment
I	Biceps fraying, intact anchor on superior labrum	Arthroscopic debridement
II	Detachment of biceps anchor	Repair versus tenotomy/ tenodesis
III	Bucket-handle superior labral tear; biceps intact	Arthroscopic debridement
IV	Bucket-handle tear of superior labrum into biceps	– <30% of tendon involvement: debridement – > 30%: repair or debridement and/or tenodesis of tendon
V	Labral tear + SLAP lesion	Stabilization of both
VI	Superior flap tear	Debridement
VII	Capsular injury + SLAP lesion	Repair and stabilization

Type II SLAP tear is the most common (IIA is anterior, IIB is posterior, IIC is anterior and posterior).

Physical Examination:

There is no single physical examination maneuver specific for SLAP tear, some tests may rise suspicious of it:

1. O’Brien Test
2. Compression rotation test
3. Speed test
4. Dynamic labral shear test
5. Kibler anterior slide test
6. Crank test
7. Kim biceps load test

See Also: Shoulder Special Tests

Oh and colleagues studied the usefulness of combinations of two and three special tests in identifying type II. Although combinations of two tests were not useful in substantially increasing the overall diagnostic utility, several combinations of three tests were. When two tests were chosen from the group with relatively high sensitivities and one from the group with relatively high specificities, the sensitivities of the three “or” combinations were approximately 75% and the specificities of the three “and” combinations were approximately 90%.

High Sensitivity (choose2)	High Specificity (choose1)
Compression rotation test + Anterior apprehension test + O’Brien test	Yergason test + Biceps load test II + Speed test

Diagnostic Utility of Combinations of Tests for Identifying Type II to IV:

Testand Study Quality	Test Combination	Population	Reference Standard	Sens	Spec
History of popping, clicking, or catching + Anterior slide test	History and test positive	55 patients with shoulder pain	Arthroscopic visualization	.40 (.10, .70)	.93 (.86, 1.0)

Imaging:

• MR arthrography is the modality of choice.
• A paralabral cyst is indicative of a SLAP tear (or posterior labral tear): Cyst may extend to spinoglenoid notch and compress the suprascapular nerve, leading to infraspinatus wasting.

SLAP Tear Treatment

Nonoperative Treatment:

Nonoperative treatment of SLAP tear should be tried in all patients.

Treatments include:

1. Rotator cuff muscles strengthening and scapular stabilization.
2. Throwers benefit from stretching of the posterior capsule.
3. Intraarticular injections.

Operative Treatment:

Surgical technique SLAP repair is selected based on the type of the tear as mentioned in the table above.

Some suggests that patients older than 40 years with obvious biceps pathology and degenerative labral changes are best treated with débridement and tenotomy/tenodesis.

If concomitant rotator cuff tear presents, recent studies have found no advantage to repairing SLAP at time of rotator cuff repair as it may result in increased rate of shoulder stiffness if SLAP tears is repaired.
Recent studies have suggested biceps tenotomy should be performed at the time of rotator cuff repair.

Postoperative Rehabilitation

• After SLAP repair, there is relatively high incidence of postoperative stiffness, so motion is begun early ( Pendulums are initiated immediately).
• Passive and active assisted exercises are begun 7 to 10 days postoperatively.
• Patient should avoid resistive biceps exercises and external rotation with the arm in 90 degrees of abduction.

Complications

• Shoulder stiffness is common after SLAP repair.
• Stiffness should be initially managed with physical therapy. If symptoms persist, arthroscopic capsular release may be performed.
• Persistent symptoms, articular cartilage injury, and loose or prominent hardware are other frequent complications following SLAP tears repair.

References

1. Michener LA, Doukas WC, Murphy KP, Walsworth MK. Diagnostic accuracy of history and physical examination of superior labrum anterior- posterior lesions. J Athl Train. 2011 Jul-Aug;46(4):343-8. doi: 10.4085/1062-6050-46.4.343. PMID: 21944065; PMCID: PMC3419145.
2. Oh JH, Kim JY, Kim WS, Gong HS, Lee JH. The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion. Am J Sports Med. 2008 Feb;36(2):353-9. doi: 10.1177/0363546507308363. Epub 2007 Nov 15. PMID: 18006674.
3. Millers Review of Orthopaedics -7th Edition Book.