Case study of anatomy

1. Case study 3- Part 3:
A 65-year old veteran athlete has a painful throwing
shoulder during delivery of the javelin and is diagnosed
as having a superior labral anterior posterior lesion of
the shoulder joint (SLAP lesion). The long head of the
biceps brachii muscle tendon is impacted in this injury.
Yergason’s- and Speed’s manual tests confirmed the
diagnosis.
NICOLE POTTINGER -217111777
THAPELO SITOTO – 217271715
HMBV311- ANATOMY III

2. INTRODUCTION
 Superior labrum anterior to posterior (SLAP) lesions are tears in the superior anterior
and posterior part of the glenoid labrum. The glenoid labrum serves as an attachment
site for the long head of the biceps tendon; together these structure help with
stabilization of the humeral head into the glenohumeral joint during abduction and
external rotation of the arm (Nuri, Evrim & Alp, 2014).
 There are several types of SLAP lesions mainly caused by overuse, injury and
degeneration; the symptoms include locking and grinding as well as reduced range of
motion, strength and stability in the shoulder joint (Bonvissuto, 2018). Diagnosis is
through physical examination tests, namely: O’Briens’s, Biceps Load, O’Driscoll’s
Dynamic Labral Shear and Speed’s tests. Treatment of SLAP lesion is determined by
severity of the tear which could range from non-operative methods (such as rest and
physical rehabilitation) and operative methods such as (repair and tenodesis).
 In relation to the case study, the objective of this assignment is to determine what might
have caused the SLAP lesion in the 65- year old javelin thrower; to prove why the tests
used for diagnosis were appropriate and to provide the appropriate intervention
strategies that could be followed to ensure that the glenoid labrum is repaired.

3. FUNCTIONAL INTEGRATION
 Anatomy of the shoulder:
https://www.youtube.com/watch?v=D3GVKjeY1FM

4. Scapulohumeral Rhythm
 https://www.youtube.com/watch?v=H4nfQEeJmFo
Brachial plexus https://www.youtube.com/watch?v=gTas7ijp0YE
According to (Drake, et al., 2015) the brachial plexus is a somatic plexus that is formed by
the anterior rami of C5 to C8 and most of the anterior ramus of T1. The originates from
the neck and passes laterally and inferiorly over rib pair 1 and enters the axilla. The
brachial plexus innervates the upper limb.
Biomechanics of Javelin throw https://www.youtube.com/watch?v=7GqhqmYjMpE

5.  There are 6 phases of throwing: Wind up, stride, arm cocking, acceleration, deceleration
and follow-through.
 The phases that influence injuries in the shoulder is arm cocking, acceleration,
deceleration and follow-through.
 Arm cocking- The athlete’s shoulder is at maximum external rotation.
 Acceleration phase- Shoulder is at maximal external rotation and begins to transition to
internal rotation.
 transition phase is where the greatest risk of injury may occur. Biceps muscles contracts to
valgus stress and hyperextension at the elbow. This leads to extreme tension on the superior
labrum and origin of the long head biceps tendon at the supraglenoid tubercle. (Lin, et al.,
2018).
 Deceleration phase- Shoulder is in maximal internal rotation. In this phase, greatest
glenohumeral joint loading occurs, increased compressive forces, adduction torque and
inferior forces. The posterior musculature helps to dissipate all these components.
 Follow-through: The athletes arm continues to decelerate via eccentric contraction of the
shoulder, scapula and elbow muscles. Follow-through phase is necessary to dissipate the
energy generated during the throwing motion, thus is associated with overuse injuries of the
posterior arm.

6. PATHOPHYSIOLOGY
 https://www.youtube.com/watch?v=WOWJacen9A0
 In the 65-year-old, the SLAP lesion could have been caused by overuse, injury
and degeneration. The follow- through phase, used for energy dissipation
during javelin throwing, is associated with overuse injuries of the posterior
arm. The other phases influence injury in that the athlete’s shoulder is at
maximal external rotation during the arm cocking phase; going into the
acceleration phase, the arm goes into internal rotation; the transition phase
subjects the athlete to the greatest risk for a SLAP lesion, in that the biceps
muscles contracts to valgus stress and hyperextension occurs at the elbow,
leading to extreme tension on the superior labrum and origin of the long head
biceps tendon at the supraglenoid tubercle. During the deceleration phase, the
shoulder is in maximal internal rotation, thus there is greatest glenohumeral
joint loading, increased compressive forces, adduction torque and inferior
forces which could cause injury. The SLAP lesion could have also been caused
by degeneration of tissue of the glenohumeral joint caused by aging.

7. Illustration of the different types of slap lesions (Pappas, et al., 2013).

8. Illustration of the different types of slap lesions (A. most severe type 4 SLAP lesion, B. Type 3,
Type 2, D. Type 1) (Stathellis, et al., 2018).
A. B. C. D.

9. TREATMENT/ INTERVENTION
 Diagnosing of SLAP lesions can be challenging as SLAP lesions don’t have a specific pain associated with it. Patients
complain about localized or radial pain that moves anterior to posterior part of the shoulder or pain is sharp or
aching deep within the shoulder. The pain can mimic other shoulder pathologies.
 Diagnosis of SLAP lesion is through physical examination tests, namely: O’Briens’s, Biceps Load, O’Driscoll’s Dynamic
Labral Shear and Speed’s tests. The Yergason’s and Speed’s tests have been used for diagnoses for this case study.
 The Yergason’s and Speeds’s test are positive when there is pain at the bicep tendon and in the region of the
bicipital groove, respectively; the athlete complains of pain during the delivery of the javelin emphasising thus the
structures mentioned are involved during a SLAP lesion. These tests are appropriate in that they test for paining of
the structures involved during a SLAP lesion.
 The type of treatment depends on the type of lesion, the age of the patient, the gender of the patient, the cause of
lesion (traumatic or non-traumatic), the functional requirement of the patient and the level of sporting activity
(Stathellis et al., 2018). A non-operative treatment is initially done. Some of the non-operative treatments are anti-
inflammatory drugs, physiotherapy or change or improvement in sporting technique. Non-operative treatment
should last for three to six months. If the non-operative treatment is not successful, surgery is considered
 According to (Hester, et al., 2018) three basic principles are followed when initial management of all SLAP injuries
occur. Decrease inflammation via cryotherapy, medications and/or injections. Postural correction via scapular
retraction exercises, posture bracing and taping, and biofeedback exercises. Balanced rotator cuff rehabilitation and
proprioceptive neuromuscular rehabilitation exercises to return to function.

10. CONCLUSION
 The SLAP lesion in the 65- year old javelin thrower was as a result of
overuse, injury and degeneration; paining of the shoulder during delivery
is caused by injury to the biceps tendon and injury in the region of the
bicipital groove which is confirmed by the Yergason’s and Speeds’s test.
Operational methods would be optional to the youth which would yield
better results, however since the operational method is less effective for
the elderly, management is rather advised for SLAP lesions and these
include cryotherapy, medications and/or injections, postural correction and
rotator cuff rehabilitation and proprioceptive neuromuscular rehabilitation
exercises.

11. REFERENCES
Bonvissuto, D. (2018). What Is a Labrum SLAP Tear? [online] WebMD. Available at: https://www.webmd.com/pain-management/labrum-slap-tear [Accessed 8 Mar.
2019].
Drake, R.L., Vogl, W. and Mitchell, A.W.M. (2015). Gray’s atlas of anatomy. Philadelphia, Pa: Churchill Livingstone/Elsevier, p 708-709.
Hester, W. A., Brian, M. L. O., Heard, W. M. & Savoie, F. H., 2018. Current concepts in the evaluation and management of type II superior labral lesions of the
shoulder. The Open Ortgopaedics Journal, Volume 12, pp. 331-341.
Lin, D. J., T.Wong, T. & K.Kazam, J., 2018. Shoulder injuries in the overhead- throwing athlete: Epidemiology, mechanisms of injury, and image findings. Radiology,
286(2).
Nuri Aydin, Evrim Sirin, Alp Arya. Superior labrum anterior to posterior lesions of the shoulder: Diagnosis and arthroscopic management. World Journal of
Orthopedics, 5(3), p.344.
Pappas, N. D., C.Hall, D. & Lee, D. H., 2013. Prevalence of labral tears in the elderly. Journal of Shoulder and Elbow surgery, Volume 22, pp. 11-15.
Prentice, W.E. (2017). Principles of athletic training: a guide to evidence-based clinical practice. New York, Ny: Mcgraw-Hill Education, p.669-677.
Stathellis, A. et al., 2018. Treatment of SLAP lesions. The open Orthopaedics Journal, 12(Suppl-1, M4), pp. 288-294.
Woldt, J. (n.d.). Javelin: The run-up & crossover phases. [online] Available at: http://javelinbiomechanics.blogspot.com/2015/06/thetwo-most-important-and-
controllable.html.