Superior labral anterior-posterior (SLAP) lesions are common shoulder injuries, especially in overhead athletes. They can cause chronic pain and loss of function if left untreated. This paper reviews the classification, pathomechanics, clinical evaluation, and treatment of SLAP lesions. Making the clinical diagnosis can be challenging, as concomitant injuries like rotator cuff tears are common. A thorough history and physical exam, along with imaging, are important to identify SLAP lesions and associated injuries to guide appropriate treatment.

1. [ CLINICAL COMMENTARY ]
CHRISTOPHER C. DODSON, MD¹ MD²
SLAP Lesions: An Update on
Recognition and Treatment
uperior labral lesions are a common occurrence in the
S
recognize and appropriately treat SLAP
athletic population, especially overhead athletes. The first lesions. Untreated, SLAP lesions can be
a potentially devastating injury that can
description of labral tears involving the superior aspect of
lead to chronic pain, as well as a signifi-
the glenoid was described by Andrews et al,1 who reported cant loss of function and performance.
on 73 overhead throwing athletes who had labral tears specifically The purpose of this article is to review
located in the anterosuperior quadrant of the glenoid, near the origin the classification, pathomechanics, clini-
of the long head of the biceps tendon.1 Snyder29 would later coin cal evaluation, and treatment of SLAP
the term “SLAP lesion” (superior labrum, anterior and posterior) to lesions. The recommendations regarding
diagnosis and treatment presented in this
describe a similar injury pattern, located ducted position. article are based on clinical experience.
at the biceps anchor and extending ante- The advancement of arthroscopic
rior to posterior. Although both authors techniques has led to a tremendous in-
reported on similar lesions, the etiology crease in our understanding of SLAP
remained unclear. Andrews et al2 pro- lesions. However, making the diagnosis comprehensive discussion of
posed that the biceps tendon acted to clinically can still be a challenge. A com- the pathomechanics of SLAP le-
“pull off ” the labrum, whereas the most prehensive approach involving a thor- sions is beyond the scope of this
common mechanism of injury in the ough history and physical examination, article. However, we do feel that a basic
Snyder29 report was compression load- adequate imaging, and ultimately diag- review of some of the proposed mecha-
ing, with the shoulder in a flexed and ab- nostic arthroscopy is often necessary to nisms of SLAP lesions can be helpful in
understanding their surgical treatment
SYNOPSIS: Superior labral tears (SLAP lesions) specifically review some of the physical examina- and rehabilitation.
can pose a significant challenge to orthopaedic tion tests that are used to diagnose SLAP lesions It is not uncommon to encounter as-
surgeons and rehabilitation specialists alike. and report on our technique of arthroscopic repair. sociated pathology when treating a SLAP
Although advancement in arthroscopic techniques Additionally, we will discuss the operative manage- lesion. Most notably, patients who have
has enhanced arthroscopic repair of SLAP lesions, SLAP tears can also have concomitant
ment of associated intra-articular pathology and,
the clinical diagnosis of SLAP lesions can still
finally, we will briefly discuss our postoperative rotator cuff tears and other labral pathol-
be difficult. There is a variety of etiologic factors
associated with SLAP lesions and a thorough rehabilitation guidelines. ogy. Andrews et al1 reported that 45% of
clinical evaluation is crucial to make the diagnosis. Level 5. J Orthop patients (and 73% of baseball pitchers)
Concomitant injury to the capsular-labral complex Sports Phys Ther 2009; 39(2):71-80.doi:10.2519/ with SLAP lesions also had partial-thick-
or rotator cuff is not uncommon and can further jospt.2009.2850 ness tears of the supraspinatus portion
confuse the clinical presentation. The purpose
instability, rotator cuff tears,
of the rotator cuff. Mileski and Snyder19
of this paper is to review the pathomechanics,
diagnosis, and treatment of SLAP lesions. We will shoulder reported that 29% of their patients with
SLAP lesions exhibited partial-thickness
1
Fellow Orthopaedic Surgery, Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY. 2 Co-Chief, Sports Medicine and Shoulder Service, Hospital for
Special Surgery, New York, NY. Address correspondence to Dr David W. Altchek, Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th St, New York,
NY 10021. Email: altchekd@hss.edu
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 71

2. [ CLINICAL COMMENTARY ]
rotator cuff tears, 11% complete rotator of throwing, which supports the concept
cuff tears, and 22% Bankart lesions of the of the “peel-back” mechanism. Additional
anterior glenoid. They also demonstrat- authors12,31 have also demonstrated that
ed that type I SLAP lesions are typically there is contact between the posterior-su-
associated with rotator cuff pathology, perior labrum and the rotator cuff when
while types III and IV are associated with the arm is in an abducted and externally
traumatic instability. Finally, they noticed rotated position, which simulates the late
that in patients with type II lesions, older cocking phase of throwing.
patients tended to have associated rota- Shepard et al27 simulated each of the
tor cuff pathology, while younger patients aforementioned mechanisms in 9 pairs
had associated anterior instability. of cadaveric shoulders that were loaded
Our recognition of these associated le- to biceps anchor failure in either a po-
sions may allow for insight with regard sition of in-line loading (similar to the
to the biomechanical etiology of SLAP deceleration phase of throwing) or in a Illustration of SLAP lesion types, as
described by Snyder et al.22 Type I represents a
lesions. There are several proposed simulated peel-back mechanism (similar
frayed or degenerative labrum with attachment of the
mechanisms, although it is still unclear to the late cocking phase of throwing). labrum to the glenoid. Type II represents detachment
what exactly causes SLAP lesions. These Their results showed that all of the simu- of the superior labrum and biceps from the glenoid
mechanisms can be divided into acute lated peel-back group failures resulted in rim. Type III represents a bucket-handle tear of the
traumatic events or chronic repetitive a type II SLAP lesion, whereas the major- labrum with an intact biceps anchor. Finally, type IV
represents a bucket handle tear of the labrum that
injuries that lead to failure. An example ity of the simulated in-line-loading group
extends into the biceps tendon.
of an acute traumatic event would be fall- failures occurred in the midsubstance of
ing onto an outstretched arm, which may the biceps tendon. Additionally, the bi-
result in a SLAP lesion, secondary to im- ceps anchor demonstrated a significantly
paction of the humeral head against the higher strength with in-line loading as
superior labrum and the biceps anchor. opposed to the ultimate strength during
T
he most common classification
Repetitive overhead activity has been the “peel-back” mechanism. These re- system for SLAP lesions was de-
hypothesized as a common mechanism sults support the theory of peel-back as scribed by Snyder et al,29 following
for producing SLAP lesions. Andrews et the predominant mechanism; but, most a retrospective review of 700 shoulder ar-
al1 first theorized that SLAP lesions in likely, a combination of mechanisms re- throscopies. They identified 4 types of su-
overhead throwing athletes was the re- sult in SLAP lesions. perior labral lesions involving the biceps
sult of the high eccentric activity of the Finally, several authors have report- anchor ( ). Type I SLAP lesions
biceps muscle, creating tension on the ed an association between SLAP lesions have fraying of the edge of the superior
long head of the biceps tendon, during and glenohumeral instability. Pagnani et labrum. Type II SLAP lesions, the most
the arm deceleration and follow-through al24 found that a complete lesion of the common, consist of frank detachment of
phases of throwing. The authors subse- superior portion of the labrum was asso- the biceps anchor from the glenoid. Type
quently applied electrical stimulation to ciated with significant increases in gle- III lesions consist of a bucket-handle tear
the bicep during arthroscopy and noted nohumeral translation. They also found of the superior labrum with, an otherwise
that contraction of the biceps caused the that the presence of a simulated SLAP normal biceps anchor. Finally, type IV
biceps anchor to effectively separate from lesion resulted in a 6-mm increase in lesions, the least common, consist of a
the glenoid.2 anterior glenohumeral translation. Kim bucket-handle tear of the superior labrum
Burkhart and Morgan4 have hypoth- et al14 reported that maximal biceps ac- that extends into the biceps tendon, caus-
esized that a “peel-back” mechanism tivity occurred when the shoulder was ing detachment of the biceps anchor.
may produce a SLAP lesion in the over- in the abducted and externally rotated Over time, many surgeons have
head athlete. They believe that when the position in patients with anterior insta- encountered numerous combined or
shoulder is placed in a position of abduc- bility. The exact cause-and-effect rela- complex SLAP lesions that cannot be
tion and maximal external rotation, the tionship of instability and SLAP lesions classified by Snyder et al’s29 original clas-
rotation causes a torsional force at the is still unclear. It may be that instability sification system. Maffet et al17 expanded
base of the biceps. In a cadaveric study, allows for a pathologic range of motion the original classification to include type
Pradham et al25 measured superior labral that facilitates the peel-back mechanism V lesions, anteroinferior Bankart-type
strain during each phase of the throwing or, possibly, that SLAP lesions allow for labral lesions in continuity with SLAP
motion. They reported increased superior excessive glenohumeral translation, lesions, type VI lesions, consisting of bi-
labral strain during the late cocking phase which leads to instability. ceps tendon separation with an unstable
72 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

3. flap tear of the labrum, and type VII le- may complain of pain during a specific
sions, consisting of an extension of the phase of throwing, most notably the late
superior-labrum biceps tendon separa- cocking phase. We have found that the
tion to beneath the middle glenohumeral most likely complaint in the thrower is
ligament. Morgan et al20 has subclassified the inability to perform at their opti-
type II slap lesions into (1) anterior, (2) mal level, which should raise suspicion
posterior, and (3) combined anterior and about an internal derangement in the
posterior lesions. They hypothesize that shoulder.
SLAP lesions cause anterior or posterior
microinstability, which can ultimately Physical Examination
lead to pseudolaxity and partial-thick- The physical exam begins with gross in- O’Briens test (active-compression
test). The patient’s shoulder is positioned at 90° of
ness, articular-sided rotator cuff tears spection of the involved extremity. Atro-
elevation, approximately 20° of adduction, and full
that are lesion specific.20 In other words, phy of the rotator cuff can be attributed to internal rotation. Resistance against elevation is
posterior SLAP lesions cause posterior possible compression of the suprascapu- applied by the examiner. A test is positive for labral
cuff tears, and anterior SLAP lesions lar nerve by a ganglion cyst and warrants involvement when pain is elicited with the forearm in
cause anterior cuff tears. evaluation with an MRI and possible pronation and relieved when the forearm is supinated.
electrodiagnostic testing (EMG). The
cervical spine is then examined for range necessary to perform all these maneu-
of motion and any evidence of nerve root vers on every patient; therefore, we will
compression. describe some of the more common tests
T
he clinical evaluation of any
patient with shoulder pain should The affected shoulder is then assessed that we typically use, as well as some of
include a subjective history, a thor- and compared to the unaffected side. Bi- the more recently reported ones.
ough physical examination, plain radio- lateral passive and active range of motion The active-compression test, as de-
graphs, and, when indicated, advanced is noted, with attention paid to any mo- scribed by O’Brien,23 has been shown to
imaging, which is usually magnetic reso- tion that elicits pain. Many patients with be helpful in diagnosing SLAP lesions.
nance imaging (MRI). The goal is to make SLAP lesions will note pain with passive The shoulder is positioned in 90° of
an accurate diagnosis, so that an appro- external rotation at 90° of shoulder ab- forward elevation and 20° of horizontal
priate treatment plan can be initiated. duction. Overhead athletes may exhibit adduction. The examiner then places a
excessive external rotation with posterior downward force on the forearm, while
History capsule tightness and resulting internal the forearm is pronated and then supi-
A comprehensive history is essential and rotation deficits. Motor strength is then nated ( ). A test is positive for a
should try to precisely define the mecha- tested and the extremity is examined for labral involvement when pain is elicited
nism of injury. Patients usually complain gross neurovascular deficits. The pres- with the forearm in the pronated position
of vague shoulder pain, often with click- ence of rotator cuff pathology or instabil- and relieved when the forearm is supi-
ing, popping, or snapping that is usually ity is then evaluated before proceeding nated. The authors also point out that a
exacerbated with overhead activity. Pa- towards specific diagnostic maneuvers test is considered negative when the pain
tients may also complain of instability if for SLAP lesions. is localized to the acromioclavicular (AC)
the lesion extends to the anterior labrum/ Numerous tests have been described to joint. O’Brien et al23 reported this maneu-
capsule. When a concomitant rotator cuff be specifically designed to determine the ver to be 100% sensitive and 95% specific
tear is present, patients may complain of presence of labral pathology, including in diagnosing labral pathology. However,
shoulder weakness. It has been our expe- the active-compression test, the compres- other authors have reported less success
rience that patients typically complain of sion-rotation or grind test, Speed’s test, using this test.30 We typically perform this
pain and dysfunction, or limited func- the clunk test, the crank test, the anterior- maneuver when assessing for labral pa-
tion when the labrum is involved, and do slide test, the biceps load test, the biceps thology and find pain inside the shoulder
not experience pain at rest or at night, load test II, and the pain provocation test. when testing with the forearm pronated
which is more common with rotator cuff Although many of these tests have been and pain relieved with supination to be
injuries. shown to accurately diagnose SLAP le- most indicative of a SLAP lesion. Pain in
The most commonly cited mecha- sions, their reproducibility among mul- the posterior aspect of the shoulder or lo-
nisms of injury include traction and tiple examiners is uncertain.9 Therefore, cated to the AC joint is not specific for the
compression of the shoulder; although, it is important to correlate the patient’s presence of a SLAP lesion.
in many instances, no antecedent trau- symptoms with the physical examination The compression rotation test is per-
ma is remembered. Overhead athletes findings to make the diagnosis. It is not formed with the patient in the supine po-
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 73

4. [ CLINICAL COMMENTARY ]
ability of multiple provocative tests to
predict the presence of labral pathol-
ogy.18,30 Although many of the tests did
provide some clinical accuracy, none
was perfect. It is possible that each test
may have varying specificity and sensitiv-
ity, depending on the type of slap lesion
present. Clearly, further investigation
regarding the accuracy of clinical tests is
warranted.
Compression rotation test. The examiner A relatively new test for SLAP lesions:
imparts a compressive force from the elbow through pronated load test. The patient’s shoulder is abducted
Imaging Studies
the long axis of the humerus as the shoulder is rotated to approximately 90°, and the examiner passively
in an attempt to grind the labrum and elicit pain. externally rotates the shoulder with the forearm in
Imaging evaluation begins with standard
pronation. At the point of maximal external rotation, radiographs of the shoulder (AP, axillary,
the examiner instructs the patient to perform an scapular-Y, and Stryker notch views). Ra-
isometric biceps contraction in an attempt to peel diographs are typically normal in cases
back the labrum.
of isolated SLAP lesions but may reveal
bony abnormalities in cases of associated
pathology (eg, Hill-Sachs lesion).
MRI is the gold standard imaging mo-
dality for diagnosing SLAP lesions. How-
ever, the reliability of MRI to diagnose
SLAP lesions has been disputed. Several
authors have found difficulty diagnosing
The resisted-supination external- labral lesions with standard MR tech-
rotation test. The patient’s shoulder is abducted to niques.10,16 Therefore, they recommend
approximately 90°, elbow flexed, and forearm in magnetic resonance arthrogram with an
neutral. The examiner then simultaneously resists intra-articular injection of gadolinium.
forearm supination, while externally rotating the
Bencardino et al3 demonstrated a sensi-
shoulder in an attempt to peel back the labrum.
tivity of 89%, a specificity of 91%, and an
sition.29 The glenohumeral joint is then Coronal view of a noncontrast magnetic accuracy of 90% in detecting labral le-
resonance imaging (MRI) demonstrating a type II
compressed and the humerus is rotated sions using this technique.
SLAP lesion (white arrow).
in an attempt to trap the labrum with- At our institution, noncontrast MRI
in the joint ( ). The presence of sensitivity (82.8%), specificity (81.8%), has become the standard advanced-
an uncomfortable clunk may indicate a positive predictive value (92.3%), nega- imaging modality for diagnosing labral
labral tear. The arm can be abducted with tive predictive value (64.3%), and diag- injuries to the shoulder. The SLAP le-
an anterior-directed force or adducted nostic accuracy (82.5%), when compared sions can typically be appreciated on a
with a posterior-directed force to assess to other provocative maneuvers. coronal sequence as a cleft between the
for anterior and posterior labral lesions, Wilk et al32 have described a similar superior labrum and the glenoid (
respectively. test that they have termed the “pronated 6). Although previous studies have re-
Myers et al21 recently described a test load test.” With the patient in supine, ported that noncontrast MRI is limited
termed the “resisted-supination external- the shoulder is abducted to 90° and in the evaluation of the superior glenoid
rotation test.” The test is performed in the externally rotated. The forearm is kept labrum, our experience has been that
supine position, with the shoulder in 90° in a fully pronated position to increase high-resolution noncontrast MRI can ac-
of abduction, the elbow in 70° of flexion, tension on the biceps tendon, and the curately diagnose superior labral lesions
and neutral forearm rotation. The shoul- patient is instructed to perform an iso- and aid in surgical management.8 In cases
der is then passively externally rotated, metric biceps contraction to simulate of suspected concomitant rotator cuff in-
while the examiner resists against supi- the peel-back mechanism ( ). volvement, we do use MRI arthrography,
nation ( ). Myers et al21 noted that The authors have found this maneuver with the arm in abduction and external
this test simulates the peel-back mecha- to cause pain and discomfort in patients rotation (ABER), to enhance the visual-
nism of SLAP lesions. A preliminary study with SLAP lesions. ization of the articular surface of the ro-
of 40 patients demonstrated a superior Several authors have evaluated the tator cuff, the superior glenoid labrum,
74 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

5. sive throwing program after 3 months
that is directed toward the patients’ spe-
cific sport and position. We have no pub-
lished data regarding the success rate of
nonoperative management; but as previ-
ously stated, it has been our experience
that the majority of patients with symp-
tomatic SLAP lesions will fail conserva-
tive management, particularly throwers.
The goal of a nonoperative program is to
reduce pain, improve motion, and restore
strength in patients who do not wish to
Magnetic resonance arthrography Arthroscopic view of a right shoulder,
proceed to operative management.
in abduction and external rotation (ABER), demonstrating a type II SLAP lesion. A probe has
demonstrating an articular partial thickness entered the joint via the standard anterior interval
rotator cuff tear (white arrow). We prefer this view portal and is used to confirm the diagnosis.
in suspected cases of associated cuff pathology
because it allows for better visualization of the
O
ur indications for surgery
articular surface, labrum, and is helpful in detecting are patients who fail conservative
intratendinous lesions.
management, patients who have a
SLAP lesion with significant rotator cuff
and the anterior inferior capsule-labrum tears ( 50%), and patients with large as-
complex. We have found this technique sociated labral tears who exhibit severe
to be particularly helpful in detecting ar- mechanical symptoms. Generally speak-
ticular-sided partial thickness tears with ing, we debride types I and III SLAP
intratendinous extension ( ). We lesions and repair types II and IV. The
believe this is important because without following is a description of our SLAP
preoperative identification of the extent repair technique.
Once the SLAP lesion has been confirmed,
of the delamination, the surgeon might We perform shoulder arthroscopy
a second anterior lateral portal (blue cannula) is
have a difficult time making that deter- created, which will be the working portal for repairing with the patient in the beach chair po-
mination in the operating room. the SLAP lesion. Establishing the proper position of sition. The patient is anesthetized under
this portal is crucial because the angle at which the intrascalene block with sedation. After a
suture anchor is inserted is completely dependent complete clinical examination under an-
upon the location of the portal. We avoid penetrating
esthesia is performed, a 30° arthroscope
the rotator cuff in creating this portal, especially in
throwing athletes. (Smith & Nephew Dyonics, Andover, MA)
is introduced into the glenohumeral joint
C
onservative management of
SLAP lesions is often unsuccessful, motion. An excessive loss of glenohumer- via the posterior soft-spot portal. Then, a
particularly when there is a compo- al internal rotation (GIRD) is common standard anterior portal is established in
nent of glenohumeral joint instability or in overhead athletes and a particular the rotator cuff interval and a complete
when a concomitant rotator cuff tear is emphasis should be placed on stretching diagnostic arthroscopy is performed. A
present. There may be, however, a small the posterior capsule and restoring inter- probe is used to confirm a SLAP lesion
subset of patients, particularly those with nal rotation, which may prevent patho- and the extent of any other concomitant
type I SLAP lesions, who are amenable to logic contact between the supraspinatus pathology is assessed ( ). In cases
conservative treatment. The initial phase tendon and the posterosuperior labrum. of an isolated repairable SLAP lesion, a
of conservative management consists of Although it is unclear if GIRD is a risk second anterosuperior lateral portal is
cessation of throwing activities, followed factor for SLAP lesions, restoring shoul- established in the rotator cuff interval
by a short course of anti-inflammatory der internal rotation may improve path- ( ). We caution against the use of
medication to reduce pain and inflamma- omechanics that could possibly reduce a transrotator cuff approach, especially in
tion. Once the pain has subsided, we initi- some of the patient’s symptoms. The pa- throwing athletes. Any unstable flaps of
ate physical therapy focused on restoring tient is eventually advanced to a strength- labrum are debrided to a stable rim, and
normal shoulder motion. Strengthening ening phase, which includes trunk, core, an arthroscopic shaver or burr is used to
of the shoulder girdle musculature is also rotator cuff, and scapular musculature. In create a bony bed at the superior rim of
crucial to restore normal scapulothoracic throwing athletes, we initiate a progres- the glenoid via the anterosuperior lateral
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 75

6. [ CLINICAL COMMENTARY ]
An arthroscopic shaver is used to prepare
the bed of the SLAP lesion (A) and then an 18-gauge A hole is drilled into the bed of the SLAP
spinal needle is passed percutaneously through lesion via the anterior lateral portal (A) and a suture
the superior labrum via the region of the portal of anchor is then inserted (B).
Neviaser (B).
portal ( ). After the bed of the
SLAP lesion has been satisfactorily pre-
pared, an 18-gauge spinal needle is passed
via a transdermal puncture in the region
of the portal of Neviaser into arthroscop-
ic view above the superior labrum. Ac-
curate suture placement is ensured by
direct arthroscopic visualization of the
spinal needle as it is passed through the The medial limb of the suture anchor is
superior labrum from superior to inferior tied to the inferior limb of the polydioxanone (PDS)
suture from the anterosuperior lateral portal (A
( ). A number 1 polydioxanone and B). The 2 sutures are tied outside the shoulder
(PDS) suture (Ethicon, Somerville, NJ) and the opposite limb of the PDS is pulled (C). This
is manually advanced through the spinal allows the medial limb of the suture anchor to be
needle into arthroscopic view ( ). shuttled through the labral tissue. This limb can now
An arthroscopic retriever is then used to be retrieved above the labral lesion and retrieved via
anterosuperior lateral portal.
retrieve the free end of the suture and
bring it out via the standard anterior por- and both sutures are brought out through
tal ( ). the anterosuperior lateral portal (
A suture anchor (Bio-Suture Tak, Ar- ). The 2 sutures are tied outside the
threx, Naples, FL) is then inserted via the shoulder and the opposite limb of the
anterosuperior portal into the superior PDS suture is pulled. The medial limb
A polydioxanone (PDS) suture is then neck of the glenoid off the face ( of the suture from the suture anchor is
manually advanced through the spinal needle (A) 12). The more-medial limb of the suture then shuttled through the superior labral
and retrieved via the standard anterior interval from the suture anchor is then retrieved tissue and then retrieved into the antero-
portal (B).
with the inferior limb of the PDS suture, superior lateral portal. A standard ar-
76 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

7. With the tear reduced, 2 spinal needles
are passed in successive fashion through the full
thickness of the rotator cuff. A polydioxanone (PDS)
suture is then advanced through each spinal needle.
A grasper is used to shuttle these sutures out of the
anterior cannula and the sutures are then tied to
each other, pulled into the joint, and the knot is then
shuttled externally by pulling on one of the sutures.
After a standard arthroscopic knot is Type IV lesions with significant biceps
tied, the labrum is probed for stability and security of involvement can be repaired. We repair the torn
fixation (A, B). For larger labral lesions, this process fragment to the major portion of the biceps tendon
can be repeated using the same technique. first (A), followed by repair of the superior labrum at
the biceps anchor (B).
throscopic knot is then tied under direct
arthroscopic visualization ( ment with a sharp tip can be used to pierce
). The labrum is probed for stabil- the torn fragment, and the major portion
ity and security of fixation ( ); a of the biceps tendon, followed by suture
second suture anchor, if needed, can be passing and arthroscopic knot-tying. For larger tears, we use multiple mattress
sutures. A second set of spinal needles is passed
employed using the same technique ( -
superiorly, and polydioxanone (PDS) sutures are
). In cases of associated instability, advanced and shuttled in the same fashion.
where the SLAP lesion extends into the Cuff Tears
anterior labrum or a separate Bankart In throwing athletes, it is not uncommon shoulder. The final effect is the placement
lesion is present, we use the exact same to encounter delaminated (split into lay- of a suture that fixes the torn articular-
technique as described above at the loca- ers), intratendinous, partial-thickness side flap to the intact peripheral rotator
tion of the additional lesion. rotator cuff tears in conjunction with cuff, reducing the articular-sided partial
Type IV lesions are complex and can SLAP lesions. We generally debride tears defect, and closing down the intrasub-
pose a challenge when encountered in- less than 50% and repair those that are stance delamination. There is no bony
traoperatively. Our approach is that if greater than 50%. We have adopted a fixation ( ).
the longitudinal tear in the biceps ten- technique of arthroscopic intratendinous
don is less than one third of the tendon repair for delaminated, articular-side,
diameter, then the fragment is excised. If partial-thickness rotator cuff tears in
the fragment is approximately one third overhead athletes using percutaneously
of the diameter or greater, we repair the placed mattress sutures. This technique
P
ostoperative rehabilitation
torn fragment to the major portion of the accomplishes 3 essential goals: (1) res- following SLAP repair is deter-
biceps tendon, followed by repair of the toration of the anatomy of the articular mined by the type of SLAP lesion,
superior labrum at the biceps anchor, as side of the rotator cuff, (2) repair of the the exact surgical procedure performed
described previously ( ). delamination component of the tear, and (debridement versus repair), and oth-
A spinal needle or a suture-passing instru- (3) prevention of overconstraining the er concomitant pathology. Generally
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 77

8. [ CLINICAL COMMENTARY ]
The postoperative rehabilitation of a lower shoulder scores and a lower per-
surgically repaired type IV SLAP lesion centage of return to their preinjury level
is similar to that of a type II repair, in of shoulder function than patients who
that range-of-motion and exercise ac- were not involved in overhead sports.
tivities are progressed similarly. How- Ide et al11 evaluated 40 patients at a
ever, there are substantial differences mean of 41 months after surgical repair
regarding the progression of biceps ac- of type II SLAP lesions. All subjects in
tivity based on the extent of bicipital in- this study were overhead athletes and,
volvement. In cases where the biceps is overall, results were favorable, with
resected, biceps muscular contractions 90% good or excellent modified Rowe
typically begin between 6 and 8 weeks scores and 75% return to preinjury
postsurgery. In cases where the biceps is shoulder function. However, throwers
The final step is to tie the sutures in the
subacromial space. repaired, no resisted biceps activities are without a specific traumatic injury had
allowed for at least 3 months following lower scores and a lower return to pre-
speaking, we immobilize the patient’s surgery. Light isotonic strengthening injury function rate than throwers with
shoulder for a short period, followed for elbow flexion is initiated between 12 a history of a specific traumatic event.
by emphasis on restoring motion and, and 16 weeks postoperatively and full These publications suggest that surgical
lastly, initiate strengthening exercises. resisted biceps activity is not initiated repair of type II SLAP tears in overhead
The following paragraph describes our until between 17 and 20 weeks postop- athletes with an overuse-related cause
postoperative guidelines for patients who eratively. The progression to sports and may be less successful than in other
underwent SLAP repair with no associ- related activities follows similar guide- patients.
ated pathology. lines to those outlined for type II repair.
For the first 2 to 3 weeks postopera- A more detailed and comprehensive
tively, the patient’s shoulder is immo- description of our postoperative guide-
bilized in internal rotation in a sling. lines is demonstrated schematically in
S
LAP lesions can be a source
During that time, we prohibit any exter- the . of pain and disability in patients,
nal rotation and limit abduction to 60°. particularly during overhead activ-
Pendulum and elbow range-of-motion ity. Diagnosing a SLAP lesion remains a
exercise are encouraged. At 4 weeks, challenge for clinicians treating shoul-
shoulder motion is increased using der disorders. Clinical examination to
S
everal studies have document-
active-assisted and passive techniques. ed successful surgical treatment of detect SLAP lesions can often be dif-
At this point, the sling is discontinued SLAP lesions. 6,7,22,26 The majority ficult because of the presence of con-
but we still limit external rotation to of publications address results following comitant pathology. A wide variety of
30° to minimize strain on the labrum surgical repair of type II SLAP lesions, physical examination “maneuvers” have
through the peel-back mechanism. because these are the most common been described to help diagnose the
Over the ensuing 4 weeks, internal type. In general, approximately 90% presence of SLAP lesions. A compre-
rotation and external rotation range- of patients demonstrate good or excel- hensive approach, including a thorough
of-motion activities are progressed to lent results at the short to intermediate history and physical examination, stan-
90° of shoulder abduction. At approxi- follow-up, but there is a paucity of long- dard shoulder radiographs, and, often,
mately 8 weeks, we initiate resistance term follow-up studies. Several recent MRI, will most likely allow the clinician
exercises, with a focus on scapular publications have provided additional to successfully diagnose this condition.
strengthening, provided adequate mo- insight into our understanding of surgi- Surgical intervention is often a success-
tion has been achieved (approximately cal results after SLAP repair. Kim et al15 ful option for the patient with a SLAP
115° to 120° of shoulder external rota- evaluated 34 patients at a mean of 33 lesion who wishes to return to opti-
tion). No resisted biceps activity (elbow months after surgical repair of type II mal function. Addressing concomitant
flexion and forearm supination) is al- SLAP lesions. While the overall results shoulder disorders at the time of sur-
lowed for the first 2 months to protect were good (94% satisfactory UCLA gery is also crucial to ensure a success-
the healing of the biceps anchor. After shoulder score, 91% return to preinjury ful outcome. Finally, a well-organized
4 months, a sport-directed throwing shoulder function), significant differ- postoperative rehabilitation program is
program is initiated in overhead ath- ences were seen between patients who mandatory for optimal results, and the
letes, and contact sports are generally participated in different types of athlet- patient undergoing such surgery should
allowed after 6 months. ics. Specifically, throwing athletes had be well aware of its importance.
78 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

9. arthroscopic superior labral repair using suture and effective test for diagnosing labral tears
anchors in overhead-throwing athletes. Am J and acromioclavicular joint abnormality. Am J
Sports Med. 2005;33:507-514. http://dx.doi. Sports Med. 1998;26:610-613.
1. Andrews JR, Carson WG. The arthroscopic treat- org/10.1177/0363546504269255 Pagnani MJ, Deng XH, Warren RF, Torzilli
ment of glenoid labrum tears in the throwing 12. Jobe CM. Posterior superior glenoid impinge- PA, Altchek DW. Effect of lesions of the su-
athlete. Orthop Trans. 1984;8:44. ment: expanded spectrum. Arthroscopy. perior portion of the glenoid labrum on gle-
2. Andrews JR, Carson WG, Jr., McLeod WD. Gle- 1995;11:530-536.
nohumeral translation. J Bone Joint Surg Am.
noid labrum tears related to the long head of the Karzel RP, Snyder SJ. Magnetic resonance ar-
1995;77:1003-1010.
thrography of the shoulder. A new technique of
biceps. Am J Sports Med. 1985;13:337-341. Pradhan RL, Itoi E, Hatakeyama Y, Urayama M,
shoulder imaging. Clin Sports Med. 1993;12:123-
Bencardino JT, Beltran J, Rosenberg ZS, et al. Sato K. Superior labral strain during the throw-
136.
Superior labrum anterior-posterior lesions: ing motion. A cadaveric study. Am J Sports
Kim SH, Ha KI, Ahn JH, Choi HJ. Biceps load
diagnosis with MR arthrography of the shoulder. Med. 2001;29:488-492.
test II: A clinical test for SLAP lesions of the
Radiology. 2000;214:267-271.
shoulder. Arthroscopy. 2001;17:160-164. http:// 26. Samani JE, Marston SB, Buss DD. Arthroscopic
Burkhart SS, Morgan CD. The peel-back mecha-
dx.doi.org/10.1053/jars.2001.20665 stabilization of type II SLAP lesions using an
nism: its role in producing and extending poste-
Kim SH, Ha KI, Choi HJ. Results of arthroscopic absorbable tack. Arthroscopy. 2001;17:19-24.
rior type II SLAP lesions and its effect on SLAP
treatment of superior labral lesions. J Bone http://dx.doi.org/10.1053/jars.2001.19652
repair rehabilitation. Arthroscopy. 1998;14:637-
Joint Surg Am. 2002;84-A:981-985. Shepard MF, Dugas JR, Zeng N, Andrews JR. Dif-
640.
16. Liu SH, Henry MH, Nuccion SL. A prospective ferences in the ultimate strength of the biceps
Chandnani VP, Yeager TD, DeBerardino T, et al.
evaluation of a new physical examination in pre- anchor and the generation of type II superior
Glenoid labral tears: prospective evaluation with
dicting glenoid labral tears. Am J Sports Med. labral anterior posterior lesions in a cadaveric
MRI imaging, MR arthrography, and CT arthrog-
1996;24:721-725.
raphy. AJR Am J Roentgenol. 1993;161:1229- model. Am J Sports Med. 2004;32:1197-1201.
Maffet MW, Gartsman GM, Moseley B. Superior
1235. http://dx.doi.org/10.1177/0363546503262643
labrum-biceps tendon complex lesions of the
6. Cohen DB, Coleman S, Drakos MC, et al. Out- Snyder SJ, Banas MP, Karzel RP. An analysis of
shoulder. Am J Sports Med. 1995;23:93-98.
comes of isolated type II SLAP lesions treated McFarland EG, Kim TK, Savino RM. Clinical as- 140 injuries to the superior glenoid labrum. J
with arthroscopic fixation using a bioabsorbable sessment of three common tests for superior Shoulder Elbow Surg. 1995;4:243-248.
tack. Arthroscopy. 2006;22:136-142. http:// labral anterior-posterior lesions. Am J Sports Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD,
dx.doi.org/10.1016/j.arthro.2005.11.002 Med. 2002;30:810-815. Friedman MJ. SLAP lesions of the shoulder.
Coleman SH, Cohen DB, Drakos MC, et al. Mileski RA, Snyder SJ. Superior labral lesions in Arthroscopy. 1990;6:274-279.
Arthroscopic repair of type II superior labral the shoulder: pathoanatomy and surgical man- Stetson WB, Templin K. The crank test, the
anterior posterior lesions with and without acro- agement. J Am Acad Orthop Surg. 1998;6:121- O’Brien test, and routine magnetic resonance
mioplasty: a clinical analysis of 50 patients. Am 131. imaging scans in the diagnosis of labral tears.
J Sports Med. 2007;35:749-753. http://dx.doi. Morgan CD, Burkhart SS, Palmeri M, Gillespie Am J Sports Med. 2002;30:806-809.
org/10.1177/0363546506296735 M. Type II SLAP lesions: three subtypes and Walch G, Boileau P, Noel E, Donell T. Impinge-
Connell DA, Potter HG, Wickiewicz TL, Altchek their relationships to superior instability and ro- ment of the deep surface of the infraspinatus
DW, Warren RF. Noncontrast magnetic reso- tator cuff tears. Arthroscopy. 1998;14:553-565.
nance imaging of superior labral lesions. 102 tendon on the posterior glenoid rim. J Shoulder
21. Myers TH, Zemanovic JR, Andrews JR. The
cases confirmed at arthroscopic surgery. Am J Elbow Surg. 1992;1:238-245.
resisted supination external rotation test: a
Sports Med. 1999;27:208-213. Wilk KE, Reinold MM, Dugas JR, Arrigo CA,
new test for the diagnosis of superior labral
Dessaur WA, Magarey ME. Diagnostic accuracy anterior posterior lesions. Am J Sports Moser MW, Andrews JR. Current concepts in
of clinical tests for superior labral anterior Med. 2005;33:1315-1320. http://dx.doi. the recognition and treatment of superior labral
posterior lesions: a systematic review. J Orthop org/10.1177/0363546504273050 (SLAP) lesions. J Orthop Sports Phys Ther.
Sports Phys Ther. 2008;38(6):341-352. http:// 22. O’Brien SJ, Allen AA, Coleman SH, Drakos MC. 2005;35:273-291. http://dx.doi.org/10.2519/
dx.doi.org/10.2519/jospt.2008.2676 The trans-rotator cuff approach to SLAP lesions: jospt.2005.1701
Green MR, Christensen KP. Magnetic resonance technical aspects for repair and a clinical follow-
imaging of the glenoid labrum in anterior shoul- up of 31 patients at a minimum of 2 years.
@
der instability. Am J Sports Med. 1994;22:493- Arthroscopy. 2002;18:372-377.
498. O’Brien SJ, Pagnani MJ, Fealy S, McGlynn SR,
11. Ide J, Maeda S, Takagi K. Sports activity after Wilson JB. The active compression test: a new WWW.JOSPT.ORG
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 79

10. [ CLINICAL COMMENTARY ]
Patient begins program, as directed by physician, on first Begin pain-free IR/ER isometrics in modified neutral Advance IR/ER to elevated position in overhead athletes
postoperative day No biceps strengthening (must be pain free and have good proximal strength)
Cryotherapy/modalities PRN Continue UBE for endurance training
Begin general flexibility exercises
Sling immobilization, as directed by physician Progress PROM/AAROM
Codman’s/pendulum exercises Continue full upper extremity strengthening
Hand/wrist/elbow ROM exercises
Restore normal shoulder flexibility
Gripping exercises Begin isotonic IR/ER strengthening in modified neutral
Begin activity-specific plyometric program
FF plane of scapula PROM/AAROM (supine), limit to 90° Begin latissimus strengthening, below 90° elevation
Continue endurance training
Passive ER to neutral Begin upper body ergometer, below 90° elevation
Type II repairs, begin gentle resisted biceps isotonic
Passive elbow abduction to 30° Begin humeral head stabilization exercises, if adequate
strengthening
Cryotherapy/modalities PRN strength and ROM exists
Discontinue sling, physician directed Continue aggressive scapula strengthening Continue flexibility exercises
Continue FF plane of scapula PROM/AAROM (wand/pul- Advance strengthening for deltoid, biceps, triceps, and Continue full strengthening program
leys), rate of progression based on patient’s tolerance latissimus, as tolerated Begin return to interval throwing, physician-directed
ER PROM/AAROM to 30° Begin PNF patterns Type IV repairs, progress to isotonic biceps strengthening
Manual scapular stabilization exercise, side lying Continue humeral head stabilization exercises Continue endurance training
Abbreviations: AROM, active range of motion; ER, external rotation; FF, forward flexion; IR, internal rotation; PNF, proprioceptive neuromuscular facilitation; PRN, as needed; PROM,
passive range of motion; ROM, range of motion; UBE, upper body ergometer.
80 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy