This document discusses SLAP lesions of the shoulder. It defines SLAP lesions as injuries to the superior labrum. The etiology of SLAP lesions is controversial but may involve traction from the biceps tendon during throwing motions. People at risk include those with poor scapular control or tight posterior capsules. Physical exams do not conclusively diagnose SLAP lesions. Treatment involves a 3-phase rehabilitation program focusing on the kinetic chain, mobility, and strengthening. Core stability, scapular stabilization, and manual therapy techniques are emphasized. While surgery is an option, adaptive changes in throwers mean repairing anatomy may hinder performance. An integrated approach addressing the whole body is most effective for shoulder pain.

1. THE MYTH OF SLAP LESION
KANNABIRAN.B
SENIOR SPORTS PHYSIOTHERAPIST
COIMBATORE

2. SLAP LESION

3. SLAP- DEFINITION
• Term SLAP coined by Snyder et al.
• Superior Labrum Anterior and Posterior (to the biceps
anchor)
• Refers to lesions of the superior labrum

4. ETIOLOGY
• Controversial
• Traction injury from biceps during deceleration phase of
throwing
• Twisting injury from biceps during late cocking phase of
throwing
• Compression injury from FOOSH
Likely, each theory has it’s own merit for a given SLAP pattern, as there are
biomechanical or clinical studies supporting each one.

5. SLAP
Fall outstretched hand in abduction
Direct blow to shoulder
TRACTION INJURY
Subluxation or dislocation
Repetitive overhead activities
Lifting heavy objects
Repeated eccentric biceps contraction (deceleration)
Sudden violent biceps contraction….

6. PEOPLE AT RISK
• Poor scapular control
• Posterior capsular tightness

7. GLENOHUMERAL ROTATION DEFICITS
• 10˚ to 12˚ side-to-side asymmetry in GIR should not be
considered pathologic, as long as the TROM is symmetric.
• In addition, it appears that in higher-level throwers, some of
the observed pathology may be adaptive and necessary for
function.
• Some of the pathology seen in the thrower’s shoulder may be
adaptive, in that the presence of the pathology may be required
for an athlete to throw at elite levels, and anatomic restoration is
not only not required but may be harmful.

8. FUNCTIONS OF LABRUM
(1) as a deformable structure with high
compliance interposed between 2
surfaces to more evenly distribute
contact pressures between the
surfaces, increase boundary lubrication,
and maximize concavity/compression
characteristics, much like a washer
between 2 surfaces
(2)as a pressure sensor maximizing
proprioceptive feedback
(3)as an attachment site for muscles and
ligaments, to optimize their tension

9. THE PHYSICAL EXAMINATION OF SLAP
• The literature, there is not a specific clinical test that
conclusively shows a clinically torn labrum or distinguishes
the clinically significant SLAP tear.

10. HIP AND SHOULDER
• Deficits in hip abductor or extensor strength, deficits in hip
rotation flexibility, or core strength weakness have been
identified in50% of SLAP injuries

11. • Scapular dyskinesis is frequently seen in patients with labral
injuries,
• GIRD and TROMD are seen in virtually all patients with SLAP
injury and have been found to be predictive of future injury in
asymptomatic patients

12. IMAGING
• MRI is best viewed as a static estimation of labral status with inconsistent
relation to the dynamic roles
• A percentage of patients will show “labral tears” without symptoms relating to
loss of the labral roles.

14. THE ARTHROSCOPIC FINDINGS MOST FREQUENTLY ASSOCIATED WITH
A CLINICALLY SIGNIFICANT LABRAL INJURY INCLUDE
• (1) a type II or higher lesion, denoting loss of attachment from the glenoid
• (2) a peel-back phenomenon, indicating labral detachment, increased compliance,
loss of washer effect, and loss of bumper effect
• (3)glenoid articular cartilage damage or chondromalacia,indicating increased
translation
• (4)Loss of capsular tension, indicated by a drive-through sign or loss of tension in
the posterior band of the inferior glenohumeral ligament;
• (5) increased posterior labral thickness, indicating increased translation and shear
with compression on the labrum
• (6) excessive posterior inferior capsular thickness and scar, indicating end-stage
capsular damage that helps create GIRD.

15. SURGICAL TREATMENT
• If return to play at the same level or a higher level is used as the
outcome measure of interest, only 5 of 22 series reported
success rates at or above 85%.

16. CONCEPT OF ADAPTIVE PATHOLOGY
• Throwing requires repetitive high loading of the osseous and
soft-tissue structures.
• Greater retroversion
• SLAP lesions
• Articular-side partial-thickness rotator cuff tears
• It is conceivable that in some throwers,
the anatomic repair of these structures will lead to an inability to achieve
the extremes of external rotation required to throw at high velocity and
may end their careers.

17. PRINCIPLES TO BE CONSIDERED WHEN
SURGERY IS REMEDY
• (1) Surgery should be considered only after extensive and appropriate
rehabilitation has failed.
• (2) The surgical approach should be minimalistic, with the concepts to
repair as needed but not to achieve normal anatomic repair of the rotator
cuff.
• (3) Surgery should be considered as a last resort to attempt to salvage a
thrower’s career, and throwers must be aware of the poor return-to-play rates

19. 3-PHASE PROGRAM
Phase 1. Kinetic chain
• a. Leg drive and lower extremity strength
• b. Hip mobility
• c. Proximal core stability
• d. Dynamic core strength/power
• e. Scapular stabilization

20. 3 PHASE PROGRAM CONT’D
Phase 2. Shoulder mobility
• a. Restoring internal and external rotation deficits to achieve safe total ROM
• b. Addressing joint restrictions in the spine and shoulder complex
• c. Addressing muscular flexibility imbalances in the
spine and scapula

21. 3 PHASE PROGRAM CONT’D
Phase 3. Arm strength and endurance
• a. Restoring scapular motor control for functional and pain-free motion
• b. Facilitating inhibited or weak scapular musculature
• c. Integrating scapular exercises with functional tasks
• d. Facilitating endurance and eccentric control by advanced shoulder and
scapular exercises
• e. Strengthening forearm, wrist, and hand

22. EXERCISE PROGRAM
• Acute phase
• Minimize loads on injured tissues
• Correcting the timing of muscular activation

23. EXERCISE PROGRAM
• Recovery phase
• should focus on strengthening and restoring core, kinetic
chain, and progressive isotonic strengthening

24. EXERCISE PROGRAM
• Functional phase
• sport-specific actions and includes endurance and ballistic
exercises

25. SCAPULA STABILIZATION
• YTML EXERCISES
• WALL STABILIZATION
• PLANK PUSH UPS
• SWISS BALL STABILIZATION
• DYNAMIC HUG EXERCISES
• EXERCISES WITH FIG 8 TUBE

26. PLANK PUSH UPS AND WALL STABILIZATION

27. GIRD CORRECTION

28. CHECK FOR PECTORALIS-MINOR TIGHTNESS

29. DYNAMIC STABILIZATION & CO CONTRACTION

30. DYNAMIC STABILIZATION

31. • Hip flexor tightness – Lunge
position with erect and
extended trunk
• Hip rotator tightness –
Quadruped position with
hips abducted knees flexed
to 90

32. CORE MOBILITY

33. Dynamic stretching for hamstring and hip mobility – walk on hands out as
far as can then ankle walk up toward hands to feel a stretch in the hamstring

34. TORSO ROTATION WITH SWISS BALL

35. CORE STABILITY AND BALANCE

36. CORE STABILITY-SWISS BALL & MED BALL
DIAGONALS

37. SPINE MOBILITY
Spinal joint mobilization Spine techniques for shoulder pain evidence is growing–
Decrease symptoms at 2 days
– Boyles J Manual Ther 2009

38. MANUAL THERAPY

39. ARM STRENGTH AND ENDURANCE
• 3 Level Rows for scapular retraction – starting in a protracted scapular
position and move into trunk extension and scapular retraction
1) low rows 2) mid rows 3) high rows

40. EXTERNAL ROTATION TO STRENGTHEN ROTATOR CUFF
WITHOUT PAIN / @0/45/90 DEGREES ABDUCTION.

41. INTERNAL ROTATION TO STRENGTHEN
ROTATOR CUFF WITHOUT PAIN

42. ADVANCED
ARM STRENGTH AND ENDURANCE

43. GLOBAL MUSCLE TRAINING

44. ENDURANCE AND FUNCTIONAL

45. SPORTS SPECIFIC

46. TO CONCLUDE
• Hitting at high velocity requires extremes of GER of the
abducted arm, where extremely high forces are endured.
Repeated hitting leads to bony remodeling of the humerus and
glenoid.
• Clinically significant SLAP tears do exist. The represent a
relatively small subset of general patients with shoulder pain

47. TAKE HOME
Use variations of exercises presented to reduce staleness and
are tailored to an individuals level of function
Shoulder pain can be successfully treated
with an integrated training program
addressing the whole body

49. Dr.B.KANNABIRAN PHD(P.T)
physiokanna@gmail.com