John Guido, PT, DPT, ATC, SCS, CSCS
Ochsner Health System
INTRODUCTION
 Very common, very
frustrating problem in
the thrower’s shoulder
 Shoulder already
functioning at the
extremes of motion
 Wide spectrum of
pathology that can
cause instability, pain
and dysfunction
INTRODUCTION
 Injuries to the biceps – labrum complex
 SLAP Lesions - Superior labral anterior to posterior tears are
recognized as a major factor in the dysfunction of the
disabled throwing shoulder
 Systematic lit review Kibler and Sciascia Arthroscopy 2016
 No consensus regarding current practice in the Rx of SLAP
lesions
 Wide variability
 Treatment approaches
 Surgical indications
 Surgical techniques
 Rehabilitation programs
BACKGROUND
 Epidemiology
 Difficult to determine exact numbers but in one sports
med practice, SLAP repairs comprised 6.3% of all s’
surgeries
 Modifications to Snyder’s original classification are
such that there are now 10 different types of SLAP
lesion variations (Modaressi S et al AJR 2011)
 Overall, SLAP repair numbers may be decreasing
 Overall, age of patient is decreasing
 “If I see it, I fix it”
ANATOMY
 Average depth of the
glenoid is doubled by
presence of labrum
 Chock block stabilizing
effect to limit translation
 Labrum increases the total
surface area for
articulation enhancing
concavity-compression
effects.
 Aids in the attachment of
the glenohumeral
ligaments to the glenoid.
 The superior labrum is
looser and more mobile
than its inferior
counterpart
WHAT EXACTLY IS A SLAP LESION?
 A tear in the superior
labrum region.
 Between 10 & 2 on a
clock face.
 Related to pull on
the origin site of
the long head of
the biceps.
 First described by
Andrews in 1985 in
overhead athletes
 fraying,
detachment,
tearing of biceps
SLAP Lesions-Classification
I
II
III
IV
Fraying &
Degeneration
Detachment
of labrum
and biceps
-UNSTABLE
Bucket handle
tear w/ rim
of intact sup.
labrum
Bucket handle
tear extending
into biceps but
anchor intact
BIOMECHANICS
 Provides 10% overall stability in the shoulder
 Labrum acts as a biofeedback mechanism to RC, will
tell it when to contract if shoulder goes too far
 Increased GHJ translation and loading of the long
head of the biceps tendon after SLAP lesions (Patzer et
al 2012)
 The tensile strength of the labrum is less than the
capsule, so it is more prone to injury with anterior
stress.
SLAP LESION
 Causes significant loss in static stability but
how?? (therefore, dynamic stability will
ultimately compromised)
 100 - 120% increase in strain on the AIGHL
 11 – 19% decrease in the GHJ’s ability to
withstand rotational force
 Therefore… significant increase in the load
on the capsular ligaments
(Cheng & Karzel 1997)
MECHANISM OF INJURY IN
THROWERS / OH ATHLETES
 Andrews 1985
 Burkhart, Morgan,
Kibler
 Jobe
 Several theories exist to
explain the MOI of SLAP
tears but the exact cause
has not been identified
 Most likely multifactorial
 May exist on a spectrum
of injuries in a thrower’s
shoulder since an
isolated SLAP lesion is
usually not seen
SLAP lesions lead to GHJ
Instability
(Support of the superior GH ligament is
lost)
MECHANISM OF INJURY IN
THROWERS / OH ATHLETES
 So, let’s take a look at SLAP lesions as they could occur
in the thrower’s shoulder based on the phase of
throwing
 In other words, marry the theory to the practice
WIND UP/EARLY COCKING/STRIDE
WEED PULLING = HORIZ ABDUCTION
LATE COCKING/MAX ER
 Burkhart, Morgan, Kibler
 “peel-back” mechanism as the
cause of SLAP lesion.
 When the shoulder is
placed in a position of
abduction and maximum
ER, the rotation produces a
twist at the base of the
biceps – torsional force
applied to the anchor.
 Peak strain occurs in this
position.
 GIRD/Scapular dyskinesis
LATE COCKING / MAX ER /
ACCELERATION
 Jobe and Jobe
 Internal impingement / anterior
instability
 Over application of normal
glenohumeral contact either on
an acute or a chronic basis
 Increased frequency or
increased load leads to damage
to 1 or more of 5 tissues:
 (1) superior labrum
 (2) biceps origin—internal
fibers of rotator cuff (PASTA)
 (3) bony glenoid
 (4)greater tuberosity
 (5) inferior glenohumeral
ligament.
LATE COCKING / MAX ER /
ACCELERATION
 Jobe and Jobe
 More than 1 of these
tissues is damaged
producing a variable
pattern of injury
 Continued loading after
the development of pain
will lead to stretching of
the inferior glenohumeral
ligament and subsequent
instability and the need
for surgical reconstruction
DECELERATION / FOLLOW
THROUGH
 Andrews 1985 AJSM
 The extremely high velocity of
elbow extension which is generated
must be decelerated through the
final 30 degrees of elbow extension
 Of the muscles of the arm that
provide the large deceleration forces
in the follow-through phase of
throwing, only the biceps brachii
traverses both the elbow joint and
the shoulder joint
 Additional forces are generated in
the biceps tendon in its function as
a "shunt" muscle to stabilize the
glenohumeral joint during the
throwing act
SYMPTOMS









Cluster of signs and symptoms
Loss of IR
Pain with OH motions
Loss of RC/scap strength and
endurance
Mechanical symptoms
Loss of velocity/control/”dead
arm”
Inability to “loosen up”
(Manske 2010)
*”Where in the throwing motion
do you have pain?”
 Cocking
 Acceleration
 After ball release
Labral Examination – Special Tests
based on MOI
 “Weed pulling”
 Clunk test
 The examiner proximal hand
provides an anterior
translation of the humeral
head while simultaneously
rotating the humerus
externally with the hand
holding the elbow.
 Attempt to trap the
labrum.
 A positive test is produced by
the presence of a clunk or
grinding sound
Labral Examination – Special Tests
based on MOI
 Peel-back injury (overhead
athlete)
 Biceps Load
 Biceps Load Test
 The shoulder is placed in 90º of
abduction and maximal ER.
 At maximal ER and with the
forearm in a supinated position,
the patient is instructed to
perform a biceps contraction
against resistance.
 A positive finding for a SLAP
lesion is deep pain within the
shoulder.
Labral Examination-Special Tests
Pronated Load Test
Same as Biceps Load test however, the
forearm is in the fully pronated position
to increase the tension on the biceps and
subsequently the labral attachment.
When maximum ER is achieved, the
patient is instructed to perform an
isometric contraction of the biceps.
Simulates the “peel-back” mechanism.
Labral Examination – Special Tests
based on MOI
 Jobe anterior
instability / Int
Impingement
 Relocation
test (+ relieves
posterior
pain)
 Anterior
drawer
Labral Examination – Special Tests
based on MOI
 Follow through
eccentric load
 Active Compression
and SLAPrehension
tests
 SLAPrehension test
 Berg and Cuillo
 O’Brien test but at
45 degrees Hadd
 The increased
adduction is
thought to increase
stress on the biceps
tendon but have to
watch AC joint
IMAGING - MRA
SLAP Lesions- Treatment
 Type I: debridement
 Type II: reattachment of unstable biceps anchor to the
glenoid rim using suture anchor
 Type III: excision vs repair of bucket handle tear of the
labrum
 Type IV: excision of torn labrum and biceps tear vs
suturing the split
 if >50% biceps torn: biceps tenodesis
Arthroscopic Repair of
Type II Slap Lesion
WHY FIX A SLAP LESION?
 SLAP repair without associated LHB tenotomy helps
normalize GH translation (Patzer et al JSES 2012)
 Rodosky et al the LHB contributes to anterior GH
stability by increasing the shoulder’s resistance to
torsional forces in the abd/ER position, diminishing
stress on the IGHL
 What we see clinical when we do PROM into abd/ER at
90-90 the bicep fires to guard the shoulder (this is
decreased if scapula is correctly positioned)
SOMETHING TO CONSIDER….
 McCulloch et al Arthroscopy





2013
Cadaveric study
7 shoulders with SLAP repair
Anterior anchor had the greatest
effect on ER
The presence of 1 or 2 anchors
posterior to the biceps did not
have a significant effect on
rotation
When performing SLAP repairs
on baseball pitchers, surgeons
should consider avoidance of the
anchor anterior to the biceps
OVERVIEW OF REHABILITATION
 Removal from offending





activity
Stretch posterior
capsule/cuff
Rotator cuff/scapular
strengthening/endurance
program
Shoulder stabilization
program
UE Prime mover/core/LE
strengthening
UE plyometrics/prethrowing program
 Interval throwing program
 Video biomechanical
analysis
 Fault correction
 Long toss and mound
program
 Interval hitting program
Rehabilitation: Reattachment
 POD 1
 SLING x 4 weeks
 ELBOW, WRIST , HAND AROM
 SCAPULAR REPOSITIONING
 PROM/ROM check: 90/90 POS/45/50 (ER/IR @ 45
abd)


ER 10 degrees to 45 degrees by week 4
IR to tolerance up to 50 degrees by week 4
Rehabilitation: Reattachment
 Pendulum swings
 S’ isometrics at 2 weeks except Flexion
 Rhythmic stabilization at week 2
 45 deg abd in ER/IR
 No stress on biceps and no closed chain positions
 Stationary bike/LE/core training
Rehabilitation: Reattachment
 POW 5-6
 Begin to work on restoring FULL THROWER”S ROM
 Focus on stretching posterior capsule
 CONTINUE STRENGTHENING PROGRAM

Rotator cuff / scapular program
 CONTINUE SHOULDER STABILIZATION
PROGRAM
 No isolated bicep strengthening x 8 weeks
Rehabilitation: Reattachment
 Assess for possible GIRD –
glenohumeral internal
rotation deficit
 Loss of > 30-40 degrees of
IR
 Burkhart et al GIRD found
in 100% of a series of 124
symptomatic baseball
throwers found to have a
SLAP tear arthroscopically
 (Non op Rx GIRD 2 weeks)
Rehabilitation: Reattachment
 Decreased posterior capsular mobility (post band of
IGHL) causes a posterior superior shear during
elevation and ER
 This is due to obligate translation as described by
Harryman in 1990 and Karduna in 1996
 An obligate translation is one that occurs following a
tightness in capsular tissues that causes motion of a
given joint segment to occur in the direction opposite
the tight joint structures
Rehabilitation: Reattachment
 Thus, an isolated tight
IGHL complex will create
an obligate translation of
the humeral head in a
superior direction with
elevation and a tight
posterior capsule will
create an anterior shear
with IR
POSTERIOR CAPSULE STRETCH
SLEEPER HANG
2-3 lbs 1’x2
Rehabilitation: Reattachment
 FULL THROWER”S




ROM by 10-12 weeks
Weeks 12-16 UE
plyometrics and pre
throwing program
Week 16 -24 return to
throwing program
Weeks 24-28 mound
program
Week 28 Release to full
activity
CORE TRAINING: ROLLING SERIES
 Arm patterns
 Leg Patterns
LOWER EXTREMITY TRAINING
 OVERHEAD DEEP
SQUAT
UE PLYOMETRICS
 Chops 3x10 R/L
 Lifts 3x10 R/L
OUTCOMES
 Weber et al – only 26% of pts stated that they were




pain-free and only 13% rated their function as normal
Boileau et al only 20% pts were able to return to sports
at their preinjury level
Gorantla et al - % of good to excellent results after
SLAP repair ranged from 40-94%
Return to play ranged from 20-94% and in OH athletes
22-64% for baseball
Ide et al Baseball 12 of 19 cases (63%) were able to
return to their preinjury level (36% failure rate)
OUTCOMES
 Neri et al AJSM 2009 - Time to return to sport 8,45
months
 Brockmeyer et al – results of SLAP repair in the
throwing athlete is far less successful with a significant
number of pts who will not regain their preinjury level
of performance
OUTCOMES
 Chalmers et al - 18 pitchers (7 uninjured controls, 6
SLAP repairs, 5 subpectoral tenodesis (KSSTA 2016)
 Altered T’ rotation in the SLAP repair subjects
 Concluded that even in high level athletes, biceps
tenodesis is a reliable option
 Boileau et al AJSM 2009 – biceps tenodesis for a type II
SLAP lesion showed a 93% satisfaction rate and an
87% return to their previous level of sport compared
with only 20% after SLAP repair
OUTCOMES
 Mollon B et al Arthroscopy 2016
 10% of pts who underwent isolated SLAP repair
required at 2nd procedure
 SAD 35%
 Debridement 27%
 Repeat SLAP repair 20%
 Biceps tenodesis or tenotomy 13%
 Patients < 20 yo after isolated SLAP repair more likely
to undergo Bankart repair males > females (80% of
cases)
CONCLUSIONS
 SLAP lesions occur on a spectrum of pathology in the







thrower’s shoulder
Not a guarantee that an athlete will be able to return to
their 100% preinjury level of function
Restore full thrower’s motion
Correct scapular dyskinesis
Create dynamic stability
Don’t forget about the LE / core
Identify and correct biomechanical throwing faults
“If you see it, fix it”