5 Crucial Things You Need to Know About Managing SLAP Lesions
The significance of a confirmed labral tear is debatable since this finding is present in more than half of asymptomatic, middle-aged patients. (1) However, in the presence of any shoulder pathology, patients will often develop compensatory movement patterns in everyday life and athletic activity; sacrificing one injured tissue for another until performance decreases or pain increases to an unacceptable level.
Overhead athletes, more specifically baseball players, are one of the most studied shoulder pain populations due to their high incidence of SLAP lesions and rotator cuff pathology. Current standards of care place little support on surgically repairing a structural lesion visualized on MRI. New studies have highlighted the importance of correcting the underlying functional movement restrictions instead of simply managing the tissue source of pain. Chiropractic management of shoulder injuries is becoming more popular as many athletes see the benefit of conservative treatment. When compared to surgical repair, conservative management yields similar or superior results in return to past performance (RPP) and return to play (RTP). (2)
Watch the following video to review the top three tests for SLAP lesion and five essential management concepts.
1. What is a SLAP Lesion?
The acronym “SLAP” stands for Superior Labrum Anterior Posterior and is used to describe a tear or detachment of the shoulder’s superior glenoid labrum; originating at the anchor site for the long head of the biceps tendon and extending into anterior or posterior portions of the labrum. (3) This pathology is relatively common. In fact, up to 1/4 of patients undergoing shoulder arthroscopy for any diagnosis will demonstrate a SLAP lesion. (4,5)
2. What patients are best suited for Chiropractic treatment?
The presence of a SLAP lesion does not automatically necessitate surgical intervention. Most clinicians view this structural abnormality with the same skepticism as “disc lesion,” “meniscus tear” or “rotator cuff tear”- wherein the imaged defect is not necessarily the primary contributor to the patient’s complaint. Most experts, including the American Academy of Orthopedic Surgeons, recommends a 6-12 week course of conservative management before considering surgical intervention. (6-8)
3. What can Chiropractors do for a SLAP lesion?
Non-surgical treatment correcting scapular dyskinesis and GIRD has a reasonable success rate in MLB players with a documented SLAP lesion. (2) Conservative treatment goals include pain reduction, enhancing mobility, and restoration of strength. (7)
Specific treatment strategies should include:
increasing glenohumeral internal rotation (i.e. posterior capsule “sleeper” stretch)
strengthening of the shoulder/ scapular muscles (i.e. YTWL, low row, Brugger with band, etc )
improving core stability ( i.e. bird dog, dead bug, side bridge, etc)
4. What patients are best suited for surgery
Immediate surgical consultation is warranted in cases of suprascapular nerve compression from an associated paralabral cyst. (10) Otherwise, there are no universally agreed-upon indications for surgical SLAP repair. The literature fails to demonstrate success for surgically repairing type 2 SLAP lesions with co-existent rotator cuff tears in older patients (greater than 50). (10) Only 7-57% of elite overhead athletes can return to the pre-injury level of competition following surgical SLAP repair. (11,12) The co-existence of a partial-thickness rotator cuff tear correlates with the inability to return to this level of competition. (12)
5. What can chiropractors do for patients who have undergone surgery?
A recent journal by Laughlin et al. (9) found that patients with SLAP repairs have characteristic movement flaws limiting their post-surgical performance. These baseball pitchers produce less shoulder horizontal abduction, external rotation, and forward trunk tilt during pitching when compared to pitchers with no history of shoulder injury. These are all protective mechanisms indicative of long-standing shoulder pain. The study suggests primary rehab strategies to facilitate normal pitching mechanics should include improving external shoulder rotation, and horizontal abduction at 90°. (9) As you can see, patients before surgery and after surgery have very similar deficits and goals.
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Schwartzberg R, Reuss BL, Burkhart BG et al. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Journal of Sports Medicine. January 2016 vol. 4 no. 1
Fedoriw WW, et al. Return to play after treatment of superior labral tears in professional baseball players. Am J Sports Med. 2014. May;42(5):1155-60. Epub 2014 Mar 27.
Knesek M, Skendzel JG, Dines JS, et al. Diagnosis and management of superior labral anterior posterior tears in throwing athletes. Am J Sports Med 2013;41(2): 444–60.
Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. J Bone Joint Surg Am. 2003 Jan. 85-A(1):66-71.
Kampa RJ, Clasper J. Incidence of SLAP lesions in a military population. J R Army Med Corps. 2005 Sep. 151(3):171-5.
Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg. 1998 Mar-Apr. 6(2):121-31
Dodson CC, Altchek DW. SLAP Lesions: An Update on Recognition and Treatment. JOSPT February 2009, Volume 39 Number 2
Franceschi F, Longo UG, Ruzzini L, et al. No advantages in repairing a type II su- perior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50: a randomized controlled trial. Am J Sports Med 2008;36(2):247–53.
Laughlin WA, et al. Deficiencies in pitching biomechanics in baseball players with a history of superior labrum anterior-posterior repair. Am J Sports Med. 2014. Dec;42(12):2837-41.
Franceschi F, Longo UG, Ruzzini L, et al. No advantages in repairing a type II su- perior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50: a randomized controlled trial. Am J Sports Med 2008;36(2):247–53.
Laughlin WA, et al. Deficiencies in pitching biomechanics in baseball players with a history of superior labrum anterior-posterior repair. Am J Sports Med. 2014. Dec;42(12):2837-41.
Neri BR, et al. Outcome of type II superior labral anterior posterior repairs in elite overhead athletes: Effect of concomitant partial-thickness rotator cuff tears. Am J Sports Med. 2011 Jan;39(1):114-20. Epub 2010 Oct 12.
