SLAP LESIONS

SLAP Lesions

Stephen S. Burkhart

The term SLAP lesion was coined by Snyder and coworkers in 1990 as an acronym for “superior labrum anterior and posterior.” Snyder and associates described the first classification system for SLAP lesions, comprising four types (Figs. 20–1A through D). Morgan, Burkhart, Palmeri, and Gillespie considered the type 2 lesions to be the most common pathologic SLAP lesions and proposed three subtypes of type 2 lesions (Figs. 20–2A,B,C).

Burkhart, Morgan, and Kibler reported on type 2 SLAP lesions as a cause of the “dead arm” in baseball pitchers. They proposed a mechanism of acceleration during the late cocking phase in contrast to Andrews’ proposed mechanism of deceleration; described the pathologic “peel-back” mechanism that can be observed arthroscopically and is pathognomonic of posterosuperior SLAP lesions; implicated a tight posterior-inferior capsule as the initiating factor in the pathologic cascade that produces SLAP lesions; and outlined surgical and rehabilitative techniques for patients with SLAP lesions.

Indications

1. Nonathlete: persistent shoulder pain with activity

2. Overhead athlete: “dead arm” symptoms with (a) pain upon attempted overhead athletic activities and (b) inability to throw with pre-injury velocity

3. Athlete and nonathlete: repair at same time as associated Bankart lesion (SLAP lesions accompany approximately 20% of Bankart lesions)

Contraindications

1. Sedentary patient with minimal symptoms

2. Resolution of symptoms through rehabilitation

Mechanisms of Injury

1. Nonathlete: (a) agonist force acting against an actively contracting biceps (e.g., a driver with his hands on the steering wheel, who is rear-ended in an auto accident); or (b) a sudden forced abduction-external rotation force applied to the shoulder (e.g., a worker who avoids falling from a height by grabbing an overhead bar with one hand); or (c) a fall onto an outstretched hand.

2. Overhead athlete: (a) acute onset with pain on acceleration in late cocking during a single pitch; or (b) gradual onset with prodromal symptoms of pain in late cocking.

Physical Examination

1. Anterior SLAP

a. Positive Speed test

b. Positive O’Brien test

2. Posterior SLAP

a. Positive Jobe relocation test

Diagnostic Tests

1. SLAP lesion is an arthroscopic diagnosis.

2. Nonarthroscopic diagnostic tests may be suggestive; the best nonarthroscopic test is magnetic resonance arthrography.

Special Considerations

Repair of SLAP lesions is accomplished much more easily by arthroscopic techniques than by open approaches.

Arthroscopic Findings

1. Positive “peel-back” sign (biceps-superior labrum complex “peels back” medially over the edge of the superior glenoid as shoulder is brought into abduction-external rotation) (Figs. 20–3A,B)

2. Positive “drive-through” sign (arthroscope can be easily “driven through” the shoulder from superior to inferior)

3. Displaceable biceps root

4. Sublabral sulcus greater than 5 mm, with a gap between the articular cartilage edge and labral attachment into bone

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