Slap Tears: How to Diagnose


Chapter 43

Slap Tears


How to Diagnose



Eric Strauss, Brian M. Capogna, and Soterios Gyftopoulos

Introduction


Superior labral tears are a significant cause of pain and disability for the active individual. First described by Andrews in his series of 73 overhead-throwing athletes, knowledge and understanding of this pathology has improved substantially with the advent of more advanced arthroscopic techniques. Snyder et al built on the work of Andrews and coined the term “SLAP” lesion (superior labrum, anterior and posterior), and they developed the classification system still used in clinical practice. The evaluation of a patient with shoulder pain can be challenging and requires a focused systematic approach to accurately identify the presence of symptomatic superior labral pathology.

The Anatomy of the Superior Labrum





  1. • The labrum is a fibrocartilagenous structure that surrounds the rim of the glenoid, providing added depth as well as resistance against translation and acting as a static stabilizer for the shoulder.
  2. • The vascular supply arises from a circumferential pericapsular ring with contributions from the suprascapular, circumflex scapular, and posterior humeral circumflex arteries.
  3. • The anterosuperior portions of the glenoid labrum are less vascular than the posteroinferior, making this area prone to injury.
  4. • The inferior labrum is rounded and typically appears contiguous with the inferior articular surface.
  5. • The superior labrum may be meniscoid in shape with a loose attachment medial to the glenoid articular surface.
  6. • The long head of the biceps tendon is intimately associated with the superior labrum with 40%–60% of its proximal insertion at the superior glenoid tubercle and the remaining fibers attaching directly to the superior labrum.
  7. • The biceps tendon insertion at the superior glenoid tubercle along with the medial attachment of the labrum creates a subsynovial recess that can be appreciated on arthroscopic examination.
  8. • There are several clinically important anatomic variants of the anterosuperior labrum surgeons should be familiar with in order to prevent inappropriately treating functional anatomy as clinical pathology:


    1. • A sublabral foramen (3.3%)
    2. • A sublabral foramen with a cordlike middle glenohumeral ligament (8.6%)
    3. • An absent anterosuperior labrum with a cordlike middle glenohumeral ligament with direct attachment to the glenoid (i.e., a Buford complex) (1.5%)

Patient and Clincial History



Patient Examination





  1. • The physical examination should always begin with full exposure and inspection of the affected shoulder to evaluate for deformity, prior surgical incisions, or muscular wasting.


  3. image
    FIG. 43.1 Demonstration of Speed test.

  4. • In addition, the surgeon should do an evaluation of the cervical spine in order to rule out referred pain to the shoulder from cervical spine pathology.
  5. • No combination of exam maneuvers can reliably predict findings of superior labral pathology at the time of diagnostic arthroscopy, owing to very high sensitivity but poor specificity of most exam techniques.
  6. • Useful examination maneuvers suggestive of SLAP pathology include the following:


    1. • Speed test: The patient resists downward pressure with his or her arm in 90 degrees of forward elevation with the elbow extended and the forearm supinated. This produces pain when the biceps tendon or its anchor is inflamed or damaged (Fig. 43.1).
    2. • Compression-rotation test: A painful clunk is experienced when the examiner compresses the glenohumeral joint and rotates the arm in an attempt to trap the labrum in the joint (Fig. 43.2A, B).
    3. • Crank test: With the examiner standing behind an up-right patient, the examiner’s distal hand is placed on the subject’s elbow, and the proximal hand on the subject’s proximal humerus. The arm is elevated to 160 degrees in the scapular plane. With the examiner’s distal hand, an axial load is placed on the humerus while the proximal hand externally and internally rotates the humerus, with a positive test producing pain (Fig. 43.3A, B).
    4. • O’Brien test: The patient places the arm in 20 degrees of adduction and 90 degrees of forward flexion. The patient resists downward force with the forearm in pronated and supinated positions. A positive test is when the patient experiences more pain in pronation (Fig. 43.4A, B)
    5. • Biceps load I test: In the supine position, the patient’s arm is held in 90 degrees of abduction with the elbow flexed 90 degrees and forearm supinated. External rotation is applied until the patient becomes apprehensive. At that point, the patient is asked to contract the biceps muscle. If the patient’s pain or apprehension decreases, the test result is negative for SLAP tear. Conversely, if the apprehension is unchanged or pain increases, the exam result is positive for SLAP tear (Fig. 43.5A, B).

    6. image
      FIG. 43.2 Demonstration of the compression-rotation test. During the test, the glenohumeral joint is compressed with an axial load applied through the patient’s elbow (A). The shoulder is then externally rotated (B) in an attempt to entrap the torn labrum.

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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Slap Tears: How to Diagnose

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