Introduction
- Thomas J. Gill, MD
- Kaitlin M. Carroll, BS
- Amee L. Seitz, PT, PhD, DPT, OCS
- Kaitlin M. Carroll, BS
Background
- •
Superior labral tears were originally described by Andrews et al. in 1985 as lesions that involve the labrum from the anterior portion of the superior glenoid notch to the posterior glenoid, including the anchor of long head of the biceps tendon.
- •
Superior Labrum Anterior to Posterior (SLAP) tears. SLAP tears are frequently associated with concurrent shoulder pathology, including anterior and posterior Bankart tears, full and partial thickness rotator cuff tears, and acromioclavicular joint arthrosis.
Epidemiology
Age
- •
20 to 50 years
- •
Sex
- •
Male
- •
Sport
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Baseball
- •
Football
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Tennis
- •
Javelin
- •
Wrestling
- •
Position
- •
Pitchers
- •
Linebackers
- •
Offensive linemen
- •
Pathophysiology
Intrinsic Factors
- •
Composed of fibrocartilaginous tissue, the labrum serves as an anchor point for the capsuloligamentous structures of the shoulder. The labrum deepens the concavity of the glenoid cavity to provide added stability to the glenohumeral joint.
- •
The pathology includes the attachment point of the long head of the biceps tendon ( Figure 4-1 ).
FIGURE 4-1
The pathology of the labrum includes the attachment of the long head of the biceps tendon.
- •
The anterior superior labrum frequently extends into the MGHL or IGHL rather than inserting onto glenoid margin ( Figure 4-2 ).
FIGURE 4-2
The anatomic position of the anterior superior labrum and its extension into the MGHL and IGHL.
- •
Functional importance:
- •
Possible humeral head depressor
- •
Restraint to external rotation in abduction
- •
Helps maintain anterior stability of the shoulder joint
- •
- •
Eccentric contraction of biceps muscle can tear the superior labrum at the biceps anchor.
- •
Deceleration phase of throwing places high eccentric stresses on the superior labrum, while the late cocking phase of throwing place high “peel-back” forces on the posterosuperior labrum.
- •
SLAP tears are often implicated as a cause of shoulder pain, weakness, and worsening athletic performance, especially in overhead athletes.
- •
Understanding the anatomy of the labrum is essential in the diagnosis and treatment of SLAP tears, particularly with respect to differentiating normal from abnormal labral morphologies. In addition, extensive SLAP tears may occur anteriorly and posteriorly, leading to associated instability symptoms as well.
- •
The labrum serves as an anchor point for the capsuloligamentous structures of the shoulder while increasing the radius of curvature of the glenoid cavity. By doing so, it provides added glenohumeral stability, as well as the attachment point for the long head of biceps tendon at the superior glenoid tubercle.
Traumatic Factors
- •
Falling on an outstretched arm
- •
Direct blow to the shoulder
- •
Sudden pull or lifting a heavy object
- •
Forceful overhead motions
- •
Compression injuries
Classic Pathological Findings
SLAP lesions are typically classified into four basic types:
- •
Type I SLAP tears consist of superior labral fraying, without instability of the biceps anchor ( Figure 4-3 ). These lesions are seldom symptomatic, and have unclear clinical significance
- •
Fraying and degeneration of the edge
- •
Firmly attached labrum and biceps anchor
FIGURE 4-3
Type I SLAP tear.
- •
- •
Type II SLAP lesions are the most commonly symptomatic and repairable type of SLAP tear ( Figure 4-4 ). They can occur by the “peel-back” phenomenon, repetitive eccentric biceps contractions, or from a fall on an outstretched arm. Type II tears involve detachment of the superior labrum from the supraglenoid tubercle, and result in an unstable biceps anchor/attachment
- •
Labrum and biceps anchor are detached
- •
Complex arches away from glenoid neck
FIGURE 4-4
Type II SLAP tear.
- •
- •
Type III tears involve a bucket-handle detachment of the labrum in which the actual biceps origin remains stable ( Figure 4-5 ). Complaints of shoulder “catching,” “locking,” or “stabbing pain” are common.
- •
Bucket handle tear
- •
Remaining portion of biceps and labrum are still well attached at their insertion
FIGURE 4-5
Type III SLAP tear.
- •
- •
Type IV SLAP lesions include a bucket handle tear of the labrum where the tear extends into the substance of the biceps tendon ( Figure 4-6 )
- •
Portions of the labrum displaceable into glenohumeral joint
FIGURE 4-6
Type IV SLAP tear.
- •
Clinical Presentation
History
- •
Diagnosing a clinically relevant SLAP tear can be difficult.
- •
Complaints of shoulder pain and weakness, especially with throwing, are typical.
- •
A history of a traction or repetitive throwing or overhead activity may help in the diagnosis.
- •
Athletes will frequently present with symptoms of pain, clicking, weakness or even instability.
- •
Pain, usually with overhead, lifting, or traction type of activities.
- •
Pain reaching out to the side.
- •
Occasional night pain or pain with daily activities.
- •
A sense of instability or the shoulder “feeling out of place.”
- •
Decreased range of motion and strength.
- •
The symptoms are usually worse with the arm in the abducted and externally rotated position (“peel-back” position) as seen in the late cocking phase of throwing, or during an overhead serve in tennis.
- •
Although a fall on an outstretched arm can also cause a SLAP tear, a history of trauma is typically not present in overhead athletes.
- •
Athletes with type III SLAP tears often present with catching, locking or “dead-arm” type symptoms that can be confused with instability, due to the bucket handle tear catching between the humerus and glenoid.
- •
There are multiple physical examination tests that have been described to diagnose SLAP tears. These tests include: Speed’s test, Yergason’s test, O’Brien’s test, Jobe’s relocation test, active compression test, pain provocation test, crank test, anterior slide, apprehension test with the arm abducted to 90° in maximum external rotation, and tenderness in the rotator interval.
- •
The active compression test (O’Brien’s test) has been shown to be a predictable and clinically useful sign in the diagnosis of SLAP tears.
- •
Throwing athletes complain of loss of velocity, control, and decreased confidence.
- •
SLAP tears often mimic the same symptoms as rotator cuff tears.
Physical Examination
Abnormal Findings
- •
Positive O’Brien’s test (“active compression test”)
- •
Pain with apprehension test
- •
Clicking
- •
Compression and internal and external rotation
- •
Pertinent Normal Findings
- •
Negative load and shift test
- •
No true “apprehension” with apprehension testing
- •
Rotator cuff strength testing is typically normal, although some false-positive weakness on empty can testing can occur
Imaging
- •
Plain radiographs
- •
Magnetic resonance imaging
- •
Technological advancements in MRI have improved our ability to confirm the diagnosis of a superior labral tear. However, MRI findings must always be interpreted in the context of the athlete’s history and physical examination. Incidental findings of labral tears on MRI are common in overhead athletes.
- •
MRI arthrography (MRA): an injection of contrast (usually gadolinium) into the joint before the MRI scan has been shown to facilitate diagnosis.
- •
Differential Diagnosis
- •
Pathologies such as rotator cuff tears and AC joint sprains/arthritis can cause false positive physical examination tests.
- •
Patients typically complain of pain when reaching out to the side or behind them, as opposed to the classic overhead pain found with rotator cuff tears.
- •
- •
An isolated sublabral foramen, a sublabral foramen with a cord-like middle glenohumeral ligament, and a cord-like middle glenohumeral ligament with the absence of tissue at the anterosuperior labrum (also termed the “Buford complex”).
- •
These variations can be seen in 10% to 15% of all shoulders and should not be mistaken for a SLAP tear.
- •
As a general rule of thumb, labral variations are generally not thought to be “pathologic” if it occurs between 12 and 3 o’clock in a right shoulder, or between 9 and 12 o’clock in a left shoulder.
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Treatment
Nonoperative Management
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Stretching
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Formal physical therapy
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Strengthening
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Cortisone injections
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Activity modification
Guidelines for Choosing Among Nonoperative Treatments
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Injections used for patients with associated pain on impingement testing
- •
Selective AC joint injection used to help differentiate AC joint pathology from true SLAP tear
- •
Stretching used in patients with associated glenohumeral internal rotation deficit (GIRD)
Surgical Indications
- •
Treatment options include superior labral repair, biceps tenodesis, or biceps tenotomy
- •
Absolute—failure to respond to rehabilitation after 6 months and symptoms deemed relative to the SLAP region
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Relative—inability to return to premorbid level of play
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
- •
Surgical treatment more commonly used for patients with an acute injury (e.g., fall on an outstretched arm), or with significant pain/weakness on examination that is not responsive to rehabilitation
- •
Nonoperative treatment preferred for pitchers and overhead athletes unless they cannot return to play due to their symptoms
Aspects of Clinical Decision Making When Surgery is Indicated
- •
Marked pain/weakness on O’Brien’s testing
- •
Inability to throw
- •
Loss of velocity/accuracy when throwing
Evidence
Multiple-Choice Questions
- QUESTION 1.
What concomitant pathologies are NOT associated with SLAP tears?
- A.
Rotator cuff tear
- B.
Bankart tear
- C.
Clavicle fracture
- D.
Acromioclavicular arthritis
- A.
- QUESTION 2.
List the traumatic factors that contribute to a SLAP tear.
- A.
Falling on an outstretched arm
- B.
Sudden pull or lifting a heavy object
- C.
Forceful overhead motions
- D.
All of the above
- A.
- QUESTION 3.
Which test is the most widely used to diagnose SLAP tears?
- A.
O’Brien’s test
- B.
Speed’s test
- C.
Yergason’s test
- D.
Jobe’s test
- A.
- QUESTION 4.
In what sport is a SLAP tear most commonly found?
- A.
Soccer
- B.
Baseball
- C.
High Jump
- D.
Lacrosse
- A.
- QUESTION 5.
What type of SLAP tear is often associated with catching, locking, or “dead-arm” type symptoms?
- A.
Type I
- B.
Type II
- C.
Type III
- D.
Type IV
- A.
Answer Key
- QUESTION 1.
Correct answer C (see Epidemiology )
- QUESTION 2.
Correct answer: D (see Pathophysiology )
- QUESTION 3.
Correct answer: A (see Clinical Presentations )
- QUESTION 4.
Correct answer: B (see Epidemiology )
- QUESTION 5.
Correct answer: C (see Clinical Presentation )
Nonoperative Rehabilitation of Slap Tears
- Amee L. Seitz, PT, PhD, DPT, OCS
- Alex J. Petruska, PT, SCS
- Thomas J. Gill, MD
- Alex J. Petruska, PT, SCS
- •
A proportion of overhead athletes with SLAP tears, regardless of type, will be able to return to full function and sport with rehabilitation. The pathoanatomical diagnosis is not predictive of outcome.
- •
A comprehensive examination to identify and address all potential contributing factors and impairments is necessary to optimize the outcome of nonoperative rehabilitation of superior labrum anterior to posterior (SLAP) SLAP tears.
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Rehabilitation of SLAP tears should be individualized to the specific underlying impairments that contribute to movement disorder that vary among athletes.
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Where an athlete begins along the phases of rehabilitation and time frames for progression outlined in this chapter is dependent upon the pain, reactivity of shoulder structures, extent of movement impairments, and individualized patient response.
- •
Although it is not necessary to follow the specific time frames outlined for each phase, it is essential to meet the milestones/criteria to advance to the next phase of rehabilitation.
Phase I (weeks 0 to 4)
Protection
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Athlete should be instructed in joint protection strategies including positioning the shoulder with pillows in the “loose pack” position to sleep and during application of cryotherapy.
- •
Athlete should be instructed to avoid activities that provoke symptoms and limit use of upper extremity below shoulder height and in front of scapular plane.
| PHASE I (weeks 1 to 4) | PHASE II (weeks 4 to 8) | PHASE III (weeks 8 to 12) | PHASE IV (weeks 12 +) |
|---|---|---|---|
|
|
|
|
Management of Pain and Swelling
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Ice intermittently, as needed up to 4 to 5 times per day 15 to 20 minutes at a time
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Nonsteroidal antiinflammatory medications as prescribed by the surgeon
- •
A TENS unit or electrical stimulation may be used to reduce pain. Using TENS for 20 minutes at a time has been shown to reduce nociceptive responses and pain perception. Electrical stimulation has also been shown to suppress inflammatory responses at the cellular level in vitro.
- •
An evaluation by the sports medicine physician for a subacromial steroid injection may be helpful to reduce pain or address any plateaus in progression to meet Phase I rehabilitation goals in a 4-week period.
Techniques for Progressive Increase in Range of Motion
- •
Phase I rehabilitation is designed to restore normal and pain-free AA/AROM of the shoulder. Athletes that do not present with AROM limitations and minimal to no pain with ROM may progress immediately to Phase II.
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ROM progressions are not limited by time frames and should be guided by the athlete’s tolerance.
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For athletes with A/PROM limitations, ROM progression should begin with restoring internal and external rotation with the arm at the side and elevation in the scapular plane.
- •
Once full A/PROM in elevation, and full IR and ER at the side is achieved, athletes can be progressed with internal and external rotation gradually to 90° of abduction.
Manual Therapy Techniques
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Grade I to II glenohumeral mobilizations inferior and posterior for pain in midrange to assist with ROM progression.
- •
Thoracic spine manipulation or grade III to IV mobilization for extension and rotation mobility and to reduce pain.
Soft Tissue Techniques
- •
Pectoralis minor active release or preferred soft tissue technique as needed to normalize muscle length to restore adequate scapular posterior tilt. Minimum length can be determined by supine assessment of acromion distance from bed should be equal bilaterally.
- •
Rotator cuff, specifically infraspinatus ( Figure 4-7 ) and/or subscapularis, soft tissue release techniques as needed.
FIGURE 4-7
Manual therapy technique to address soft tissue impairments in the infraspinatus with application of pressure to infraspinatus ( A ) in flexion and move into ( B ) horizontal abduction of the shoulder.
- •
Biceps soft tissue release techniques as needed.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Normalize full passive glenohumeral ROM within pain tolerance in all planes starting external/internal rotation in neutral progressing to 45° and 90° of abduction
- •
T-Bar/stick exercises for AAROM in ER with the arm at side in standing ( Figure 4-8 ) progressing to 90° abduction in supine ( Figure 4-9 )
FIGURE 4-8
External rotation active assistive range of motion with the shoulder in neutral.
FIGURE 4-9
External rotation active assistive range of motion in 90° abduction.
- •
Elbow and wrist ROM stretching
- •
IR behind the back internal rotation stretching ( Figure 4-10 )
FIGURE 4-10
Internal rotation/behind AAROM with a stick.
- •
Horizontal adduction stretching AAROM ( Figure 4-11 )
FIGURE 4-11
Horizontal adduction posterior shoulder self-stretching.
- •
Thoracic spine extension AROM over 4-inch foam roll
- •
Initiate hip stretching ABD/IR/ER/flexion as needed. Adequate hip motion will permit normal mechanics with throwing/pitching reducing unwarranted strain at the shoulder.
Other Therapeutic Exercises
- •
Nonimpact light aerobic activity (bike, elliptical, StairMaster) within pain tolerance
- •
Lower extremity resistance training is indicated
- •
Core stability is initiated as able with seated ball exercises and unilateral stance lower extremity reaches and lateral slides on stable surface progressed as technique allows
Activation of Primary Muscles Involved
- •
Although the focus of this phase of rehabilitation is restoration of normal range of motion, activation of the rotator cuff muscles (IR/ER) with submaximal isometrics is indicated within pain tolerance with the arm at the side progressing to 45° of scapular plane elevation.
Sensorimotor Exercises
- •
Scapular control exercises with side-lying scapular clock exercises
- •
Active elevation in scapular plane with mirror and verbal feedback to normalize dynamic scapulohumeral motor control
Techniques to Increase Muscle Strength, Power, and Endurance
- •
LE strength training exercises to target hip extensors and rotators
- •
Elliptical and stair stepper for cardiovascular conditioning
Neuromuscular Dynamic Stability Exercises
- •
Manual rhythmic stabilization with the arm in pain-free mid-range of motion positions with light resistance
Sport-Specific Exercises
- •
Overhead athletes should initiate core and lower extremity stability drills progressing to unstable surfaces and in unilateral stance (standing balance, excursions anterior lateral and diagonals) as able with good core control. Unstable surfaces require additional core muscle activity and greater challenge to the athlete.
Milestones for Progression to the Next Phase
- •
Full AROM in all planes of motion, with only mild discomfort at end ranges
- •
Normal scapulohumeral dynamic control during elevation without resistance as determined by the scapular dyskinesis Test. With this test, the athlete should demonstrate no dysrhythmia or scapular winging during five repetitions of full flexion and abduction.
- •
Pain minimal to none at rest; minimal increase in pain following exercise
Phase II (weeks 6 to 12)
Protection
- •
Athletes will be encouraged to minimize painful resisted shoulder motions above shoulder height and behind the plane of the body during daily activities.
Management of Pain and Swelling
- •
Ice after exercise and as needed 15 to 20 minutes at a time
- •
Nonsteroidal antiinflammatory medications as prescribed by the surgeon
- •
TENS unit or electrical stimulation only as needed after exercise
Techniques for Progressive Increase in Range of Motion
- •
Athletes should have normal AROM but may present with end range restrictions and abnormal arthrokinematics that should be addressed in this phase of rehabilitation.
- •
Normal inferior glide should be observed in terminal elevation. This can be visually observed with symmetrical skin creases at terminal elevation. Additionally inferior glides can be assessed and compared bilaterally at end range of glenohumeral elevation. Posterior shoulder length should be normalized with at least 20° of horizontal adduction from the vertical while lying supine with the scapula stabilized.
- •
Glenohumeral total arc of motion should be normalized with the sum of internal and external rotation at 90° of abduction approximating 180°.
- •
The dominant shoulder in overhead, particularly throwing athletes may demonstrate loss of IR compared to contralateral due to osseous changes of the humerus, but the total arc of internal and external rotation motion should be comparable to the opposite shoulder.
Manual Therapy Techniques
- •
Common restrictions in posterior and inferior accessory joint motion of the glenohumeral joint should be normalized with grade III mobilizations, mobilizations with movement, and/or terminal ROM stretching. Arthrokinematics with manual accessory motion testing should be assessed in the posterior and inferior direction. Posterior shoulder range of motion can be evaluated with passive horizontal adduction with the scapula stabilized should be greater than 90° or beyond vertical position towards the chest. Internal rotation should be sufficient to allow for the total arc of motion (internal + external rotation ROM) to approximate total arc of motion values for the uninvolved shoulder.
- •
Manual assisted horizontal adduction stretching while stabilizing the scapula at varying angles of elevation 70° to 100° and IR stretching to appropriately address posterior shoulder soft tissue restrictions.
Soft Tissue Techniques
- •
Pectoralis minor active release or preferred soft tissue technique as needed to normalize muscle length to restore adequate scapular posterior tilt. Minimum length can be determined by supine assessment of acromion distance from bed should be equal bilaterally
- •
Continue rotator cuff and/or biceps soft tissue techniques as needed
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Sleeper stretch starting at 45° of flexion progressing to 90° as tolerated ( Figure 4-12 )
FIGURE 4-12
Sleeper stretch at 90° flexion for posterior shoulder.
- •
Bar hang stretch for latissimus and shoulder flexion ( Figure 4-13 )
FIGURE 4-13
Overhead bar assisted shoulder flexion and latissimus dorsi stretch.
- •
Full pain-free shoulder ROM IR/ER at 90° of abduction
- •
Continue hip ER/IR/flexion stretching as needed
- •
Continue thoracic spine extension and rotation stretching as needed
Other Therapeutic Exercises
- •
Return to all aerobic activity
- •
Lower extremity resistance training is progressed
- •
Core stability exercises are progressed to sport-specific positions and conditions
- •
Total arm strengthening (TAS) is initiated with exercises at or below shoulder height and anterior to scapular plane
Activation of Primary Muscles Involved
Initiate rotator cuff and scapular prone exercises to light isotonic and/or elastic resistance as ROM is normalized without scapular substitution patterns. The scapula should not wing or excessively shrug with any exercise as determined by visual observation.
- •
Resisted ER in neutral ( Figure 4-14 )
FIGURE 4-14
Resisted external rotation in neutral humeral abduction ( A ) start position and ( B ) end position.
- •
Resisted IR in neutral ( Figure 4-15 )
FIGURE 4-15
Resisted internal rotation in neutral humeral abduction ( A ) start position and ( B ) end position.
- •
Sideling ER ( Figure 4-16 )
FIGURE 4-16
Side-lying isotonic external rotation ( A ) start position and ( B ) end position.
- •
Shoulder retractions ( Figure 4-17 )
FIGURE 4-17
Resisted shoulder retractions ( A ) start position and ( B ) end position.
- •
Standing “W”s ( Figure 4-18 )
FIGURE 4-18
Standing “W”s ( A ) start position and ( B ) end position.
- •
Dynamic hug ( Figure 4-19 )
FIGURE 4-19
Dynamic hug strengthening exercise ( A ) start position and ( B ) end position.
- •
Prone rowing ( Figure 4-20 )
FIGURE 4-20
Prone rowing ( A ) start position and ( B ) end position.
- •
Prone extension ( Figure 4-21 )
FIGURE 4-21
Prone extension ( A ) start position and ( B ) end position.
Sensorimotor Exercises
- •
Rhythmic stabilization and manual strengthening of the UE with short moment arms/proximal resistance
- •
The Bodyblade at 0° abduction as well as 90° scapular elevation
- •
Core stability exercises with manual resistance on stable progressing to unstable surfaces
Open and Closed Kinetic Chain Exercises
- •
PNF in D1–2 with manual resistance to scapula and humerus with slow reversals
- •
Closed chain upper extremity PNF in quadruped
- •
Closed chain rhythmic stabilization in quadruped with hand on ball to provide an unstable surface to challenge the athlete
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Progression of lower extremity strength training exercises
- •
Progress to elliptical and stair stepper for cardiovascular conditioning; initiate jogging/running
Plyometrics
- •
Lower extremity plyometrics can be initiated
Milestones for Progression to the Next Phase
- •
Normal posterior shoulder flexibility (internal rotation and horizontal adduction). Posterior shoulder range of motion can be evaluated with passive horizontal adduction with the scapula stabilized should be greater than 90° or beyond vertical position towards the chest. Internal rotation should be sufficient to allow for the total arc of motion (internal + external rotation ROM) to approximate total arc of motion values for the uninvolved shoulder.
- •
Normal arthrokinematics glenohumeral joint. Arthrokinematics with manual accessory motion testing should be assessed in the posterior and inferior direction with the arm at 90° of abduction and external rotation.
- •
Normal scapulohumeral motion during active ROM in all planes as determined by the scapular dyskinesis test. With this test, the athlete should demonstrate no dysrhythmia or winging during five repetitions of full flexion and abduction holding 5-lb hand weights.
- •
Shoulder strength 75% to 80% uninvolved below shoulder height can be assessed with the arm at 0° and 45° of abduction through range of motion with manual resistance of the examiner, but isometrically in multiple ranges with an hand-held dynamometer because an objective measure is more sensitive to detect apparent weakness up to 20% when manual resistance is deemed normal. Isokinetic testing could be used as a more objective measure.
- •
Normal dynamic trunk and kinetic chain strength and motor control with functional tests including single leg squat or step down with demonstration of neutral varus or valgus alignment of the knee avoidance of pelvic drop and good balance/control, unilateral balance and hold with pitching stance, plank trunk stability with neutral spine for at least 1 minute.
Phase III (weeks 12 to 16)
Management of Pain and Swelling
- •
Cryotherapy after exercise as needed
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Continue grade III glenohumeral joint mobilizations and terminal ROM stretching for posterior shoulder as needed to maintain ROM
- •
Thoracic spine mobilization/manipulation as needed
Soft Tissue Techniques
- •
Continue soft tissue techniques to maintain posterior shoulder (infraspinatus and teres minor) muscle extensibility as needed
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Specific stretching following exercise should be continued to maintain shoulder, thoracic spine and hip flexibility
- •
Continue sleeper stretches
- •
Shoulder horizontal adduction stretching
- •
Hip ABD/IR/ER/flexion stretching
- •
Thoracic spine extension and rotation
- •
Pectoralis major stretching in doorway or corner ( Figure 4-22 ) with emphasis on scapular retraction and sensation of the stretch in chest not shoulder
FIGURE 4-22
Pectoralis major stretch in doorway.
- •
Continue bar hang stretch for latissimus dorsi stretching
Other Therapeutic Exercises
- •
Progress aerobic activity
- •
Lower extremity resistance training is progressed
- •
Core stability exercises are progressed to sport-specific positions and conditions
- •
Total arm strengthening initiated with biceps curl, triceps extension, wrist supination, and pronation
Activation of Primary Muscles Involved
Progress shoulder and rotator cuff strengthening to complete a modified Thrower’s Ten program with the addition of:
- •
Prone horizontal abduction “T”s ( Figure 4-23 )
FIGURE 4-23
Prone horizontal abduction “T”s in neutral rotation ( A ) start position and ( B ) end position.
- •
Prone scaption “Y”s ( Figure 4-24 )
FIGURE 4-24
Prone scaption “Y”s in external rotation at 110° ( A ) start position and ( B ) end position.
- •
Prone external rotation at 90° abduction ( Figure 4-25 )
FIGURE 4-25
Prone external rotation at 90° abduction ( A ) start position and ( B ) end position.
- •
Shoulder scaption to 90° elevation full can position ( Figure 4-26 )
FIGURE 4-26
Scapular plane “full can” elevation to 90°.
- •
Supine inclined pull ups with scapular retraction
Sensorimotor Exercises
- •
Rhythmic stabilization and manual strengthening of the UE with long moment arms/distal resistance
- •
The Bodyblade at 0° abduction as well as 90° scapular elevation
- •
Core stability exercises with manual resistance on stable progressing to unstable surfaces. Progressing to unstable surface requires additional core stability and provides an additional challenge to the athlete.
Open and Closed Kinetic Chain Exercises
- •
PNF in D1–2 with manual resistance to scapula and humerus with slow reversals and midrange holds.
- •
Closed chain stability holds in quadruped, plank prone, and side-on stable and unstable surfaces with manual perturbations.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Progression of lower extremity strength training exercises.
- •
Progress to elliptical, stair stepper, jogging/running for cardiovascular conditioning.
Plyometrics
- •
Light plyometrics with throw at the side ( Figures 4-27 A-D )
FIGURE 4-27
Plyometrics one arm throw at the side ( A ) wind up, ( B ) release, ( C ) catch, and ( D ) eccentric follow-through.
- •
Wall dribbles light resistance overhead and various arm angles ( Figure 4-28 )
FIGURE 4-28
Wall dribbles light resistance in various positions ( A ) overhead, ( B ) above 90°, and ( C ) just below 90° abduction.
- •
Decelerations/eccentric control of follow-through in half-kneeling ( Figure 4-29 )
FIGURE 4-29
Decelerations with eccentric control with ( A ) a catch from a toss behind, and ( B ) eccentric control during follow-through followed by concentric toss behind.
- •
Two-hand medicine ball chest pass and side toss
- •
Continue lower extremity plyometrics with emphasis on frontal plane/lateral movements
Sport-Specific Exercises
- •
Initiate exercises and sport-specific drills with arm below shoulder height such as fielding drills and base work
Milestones for Progression to the Next Phase
- •
No complaints of symptoms/pain with exercise, and minimal discomfort after exercise resolves with cryotherapy
- •
Full pain-free uncompensated AROM of shoulder complex. AROM should be assessed in all planes and considered normal when equal bilaterally
- •
Excellent core and proximal stability of hips and lower extremity with functional tests such as single leg squat or step down with demonstration of neutral varus or valgus alignment of the knee avoidance of pelvic drop and good balance/control
- •
Strength of rotator cuff, shoulder and scapular stabilizers at least 80% to 90% uninvolved with isokinetic testing, or if unavailable, hand-held dynamometry at multiple arm angles in external rotation, internal rotation and abduction to 90°. Isokinetic testing is preferred.
- •
Self-report outcome scores >80% such as the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score are more sensitive than regional outcome tools such as the Disability of the Shoulder Arm and Hand.
Phase IV (weeks 16 to 24)
Management of Pain and Swelling
- •
Cryotherapy with/without electrical stimulation after exercise as needed
Techniques for Progressive Increase in Range of Motion
- •
Athlete must maintain ROM and flexibility achieved in prior phases
- •
Strengthening and dynamic plyometric activities progress to more challenging positions of sport in abduction and external rotation
Manual Therapy Techniques
- •
Continue grade III mobilizations and terminal ROM stretching for posterior shoulder as needed to maintain ROM
- •
Thoracic spine mobilization/manipulation as needed
Soft Tissue Techniques
- •
Continue soft tissue techniques to maintain posterior shoulder (infraspinatus and teres minor) muscle extensibility
Stretching and Flexibility Techniques for the Musculotendinous Unit
Specific stretching following exercise should be continued to maintain shoulder, thoracic spine and hip flexibility:
- •
Sleeper stretches
- •
Horizontal adduction
- •
IR/ER/flexion hip stretching
- •
Thoracic spine extension and rotation. Extension can be facilitated by lying supine over physioball. Rotation can be achieved with side-lying thoracic rotation with hips and lumbar spine flexed to isolate stretch to thoracic region.
Other Therapeutic Exercises
- •
Progress aerobic activity
- •
Lower extremity resistance training is progressed
- •
Core stability exercises are progressed to target deficits noted in sport-specific positions such as unilateral stance in cocking position for pitchers and throwing for fielders
- •
Total arm strengthening continue; progress with biceps curl, triceps extension, wrist supination and pronation
Activation of Primary Muscles Involved
- •
Begin sport-specific return to sport progressions (i.e., interval throwing, swimming, tennis programs) and/or collaboration with sports performance specialists once strength, self-report outcome and full uncompensated active and passive ROM goals of this phase are achieved
Sensorimotor Exercises
- •
Progress rhythmic stabilization and manual strengthening of the UE progressed to long moment arms and distal points of resistance.
- •
Progress the Bodyblade to 90° abduction and external rotation in bilateral and unilateral stance.
- •
Progress core stability exercises with manual resistance to unstable surfaces.
Open and Closed Kinetic Chain Exercises
- •
PNF in D1–2 with manual resistance with fast reversals and terminal holds with perturbations.
- •
Closed chain PNF in plank and long arc positions progressing to unstable surfaces with emphasis on good scapular control without evidence of winging or shrugging with visual observation.
- •
Upper extremity closed chain functional training used later for testing. The upper extremity closed chain function test requires the athlete to move their hands alternately back and forth from a pushup position, touching one of two lines at a time placed 3 feet apart on the ground.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Progression of LE strength training exercises
- •
Sport-specific exercises and drills
Plyometrics
Progress plyometrics to unilateral and overhead positions:
- •
One arm rebounder throwing in abduction ( Figure 4-30 )
FIGURE 4-30
Plyometrics one arm throw in abducted position ( A ) wind up, ( B ) release, ( C ) catch, and ( D ) eccentric follow-through.
- •
Progress endurance with wall dribbles at various angles approximating 90° abduction
- •
Heavy full kinetic chain plyometrics (such as medicine ball floor slams, wall throws, chest pass/side trunk rotation scoop toss/squat throws)
- •
Continued lower extremity plyometrics with emphasis on frontal plane/lateral movements for throwers
Sport-Specific Exercises
- •
Initiate return to sport specific interval progressions (throwing/catch, swimming, tennis groundstrokes, etc.) performed on an every-other-day basis
- •
Athletes should work closely with coaches and trainers to insure proper technique with sport activity, particularly when the athlete is fatiguing
- •
Pitchers should work with a coach to insure proper mechanics with various types of pitches
- •
Swimmers should work with a coach to insure proper mechanics with freestyle progressing to other types of swimming strokes
- •
Tennis players should work with a coach to insure proper mechanics with ground strokes progressing to all types of overhead hits and serves
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
No symptoms of pain or discomfort during or following exercise
- •
Functional closed kinetic chain tests (upper extremity, core, lower extremity) are >90% uninvolved or considered normal with good control and accuracy
- •
Davies closed kinetic chain upper extremity stability test
- •
At least an average of 7 in 3 trials of timed modified pullup for 15 seconds
- •
At least an average of 15 in 3 trials of timed pushup for 15 seconds
- •
Single arm seated shot put test performed with lower extremities elevated on a chair with a distance of at least 2 m using a 2.72 kg (small softball size) medicine ball
- •
- •
Strength >90% uninvolved with isokinetic testing or at minimum hand-held dynamometry specific to internal, external, and abduction in multiple arm angles.
- •
Normal flexibility ROM of posterior shoulder, thoracic spine and hips. Posterior shoulder range of motion can be evaluated with passive horizontal adduction with the scapula stabilized should be greater than 90° or beyond vertical position towards the chest. Internal rotation should be sufficient to allow for the total arc of motion (internal + external rotation ROM) to approximate total arc of motion values for the uninvolved shoulder. Hip flexion ROM should be at least 110° of flexion, and 40° internal rotation.
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Inability to meet milestones/criteria for progression to next phase of rehabilitation in upper limit of time frames specified
- •
Pain increases with appropriately phased exercises and does not respond to rest, modalities, ANSAIDS or corticosteroid injection(s)
- •
Recurrence of injury during any phase of rehabilitation
- •
Unable to achieve level of performance necessary to successfully return and compete in sport
Tips and Guidelines for Transitioning to Performance Enhancement
- •
Although skilled rehabilitation of the shoulder and kinetic chain is achieved during Phase I to IV interventions, skill and optimal performance in the specific-sport activities is a necessary component to successful recovery and is frequently overlooked at the end of rehabilitation.
- •
Performance enhancement further develops the specific skills to optimize performance with the demands required of the athlete’s particular specialty within each sport.
- •
Specialists trained in functional movement screens and evaluation techniques to identify remaining movement dysfunctions and maximize performance are essential to return to sport success. Rehabilitation specialists should work closely with strength and performance enhancement specialists during this final stage of rehabilitation to then transition to a comprehensive performance enhancement program.
- •
This team approach is optimal for full recovery of the athlete at participating at competitive levels.
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance
- •
Performance enhancement and optimization will include a comprehensive program to address performance aspects of the sport including power, strength, accuracy, velocity.
- •
Performance enhancement should be initiated near the end of rehabilitation in combination or before return to sport progressions are initiated.
- •
Detailed information regarding sports performance enhancement can be found in the Beyond the basics section.
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Normal uncompensated scapulothoracic and glenohumeral motion under fast and resisted conditions with sport-specific activities. Can observe scapular motion during the functional closed chain upper extremity functional test, and can consult pitching coach to insure adequate mechanics with pitching or throwing. Should assess scapular stability for winging or shrugging with all strengthening exercises and sport-specific drills.
- •
No symptoms of pain or discomfort during or following exercise
- •
Maintenance of normal strength and flexibility shoulder, core, lower extremity
- •
Shoulder strength >90% uninvolved with isokinetic testing or at minimum hand-held dynamometry specific to internal, external, and abduction in multiple arm angles.
- •
Normal posterior shoulder ROM can be maintained with diligent stretching with sleeper stretching and assistance with IR glenohumeral stretching on a daily basis. Passive horizontal adduction with the scapula stabilized should be greater than 90° or beyond vertical position towards the chest. Internal rotation should be sufficient to allow for the total arc of motion (internal + external rotation ROM) to approximate total arc of motion values for the uninvolved shoulder.
- •
Lower extremity star excursions or step-downs should be equal bilaterally with good pelvic control.
- •
- •
Successful completion of return to sport interval progression
- •
Normal mechanics with sport (throwing, swimming, tennis) and confirmation from coach, trainer, and/or sports performance specialist that performance is optimized for return to competitive play
Evidence
Multiple-Choice Questions
- QUESTION 1.
The rehabilitation for nonoperative management of SLAP tears is focused on:
- A.
Rotator cuff strengthening
- B.
Core stability
- C.
Posterior shoulder flexibility
- D.
Impairments identified from a comprehensive examination
- A.
- QUESTION 2.
The following is true of Phase I rehabilitation of SLAP tears EXCEPT:
- A.
Include normalizing glenohumeral AROM in all planes
- B.
Is necessary to complete for at least 4 weeks in all athletes
- C.
Includes modalities and cryotherapy as needed to improve pain
- D.
Includes strengthening at terminal ranges of motion
- A.
- QUESTION 3.
Common to most overhead athletes with SLAP tears, posterior shoulder flexibility should be addressed with:
- A.
Sleeper stretch
- B.
Horizontal adduction self-stretching
- C.
Glenohumeral joint mobilizations and soft tissue techniques
- D.
All of the above
- A.
- QUESTION 4.
Plyometrics for the involved shoulder and upper extremity should be initiated:
- A.
In positions of stability with the arm in neutral and below shoulder height
- B.
In simulated positions of throwing/serving/swimming
- C.
In closed chain behind the plane of the body
- D.
Rarely
- A.
- QUESTION 5.
The final decision for return to play following rehabilitation of a SLAP tear should be based on testing from:
- A.
Successful completion of interval return to sport program
- B.
Clearance from the rehabilitation specialist and physician that milestones have been met
- C.
Approval from the coach, trainer/strength and conditioning specialist
- D.
All the above
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see key points)
- QUESTION 2.
Correct answer: B (see key points)
- QUESTION 3.
Correct answer: A (see Phase II )
- QUESTION 4.
Correct answer: A (see Phase III )
- QUESTION 5.
Correct answer: D (see Phase IV )
Postoperative Rehabilitation after Treatment of SLAP Tears
- Amee L. Seitz, PT, PhD, DPT, OCS
- Thomas J. Gill, MD
Indications for Surgical Treatment
Indications for surgical treatment of a superior labrum anterior to posterior (SLAP) tear are persistent symptoms with loss of function and sports performance despite conservative treatment. Symptoms can include:
- •
Pain, usually with overhead activities
- •
Loss of strength
- •
Catching, locking, popping, or grinding
- •
Occasional night pain or pain with daily activities
- •
A sense of instability in the shoulder
- •
Decreased range of motion
Brief Summary of Surgical Treatment
Major Surgical Steps
- •
General anesthesia and shoulder arthroscopy
- •
Beach chair position
- •
Arthroscopic portals
- •
A posterior viewing portal placed 2 cm inferior to the posterolateral corner of the acromion
- •
A standard anterior portal placed under direct visualization anterior and 1 cm lateral to the coracoid, with the cannula inserted just inferior to the biceps in the rotator interval
- •
- •
Arthroscopic evaluation to determine type of SLAP, evaluation of the entire glenoid labrum, biceps tendon, articular surface of the glenoid and humeral head, glenohumeral ligaments, subscapularis tendon, and rotator cuff
- •
A lateral portal is made under direct visualization just posterior to the biceps tendon at the anterior margin of the supraspinatus in the rotator interval
- •
The superior glenoid was abraded down to a gently bleeding bony bed posterior to the biceps anchor footprint with a 4.2 mm bone cutting shaver
- •
Single loaded 3.5 mm suture anchors are placed posterior to the biceps footprint.
- •
The sutures are passed using a suture passing device. The sutures are tied using an arthroscopic sliding knot (Duncan loop) followed by half hitches.
- •
A probe is used to evaluate the repair integrity
Factors That May Affect Rehabilitation
Surgical
- •
The type of SLAP repair strongly dictates rehabilitation progression. A type II and IV involving the biceps anchor have precautions regarding early biceps use and graded return of ROM
- •
Type I and III SLAP repairs typically require arthroscopic debridement of the labrum and not an anatomic repair. Thus rehabilitation progression may be more aggressive to restore range of motion in early phase
Other Surgical Techniques and Options
- •
If the patient has involvement that necessitates surgical repair of other structures (rotator cuff tendons) the postoperative rehabilitation course will deviate from SLAP to rotator cuff repair guidelines.
Before Surgery: Overview of Goals, Milestones, and Guidelines 1
1 Prehabilitation, if appropriate, is described in the Nonoperative Rehabilitation section of this chapter.
- •
A thorough understanding regarding the type of SLAP repair and other procedures is essential to rehabilitation success (concomitant rotator cuff repair should follow rotator cuff rehabilitation guidelines)
- •
Adequate protection of repair including biceps when applicable while minimizing postoperative morbidities
- •
Understanding of positions and activities that stress repair and time frames for healing
- •
Restoration of normal arthrokinematics and dynamic neuromuscular control of the shoulder complex is critical to successful recovery
Phase I: Immediate Postoperative Period (days 0 to 14)
- •
In the week or so immediately following surgery, comfort and pain control is important.
- •
The patient should be educated in positions to maximize comfort including the use of pillows to prop the shoulder in a “loose pack” position (slight abduction, flexion and neutral rotation) and may be encouraged to sleep in a recliner for the first few days following surgery to achieve this. When the patient lies supine without support behind the elbow, there is tension on the repair and/or superior shoulder joint soft tissues.
- •
Additionally, the patient would benefit from instruction in strategies to put on a shirt and wash under the arm of the involved shoulder by bending at the waist, similar to a Codman’s pendulum exercise.
| PHASE I (weeks 1 to 2) | PHASE II (weeks 3 to 6) | PHASE III (weeks 6 to 10) | PHASE IV (weeks 10 to 14) | PHASE V (weeks 14 to 24) | PHASE VI (weeks 24+) |
|---|---|---|---|---|---|
|
|
|
|
|
|
| PHASE I (weeks 1 to 2) | PHASE II (weeks 3 to 6) | PHASE III (weeks 6 to 10) | PHASE IV (weeks 10 to 14) | PHASE V (weeks 14 to 24) |
|---|---|---|---|---|
|
|
|
|
|
Goals
- •
Control pain and swelling
- •
Protect the repair and promote healing
- •
Minimize side effects of immobilization including stiffness and muscular atrophy
Protection
- •
The use of a sling at all times is necessary except during ROM exercises and bathing. Patients instructed to avoid active biceps contraction, but use of hand and wrist in front of body while in the sling is permitted within pain tolerance.
- •
No lifting or carrying objects with the involved hand is instructed.
Management of Pain and Swelling
- •
Patient education regarding proper positioning to reduce tensile loads on repair and surrounding soft tissue using pillows and/or recliner when resting.
- •
Ice intermittently, 4 to 5 times per day 15 to 20 minutes at a time
- •
Oral pain medications as instructed by the surgeon
- •
TENS unit may be used
- •
Use of Cryo Cuff or ice packs to minimize pain and inflammation
- •
Modalities including electrical stimulation
Techniques for Progressive Increase in Range of Motion
Guidelines for progressive increase in ROM ( Table 4-1 ) are based on tissue healing and have been adapted from published literature.
- •
Initial ROM HEP before postoperative surgeon’s visit consists of Codman’s pendulum exercises for the shoulder or modified version of table forward bow ( Figure 4-31 ) which does not differ in the amount of electrical muscle activity of the shoulder from the pendulum exercise.
FIGURE 4-31
Table forward bows for passive range of motion. ( A ) Start position and ( B ) end position.
- •
Wrist and hand active ROM exercises are encouraged 4 to 5 times per day
- •
Postural scapular squeezes with arm supported in the sling 4 to 5 times per day
| Postop Timeframe | Type SLAP Repair | Range of Motion | Scaption (degrees) | Flexion (degrees) | External Rotation (degrees) | Internal Rotation (degrees) | Abduction (degrees) | Adduction (degrees) | Extension (degrees) | Elbow AROM |
|---|---|---|---|---|---|---|---|---|---|---|
| 0–14 d | Type II, IV | PROM | 60 | 60 | 15 (in 30 scaption) | 45 (in 30 scaption) | N/a | 0 | 0 | No active flexion |
| Type I, III | P/AAROM/AROM | 120 | 120 | 60 (in 30 &45 abduction) | 60 (in 45 Abduction) | 90 | 0 | 20 | No active flexion | |
| 2–4 wk | Type II, IV | P/AAROM | 90 | 90 | 30 (in 30 scaption) | 60 (in 30 scaption) | 80 | 0 | 0 | No active flexion |
| Type I, III | P/AAROM→AROM | Full | Full | Full (in 90 abduction) | Full in 90 Abduction | Full | Full | Full | Active/resisted | |
| 4–6 wk | Type II, IV | P/AAROM→AROM | 145 | 145 | 60 (in 45 abduction) | 60 (in 45 Abduction) | 90 | 0 | 20 | AROM flexion |
| 6–10 wk | Type II, IV | AAROM/AROM | Full | Full | 90 (in 90 abduction) | 75 (in 90 Abduction) | Full | H Add to 90 | Full | Full |
| 10–14 wk | Type II, IV | AROM | Full | Full | Full (in 90 Abduction) | Full | Full H Add | Full | Resisted |
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Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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