Clinical Features And Evaluation

SLAP lesions have received significant attention from shoulder surgeons over the past 20 years. Andrews et al1 initially described superior labrum tears at the insertion point of the long head of the biceps tendon in 1985. Snyder et al3 subsequently defined the SLAP lesion in 1990, outlining four types. This chapter provides an overview of the diagnostic criteria, pertinent anatomy, treatment options including operative technique, and postsurgical rehabilitation program. Anterior and posterior labral tears and their association with glenohumeral instability are specifically addressed in Chapters 18 and 19, respectively.

Patients with superior labral tears will typically present with deep anterior shoulder pain, most pronounced with overhead activities. Clicking, catching, or popping may trouble the patient as well. The patient may report a history of specific injury.3,4 Overhead-throwing athletes may develop superior labral tears without specific injury. Andrews et al1 suggest that the long head of the biceps tendon places traction on the superior labrum during the deceleration phase of throwing. Repetitive throwing may lead to superior labrum and biceps anchor detachment. Capsular tightness and poor throwing mechanics may contribute to the problem. Traumatic injuries may cause SLAP tears through traction or compression. The labrum may be pulled off the glenoid from an inferiorly directed traction force, such as catching a heavy falling object. A superiorly directed traction force could have the same effect, as in an attempt to prevent a fall by holding onto an overhead object. A fall onto an outstretched arm or a direct blow to the lateral shoulder may tear the superior labrum through a compressive load. Some patients develop SLAP tears with no history of overuse or trauma.2,5

A detailed shoulder physical examination, as described in Chapter 16, should be performed. Examination findings specific to superior labral pathology remain somewhat controversial. SLAP tears are commonly associated with other pathology, which complicates the interpretation of the examination.6 The combination of history and physical examination findings should raise suspicion for SLAP injuries and direct further evaluation and treatment. Table 22-1 includes several signs and symptoms that are commonly seen with SLAP tears. Anterior tenderness in the bicipital groove, pain with resisted forward elevation (Speed's test), and pain with resisted forearm supination (Yergason's test) suggest biceps anchor pathology. Pain with resisted forward elevation in adduction and internal rotation, which is more intense than when repeated in external rotation (O'Brien's test), has been popularized as a specific test for SLAP tears.7 Rotation and a compressive force applied to the humerus in abduction may elicit a painful click (compression rotation test). A positive apprehension/relocation test may be demonstrated in patients with SLAP tears and associated anterior instability. Physical examination findings consistent with sub-acromial impingement or internal impingement may be seen. An abnormal arc of motion with an internal rotation deficit may be identified in throwers.

Plain radiographs of the shoulder are typically normal in patients with SLAP lesions. Magnetic resonance imaging is the gold standard study for the radiographic diagnosis of a SLAP tear.8 Intra-articular contrast may improve the ability to identify labral pathology. A positive study will demonstrate increased signal extending into the superior labral tissue. While the sagittal and axial images may demonstrate the tear, the coronal images are typically the most sensitive. Paralabral cysts visualized in the proximity of the superior labrum should raise suspicion of a SLAP tear.

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