SLAP+Lesion

There are four main SLAP lesion types, classified as Type I, II, III, or VI. Types II and VI include involvement of the long head of the biceps brachii tendon. The type of lesion will guide rehabilitation approaches, whether the patient chooses surgical or conservative treatment. The following describes each type in detail.

Type I SLAP lesions degenerative fraying of the superior labrum biceps attachment to the labrum intact, biceps anchor intact

Type II SLAP lesions biceps anchor has pulled away from the glenoid attachment “peel back” mechanism

Type III SLAP lesion bucket-handle tear of this superior labrum intact biceps anchor.

Type IV SLAP lesions bucket-handle tear of the superior labrum with tear EXTENDING into the biceps tendon torn biceps tendon and labrum displaced into the joint.

Complex SLAP lesions: combination of two or more SLAP types, usually II and III or II and IV.

__**DURATION**__: 6-9 months treatment



__**PROTOCOLS:**__ Physical Therapy Protocol’s s/p Surgical Repair In general, surgical approach for Type I and III tears is SLAP lesion debridement, and because the biceps tendon is stable, post-operative treatment can progress as patient tolerates with less ROM restrictions.

SLAP Debridement Protocol

Phase 1 (days 1-10) o PROM/AAROM o Isometrics-NO biceps for 7 days o Decrease pain and inflammation

Phase 2 (weeks 2-4) o Restore full PROM o Initiate isotonics o Begin trunk strengthening o Begin neuromuscular control drills and dynamic stability drills

Phase III (weeks 4-6) o Should have full PROM/AROM with no pain o Begin tubing exercises at 90/90 o Continue strengthening o Begin tubing exercises for biceps o Begin PNF o Continue proprioception and endurance exercises

Phase IV (week 7-on) o Initiate interval throwing program

Types II, VI, and complex lesions require that the tear be REPAIRED, and post- op ROM and strengthening restrictions must be adhered to strictly to protect the surgical anchors.

SLAP Repair Protocol

Sling for 4 weeks

Week 0-2 o Gripping exercises o PROM flexion to 60, 75 degrees o ER to 15, IR to 45 o NO ACTIVE ROM o Sub max isometrics o NO BICEPS CONTRACTION

Week 3-4 o PROM flexion to 90 o ER to 30; IR to 60 o No active ER, extension or elevation o Start rhythmic stabilization o Start tubing ER/IR at 0 degrees abduction

Week 5-6 o PROM flexion to 145 o ER to 50; IR to 60 o Start prone row, prone abd o Initiate stretching o Initiate PNF with manual resistance o NO BICEPS STRENGTHENING

Weeks 7-9 o Full ROM o Progress strengthening o Begin AROM of biceps

Week 10-12 o Begin ER at 90/90 o Progress into more aggressive strengthening

Week 12-16 o Begin resisted biceps/supination strengthening o Maintain throwers motion (ER)

Progress strengthening beginning light plyometric program

Week 16-20 o Begin and progress sport specific activities

In the article “Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete” out of the journal Physical Therapy in Sport, the authors describe a similar protocol with added detail supporting treatment in five different phases. Phase1: Protective Phases (Day 1-Week 6) Phase 2: Moderate Protection Phase (Week 7-12) Phase 3: Minimum Protection Phase (Week 13-20) Phase 4: Advanced Strengthening Phase (Weeks 21-26) Phase 5: Return to Activity (Months 6-9)

The above article also promotes pre-surgical conservative treatment including the following
 * __Conservative Physical Therapy for SLAP Lesions__**
 * Conservative course of treatment ALWAYS indicated for overhead athlete
 * Endurance and strength training for rotator cuff muscles
 * Focus on scapular stabilization
 * Stretching and mobilization of tight posterior GH capsule/cuff
 * HEP with focus on stretches to increase IR

An additional article titled “Nonoperative Treatment of Superior Labrum Anterior Posterior Tears : Improvements in Pain, Function, and Quality of Life” out of The American Journal of Sports Medicine describes results of a study conducted to compare operational vs. conservative management of SLAP lesions.

PT treatment included:
 * Posterior capsule stretching
 * Scapular dynamic stabilization exercises
 * Treatment group also prescribed NSAIDS

Conclusions:
 * Significant functional improvement in non-surgical treatment group
 * Decreased pain scores
 * Improved quality of life
 * 15/18 subjects returned to overhead sport activity in less than 6 months
 * 10/15 that returned to sport indicated they performed at the same level or a better level than prior to conservative PT treatment

Bottom Line: Half of the patients in this study did require surgery due to complex, non-stable tears; however, for those athletes who completed conservative treatment, functional results and quality of life improved to comparable levels of those treated with operative approach.

Edwards, Sara L, Jessica A, John-Erik Bell, Jonathan D Packer, Christopher S Ahmad, William N Levine, Louis U Bigliani, and Theodore A Blaine. "Nonoperative Treatment of Superior Labrum Anterior Posterior Tears : Improvements in Pain, Function, and Quality of Life." //American Journal of Sports Medicine// 38.7 (2010): 1456-1461. //PubMed//. Web. 17 Apr. 2012. Manske, Robert. "Superior Labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete." //Physical Therapy in Sport// 11.4 (2010): 110-118. //PubMed//. Web. 17 Apr. 2010. "SLAP Lesion - Physiopedia, universal access to physiotherapy knowledge.." //Main Page - Physiopedia, universal access to physiotherapy knowledge.//. N.p., 7 June 2011. Web. 18 Apr. 2012. . Will, K, et. al. "Arthroscopic Labral Repair Protocol-Type II, IV, and Complex Tears:." //Brigham and Women's Hospital//. N.p., n.d. Web. 17 Apr. 2012. <www.bosshin.com/_userfiles/Shoulder%20-%20%20SLAP%20II%20&%20IV%20&%20Co