superior labrum anterior to posterior (SLAP) tear
Superior Labrum Anterior to Posterior (SLAP) Tear Diagnosis
The diagnosis of a Superior Labrum Anterior to Posterior (SLAP) Tear lesion is usually made by obtaining the history, imaging studies, and physical examination.
The most common cause of Superior Labrum Anterior to Posterior (SLAP) Tear is due to falls onto the shoulder or outstretched arm, lifting heavy objects, traumatic dislocation and overuse from overhead sports (e.g. pitcher). Therefore patient should be asked about any such incidents and/or occupation. Additionally, patients should be asked about any of the following symptoms which are commonly associated with SLAP tears:
- A sensation of locking, popping, and/or catching in the shoulder
- Pain when lifting heavy objects overhead
- Recent decrease in shoulder strength and/or range of motion
- Feeling that the shoulder is going to ‘pop out of its socket’
Physical Examination of Superior Labrum Anterior to Posterior (SLAP) Tear:
Physical examination consists of evaluation of range of motion, strength and stability of the shoulder. The following examination maneuvers are used to assess for Superior Labrum Anterior to Posterior (SLAP) Tear:
- Active compression test (O’Brian’s sign) – The active compression test has two parts and is performed with the patient standing.
- The patient flexes his/her shoulder 90 degrees with the elbow in full extension.
- Next, the patient adducts their arm 10 degrees (moves it slightly toward the midline).
- The patient internally rotates his/her arm until the thumb points downward.
- The examiner then pushes the arm toward the floor while the patient resists by maintaining their arm in the starting position.
- This first part of the test may elicit deep shoulder pain or a clicking sensation in the glenohumeral region. The maneuver is then repeated with the patient’s arm fully supinated. The test is positive if the pain or click is reduced or eliminated during the second part of the test.
To perform the crank test:
- The patient stands and abducts his/her arm 160 degrees while keeping the arm in the plane of the scapula.[i]
- The elbow is flexed 90 degrees.
- The examiner then applies an axial load to the humerus with one hand while rotating the patient’s arm internally and externally with the other.
A positive test results in pain, a clicking sensation during the maneuver, or reproduction of symptoms similar to those experienced at work or sport.
During the Speed’s test:
- The patient’s arm is extended in full supination with the shoulder flexed.
- The patient is then asked to elevate the arm against a resisted isometric force applied by the examiner.
A positive test results in pain in the anterior shoulder.[ii] Note: Speeds test is often used as a test for biceps tendon pathology, however it is also useful for assessing SLAP lesions. When performed following the first two tests it is has a specificity of 90% and sensitivity of 70% for diagnosis of a SLAP tear.[iii], [iv]
Imaging studies are always performed during evaluation of any orthopedic injury. Radiographic evaluation often starts with radiographs (x-rays) of the shoulder.
- Radiographs: Common diagnostic x-ray views include: anteroposterior, axillary, scapular-Y and Stryker notch views. While the labrum of the shoulder does not show up on an x-ray since it is soft tissue, x-rays can be used to rule out alternate causes of pain and symptoms such as arthritis, Hill-Sachs lesion or a fracture.
- Computed tomography (CT) – CT scan with arthrography allows visualization of labral attenuation and hypertrophy and evaluation of shoulder joint instability. CT arthography has been shown to be highly accurate in diagnosis of SLAP tears, has good inter-observer concordance, however it has limited ability for classification of the specific labral tears.[v]
- Magnetic Resonance Imaging (MRI) – MRI is the gold standard radiologic test for evaluation of SLAP tears. MRI is used to visualize soft tissues such as the labrum. Many surgeons recommend use of a high-resolution non-contrast MRI to accurately diagnose SLAP tears.[vi] When there is suspected concomitant rotator cuff involvement, MR arthrography (performed with the patient’s arm in abduction and external rotation), provides accurate diagnosis. [vii] The characteristic finding of a SLAP tear includes a high signal (fluid on T2WI or arthrographic contrast on T1WI) extending into the superior labrum, and tracking into the labrum or biceps tendon.
- Ultrasonography – Ultrasonography, though rarely used, has been show to accurately depict labral tears and associated fractures in patients with anterior shoulder instability.[viii] It also helps detect other conditions in patients who have shoulder pain, such as full-thickness tears of the supraspinatus tendon, tendonitis of the long head of the biceps, and tears of the biceps.
In most cases, the first line treatment for a SLAP tear is non-surgical and includes anti-inflammatory medication, rest and physical therapy. Non-steroidal anti-inflammatory medication is often used; this includes medications such as ibuprofen and naproxen. Other medications such as prescription pain relievers can be used to alleviate discomfort.
Conservative Management: Conservative management (non-surgical treatment) of SLAP has been shown to be unsuccessful in most patients. A trial course (6 to 8 weeks) of physical therapy and rehabilitation is recommended for patients who are not professional athletes. If pain and mechanical limitations persist, then surgical treatment should be strongly considered.[ix]
Post-operative Outcomes: Most patients report good to excellent results, with little or no physical restrictions within 3 months after arthroscopic surgical repair.[x], [xi], [xii]
However, the results were not as good in patients who were throwing athletes.[xiii] Therefore surgical treatment of Superior Labrum Anterior to Posterior (SLAP) Tear due to over-use in athletes who throw over-head may be less successful than in other patients.
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[ii]Gill HS, El Rassi G, Bahk MS, Castillo RC, McFarland EG. Physical examination for partial tears of the biceps tendon.Am J Sports Med. 2007;35(8):1334. PMID:17369556
[iii]Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions.Am J Sports Med. 2009;37(11):2252. PMID:19095895
[iv]Oh JH, Kim JY, Kim WS, Gong HS, Lee JH. The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion.Am J Sports Med. 2008;36(2):353. PMID:18006674
[v]Kim YJ, Choi JA, Oh JH, Hwang SI, Hong SH, Kang HS. Superior Labral Anteroposterior Tears: Accuracy and Interobserver Reliability of Multidetector CT Arthrography for Diagnosis. Radiology
. Jul 2011;260(1):207-15. PMID:21518776
[vi] Connell DA, Potter HG, Wickiewicz TL, Altchek DW, Warren RF. Noncontrast magnetic resonance imaging of superior labral lesions. 102 cases confirmed at arthroscopic surgery. Am J Sports Med.
[vii] Dodson CC, Altchek DW. SLAP Lesions: An update on recognition and treatment. J Orth Sports PhysTher 2009; 39: 71-79. PMID:19194018
[viii]Taljanovic MS, Carlson KL, Kuhn JE, et al. Sonography of the glenoid labrum: a cadaveric study with arthroscopic correlation. AJR Am J Roentgenol
. Jun 2000;174(6):1717-22. PMID:10845512
[ix]Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg
. Mar-Apr 1998;6(2):121-31. PMID: 9682075
[x]Kim SH, Ha KI, Choi HJ.Results of arthroscopic treatment of superior labral lesions.J Bone Joint Surg Am.
[xi] Coleman SH, Cohen DB, Drakos MC, et al.Arthroscopic repair of type II superior labral anterior posterior lesions with and without acromioplasty: a clinical analysis of 50 patients. Am J Sports Med.
[xii] Schroder CP, Skare O, Gjengedal E, Uppheim G, Reikeras O, Brox JI. Long-term results after SLAP repair: A 5-year follow-up study of 107 patients with comparison of patient aged over and under 40 years. PMID: 22608888
[xiii] Ide J, Maeda S, Takagi K. Sports activity after arthroscopic superior labral repair using suture anchors in overhead-throwing athletes. Am J Sports Med.