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Stretches and Exercises for SLAP Lesions

Stretches and Exercises for SLAP Lesions - El Paso Chiropractor


When it comes to SLAP lesions, a type of shoulder injury, there are numerous types of treatment options available for the affected individuals. According to the type of lesion, the age of the individual and the functional level of the athlete, a specific treatment plan will be prescribed for these SLAP lesions. Labrum repair, biceps tenodesis, debridement, tenotomy, and conservative treatment are all frequently considered treatment options depending on the characteristics of the lesion.
Many variations of SLAP lesions can primarily be treated conservatively with methods to initially improve the patho-mechanical factors that affect SLAP lesions, such as glenohumeral internal rotation deficit (GHIRD) and scapular dyskinesis. With a majority of type 1 lesions, this can be significantly effective in eliminating the symptoms of the lesion without the need for surgery. However, once an athlete has surgically treated their SLAP lesions, they can follow a similar rehabilitation process to achieve overall wellness.

Types of Surgery for SLAP Lesions

Minor type-1 SLAP lesions may only require a simple debridement without disrupting the biceps anchor, whereas type-2 SLAP lesions are the most commonly seen type by many healthcare providers, involving a detachment of the biceps anchor from the labrum. Type-2 lesions can be treated with arthroscopic fixation of the superior labrum to develop biceps anchor stability.
Type 3 SLAP lesions are identified by bucket-handle tears along the superior labrum with intact biceps anchor. This bucket handle fragment can easily be debrided by an arthroscopic shaver, and further treatment may often not be needed. The other types of SLAP lesions are not as common as the type 2 lesions, although if they do occur, these will almost certainly require surgical intervention.
A large database study found that the highest incidence of repair is among the 20-29 years and 40-49 years of age groups. This is believed to occur due to the younger population’s higher participation in sports activities. In the 40-49-year-old group however, the high incidence most likely occurs due to the degeneration of the labrum, which may primarily develop around this age. Also men have a three times higher incidence of repair. This is believed to occur due to how males are more likely to participate in a sport which may cause SLAP lesions.  

Rehabilitation

Several guidelines have been developed when it comes to managing post-operative SLAP lesions. First, in injuries caused by a compressive mechanism, the individual must avoid weight bearing exercises on the affected limb during the early stages of injury to avoid the compression and shear effect on the labrum. Second, in injuries caused by a sudden traction, the individual must avoid any heavy, eccentric biceps load to minimize the traction effect on the biceps anchor. And last, in injuries caused by a peel-back mechanism, individuals must avoid excessive shoulder external rotations in the early post-surgical period. Keeping the above guidelines in mind, the general rehabilitation plan can be completed over six stages. The rehabilitation time frames for each phase is only an approximation but the key decision to progress from one stage to another must meet the exit criteria listed at the end of each rehabilitation phase. Most commonly, throwing and contact sport athletes generally return to competition at 6-9 months post-surgery, depending on the athlete and their specific sport.

Surgical Intervention 



The purpose of surgical intervention is to develop a strong enough repair of the injured structure in order to follow up with a more intense rehabilitation of the shoulder to speed up the recovery process. Surgical intervention for SLAP lesions is frequently performed under arhtroscoply. The basic SLAP lesion repair is as follows: First, the glenoid and labrum are roughened to increase the contact surface region and produce a blood clot which will benefit re-growth. Next, the locations of bone-anchors are chosen according to the size of the labral/SLAP lesions. Then, the glenoid is drilled for anchor implantation. And finally, the anchors are introduced and the suture component of the anchor is tied through the labrum, in tight contact with the glenoid surface.

A study conducted in 2011 determined that 87 percent of individuals who underwent
arthroscopic repairs after experiencing type II SLAP showed excellent results. However, the study also showed that only 74 percent of the affected individuals could return to pre-injury levels of competition for their specific sport. Full return to throwing and contact sports occurred among 80-90 percent of athletes overall.

Stage 1 Rehabilitation (weeks 1-3) 


During stage 1 of the rehabilitation process for SLAP lesions, the affected individual should foremost protect the shoulder to allow full tissue healing, starting with gentle, isometric scapular and rotator cuff strengthening. Generally starting at 5-7 days post-surgery, elite athletes should receive daily treatment while regular recreational athletes should receive treatment 1-2 times per week. At this stage, the individual should use sling immobilization to avoid biceps contraction, external rotations should be limited to 40 degrees with the arm by side. Also, abductions are not allowed, extensions past the body should not be practiced along with no forward flexions past 90 degrees. It’s important to also test the skin over the deltoid to rule out any axillary nerve hypersensitivity. Stage 1 rehabilitation may include active elbow extension movements, passive elbow flexions with no biceps contractions, passive flexions and external/internal rotations within the above limits. During the first 3 weeks, there should be no direct exercises but walking and biking with the sling on are allowed. The exit criteria for stage 1 must include no axillary nerve lesions and the injury should be pain-free in the protected shoulder sling. A post-surgical review may be required at 3 weeks to continue to the next stage of rehabilitation.

Stage 2 Rehabilitation (weeks 4-6)



During stage 2 of the rehabilitation process for SLAP lesions, the athlete must continue to protect the surgically repaired tissue, while progressing with scapular stability, to begin light shoulder muscle and rotator cuff activation. Daily treatment should still be followed by elite athletes and sub-elite/recreational athletes should follow treatment twice per week. Although some surgeons may allow this to be removed at 4 weeks post-surgery, the use of sling immobilization should still be continued with no biceps contractions, no abductions past 45 degrees, no extensions past the body and no forward flexions past 90 degrees. The use of soft tissue massages to the pectoralis minor/major, infraspinatus, upper trapezius, levator scapulae and biceps/triceps may be recommended at this point. Passive and active assisted flexion, abduction, and external/internal rotations above the individual’s limits may be practiced. External rotations can be pushed to 60 degrees in neutral. For strengthening, the athlete can begin isometric internal/external rotations, adductions/abductions and flexions/extensions within a neutral arm position with continued isometric scapula-setting exercises. Walking and biking with the sling on are allowed. The exit criteria for stage 2 must include no symptoms of pain while the shoulder is in its sling-protected position and a surgical review at week 6 may be required post-surgery to remove the sling and begin further rehabilitation methods.


Stage 3 Rehabilitation (weeks 7-12)



With stage 3 of the rehabilitation process for SLAP lesions, the goals of the procedure include restoring the individual’s active range of movement of flexion/abduction/external rotation to 90 percent on the other side while strengthening the rotator cuff and progressing scapular exercises into more functional positions. In elite athletes, daily physiotherapy should be followed while sub-elite athletes should follow treatment once per week to progress into rehabilitation exercises. The purpose of therapy at this phase is to continue soft-tissue work on rotator cuff tightness, and to tone the muscles of the pectoralis major/minor, latissimus dorsi and upper trapezius/levator scapula. During stage 3, it’s essential for the individual to gradually start to load the biceps, beginning with isometric techniques and then progressing to full-range elbow flexions. Biceps loading should still be avoided if the surgery included a repair of the bicep tear or a bicep tenodesis. Passive abduction, external rotations and horizontal extension movements should be avoided as these can add unnecessary strain. The affected individual can begin to use active shoulder flexions while in side-lying positions to reduce the weight of the biceps during weeks 7, 8 and 9. During weeks 10, 11 and 12, active flexions while standing may be used. For weeks 7, 8, and 9, the athlete can begin abductions in the supine to restrict the load on the biceps but active abductions while standing are still allowed while avoiding hand behind back positions in this stage. At the stage 3 of the rehabilitation process, strengthening exercises should include scapula exercises with arms at 90 degrees flexions, gentle, controlled biceps contractions with a Thera band while avoiding any shoulder extension positions. Also, leg training exercises should not include any weight on the shoulder, such as dumbbells, no back squats and no deadlifts as these tend to have a traction effect. Walking and biking are allowed as long as there are no arm movements. The exit criteria for stage 3 of the rehabilitation process must be met before progressing to the next stage by achieving full active and un-resisted shoulder flexion, abduction and external rotation without attempting to measure hand behind back positions. A three month review with a surgeon should be cleared before starting strength work.

Prone-Retraction Drill for Lower Trapezius


The individual should lie facing down with the arms positioned vertically, then slowly retract and depress the scapula. Hold for 5 seconds and return.

Prone-Retraction Drill for Lower Trapezius - El Paso ChiropractorProne-Retraction Drill for Lower Trapezius 2 - El Paso Chiropractor


Supine Protraction Drill for Serratus Anterior



The individual should lie supine, or facing up, with the arms positioned in 90 degrees flexion, holding a length of flexible tubing with the hands, followed by actively lifting the hands towards the ceiling. Perform sets of 10 repetitions.

Supine Protraction Drill for Serratus Anterior - El Paso Chiropractor


Stage 4 Rehabilitation (weeks 12-16)



By stage 4 of the rehabilitation process for SLAP lesions, the affected individual should be able to regain their active range of movement and restore the strength of their rotator cuff to be able to begin with gentle, gym-based exercises. Elite athletes may continue to receive treatment as needed, focusing on improving the symptoms of tightness on the posterior capsule through stretches and humeral head glides while sub-elite/recreational athletes may visit a healthcare professional for treatment once per week for an evaluation. The individual should be cautious and perform only low weight and low velocity movements, excluding swimming and throwing movements. The injured athlete can begin to push and regain full active flexion, abduction and rotation movements to improve their range of motion by carefully mobilizing the shoulder into full internal rotation hand behind back positions. Additionally, active posterior cuff stretches, such as the sleeper stretch and the hand behind back stretches can also help improve the range of motion within the shoulder. It’s important to avoid excessive pressure when performing the following stretches to prevent further injury. Rotator cuff, scapular and gym strengthening exercises are frequently used at this stage to rehabilitate SLAP lesions after surgery has taken place. Rotator cuff strengthening workouts should involve flexion and abduction positions while using external rotations sparingly as to not tighten the posterior cuff further and restrict mobility in the shoulder. For scapular strengthening, a variety of push-ups may be practiced: standing against the wall push-ups; against the wall push-ups with forward body lean; knees on floor push-ups; and full push-up position. Serratus anterior slide drills may follow as long as these are within the limits of shoulder pain. The closed kinetic chain with hands on the wall exercise is often used in both scapular retraction and scapular protraction positions together with the Thera band around the clock drill to also add scapular strength. Once the athlete begins to use gym strengthening exercises to rehabilitate from their post-surgery SLAP lesions, these should first, only include light horizontal pulling movements, such as the wide row, prone fly and seated row, together with controlled triceps extensions. The following weeks, exercises should include, light horizontal push movements, such as floor dumbbell press, with light dumbbell bicep curls, then, the individual should begin practicing light vertical pulling, such as pulldowns and close grip pulldowns while avoiding chin ups, and finally, the individual should progress to vertical push movements, such as front and side raises and hammer press drills, to ultimately achieve a proper rehabilitation of SLAP lesions at this phase.  At stage 4 of the rehabilitation process for SLAP lesions, the individual can begin running while avoiding aggressive arm actions, they can practice aerobic interval running, or they can participate on cycling and rowing training with no limits. Swimming and boxing should be ultimately avoided at this stage.

Sleeper Stretch


The individual can perform this by laying on the affected side with the arm positioned into a 90-degree shoulder flexion and elbow flexion and force the arm into internal rotation, holding for 15 seconds and repeating.

Sleeper Stretch - El Paso Chiropractor

Hand Behind Back Stretch


The individual can perform this by placing the hand behind their back, rotating the pelvis by moving the opposite knee over the body, holding for 15 seconds and then repeating.

Hand Behind Back Stretch - El Paso Chiropractor

Pec Stretch on Roller


An athlete can perform this by laying on a foam roller with the arms at 45-degrees abduction, and in external rotation/supination, holding for 5 minutes to stretch the pectoralis major and minor.

Pec Stretch on Roller - El Paso Chiropractor

Serratus Anterior Slide Drill


The athlete can perform this exercise by placing a foam roller on the wall and pinning the roller with the wrists. The individual should then protract the scapula and hold the protraction, rolling the roller up the wall using the forearms and simultaneously rotate the arms into external rotation. Hold at the top for 2-3 seconds then return.

Serratus Anterior Slide Drill - El Paso Chiropractor Serratus Anterior Slide Drill 2  - El Paso Chiropractor

Around the Clock Drill


The athlete can perform this exercise by placing some Thera tubing around the wrist, following by placing the hands on the wall in front of the chest. Protract the scapula and then move and touch the right hand into the 1-3-5 o’clock positions, then place the left hand into the 11-9-7 o’clock positions. Now retract the scapula and repeat the sequence.

Around the Clock Drill - El Paso Chiropractor Around the Clock Drill 2 - El Paso Chiropractor

Closed Kinetic Chain (CKC) Test


An athlete can perform this exercise by placing two pieces of tape 36 inches apart on the floor. While in a push up position (knees position may be used as well), place a hand on each piece of tape and as quickly as possible, the individual should lift one hand and place it on the other, then return the hand to the tape and repeat with the other hand. This counts for two touches. The athlete should repeat this process as quickly as possible and count hand touches in 15 seconds, then rest for 45 seconds and repeat.

Closed Kinetic Chain (CKC) Test - El Paso Chiropractor


Stage 5 Rehabilitation (weeks 16-22)



In stage 5 of the rehabilitation process for SLAP lesions, the individual should be able to regain full strength of their shoulder in all planes of movement. Treatment at this point should be followed as needed for myofascial release of the shoulder and scapular muscles, myofascial sling mobility and thoracic or rib cage mobility, especially in throwing sports. There should also be an unrestricted range of movement with slow progression of weight and speed into tendon loading positions, such as deep bench press and overhead press movements. Joint mobilization, trigger-point dry needling and manual therapy as well as strong stretches can be utilized to restore the shoulder’s last remaining degrees of movement. Other interventions to improve previous restricted mobility can be followed more intensively as well. Regarding general strength and conditioning, all shoulder planes of movement should now be incorporated while avoiding any behind the neck positions. The athlete can begin participating in chin ups. Furthermore, a careful progression of high bicep-loading movements can be followed, including rotational strength training to begin incorporating original shoulder function, specific to the athlete’s sporting requirements. The athlete may also need consistent guidance on other recommended exercises to improve shoulder function. In this phase of rehabilitation, the individual can participate in unrestricted running and sprinting with change of directions and can also start with swimming and boxing drills at this stage. The exit criteria for stage 5 of the rehabilitation process for SLAP lesions includes having the athlete be able to perform a CKC drill of 25 touches in 15 seconds with a pushing strength of 90% the original levels before the injury took place and there should be no apprehension in high velocity throwing actions.

Integrated Scapular/Rotator Cuff Exercises


Throwers Wind Up Drill


To perform the following exercise, the individual should first attach Thera tubing to a post at shoulder height, then follow by wrapping the tube around the upper arm, looping it back around the post and then holding it in their hands.

Throwers Wind Up Drill - El Paso Chiropractor

Throwers Release Drill


To perform this specific exercise, the individual should first place a square of foam or Dura disc on the wall at about shoulder height, then place the elbow against the wall and rotate the body around so that the arm and scapula are in line. The athlete can then actively protract and upwardly rotate the scapula, holding the scapula and rotating the arm internally.

Throwers Release Drill - El Paso Chiropractor

Stage 6 Rehabilitation (Week 22 Onwards) 


And finally, once the individual has reached stage 6 of the rehabilitation process for SLAP lesions, they may be able to return to competition with confidence and no apprehension. Strength conditioning in a gym should be continued to improve the function of the shoulder and continue strengthening the movements of the joint. Treatment should only be used as needed for maintenance of myofascial, neural and articular restrictions. The athlete’s range of motion in the shoulder should be full and unrestricted using a gradual progression of sport specific movements. The individual’s shoulder should be working to full strength in all lifting patterns post-surgery while still avoiding certain positions of full external rotation. Fitness levels should be unrestricted at this point. The exit criteria for stage 6 of the rehabilitation process for SLAP lesions should include no pain or apprehension with throwing movements or contact on the shoulder and a coaching staff and/or an athletic performance staff member should be confident that the athlete’s original skill acquisition has been achieved.

In conclusion, SLAP lesions are considered to be a relatively common injury among many throwing athletes and these can also be the origin of shoulder pain in the contact athlete. Unfortunately, certain types of SLAP lesions will require surgical intervention depending on their severity. The rehabilitation program following this type of injury may require plenty of time and patience to properly heal the injured shoulder, however, most athletes are able to return to their specific sport or physical activity at six to nine months following a necessary shoulder surgery.


Shoulder Stretches




By Dr. Alex Jimenez

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