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Environmental Factors Behind Thyroid Disease | Wellness Clinic

The thyroid gland is a butterfly-shaped organ located in the base of the neck. It's in charge of releasing essential thyroid hormones which control the body's metabolism, the way the body uses energy. The thyroid gland's hormones regulate vital body functions, such as breathing, heart rate, central and peripheral nervous systems, body temperature and more.

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The Different Types of SLAP Lesions and their Treatment

The Different Types of SLAP Lesions and their Treatment - El Paso Chiropractor

From baseball pitchers, tennis, swimming, water polo to throwing sport athletes who participate in overhead sports and physical activities, a tremendous amounts of stress is exerted on their shoulders and its surrounding structures when they perform strenuous activities in their specific athletics. For example, an elite baseball pitcher’s arm has been recorded at over 7000 degrees/second, which makes it the fastest human body movement from any sport.
Shoulder pain is the most prevalent symptom among the overhead athlete where throwing athletes will generally describe experiencing dead arm, defined as a condition which restricts them from throwing at pre-injury speeds or control. SLAP, or superior labrum anterior-posterior, lesions are frequent causes leading to this type of dysfunction.

What is a SLAP Tear?

A SLAP tear occurs on the glenoid labrum from the anterior to posterior angle of the long head of the biceps tendon. The glenoid labrum is a wedge-shaped fibrous tissue structure that is attached to the edge of the glenoid, functioning to deepen the glenoid cavity to improve stability as well as implement muscular control and proprioception. The anatomy of the proximal long head bicep tendon may actually vary but, in a majority of cases, it originates from the posterior superior labrum and it is broader and innervated more sensory fibres than the distal tendon.
There are four main subgroups of SLAP lesions: type 1, where the connection between the labrum and the glenoid remains intact while degeneration and some shredding has occurred. It’s believed this may not be a cause of many symptoms; type 2, the most common type of SLAP lesion which causes a majority of the symptoms and may require surgery to heal, involves the detachment of the superior labrum and the long head of the biceps tendon from the glenoid rim; type 3, where the meniscoid superior labrum tears and is removed from the joint but the connection between the tendon and the labral rim remains intact; and type 4, where the tear of the superior labrum extends into the tendon, partially removed from the joint along the superior labrum.

Types of SLAP Lesions - El Paso Chiropractor

Mechanism of Injury

Three main controversial theories have been proposed to explain the exact mechanism of injury for SLAP lesions. The deceleration theory suggests that in a throwing athlete, a SLAP lesion occurs during the deceleration stage of throwing as a result of the eccentric contractions of the biceps tendon. Moreover, they advised that this overloaded the biceps anchor, tearing it from its intra-articular attachment. A direct impact to the shoulder is also believed to be a cause for a SLAP lesion. For instance, if an athlete lands on an outstretched arm, the labrum may become compressed or pinched between the glenoid and the humerus. Currently, the mechanism of acceleration, or peel back, has been demonstrated to occur when the arm is in the cocked position of abduction and external rotation. Researchers described at the time that during arthroscopy in shoulder abduction and external rotation, the bicep tendon undertakes a more vertical and posterior angle which causes the base of the biceps to twist, resulting in a torsional force against the posterior superior labrum.
Furthermore, researchers compared these deceleration and acceleration theories during an experiment in cadaver models. First, they applied tension to the tendon of the biceps in which they were able to generate a superior labral avulsion in approximately 20 percent of the specimens using an increased force. To reproduce the mechanism of acceleration, or peel back, researchers positioned the arm in an abducted and externally rotated position. In about 90 percent of the shoulders tested, a type 2 SLAP lesion was generated with approximately 20 percent less force than in the deceleration model. The study concluded that the peel back mechanism is most likely to cause a SLAP lesion than the deceleration model, furthermore demonstrating that the bicep tendon is not pulled but rather peeled from the bone.

Auto Accidents and SLAP Lesions

While sports and physical activities are the most common cause for SLAP lesions, many individuals have reported experiencing shoulder pain and other symptoms suggesting a SLAP tear after being involved in an automobile accident. During an automobile accident, the rapid acceleration of the vehicle after an impact pushes the body into a forward momentum. Besides other common car wreck injuries, such as whiplash, the involved individual may also suffer shoulder injuries as a result of tightly gripping the steering wheel or even from reaching out at the exact time of the incident. For instance, when a mother accompanied by a passenger is involved in an automobile accident, their initial instinct is to reach over with a single arm and attempt to secure the passenger in their seat. Unfortunately, due to the momentum of the collision, the individual’s arm may be pushed away, causing damage on the shoulder and possibly leading to a SLAP lesion. Regardless of the cause of injury, SLAP lesions can be very painful, often being debilitating to the affected individual.

Clinical Presentation

Athletes with SLAP tears generally describe pain within the shoulder. Throwing athletes also often report weakness when throwing. While they may still be able to throw, their normal throwing velocity may decrease. Many individuals affected with SLAP lesions experience tightness on the back of their shoulder along with pain and weakness at the front, specifically over the coracoid process area. They may also describe a clicking or popping sensation when they throw. It’s essential to determine whether the symptoms are recent and if they are painful or not. As mentioned before, an athlete who experiences pain or weakness in the late cocking stage may have a SLAP tear whereas an athlete who only describes pain on follow-through may be more likely have impingement-related symptoms.

Standing Posture


Standing Posture - El Paso Chiropractor


Frequently, athletes with SLAP lesions experience an improper placement of the scapula at rest. Researchers describe that an asymmetrical placement of the scapula can be characterized by scapular malposition, inferior border prominence, coracoid pain and dyskinesis of scapula movement. It’s essential to point out the athlete’s thoracic posture as an increased kyphosis and a lack of trunk rotation an additionally increase the weight being placed against the shoulder during throwing motions.

Shoulder Range of Motion


Shoulder Range of Motion - El Paso Chiropractor


The range of motion of the shoulder may be evaluated to conclude the individual’s symptoms and restricted mobility. An athlete’s glenohumeral range of rotation should be properly analyzed in all overhead athletes. A thrower’s shoulder must have enough flexibility for excessive external rotation with plenty of dynamic stability to avoid subluxations, or misalignments. Glenohumeral range of rotation assessments are accomplished in a supine position with the arm in a 90-degree abduction. These athletes commonly experience an increase in the range of their external rotation due to a constant stretching of their anterior capsule in the cocking stage and/or humeral retroversion if they consistently practiced throws since a young age as well as a decrease in their internal range of rotation. A lack of internal rotation generally occurs as a result of a contracture on the postero-inferior capsule contracture, commonly referred to as GIRD, or glenohumeral internal rotation deficit. Sleeper stretches have been demonstrated to decrease GIRD as well as decrease the risk of shoulder injuries by up to 40 percent in major league baseball players.

Orthopedic Assessment for SLAP Lesions

 Various distinct shoulder evaluations to determine SLAP lesions have been previously described above, however, it’s essential to understand that these tests may not necessarily be sensitive or specific, therefore, several tests should be utilized in each examination. A SLAP lesion should be suspected if most of the following tests conclude as positive and prior history of a SLAP lesion is suspected.
Individual tests for SLAP lesions include:

O’Brien’s Active Compression Test


O' Brien's Active Compression Test - El Paso Chiropractor


During stage 1 of this test, the patient’s arm must initially be in a 90-degree flexion as its horizontally flexed, or adducted, 10 degrees with the thumb pointing down. The individual is required to withstand the healthcare professional’s downward pressure, noting the presence of any pain or symptoms.

O' Brien's Active Compression Test 2 - El Paso Chiropractor

During stage 2 of this test, an identical procedure is followed with the individual’s palm facing up. If the individual reports pain within the shoulder during the exercise but no pain after the exercise, the test is considered positive.  

Biceps Load 1


Biceps Load 1 - El Paso Chiropractor


For this assessment, the athlete suspected of injury must sit with the shoulder in a 90-degree abduction with an external rotation, or a position of apprehension, while the forearm is in supination, taking note of any painful symptoms. The individual will then be instructed to contract their biceps while the healthcare professional withstands elbow flexion. It is suggested that the contraction of the biceps may increase pain if there’s in the case of a SLAP tear while it would decrease pain in the case of an anterior instability only as the bicep contraction would stabilize the front of the shoulder.

Biceps Load 2


Biceps Load 2 - El Paso Chiropractor


This assessment was particularly developed to recognize the presence of SLAP lesions on the shoulder. The individual’s arm is placed in a 120-degree abduction along with a full external rotation while the elbow is supinated and flexed to 90-degrees. The individual is then indicated to flex their elbow while the healthcare professional withstands the load. Researchers describe a positive test is shown when the individual’s pain increases with the resisted elbow flexion.

 Resisted Supination Test


Resisted Supination Test - El Paso Chiropractor


This test is utilized to recreate the peel back mechanism believed to be responsible for SLAP lesions during throwing sports or physical activities. The evaluated extremity is placed in a 90-degree abduction with neutral rotation and the elbow is placed in a 60-70-degree flexion.The healthcare professional withstands supination while passively externally rotating the arm to end of range. A positive test is demonstrated when the individual experiences clicking, catching and anterior or deep shoulder pain only. Researchers added that with this test, posterior shoulder pain or apprehension does not necessarily suggest the presence of a SLAP lesion.

Crank Test


Crank Test - El Paso Chiropractor


The individual is placed supine with the arm in a 160-degree abduction in the scapula plane. The healthcare professional then applies an axial load to the glenohumeral joint while internally and externally rotating the shoulder. This test is considered positive if the individual’s pain is reproduced or a painful mechanical click is reproduced.

Dynamic Labral Shear Test


Dynamic Labral Shear Test - El Paso Chiropractor


The individual’s arm is placed in a 120-degree abduction and external rotation. The healthcare professional places shear stress on the arm by maintaining external rotation and horizontally abducting as well as lowering the arm from a 120 to a 60-degree abduction. A positive test is indicated by reproducing the individual’s pain or a painful click.

Treatment

Shoulder injuries in throwing athletes may be first managed utilizing conservative treatments focused on improving GIRD and/or scapula control. In a majority of cases, the entire kinetic chain must be evaluated and the proper exercises should be carried out according to the specific demands of the sport.

SLAP Lesions Treatment 1 - El Paso Chiropractor

For instance, a cricketer who bowls and throws with the right arm reported experiencing symptoms of pain and weakness in the shoulder with activity. The individual displayed symptoms of pain on the O’ Brien’s Active Compression Test, Biceps Load 2 and Dynamic Labral Shear Test. The individual also experienced pain through range on abduction, which improved when the position of the scapula was corrected, or tilted posteriorly. Moreover, the individual had no loss of glenohumeral range on the right side.

SLAP Lesions Treatment 2 - El Paso Chiropractor

Due to the success of posteriorly tilting the scapula upon experiencing pain during the assessment, treatment must be focused on lengthening techniques of the muscles which anteriorly tilt the scapula, helping to strengthen the lower and middle trapezius and further improving the condition of the scapula. The individual was assigned a range of exercises to improve scapula placement. The individual involved in the assessment experienced improved symptoms over a four-week period and was able to throw from the boundary without experiencing any symptoms.

SLAP Lesions Treatment 3 - El Paso Chiropractor

Conservative treatment may not always be successful, specifically if a type 2 SLAP lesion is present. In these instances, surgical procedures may be required and the athlete will take 9 to 12 months to return to their specific sport or physical activity and they will report that it takes up to two years to return to their pre-injury level of fitness.

SLAP Lesions Treatment 4 - El Paso Chiropractor

Rehab or Surgery for SLAP Lesions



Chiropractic for SLAP Tears

According to the severity of an athlete’s injuries, each individual may respond differently to treatment. Several studies have demonstrated that conservative treatment can help some athletes return to their specific sport of physical activity. A 2010 study displayed a 71 percent success rate, allowing athletes to return to participation levels after rehabilitation, although about 66 percent of these individuals were able to perform at the level prior to injury. Chiropractic care is an effective, alternative treatment option for a wide variety of musculoskeletal injuries and conditions, primarily focusing on the spine and nervous system dysfunction. After performing several evaluations to determine the source of an individual’s pain and symptoms, a chiropractor may commonly utilize spinal adjustments and manual manipulations to first correct any misalignments of the spine. Following these initial procedures, a chiropractor may use mobilization stretches and exercises to carefully restore strength, flexibility and mobility to the structures surrounding the shoulder. As with any type of injury or condition, time and patience is often required to fully restore the body back to its original condition of health.

By Dr. Alex Jimenez

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