Skip to main content

Todays Trending Topic ♛

Interventional Chronic Pain Management Treatments | Central Chiropractor

Chronic pain is known as pain that persists for 12 weeks or even longer, even after pain is no longer acute (short-term, acute pain) or the injury has healed. Of course there are many causes of chronic pain that can influence any level of the spine, cervical (neck), mid back (thoracic), lower spine (lumbar), sacral (sacrum) or some combination of levels.

What treatments do interventional pain management specialists perform?
Oftentimes, early and aggressive therapy of chronic neck or back pain can earn a difference that is life-changing. But remember that knowledge is power: Be certain that you know your choices. There are various treatment procedures and treatments available for chronic pain, each completed by a treatment specialists. Interventional pain management specialist treatments may be a fantastic solution for some people with chronic pain symptoms.

Interventional Pain Management Specialists
Interventional pain management (IPM) is a special field of medicine that uses injecti…

SLAP Lesions, The Overhead Athlete & Science

Science based therapist, Dr. Alexander Jimenez looks at the several types of SLAP lesions, a few frequent clinical indicators, orthopedic evaluations and explores the very best rehab methods...

Overhead athletes (like baseball pitchers, tennis, swimming, water polo and throwing athletes). All put enormous strain on their shoulders when participating in their chosen sport. An elite baseball pitcher's arm was listed at over 7000deg/second which puts it arguably as the fastest human body movement in game. This all happens at a joint that's been likened to a golf ball sitting on a tee -- ie it is structurally unstable. Considering all of this, is it any wonder that shoulder pain is a common occurrence in the overhead athlete? Throwers with shoulder pain will often complain of a "dead arm" which restricts them from throwing at pre-injury velocity/or control. SLAP (Superior Labrum Anterior-Posterior) lesions are common causes of this "dead arm" and will be the focus of this article.

What Is A SLAP Tear?

A SLAP tear is a tear of the glenoid labrum from anterior to posterior of the long head of biceps tendon. The glenoid labrum is a wedge-shaped fibrous tissue structure that's attached to the edge of the glenoid and its function is to weaken the glenoid cavity, thus improving stability, and it also has a role in muscle control and proprioception(1). The anatomy of the proximal long head bicep tendon is variable but typically it is derived from the posterior superior labrum and is wider and more densely innervated with sensory fibers compared to its distal tendon(5). Snyder has described four main subgroups of SLAP lesions(4) (see Figure 1):

Type 1 – the attachment of the labrum to the glenoid is intact but there is some fraying and degeneration. This is not thought to be the cause of many symptoms.

Type 2 – involves detachment of the superior labrum and long head biceps tendon from the glenoid rim. This is the most common type of SLAP lesion causing symptoms and often requires surgery.

Type 3 – the meniscoid superior labrum is torn away and displaced into the joint but the tendon and labral rim attachment remains intact.

Type 4 – the tear of superior labrum extends into the tendon, part of which is displaced into the joint
along with the superior labrum.

What Is The Mechanism Of Injury?

The exact mechanism still remains controversial with three major theories present. The deceleration theory initially proposed that in a throwing athlete a SLAP lesion happened during the deceleration phase of projecting as a result of eccentric contraction of the biceps tendon(7). They suggested that this overloaded the biceps anchor that detached it from its intra- articular attachment. A direct blow to the shoulder has also been believed to be a cause for a SLAP lesion -- for instance, an athlete landing in an outstretched arm might compress/pinch the labrum between the glenoid and the humerus(1). More lately, Burkhart described the acceleration or "peel back mechanism" which occurs when the arm is at the cocked position of abduction and external rotation. They explained that during arthroscopy in shoulder abduction and external turning the thoracic fascia presumes a more vertical and posterior angle which generates a twist at the bottom of their biceps and a torsional force on the anterior superior labrum(1).

Kuhn experimentally compared the deceleration and acceleration theories in cadavers models(1). They applied a brute force to the biceps tendon from the follow through place and were able to generate a superior labral avulsion in 20% of his specimens with a massive push. To simulate the peel back mechanism they placed the arm at an abducted and externally rotated position. In 90% of the shoulders analyzed, they could create a type 2 SLAP lesion with 20 percent less force than at the deceleration version. From this it can be proposed that the peel back mechanism is more likely to cause a SLAP lesion than the deceleration model and that the bicep tendon is not pulled but peeled from the bone.

What Is The Clinical Presentation?


Athletes who have a SLAP tear will often describe pain deep in the shoulder and it can be anterior or posterior. A throwing athlete may describe weakness when they throw and may state that they have lost their “zip”. Often the athletes may still throw, but maybe not at their normal velocity. They may describe a history of tightness on the back of their shoulder and pain/ weakness at the front especially within the coracoid process area(8). They may also clarify a click or pop when they toss and it is important to ascertain whether these symptoms are fresh and/or are painful. From the throwing athlete, it's important to inquire when exactly from the casting action they obtain their pain. As outlined earlier, an athlete that has pain/weakness at the late night phase may have a SLAP tear whereas an athlete who merely explains pain on follow-through may be more inclined to have impingement-type pain.


Standing Posture

Ordinarily, overhead athletes with SLAP tears will have poor scapula position at rest on their dominant side: Figure 2 shows inferior scapula position in a right-arm thrower. Burkhart explained this asymmetrical scapula position as with a SICK (Scapular malposition, Inferior border prominence, Coracoid pain and dysKinesis of scapula motion) scapula(3). It is also important to note thoracic posture, as increased kyphosis and lack of trunk rotation can also increase load on the shoulder when throwing.

Shoulder ROM

Active ROM of the shoulder must then be assessed to ascertain any motion restriction or pain. Glenohumeral rotation range ought to be assessed in all overhead athletes. A thrower's shoulder needs to have enough laxity to allow for excessive external rotation (demand of good throwing) with adequate dynamic stability to avoid subluxation. Glenohumeral rotation array is conventionally done in supine with the arm in 90-degree abduction. Commonly these athletes will get an increase in external rotation range (possibly due to repetitive stretching of their anterior capsule at the cocking phase and/ or humeral retroversion when they threw a lot if they were young) and a drop in internal rotation range. This absence of internal rotation range is frequently due to contracture of the posteroinferior capsule contracture and is popularly known as GIRD (Glenohumeral Internal Rotation Deficit). Sleeper stretches (see Figure 3) have been demonstrated to not only reduce GIRD but also to reduce shoulder injuries by around 40% in major league baseball players(1).


A Case Study

Shoulder injuries in the throwing athlete would be initially managed with conservative therapy with therapy focused on improving GIRD and/ or scapula control. In most cases the whole kinetic chain should be assessed and proper exercises should be implemented based upon the requirements of their game.

Figure 2 reveals a cricketer who bowls and throws with his right arm. When I first saw him, he complained of pain and "fatigue" in his shoulder when he bowled and threw from the boundary. He also had pain through range on abduction, which resolved if his scapula position was fixed (posterior tilted). He had no reduction of glenohumeral range on his right side. In this case (because of the success of posteriorly tilting his scapula on his pain through the evaluation) treatment focused on lengthening techniques of the muscles that anteriorly tilt his scapula, ie pec minor, and strengthening for his lower and middle trapezius that help to posteriorly tilt his scapula. This player was given a range of exercises in prone to improve his scapula position (see Figures 10 - 11).

His pain improved over a four- week period and he is now able to throw in the boundary without any signs.

Conservative treatment isn't always effective especially if a type 2 SLAP lesion is current. In such cases operative therapy is required and the athlete can take 9-12 months to return to sport and they'll report that it requires up to two years to go back to their pre-injury level.


In summary, SLAP lesions are typical in the overhead athlete and a structured evaluation particularly looking at scapula control, glenohumeral rotation range in addition to orthopaedic tests can help to identify when a SLAP lesion is current and will also help direct therapy. Frequently in elite-level athletes, particularly when a type 2 lesion is present, surgery is needed(4).

1. Burkhart S, Morgan C, Kibler B (2003) The disabled throwing shoulder: Spectrum of pathology, Part 1: Pathoanatomy and Biomechanics. Arthroscopy: the Journal of arthroscopic and related surgery, Vol 19, No4, 404-420
2. Burkhart S, Morgan C, Kibler B (2003) The disabled throwing shoulder: Spectrum of pathology, Part 2: Evaluation and treatment of SLAP lesions in throwers. Arthroscopy: the Journal of arthroscopic and related surgery, Vol 19, No5, 531-539
3. Burkhart S, Morgan C, Kibler B (2003) The disabled throwing shoulder: Spectrum of pathology, Part 3: The SICK scapula, scapula dyskinesis, the kinetic chain and rehabilitation. Arthroscopy: the Journal of arthroscopic and related surgery, Vol 19, No6, 641-661
4. Brukner P and Khan K (2012) Clinical Sports Medicine 4th edition McGraw Hill
5. Krupp R et al (2009) Long head of bicep tendon pain: differential diagnosis and treatment. Journal of orthopaedic and sports physical therapy Vol 39, no 2 55-70
6. McFarland E, Tanaka M, Papp D (2008) Examination of the shoulder in the overhead and throwing athlete, Clinical Sports Medicine 27, 553-578
7. Myers T et al (2005) The resisted supination external rotation test; A new test for diagnosis for SLAP lesions, the American Journal of Sports Medicine, Vol 33, No9 1315-1320
8. Ryu J, Pedowitz R (2010) Rehabilitation of bicep tendon disorders in athletes. Clinical Sports medicine 29 229-246

Popular posts from this blog

Pain in the Quadratus Lumborum Muscle

A majority of the population have at some point experienced low back pain in their lifetimes. Although low back pain is recognized to result from numerous conditions or injuries on the lumbar spine, muscle strains such as a quadratus lumborum muscle strain, are believed to be a leading cause for the recognizable symptoms of pain and discomfort.
The quadratus lumborum muscle is a sizable muscle in the shape of a triangle, located deep on each respective side of the lower back. The role of the wide muscular tissue is to grant mobility to the lumbar spine in sequence for the torso to move laterally from side to side as well as extend and stabilize the lower spine to improve posture. When this muscle is strained or pulled, the symptoms can restrict movement on the lower back and since the muscular tissue is so extensive, recovery from this type of injury usually requires more time and patience to fully heal.

Quadratus Lumborum Syndrome V.S. Facet Joint Syndrome
When symptoms of back pa…

Achilles Tendon Injury

Achilles tendonitis is a medical term used to describe a condition resulting in irritation of the large tendon, the Achilles tendon. Found in the back of the ankle, this condition is recognized as a common cause for injury among athletes. Excessive use of the Achilles tendon results in inflammation together with swelling and pain.
The development of Achilles tendonitis can be associated with two important factors, most frequently among athletes, which are, lack of flexibility and over-pronation. With age, the tendons will begin to lose flexibility, just the same as other tissues in the body. This change causes the tendons to become more rigid and more vulnerable to injury. For some people, the ankle may roll too far downward and inward with each step they take. This is called over-pronation, which places more stress on the tendons and ligaments of the foot, contributing to injury if not corrected.
Achilles tendonitis may also develop from other factors. An increase in an athlete’s …

5 Common Causes for Shoulder Pain

The shoulders are the most mobile joints in the human body. Because the ball of the humerus is designed to be larger than the shoulder socket that holds it, the shoulders need to be supported by muscles, tendons, and ligaments to secure them in a stable or natural position. Since the shoulder can be unstable, it is often a site for many common complications. Below are 5 common causes of shoulder pain and their associated symptoms.
Rotator Cuff Tear
Rotator cuff tears within the shoulder are a very common type of shoulder injury. The rotator cuff consists of a set of four muscles: the supraspinatus, the infraspinatus, the subscapularis, and the teres minor. All of these muscles are attached to the bones of the shoulders by tendons, which purspose is to support, stabilize, and grant the arm movement to move up, down and rotate. The rotator cuff ensures that the arm remains in the shoulder socket. Damage or injury from an accident or gradual wear and tear can result in inflammation to t…

Today's Chiropractic

Location Near You

Community: Google+ Followers 10K+