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.
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.
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.
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.
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.
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.
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.
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.
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 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.
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
