Superior Labral Anterior Posterior Repair
Timothy F. Tyler and Craig Zeman
Introduction
Superior labral anterior posterior (SLAP) lesions were not realized until the advent of shoulder arthroscopy. Andrews, Carson, and McLeod1 were the first to describe labral tears of the biceps anchor, but it was Synder2 who was the first to classify them, outline their treatment, and describe four basic types of lesions: I to IV (Fig. 6-1). Since then, several other variants have been described. So as to not get caught up in the subtleties of the classifications, SLAP lesions can best be understood by how they are treated and by the patient’s concurrent diagnosis. The two major ways that a SLAP lesion can be treated are by débridement and repair. SLAP lesions are seen in patients who either have instability or impingement, and the kind of rehabilitation patients receive is determined by which factors they have.
Overall, nonoperative management has proven unsuccessful for a large number of patients with unstable SLAP lesions,1,3,4 but Edwards feels that a course of nonoperative conservative management of nonsteroidal antiinflammatory drugs (NSAIDs) and physical therapy should be tried. A 50% failure rate was observed in their study.5 In many studies, patients underwent diagnostic arthroscopy at an average of 12 to 30 months from their initial symptoms. In one study, patients had an extended trial of activity modification and rehabilitation exercises.6 Most patients had been treated with rest, physical therapy, steroid injections, and NSAIDs without relief of their symptoms before diagnostic arthroscopy. Arthroscopic tools, anchors, and sutures have continued to advance making the surgical treatment more effective and easier to perform.7–16 Treatment of these lesions is directed according to their type.* In general, type I and III lesions are débrided, whereas type II and many type IV lesions are repaired.4,17–19 After all SLAP repairs, rehabilitation plays an integral part in the patient’s outcome.20
Surgical Indications and Considerations
Cause
The superior labral is part of the attachment of the long head of the biceps.3,9,11,21 The role of the long head of the biceps is to be a humeral head depressor and an anterior stabilizer.7,10 The SLAP area is in continuity with the anterior and posterior labrum. Therefore a tear in the superior labrum can affect the entire labrum, and conversely a tear in the anterior or posterior labrum can disrupt the superior labrum. The classic mechanism to develop a SLAP lesion is force, which either pushes the humeral head over or pulls the humeral head away from the superior labrum.8,22 The humeral head will pull on the superior labrum and the biceps anchor tearing them away from the glenoid.23,24 In addition, a tear of the anterior or posterior labrum from a dislocation can extend into the superior labrum. Repetitive overhead lifting, which can pinch the superior labrum and pull on it in a downward fashion, can also cause degenerative SLAP tears. In the deceleration phase of pitching, the biceps fires to stop the elbow from hyperextending, which causes a force to be placed across the superior labrum. It is this repetitive action that is felt to cause SLAP lesions in pitchers.25
Clinical Evaluation
The therapist should look in the patient’s history for an injury that placed an upward shear force across the shoulder—a fall on an outstretched arm that was overhead or that placed a traction force across the arm, a sudden grab and pull on something, having the arm pulled forcefully (e.g., the shoulder getting pulled on while waterskiing)—as well as mild instability in the shoulder with the repetitive throwing motion.26–28 Some patients can develop SLAP lesions with no apparent cause. In questioning for cause, it is important to ask about repetitive overhead lifting and throwing activities. Patient complaints can range from instability to a vague ache in the shoulder. Many patients can show signs of impingement, and some have symptoms of locking, popping, and catching. No classic symptom pinpoints a SLAP lesion. Many physical examination tests have been described to help diagnose a SLAP lesion.4,17,20,29 The two most common are the Speeds test and O’Brien test, which are modified supraspinatus isolation tests and therefore can be positive if the patient has impingment.30 The problem with diagnosing a SLAP lesion is that it is usually found in combination with either impingement or instability. Overall it appears that the primary authors of these tests report overall good sensitivity and specificity but other authors are unable to repeat their results when tested.31–39 The clinician needs to be aware of other problems that can be associated with SLAP lesions such as ganglion cyst, rotator cuff tears, posterior instability, and acromioclavicular (AC) joint arthritis.40–46
Diagnostic Testing
Plain radiographs are of little use in evaluating a SLAP lesion. Magnetic resonance imaging (MRI) with gadolinium is probably the best way to see a SLAP lesion.47–56 An MRI without gadolinium has been reported to have had some success.57 The problem with an MRI is that it can be too sensitive and tends to “overread” the lesion. A computerized tomography (CT) scan with contrast and three-dimensional (3-D) reconstruction can also be used to see labral tears, but once again it can be too sensitive. A glenolabral cyst can be seen on both MRI and CT scan and can be commonly caused by a SLAP lesion.58
Surgical Procedure
The treatment of SLAP lesions is an arthroscopic procedure. It is very difficult if not impossible to treat a SLAP lesion open. Most SLAP lesions are found on diagnostic arthroscopy; therefore the surgeon must be prepared to treat a SLAP lesion at the time of surgery.
Type I
These lesions are simply the fraying of the superior labrum without any significant detachment of the labrum from the superior glenoid (Figs. 6-1, A, and 6-2). The frayed area usually covers a portion of the superior glenoid; however, no gross instability of the labral tissue exists. This lesion is commonly seen in patients with impingement or rotator cuff tears. It is not usually seen in patients with instability and it does not seem to cause capsular laxity. These lesions are simply débrided down to the attached base of the superior labrum with an arthroscopic shaver (Fig. 6-3).59
Type II
These lesions have an unstable attachment of the superior labrum. The base of the labrum is pulled away from the superior glenoid and is highly mobile (Figs. 6-1, B, and 6-4, A). If the labrum pulls away from the superior glenoid more than 3 to 4 mm when traction is applied to the biceps tendon, the tear is considered unstable.60–63 When the labrum is reduced, one will usually see a reduction in the capsular volume and a change in the position of the anterior and posterior labrum to a more upright position (Fig. 6-4, B). A type II lesion needs to be surgically reduced (Fig. 6-5, A and B). It is done through three portals: one posterior and two anterior. Some type of anchor with suture attached will be used to repair the tear. The detached labrum will be reattached to its anatomic position on the glenoid.
Once the portals have been established, a burr is used to débride the bone of the superior glenoid under the torn labrum. This exposes a bleeding bed of bone that will aid in the healing process. Any loose or frayed ends of the labrum are débrided down to a stable base, and an anchor is placed into the prepared bone through the superior portal. The next task is to pull the two suture ends through the torn labral tissue. This can be done in a multitude of ways; the general concept is as follows: A device with a loop on the end is passed through the torn labral tissue. One end of the suture is then placed into this loop, which is then pulled back through the labral tissue pulling the suture through the labrum. This process is repeated again so that both ends of the suture are passed through the labrum. Using arthroscopic tying techniques, the torn labrum is firmly reattached back down to the bone of the glenoid (Fig. 6-6). Depending on the size of the tear, more anchors may need to be used to get a secure repair.
Type III
A type III SLAP can be thought of as a bucket handle tear of the labrum (Figs. 6-1, C, and 6-7, A and B). The unstable handle portion floats around inside the glenohumeral (GH) joint, getting caught between the humeral head and the glenoid during shoulder range of motion (ROM). This pulls on the labral and capsular tissue, producing pain in the shoulder. The portion of the labrum not involved in the tear is normally firmly attached to the glenoid; therefore the symptomatic part is the bucket handle tear, which can simply be débrided down to a stable base such as a meniscus tear in the knee.
Type IV
This lesion involves a bucket handle tear of the labrum, which extends into the biceps tendon (Figs 6-1, D, and 6-8, A–C). Treatment of these lesions depends on the extent of the tear and the age and activity level of the patient. If at least 30% of the biceps remains and the remaining portion of the labrum is stable, the torn part can be débrided down to stable tissue. The surgical options are much more complicated if more than 30% of the biceps is torn. In a less active individual, a good option would be to débride the tear and perform a biceps tenodesis. In a throwing athlete, the best option might be to stabilize the labral tear like a type II lesion and repair the tendon of the biceps. A repair would help stabilize an unstable shoulder.
Combined Lesions
SLAP lesions can be seen with anterior and posterior labral tears and with impingement and rotator cuff tears. All other surgical lesions should be treated at the same time as the SLAP repair. More times than not, the therapist will be rehabilitating patients who have undergone multiple procedures. There has been controversy over whether during a rotator cuff repair a SLAP repair should be done. A review of these papers would suggest that in middle-age patients, it is probably best not to repair the SLAP because this can lead to increased stiffness after the surgery.64–66 In contrast, Levy and associates67 demonstrated that predictable short-term surgical results and return to activity can be expected after repair of type II superior labrum anterior posterior lesions in patients younger than 50 years who have a coexistent rotator cuff tear. 
It is important to understand every procedure that has been done to the patient so that a proper treatment plan can be designed.
Outcomes
Overall mixed results of operative treatment of SLAP lesions and nonoperative care have been reported.68–71 Short-term improvement can be seen in patients with just simple débridement, but at long-term follow-up, the patients had a high failure rate.72 This failure is probably because the underlying instability was not addressed. Early treatment with staple fixation yields good to excellent results in 80% of the patients.68 The first reports of suture anchor repair had 100% success.29 A review of later reports using various techniques of fixation have seen a success rate of about 85%.17,20,73 Stetson and associates4 reported on patients who had SLAP repairs and no other procedures for whom an 82% success rate was achieved. Recently, better results with longer follow-up have been reported after type II SLAP repair, especially in those athletes with traumatic injury and repair.73,74 Properly performed treatment of SLAP lesions is a reliable procedure.
Therapy Guidelines For Rehabilitation
Postoperatively, the shoulder is placed in a sling without a swathe for 2 to 4 weeks to minimize biceps muscular activity and protect any additional structures addressed during the surgical procedure. The position of the arm is in internal rotation (IR) slightly anterior to the frontal plane. Because the early labral tensile strength is weak, the early rehabilitation program is more conservative than other open-stabilization procedures.29,47,68
The main focus of the early protective postoperative period (up to 4 weeks) is to maintain proximal and distal strength and mobility, provide pain relief, and prevent selective hypomobility of sections of the capsule as a result of iatrogenic change from the surgery. During this period, elbow ROM and gripping exercises are encouraged. The authors have found that instructing patients to sleep with a pillow under their elbow to support the shoulder may take stress off the labrum and reduce discomfort. Modalities can be useful tools in providing pain relief. The level of pain, postoperative swelling, and type of SLAP tear that was surgically addressed will determine progression of the patient.48,49 As the treating clinician, good communication with the surgeon is essential to proper care.48 Understanding the specific procedure, concomitant injuries, and tissue quality may also affect the level of progression.
The rehabilitation process will focus on four keys to success:
Phase I (Early Protective Phase)
TIME: Day 1 to 4 weeks after surgery
GOALS: Protect surgical procedure, educate patient on procedure and therapeutic progression, regulate pain and control inflammation, initiate ROM and dynamic stabilization, neuromuscular reeducation of external rotators and scapulothoracic muscles
Initial Postoperative Examination
Outpatient physical therapy can begin as early as 3 days after SLAP repair. At this time the mobility of the sternoclavicular (SC) joint, AC joint, and scapulothoracic joint are addressed and mobilized if indicated. Initial evaluation documentation should include the observation of the portal sites, atrophy, swelling, posture, and functional difficulties. Observation and documentation of ROM and general willingness to move the shoulder and neurovascular measurements should be documented. 
Care should be taken to avoid contracting the biceps (active elbow flexion) until week 2. Tests to assess shoulder instability or labral pathology at this point would be inappropriate.
Early Protective Postoperative Rehabilitation
Once the milestone of mobility of the proximal joints is obtained, manual scapular stabilization is initiated. In the side-lying position, manual resistance can be given to the scapula to resist elevation, depression, protraction, and retraction (Fig. 6-9). Pain can be a limiting factor for starting scapular stabilization and rotator cuff isometrics; however, submaximal pain-free alternating isometrics for IR and external rotation (ER) may begin as early as 7 days after surgery (Fig. 6-10). Because the rotator cuff muscles are not violated, this exercise can begin with the arm at the side. Early mobilization exercises such as the pendulums are recommended for pain relief and could prevent adhesions from forming. Pendulums have been shown to produce very little muscular activity and are considered to be a safe exercise during this period for most shoulder surgeries.58
However, some surgeons feel the arm hanging in a dependent position may put unwanted stress on the repaired labral. Initiation of active assistive range of motion (A/AROM) using a pulley for sagittal plane flexion and scapular plane elevation is advised. In addition, a cane, golf club, or umbrella can be used to assist with regaining flexion, abduction, adduction, and ER at 0° and 30° of abduction (or where the surgeon sets the shoulder during surgery). Gentle mobilization (grades I and II) consisting of posterior glides can be performed at this time for pain relief.
Contraindications
• No ER past the set point for 3 weeks
• No ER in the 90°/90° position for 6 weeks to avoid the peel-back mechanism
Early strengthening of the serratus anterior muscle is also encouraged if it is maintained slightly below 90° of shoulder flexion and is pain free. Subsequent atrophy of the serratus anterior muscle, as a result of immobilization, may allow the scapula to rest in a downwardly rotated position, causing inferior border prominence. Decker and associates75 used EMG to determine which exercises consistently elicited the greatest maximum voluntary contraction (MVC) of the serratus anterior. It was revealed that the serratus anterior punch, scaption, dynamic hug, knee push-up with a plus, and push-up plus exercises consistently elicited more than 20% of MVC. Most importantly, it was determined that the push-up with a plus and the dynamic hug exercises maintained the greatest MVC, as well as maintained the scapula in an upwardly rotated position (Fig. 6-11). Although it would be too early in the rehabilitation process to perform these later exercises, Decker and associates75 highlighted the serratus anterior punch as a valuable exercise. Performed in a controlled, supervised setting, this is an excellent choice to initiate early serratus anterior strengthening. Transition to the more challenging serratus anterior exercises should occur after 8 weeks and be based on logical exercise progression.
A fine line exists between pushing patients too hard and progressing them as planned. Often patients may feel better than expected during this early protective phase, so therapists must always respect the laws of tissue healing. Three milestones to achieve for progression to the next phase of rehabilitation are (1) to educate the patient on the procedure he or she had and what to expect during the rehabilitation, (2) to provide some pain relief so that the patient is able to tolerate submaximal isometrics of the rotator cuff muscles at 0° abduction, and (3) to attain symmetrical mobility of the SC, AC, and scapulothoracic joints, as well as the ability to protract, retract, elevate, and depress the scapula against submaximal manual resistance. A/AROM goals include achieving flexion to 110° to 130°, abduction to 70°, scapula plane IR to 60°, and scapula plane ER to set point.
Phase II (Intermediate Phase)
TIME: 5 to 8 weeks after surgery
GOALS: Normalize arthrokinematics, gains in neuromuscular control, normalization of posterior shoulder flexibility
During weeks 5 to 8, three visits per week should focus on the return of scapular stability and GH ROM. Later in this period, rotator cuff isotonic strengthening is initiated. During this period, the patient removes the sling, and more aggressive A/AROM exercises are initiated. These exercises may include the use of a pulley or cane to assist in forward elevation in the plane of the scapula and IR. Initially, ER stretching is performed in the guarded neutral position with the arm at the side, and then it is progressed into the scapular plane. While progressing through rehabilitation, the therapist should always consider patients’ morphology, understanding if they are hypermobile by nature and returning motion quickly and easily; if so, they do not need to be pushed.
Patients with excessive joint laxity or generalized joint hypermobility must be progressed under a watchful eye.76 Excessively stretching ER in the 90°/90° position in these patients too early during their postoperative care may jeopardize the end result. Burkhart and Morgan77 discovered the peel-back mechanism, which can occur during rehabilitation when ER is forced passively in the 90°/90° position before healing has occurred. Kuhn and associates78 demonstrated failure of the biceps superior labral complex in 9 of 10 cadaveric shoulders when the biceps was tensioned in the cocking position. The peel-back phenomenon occurs when the biceps-labral complex is abducted and externally rotated causing a posterior biceps vector, and shearing the biceps anchor repair off its origin.
One therapeutic intervention that can assist in decreasing tension in the biceps-labral complex is restoring posterior extensibility. By restoring posterior capsule extensibility, it allows the humeral head to centralize in the glenoid fossa and not be forced anterior. A tight posterior capsule forces the humeral head anterior, creating unwanted tension in the biceps-labral complex as the phenomenon occurs. Stretching and mobilization of the posterior capsule should be emphasized because tightness of the posterior shoulder structures has been linked to a loss of IR ROM.79 Loss of mobility can potentially limit progress, considering a tight posterior capsule is thought to cause anterior-superior migration of the humeral head with forward elevation of the shoulder, possibly contributing to a SLAP tear.80 If posterior shoulder tightness and a decrease in IR ROM are observed, careful assessment must be undertaken. The Tyler test for posterior shoulder tightness can be performed to determine if posterior shoulder tightness is present (Fig. 6-12).79,81 Recently Mullaney and associates82 have made the measurement easier and shown its reproducibility using a digital level. To further determine if the loss of IR is due to capsular contracture, a posterior glide must be performed (Fig. 6-13). An effective method of stretching this area is to stabilize the patient’s scapula at the inferior angle manually while the patient provides a cross-chest adduction force in the supine position (Fig. 6-14). Further stretch may be felt by having the patient add slight pressure into IR by pressing inferiorly on the dorsal aspect of the hand or wrist. This posterior shoulder protocol has been shown to be effective in the correction of posterior shoulder tightness in patients with internal impingement, six of which were more than 6 months after SLAP repair.83
Passive range of motion (PROM) of ER and abduction should be limited to 65° and 70°, respectively, as to not put stress on the healing biceps-labral complex. Initial ROM goals are to achieve within 10° of full IR and 150° to 165° of passive flexion in the plane of the scapular. The goal is to maintain available mobility and prevent excessive scarring. Similar to Burkhart and Morgan84 and Burkhart, Morgan, and Kibler,85 isotonic strengthening exercises are initiated for abduction, scaption, IR, and ER in the scapular plane.86 In addition, rhythmic stabilization at the end ROM can be performed at this time. To have normal scapulohumeral rhythm, dynamic scapula stability of this joint needs to be restored. Scapula exercises are encouraged in this phase of rehabilitation to counteract scapulohumeral dissociation and provide a stable base of support for active range of motion (AROM) to be performed.87 Recently, the authors of this chapter reported on the importance of scapula stability in generating shoulder rotation torque in microinstability patients. The results of the authors’ study demonstrated patients with microinstability exhibited a significant decrease in peak shoulder ER and IR torque after exercise-induced fatigue of the scapular stabilizer.88 Many authors have examined the EMG activity during scapular strengthening exercises; however, when choosing the appropriate exercise, the clinician must keep the activity pain free and protect the surgical repair.89–92 Three relatively low-level exercises the authors like to use after SLAP repair are (1) elastic resistance rows (not to brake the frontal plane with the involved elbow); (2) standing scapular retraction against elastic resistance with straight arms just below 90° of shoulder flexion; and (3) shoulder oscillation in the plane of the scapula, keeping the wrist, elbow, and shoulder steady (Fig. 6-15). Finally, in the later phases of rehabilitation, the patient can progress to more demanding open and closed kinetic chain scapular strengthening exercises.
Strengthening exercises should progress to resistance training with elastic bands for IR, ER, abduction, and extension. Maintaining the GH joint in the scapular plane (30° to 45° anterior to the frontal plane) will minimize the tensile stress placed on the labral repair.93
The authors have found that giving verbal feedback to lift the chest up and pinch the shoulders back can facilitate scapular stabilization while training the external rotators. Hintermeister and associates94 found shoulder elastic resistance training to have a low load on the shoulder and therefore to be safe for postoperative patients.
It is our opinion that the use of free weights with the arm in a dependent position should be used accordingly during this period to minimize the potential for detrimental humeral head translation. Side-lying ER is typically initiated during the later portion of this phase (Fig. 6-16). Proper technique, weight, and ROM are important to execute this safely. Stabilizing the humerus to the thorax and not allowing the elbow to drift past the frontal plane of the body will place minimal winding on the labral repair.
At this phase, minimal weight should be used within the comfortable ROM to prevent ill-advised stress to the healing biceps-labral complex. It may also be recommended that the patient wait until the end of the intermediate postoperative period to initiate jogging or running for this same reason (the humeral head may be forcibly thrusted anteriorly). It is imperative that the therapist maintain supervision of the ROM progression during this period to protect the healing tissue.86 Clinical milestones to progress to the next phase of rehabilitation include (1) achieving 160° of flexion in the scapular plane, (2) scapular plane ER to 65°, (3) ER at 90° abduction to 45°, (4) near full IR in the scapular plane, (5) IR at 90° abduction to 45°, (6) 150° of abduction, (7) symmetrical posterior shoulder flexibility, and (8) improved isotonic internal and external strength in available ROM.
Phase III (Strengthening Postoperative Phase)
TIME: 9 to 14 weeks after surgery
GOALS: Normalize ROM, progression of strength, normalize scapulothoracic motion and strength, overhead activities without pain
