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

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

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

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

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.

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.

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.

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.

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.

It is at this point that a sleeper stretch may safely be given to a patient to regain passive IR ROM (Fig. 6-17). This is in agreement with other authors who demonstrated a lack of full return of ROM in patients 12 weeks after SLAP repair.^84,85,95,96 In our opinion, the key to a successful rehabilitation of these patients, at this phase, is finding the balance point between stretching ER and letting them naturally regain their ROM.

An arm upper body ergometer (UBE) using light resistance can be beneficial at this time to facilitate ROM and initiate active muscular control of the shoulder.

The axis of rotation of the UBE should remain below the level of the shoulder joint so as not to force forward flexion above 80°. To avoid stress to the biceps-labral complex, the patient should be positioned at a distance from the axis of rotation that does not allow the elbow to move posterior to the frontal plane when performing ergometer revolutions. This exercise is not initiated earlier because the amount of stress placed on the biceps-labral complex during the use of an UBE is unknown.

When designing the strengthening program, it is important to match patients’ needs with their limitations and goals. A properly designed strengthening program will address their needs by attempting to get the most benefit from each exercise prescription. Previous EMG studies have set forth which shoulder exercises activate particular muscles, and these should be considered as the clinician prescribes a program.^{58,75,76,90,91} We have combined many of these programs to address generalized specific weaknesses. From these studies, we have developed the “prone program plus” to address scapular stability and generalized weakness. The prone program plus can be started in this phase of the rehabilitation if the exercises are pain free. The prone program plus includes prone GH horizontal abduction with GH IR (thumb down), prone scapula adduction with GH ER (thumb up), prone rows, prone shoulder flexion in the scapular plane, prone 90°/90° ER, push-ups with a plus (therapist initiates exercise in quadruped), and ball press downs. Patients can easily get into poor habits or begin performing these exercises with improper form. It is recommended that clinicians educate their patients on these exercises and allow ample time for them to develop proper form before prescribing these as part of a home program.

Proprioceptive neuromuscular facilitation (PNF) can be described as movements that combine rotation and diagonal components that closely resemble the movement patterns required for sport and work activities. PNF acts to enhance the proprioceptive input and neuromuscular responses while stressing motor relearning in the postoperative phases of rehabilitation. PNF patterns are initiated with the scapula because scapular stability is essential for total function of the shoulder. Scapular patterns are generally performed in the side-lying position, with the head and neck in neutral alignment. The coupled patterns of anterior elevation–posterior depression and anterior depression–posterior elevation are used, respectively. Trunk rotation should eventually be combined with scapular and extremity PNF patterns to maximize combined muscular movement patterns. Techniques such as hold-relax, slow reversals, and contract-relax are used specifically to improve motion, whereas rhythmic stabilization, repeated contractions, and combination isotonics are used to enhance concentric and eccentric muscle action. Specifically, the D2-flexion pattern combines flexion, abduction, and ER, emphasizing the posterior rotator cuff and posterior deltoid (Fig. 6-18). These neuromuscular control exercises strive to reestablish scapular positioning and stability of the humeral head in the glenoid.⁸⁷

As the patient progresses through the program, periodical reevaluation of the scapular dyskinesis is highly recommended. The authors stress this, especially as the patient gains full ROM and may no longer be inhibited by tight soft tissue structures. The term scapular dyskinesis, although indicating that an alteration exists, is a qualitative collective term that does not differentiate between types of scapular positions or motions.⁹⁷ Therefore scapular evaluation and categorization is challenging. The most common techniques for objective quantification include visual evaluation, the lateral scapular slide test (LSST), and 3-D techniques. Kibler and associates⁹⁷ have recently introduced a new visual technique that may help clinicians standardize categorization. This dynamic technique categorizes the dyskinesis in one of four groups:

Like all scapular categorization techniques, the therapist must be concerned with combined movements, a learning curve, and patient experience; however, it does present clinicians with a valuable tool that, with practice, may enhance clinical communication.

The authors also believe that exercises directed toward facilitation of functional muscular firing patterns in both the open and closed chain may provide useful input for return to function after SLAP repair. Lear and Gross⁹³ demonstrated scapular muscle activity increases with a wall push-up progression. However, the strain on the biceps-labral complex is unknown and may be too great for patients after SLAP repair. This exercise should be gradually built up to and proceeded to with caution. Clinicians should hold this exercise until the advanced strengthening postoperative phase to protect the healing tissue.

Isotonic exercises emphasizing light resistance and increased repetitions are used for isolated and combined movement patterns of the shoulder. The authors use a progression from three sets of 10, to two sets of 15, and on to one set of 30 repetitions. If the patient can perform one set of 30 repetitions with good form and no substitution, he or she can be progressed to 1- to 2-lb weights and back down to three sets of 10 to repeat the cycle. This rationale is based on lending objectivity to the progression and the tonic nature of the rotator cuff muscles and the scapular stabilizers. Isolated exercises are used to enhance or increase the strength of a particular muscle. Combining isotonic exercises in functional-movement patterns are performed with PNF patterns using elastic resistance or the cable column to enhance coordinated movement. In the case of a swimmer, the D1 pattern with elastic resistance will lead to a carryover to his athletic function. Initiation of isokinetic strengthening at this phase may enhance the shoulder’s ability to strengthen in a pain-free ROM. It is encouraged that slower speeds be used when strengthening patients with shoulder instability. Isokinetic principles suggest that faster isokinetic speeds create greater translational forces, whereas slower speeds create stronger compressive forces (which stabilize the shoulder). Milestones that should be met to move to the next rehabilitation phase include (1) within 10° of full AROM in flexion, abduction, IR, and ER in the plane of the scapula; (2) normalized scapulothoracic motion and strength; (3) moderate overhead activities without pain; and (4) isometric internal and external strength should be at least 50% that of the uninjured side.

Posterior capsule stretching is appropriate if full IR has not been obtained yet. Performing the side-lying sleeper stretch encourages ROM for IR (see Fig. 6-17). At the onset of this phase, a thorough strength assessment is needed to evaluate the direction of strengthening needed for the particular patient. This assessment may include manual muscle testing, hand-held dynamometry, and isokinetic strengthening (or a combination of these techniques). Assessment should include the primary shoulder movers, shoulder rotators, and scapula stabilizers. Results of this assessment should be addressed with a well-rounded strengthening program to include isotonic, concentric, and eccentric loading exercises. When designing these programs, consider the everyday demands of each patient. For an overhead-throwing athlete, strengthening in the throwing position is imperative (Fig. 6-19). Once this phase of rehabilitation is reached, treatment should begin to streamline toward the functional demands of the patient.⁹⁸

Initiation of a properly designed plyometric training program is often the missing link to discharging a high-level patient. Plyometric training for the upper extremity is used to generate rapid and powerful muscular contractions in response to a dynamic stretch–inducing load to a muscle or group of muscles. It is suggested that plyometrics train the entire neuromuscular system, using the principles of stored elastic energy to use strength as quickly and forcefully as possible. The myotatic stretch reflex develops stored elastic potential. If the exercise movement is slow, such as in weight lifting, the energy is dissipated and nonproductive. However, with rapid movement, this stored elastic energy can be used to generate a force greater than that of the concentric contraction of the muscle alone. Plyometrics use the principles of progressive loading with the ultimate goal of power development. Using a trampoline will increase the EMG activity and elevate the level of eccentric loading of the shoulder rotators.⁹⁹ Therefore a progression from two-handed, side-to-side throws to overhead throws to one-handed overhead throws is encouraged to maximize the power development of the overhead athlete. A well-rounded program will address both the internal and external rotators of the shoulder, together with the core muscles of the trunk. Externally challenging the patient, by permitting stability from a naturally unstable surface, such as a ball, will challenge the entire kinetic chain. Advanced exercises, such as the Physioball “walk outs,” exemplify this concept (Fig. 6-20). As the patient walks out from the ball with the hands, core stabilizers, as well as GH stabilizers, are challenged. Milestones to progress to the final phase of rehabilitation include (1) pain-free full ROM, (2) less than 20% strength deficits for IR and ER at 90°/second, and (3) 20% strength deficits in all positions.

All too often patients lose interest, exhaust insurance coverage, or just neglect the importance of fine-tuning their shoulders before fully returning to their lifestyle. This stage is designed to prepare patients to return, without hesitation, to full participation in all activities. Milestones to successfully complete this phase include (1) total confidence in the shoulder, (2) pain-free full ROM, and (3) an isokinetic or hand-held dynamometry with less than 10% deficit in all positions.100

Exercises in this phase continue to emphasize functional positions, including the plyometric program (isokinetic strengthening at 90° of abduction). A gradual return to sport is permitted once the patient is pain free, has nearly full ROM in all planes, confidence in the shoulder, and 85% to 90% of the strength of the opposite side on isokinetic testing at 90°, 180°, and 300°/second for IR and ER motions.

Confidence is achieved with the ability to perform pain-free functional movement in the patient’s sport. Our experience has demonstrated that the throwing athlete requires an additional 1 to 2 months to allow the shoulder to adjust to the motion. Patients also report that it takes up to 1 year before the shoulder feels “normal” after SLAP repair. We currently are using the American Shoulder and Elbow Surgeons Shoulder Evaluation Form to standardize the documentation of pain, motion, strength, stability, and function. Although it remains difficult to gather enough data to determine a criterion score for return to sports, once 6 months have passed and clinical milestones have been met, the athlete is cleared for full throwing. This time frame is in agreement with other authors’ findings¹⁰¹ (Table 6-1).