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6 Keys to Shoulder Instability Rehabilitation

Shoulder instability is a common injury encountered in physical therapy. But there are many different types of shoulder instability.

Would you treat a high school baseball player that feels like their shoulder is loose when throwing the same as a 35 year old that fell on ice onto an outstretched arm and dislocated their shoulder?  They both have “shoulder instability,” right?

There exists a wide range of symptomatic shoulder instabilities from subtle recurrent subluxations to traumatic dislocations. Nonoperative rehabilitation is commonly utilized for shoulder instability to regain previous functional activities through specific strengthening exercises, dynamic stabilization drills, neuromuscular training, proprioception drills, scapular muscle strengthening program and a gradual return to their desired activities.

But to truly understand how to successfully treat shoulder instability, there are several key factors that you must consider.

Key Factors When Designing Shoulder Instability Rehabilitation Programs

Because there are so many different variations of shoulder instability, it is extremely important to understand several factors that will impact the rehabilitation program.  This will allow us to individualize shoulder instability rehabilitation programs and enhance recovery.

There are 6 main factors that I consider when designing my rehabilitation programs for nonoperative shoulder instability rehabilitation.  I’m going to cover each in detail.

Factor #1 – Mechanism and Chronicity of Shoulder Instability

The first factor to consider in the rehabilitation of a patient with shoulder instability is the mechanism and chronicity of the injury. There are two different types of instability that can be classified as:

  1. Acute, traumatic instability
  2. Chronic, atraumatic instability

Pathological shoulder instability may result from an acute, traumatic event or chronic, recurrent instability. The goal of the rehabilitation program may vary greatly based on the onset and mechanism of injury.

Following a traumatic subluxation or dislocation, the patient typically presents with significant tissue trauma, pain and apprehension. The patient who has sustained a dislocation often exhibits more pain due to muscle spasm than a patient who has subluxed their shoulder. Furthermore, a first time episode of dislocation is generally more painful than the repeat event.

Here’s a great example of a traumatic dislocation. Note the amount of pain the athlete is in as they walk off the field with the shoulder still dislocated.

Rehabilitation will be progressed based on the patient’s symptoms with emphasis on early controlled range of motion, reduction of muscle spasms and guarding and relief of pain. But the main goal is to allow the shoulder capsule to heal.

The primary traumatic dislocation is most often treated conservatively with immobilization in a sling and early controlled passive range of motion (ROM) exercises especially with first time dislocations.

The incidence of recurrent dislocation ranges from 17-96% with a mean of 67% in patient populations between the ages of 21-30 years old. Therefore, the rehabilitation program should progress cautiously in young athletic individuals. It should be noted that Hovelius has demonstrated that the rate of recurrent dislocations is based on the patient’s age and not affected by the length of post-injury immobilization. Individuals between the ages of 19 and 29 years are the most likely to experience multiple episodes of instability. Hovelius also noted patients in their 20’s exhibited a recurrence rate of 60% whereas patients in their 30’s to 40’s had less than a 20% recurrence rate. In adolescents, the recurrence rate is as high as 92% and 100% with an open physes.

Conversely, a patient presenting with atraumatic instability often presents with a history of repetitive injuries and symptomatic complaints. Often the patient does not complain of a single instability episode but rather a feeling of shoulder laxity or an inability to perform specific tasks.

They often times also have the ability to move their shoulder into excessive motion.

multidirectional instability excessive capsular laxity

Rehabilitation for this patient should focus on early proprioception training, dynamic stabilization drills, neuromuscular control, scapular muscle exercises and muscle strengthening exercises to enhance dynamic stability due to the unique characteristic of excessive capsular laxity and capsular redundancy in this type of patient.

Chronic subluxations, as seen in the atraumatic, unstable shoulder may be treated more aggressively due to the lack of acute tissue damage and less muscular guarding and inflammation. Rotator cuff and periscapular strengthening activities should be initiated while ROM exercises are progressed. Caution is placed on avoiding excessive stretching of the joint capsule through aggressive ROM activities.

Remember, in these patients, the primary need is stability, not mobility.

The goal is to enhance strength, proprioception, dynamic stability and neuromuscular control especially in the specific points of motion or direction which results in instability complaints.

Factor #2 – Degree of Shoulder Instability

The second factor is the degree of instability present in the patient and its effect on their function.

Varying degrees of shoulder instability exist such as a subtle subluxation or gross instability. The term shoulder subluxation refers to the complete separation of the articular surfaces with spontaneous reduction.

Conversely, a dislocation is a complete separation of the articular surfaces and requires a specific movement or manual reduction to relocate the joint. This will result in underlying capsular tissue trauma. Thus, with shoulder dislocations the degree of trauma to the glenohumeral joint’s soft tissue is much more extensive.

In the situation of an acute traumatic dislocation, the anterior capsule may be avulsed off the glenoid. This is called a Bankart lesion, and the posterior capsule may be stretched, allowing the humeral head to dislocate. This has been referred to as the “circle stability concept.”

Bankart lesion shoulder instability

Speer has reported that in order for a shoulder dislocation to occur, a Bankart lesion must be present and also soft tissue trauma must be present on both sides of the glenohumeral joint capsule.

The rate of progression will vary based upon the degree of instability and persistence of symptoms. For example, a patient with mild subluxations and muscle guarding may initially tolerate strengthening exercises and neuromuscular control drills more than a patient with a significant amount of muscular guarding.

Factor #3 – Concomitant Pathology

The third factor involves considering other tissues that may have been affected and the premorbid status of the tissue.

As we previously discussed, disruption of the capsulolabral complex from the glenoid commonly occurs during a traumatic injury resulting in an anterior Bankart lesion. But other tissues may also be involved.

Often osseous lesions may be present such as a concomitant Hill Sach’s lesion caused by an impaction of the posterolateral aspect of the humeral head as it compresses against the anterior glenoid rim during relocation.

This has been reported in up to 80% of dislocations. Conversely, a reverse Hill Sach’s lesion may be present on the anterior aspect of the humeral head due to a posterior dislocation. Similarly, the glenoid can also sustain a boney lesion.

The more boney involvement, the greater amount of instability that is often present.

Occasionally, a bone bruise may be present in individuals who have sustained a shoulder dislocation as well as pathology to the rotator cuff. In rare cases of extreme trauma, the brachial plexus may become involved as well. Other common injuries in the unstable shoulder may involve the superior labrum (SLAP lesion) such as a type V SLAP lesion characterized by a Bankart lesion of the anterior capsule extending into the anterior superior labrum. These concomitant lesions will affect the rehabilitation significantly in order to protect the healing tissue.

Factor # 4 – Direction of Shoulder Instability

The next factor to consider is the direction of shoulder instability present. The three most common forms include anterior, posterior and multidirectional.

Anterior shoulder instability is the most common traumatic type of instability seen in the general orthopedic population. It has been reported that this type of instability represents approximately 95% of all traumatic shoulder instabilities. However, the incidence of posterior instabilities appears to be dependent on the patient population. For example, in professional or collegiate football, the incidence of posterior shoulder instability appears higher than the general population. This is especially true in linemen. Often, these posterior instability patients require surgery as Mair reported 75% required surgical stabilization.

Following a traumatic event in which the humeral head is forced into extremes of abduction and external rotation, or horizontal abduction, the glenolabral complex and capsule may become detached from the glenoid rim resulting in anterior instability, or a Bankart lesion as discussed above.

Conversely, rarely will a patient with atraumatic instability due to capsular redundancy dislocate their shoulder. These individuals are more likely to repeatedly sublux the joint without complete separation of the humerus from the glenoid rim.

Posterior shoulder instability occurs less frequently, only accounting for less than 5% of traumatic shoulder dislocations.

This type of instability is often seen following a traumatic event such as falling onto an outstretched hand or from a pushing mechanism. However, patients with significant atraumatic laxity may complain of posterior instability especially with shoulder elevation, horizontal adduction and excessive internal rotation due to the strain placed on the posterior capsule in these positions.

Multidirectional instability (MDI) can be identified as shoulder instability in more than one plane of motion. Patients with MDI have a congenital predisposition and exhibit ligamentous laxity due to excessive collagen elasticity of the capsule.

One of the most simple tests you can perform to assess MDI is the sulcus sign.

sulcus sign multidirectional shoulder instability

I would consider an inferior displacement of greater than 8-10mm during the sulcus maneuver with the arm adducted to the side as significant hypermobility, thus suggesting significant congenital laxity.  You can see this pretty good in this photo, the sulcus is clearly larger than my finger width.

Due to the atraumatic mechanism and lack of acute tissue damage with MDI, range of motion is often normal to excessive.

Patients with recurrent shoulder instability due to MDI generally have weakness in the rotator cuff, deltoid and scapular stabilizers with poor dynamic stabilization and inadequate static stabilizers. Initially, the focus is on maximizing dynamic stability, scapula positioning, proprioception and improving neuromuscular control in mid range of motion.

Also, rehabilitation should focus on improving the efficiency and effectiveness of glenohumeral joint force couples through co-contraction exercises, rhythmic stabilization and neuromuscular control drills. Isotonic strengthening exercises for the rotator cuff, deltoid and scapular muscles are also emphasized to enhance dynamic stability.

Factor #5 – Neuromuscular Control

The fifth factor to consider is the patient’s level of neuromuscular control, particularly at end range.

Injury with resultant insufficient neuromuscular control could result in deleterious effects to the patient. As a result, the humeral head may not center itself within the glenoid, thereby compromising the surrounding static stabilizers. The patient with poor neuromuscular control may exhibit excessive humeral head migration with the potential for injury, an inflammatory response, and reflexive inhibition of the dynamic stabilizers.

Several authors have reported that neuromuscular control of the glenohumeral joint may be negatively affected by joint instability.

Lephart compared the ability to detect passive motion and the ability to reproduce joint positions in normal, unstable and surgically repaired shoulders. The authors reported a significant decrease in proprioception and kinesthesia in the shoulders with instability when compared to both normal shoulders and shoulders undergoing surgical stabilization procedures.

Smith and Brunoli reported a significant decrease in proprioception following a shoulder dislocation.

Blasier reported that individuals with significant capsular laxity exhibited a decrease in proprioception compared to patients with normal laxity.

Zuckerman noted that proprioception is affected by the patient’s age with older subjects exhibiting diminished proprioception than a comparably younger population.

Thus, the patient presenting with traumatic or acquired instability may present with poor neuromuscular control that must be addressed.

Factor # 6 – Pre-injury Activity Level

The final factor to consider in the nonoperative rehabilitation of the unstable shoulder is the arm dominance and the desired activity level of the patient.

If the patient frequently performs an overhead motion or sporting activities such as a tennis, volleyball or a throwing sport, then the rehabilitation program should include sport specific dynamic stabilization exercises, neuromuscular control drills and plyometric exercises in the overhead position once full, pain free motion and adequate strength has been achieved.

Patients whose functional demands involve below shoulder level activities will follow a progressive exercise program to return full ROM and strength. The success rates of patients returning to overhead sports after a traumatic dislocation of their dominant arm are often low, but possible.

Arm dominance can also significantly influence the successful outcome. The recurrence rates of instabilities vary based on age, activity level and arm dominance. In athletes involved in collision sports, the recurrence rates have been reported between 86-94%.

Keys to Shoulder Instability Rehabilitation

To summarize, nonoperative rehabilitation of shoulder instability has many subtle variations.  To simplify my thought process, I always think of these 6 key factors before I decide what I want to focus on for each person.  

Learn How I Evaluate and Treat the Shoulder

mike reinold shoulder seminar

Want to learn exactly how I rehabilitate shoulder instability?

I have a whole lesson on this as part of my comprehensive online program on the Evidence Based Evaluation and Treatment of the Shoulder.  If you want to learn exactly how I evaluate and treat the shoulder, including shoulder instability, this course is for you.  You’ll be an expert on shoulders!

Clinical Examination of Superior Labral Tears – What is the Best Special Test for a SLAP Tear?

What is the best special test for a SLAP tear?  There are many options all with varying efficacy, however without a proper understanding of the different types of SLAP tears and mechanism of injury, it’s difficult to select the best special test for SLAP tears.

Clinical examination to detect SLAP lesions is often difficult because of the common presence of concomitant pathology in patients presenting with this type of condition. Andrews has shown that 45% of patients (and 73% of baseball pitchers) with superior labral lesions have concomitant partial thickness tears of the supraspinatus portion of the rotator cuff.  Mileski and Snyder reported that 29% of their patients with SLAP lesions exhibited partial thickness rotator cuff tears, 11% complete rotator cuff tears, and 22% Bankart lesions of the anterior glenoid.

The clinician should keep in mind that while labral pathologies frequently present as repetitive overuse conditions, such as those commonly seen in overhead athletics, the patient may also describe a single traumatic event such as a fall onto the outstretched arm or an episode of sudden traction, or a blow to the shoulder.  This is an extremely important differentiation you need to make when selecting which tests you should perform.

A wide variety of potentially useful special test maneuvers have been described to help determine the presence of labral pathology.  Lets review some of them now.

This article is part of a 4-part series on SLAP Lesions

Special Tests for a SLAP Tear

There are literally dozens of special tests for SLAP tears of the shoulder.  I am going to share some of the most popular SLAP tests.

Active Compression Test

active compression SLAP testThe active compression test is used to evaluate labral lesions and acromioclavicular joint injuries. This could be the most commonly performed test, especially in orthopedic surgeons.  I am not sure why, though, I do not think it is the best.

The shoulder is placed into approximately 90 degrees of elevation and 30 degrees of horizontal adduction across the midline of the body. Resistance is applied, using an isometric hold, in this position with both full shoulder internal and external rotation (altering humeral rotation
against the glenoid in the process). A positive test for labral involvement is when pain is elicited when testing with the shoulder in internal rotation and forearm in pronation (thumb pointing toward the floor). Symptoms are typically decreased when tested in the externally rotated position or the pain is localized at the acromioclavicular (AC) joint.

O’Brien et al found this maneuver to be 100% sensitive and 95% specific as it relates to assessing the presence of labral pathology.  These results are outstanding, maybe too outstanding. Pain provocation using this test is common, challenging the validity of the results. In my experience, the presence of deep and diffuse glenohumeral joint pain is most indicative of the presence of a SLAP lesion. Pain localized in the AC joint or in the posterior rotator cuff is not specific for the presence of a SLAP lesion. The posterior shoulder symptoms are indicative of provocative strain on the rotator cuff musculature when the shoulder is placed in this position.

The challenging part of this test is that many patients will be symptomatic from overloading their rotator cuff in this disadvantageous position.

  • Sensitivity: 47-100%, Specificity: 31-99%, PPV: 10-94%, NPV: 45-100% (a lot of variability between various authors)

Biceps Load Test

The biceps load testBiceps Load SLAP Test involves placing the shoulder in 90 degrees of abduction and maximally externally rotated. At maximal external rotation and with the forearm in a supinated position, the patient is instructed to perform a biceps contraction
against resistance. Deep pain within the shoulder during this contraction is indicative of a SLAP lesion.
The original authors further refined this test with the description of the biceps load II maneuver. The examination technique is similar, although the shoulder is placed into a position of 120 degrees of abduction rather than the originally described 90 degrees.  The biceps load II test was noted to have greater sensitivity than the original test.  I like both of these tests and usually perform them both.
  • Sensitivity: 91%, Specificity: 97%, PPV: 83%, NPV: 98% for Biceps Load I; Sensitivity: 90%, Specificity: 97%, PPV: 92%, NPV: 96% for Biceps Load II

Compression Rotation Test

Compression Rotation SLAP TestThe compression-rotation test is performed with the patient in the supine position. The glenohumeral joint is manually compressed through the long axis of the humerus while, the humerus is passively rotated back and forth in an attempt to trap the labrum within the joint. This is typically performed in a variety of small and large circles while providing joint compression when performing this maneuver, in an attempt to grind the labrum between the glenoid and the humeral head. Furthermore, the examiner may attempt to detect anterosuperior labral lesions by placing the arm in a horizontally abducted position while providing an anterosuperior directed force. In contrast, the examiner may also horizontally adduct the humerus and provide a posterosuperiorly directed force when performing this test.  I think of this test as “exploring” the joint for a torn labrum.  It is hit or miss for me.

  • Sensitivity: 24%, Specificity: 76%, PPV: 90%, NPV: 9%

Dynamic Speed’s Test

dynamic speeds SLAP testThe Speed’s biceps tension test has been found to accurately reproduce pain in instances of SLAP lesions.  I have personally not seen this to be true very often.

It is performed by resisting downwardly applied pressure to the arm when the shoulder is positioned in 90 degrees of forward elevation with the elbow extended and forearm supinated. Clinically, we also perform a new test for SLAP lesions.

Kevin Wilk and I developed a variation of the original Speed’s test, which we refer to as the “Dynamic Speed’s Test.”  (I came up with the name, what do you think?)  During this maneuver, the examiner provides resistance against both shoulder elevation and elbow flexion simultaneously as the patient  elevates the arm overhead. Deep pain within the shoulder is typically produced with shoulder elevation above 90 degrees if this test is positive for labral pathology.

Anecdotally, we have found this maneuver to be more sensitive than the originally described static Speed’s test in detecting SLAP lesions, particularly in the overhead athlete.  To me, it seems like you only get symptoms with greater degrees of elevation, making the original Speed’s Test less sensitive in my hands.

  • Sensitivity: 90%, Specificity: 14%, PPV: 23%, NPV: 83% for the Speed’s test

Clunk and Crank Tests

clunk crank slap testThe clunk test is performed with the patient supine. The examiner places one hand on the posterior aspect of the glenohumeral joint while the other grasps the bicondylar aspect of the humerus at the elbow. The examiner’s proximal hand provides an anterior translation of the humeral head while simultaneously rotating the humerus externally with the hand holding the elbow.  The mechanism of this test is similar to that of a McMurray’s test of the knee menisci, where the examiner is attempting to trap the torn labrum between the glenoid and the humeral head. A positive test is produced by the presence of a clunk or grinding sound and is indicative of a labral tear.

The crank test can be performed with the patient either sitting or supine. The shoulder is elevated to 160 degrees in the plane of the scapula. An axial load is then applied by the examiner while the humerus is internally and externally rotated in this position. A positive test typically elicits pain with external rotation. Symptomatic clicking or grinding may also be present during this maneuver.  These tests seem to do well with finding a bucket-handle tear of from a Type III or Type IV SLAP lesion more than anything else for me.

  • Sensitivity: 39-91%, Specificity: 56-93%, PPV: 41-94%, NPV: 29-90%

2 New(er) Special Tests for SLAP Lesions

In addition to the classic SLAP tests that have been described, there are two additional tests that gained popularity more recently.

I wanted share a video that I have on YouTube that demonstrates these two tests. These were actually published in a paper I wrote in JOSPT a few years ago, but I have modified them a little and wanted to share. These two tests are both excellent at detecting peel-back SLAP lesions, specifically in overhead throwing athletes, but are useful for any population. I share these two tests because I know that there is a lot of confusion regarding the “best” test. These may not be them, but in my hands, both have been extremely helpful and, more importantly, accurate.

Pronated Load SLAP Test

The first test is the “Pronated Load Test,” it is performed in the supine position with the shoulder abducted to 90° and externally rotated. However, the forearm is in a fully pronated position to increase tension on the biceps and subsequently the labral attachment. When maximal external rotation is achieved, the patient is instructed to perform a resisted isometric contraction of the biceps to simulate the peel-back mechanism. This test combines the active bicipital contraction of the biceps load test with the passive external rotation in the pronated position, which elongates the biceps. A positive test is indicated by discomfort within the shoulder.

Resisted Supination External Rotation SLAP Test

The second test was described by Myers in AJSM, called the “Resisted Supination External Rotation Test.” Dr. Myers was a fellow at ASMI and a good friend of mine, he really wanted to call this the SUPER test (for SUPination ER) but I was one of many that advised him against this for obvious reasons!

During this test, the patient is positioned in 90° of shoulder abduction, and 65-70° of elbow flexion and the forearm in neutral position. The examiner resists against a maximal supination effort while passively externally rotating the shoulder. Myers noted that this test simulates the peel-back mechanism of SLAP injuries by placing maximal tension on the long head of the biceps by supinating.

Myers’ study of 40 patients revealed that this test had better sensitivity (82.8%), specificity (81.8%), positive predictive value (PPV) (92.3%), negative predictive value (NPV) (64.3%), and diagnostic accuracy (82.5%) compared to the crank test and extremely popular O’Brien’s or active compression test. A positive test is indicated by discomfort within the shoulder.

When Do You Perform These Tests?

Now that you know a bunch of special tests for SLAP tears, the real key is understanding “when” to pick each test.  In my mind, they all are slightly different and may even be better at detecting different types of SLAP lesions.  I have an Inner Circle webinar that discusses this and shows you my clinical algorithm on how and why I perform special tests to diagnose a SLAP tear:

Learn Exactly How I Evaluate and Treat the Shoulder

shoulder seminarIf you want to learn even more about the shoulder, my online course will teach you exactly how I evaluate and treat the shoulder.  It is packed with tons of educational content that will help you master the shoulder, including detailed information on the clinical examination and treatment of SLAP tears.

How do SLAP Tears Occur: Mechanisms of Injury to the Superior Labrum

SLAP tears of the shoulder can occur for a variety of reasons, from a traumatic fall to wear-and-tear over time, to more specific injuries that we see in overhead athletes like baseball players.

But that’s a common question I here often.

Now that we have discussed the different types and classification of SLAP tears to the superior labrum, I wanted to now talk about how these shoulder injuries occur. There are several injury mechanisms that are speculated to be responsible for creating a SLAP lesion. These mechanisms range from single traumatic events to repetitive microtraumatic injuries.

This article is part of a 4-part series on SLAP Lesions

Traumatic SLAP Injuries

mechanism of slap tearTraumatic events, such as falling on an outstretched arm or bracing oneself during a motor vehicle accident, may result in a SLAP lesion due to compression of the superior joint surfaces superimposed with subluxation of the humeral head. Snyder referred to this as a pinching mechanism of injury. Other traumatic injury mechanisms include direct blows, falling onto the point of the shoulder, and forceful traction injuries of the upper extremity.

To be honest with you, I don’t know if this is actually the underlying cause of the SLAP lesion. I have questioned this theory in the past and don’t know the answer, but part of me at least wonders if these patients already had a certain degree of pathology to their superior labrum and the acute injury led to a MRI and diagnosis of a SLAP tear.

Essentially the MRI may have found an old SLAP tear.

Repetitive Overhead Activities

Repetitive overhead activity, such as throwing a baseball and other overhead sports, is another common mechanism of injury frequently responsible for producing SLAP injuries.

This is the type of SLAP lesion that we most often see in our athletes. In 1985, Dr. Andrews first hypothesized that SLAP pathology in overhead throwing athletes was the result of the high eccentric activity of the biceps brachii during the arm deceleration and follow-through phases of the overhead throw. To determine this, they applied electrical stimulation to the biceps during arthroscopic evaluation and noted that the biceps contraction raised the labrum off of the glenoid rim.

Peel Back SLAP Tear

Burkhart and Morgan have since hypothesized a “peel back” mechanism that produces SLAP lesion in the overhead athlete. They suggest that when the shoulder is placed in a position of abduction and maximal external rotation, the rotation produces a twist at the base of the biceps, transmitting torsional force to the anchor.

This mechanism has received a lot of attention and several studies seem to show its accuracy.

Pradham measured superior labral strain in a cadaveric model during each phase of the throwing motion. They noted that increased superior labral strain occurred during the late-cocking phase of throwing.

Another study from ASMI simulated each of these mechanisms using cadaveric models. Nine pairs of cadaveric shoulders were loaded to biceps anchor complex failure in either a position of simulated in-line loading (similar to the deceleration phase of throwing) or simulated peel back mechanism (similar to the cocking phase of overhead throwing). Results showed that 7 of 8 of the in-line loading group failed in the midsubstance of the biceps tendon with 1 of 8 fracturing at the supraglenoid tubercle. However, all 8 of the simulated peel back group failures resulted in a type II SLAP lesion. The ultimate strength of the biceps anchor was significantly different when the 2 loading techniques were compared. The biceps anchor demonstrated significantly higher ultimate strength with the in-line loading (508 N) as opposed to the ultimate strength seen during the peel back loading mechanism (202 N).

You can see photos of the study below.  The first photo is a normal glenoid with the labrum and attaching long head of the biceps.  The second photo is the simulation of the traction and eccentric biceps contraction.  The final photo is simulation of the peel-back lesion.

In theory, SLAP lesions most likely occur in overhead athletes from a combination of these 2 previously described forces. The eccentric biceps activity during deceleration may serve to weaken the biceps-labrum complex, while the torsional peel back force may result in the posterosuperior detachment of the labral anchor.

shoulder seminarLearn Exactly How I Evaluate and Treat the Shoulder

If you want to learn even more about the shoulder, my online course will teach you exactly how I evaluate and treat the shoulder.  It is packed with tons of educational content that will help you master the shoulder, including detailed information on the clinical examination and treatment of SLAP tears.

What Exactly Is a SLAP Tear? Top 5 Things You Need to Know About a Superior Labral Lesion

Superior Labral SLAP TearA SLAP tear is an injury to the superior part of the labrum in the shoulder.  The term SLAP stands for Superior Labral tear Anterior to Posterior.  This is a very common diagnosis for shoulder injuries.  There many different variations of SLAP tears, which have different levels of severity and treatment strategies.  In the past, surgeons would want to operate on all SLAP tears but we have learned that some do well without surgery.  In fact, some SLAP tears aren’t even worrisome .

Understanding how a SLAP lesion occurs and what exactly is happening pathologically is extremely important to diagnose and treat these shoulder injuries appropriately.

This article is part of a 4-part series on SLAP Lesions

Classification of SLAP Lesions

As you can see in the figure, the long head of the biceps tendon inserts directly into the superior labrum.  There are several variations of injuries that can occur to the superior labrum where the biceps anchor attaches.

Following a retrospective review of 700 shoulder arthroscopies, Snyder et al: Arthroscopy 1990, identified 4 types of superior labrum lesions involving the biceps anchor. Collectively they termed these SLAP lesions, in reference to their anatomic location: Superior Labrum extending from Anterior to Posterior. This was the original definition but as we continue to learn more about SLAP tears, they certainly do not always extend from anterior to posterior. But, the most important concept to know is that a SLAP lesion is an injury to the superior labrum near the attachment of the biceps anchor.

SLAP Tear Classification

Type I SLAP Lesions

Type I SLAP lesions were described as being indicative of isolated fraying of the superior labrum with a firm attachment of the labrum to the glenoid. These lesions are typically degenerative in nature. At this time, it is currently believed that the majority of the active population may have a Type I SLAP lesion and this is often not even considered pathological by many surgeons.

Type II SLAP Lesions

Type II SLAP lesions are characterized by a detachment of the superior labrum and the origin of the tendon of the long head of the biceps brachii from the glenoid resulting in instability of the biceps-labral anchor. These is the most common type of SLAP tear. When we receive a script from a surgeon to treat a “SLAP repair” he or she is more than likely talking about a Type II SLAP and surgery to re-attach the labrum and biceps anchor.

Three distinct sub-categories of type II SLAP lesions have been further identified by Morgan et al: Arthroscopy ’90. They reported that in a series of 102 patients undergoing arthroscopic evaluation 37% presented with an anterosuperior lesion, 31% with a posterosuperior lesion, and 31% exhibited a combined anterior and superior lesion.

These findings are consistent with my clinical observations of patients. Different types of patients and mechanisms of injuries will result in slightly different Type II lesions. For example, the majority of overhead athletes present with posterosuperior lesions while individuals who have traumatic SLAP lesions typically present with anterosuperior lesions. These variations are important when selecting which special tests to perform based on the patient’s history and mechanism of injury.

Type III SLAP Lesions

Type III SLAP lesions are characterized by a bucket-handle tear of the labrum with an intact biceps insertion. The labrum tears and flips into the joint similar to a meniscus. The important concept here is that the biceps anchor is attached, unlike a Type II.

Type IV SLAP Lesions

Type IV SLAP lesions have a bucket-handle tear of the labrum that extends into the biceps tendon. In this lesion, instability of the biceps-labrum anchor is also present, similar to that seen in the type II SLAP lesion. This is basically a combination of a Type II and III lesion.

What is complicated about this classification system is the fact that the Type I-IV scale is not progressively more severe. For example a Type III SLAP lesion is not bigger, or more severe, or indicative to more pathology than a Type II SLAP lesion.
To further complicate things, Maffet et al: AJSM ’95 noted that 38% of the SLAP lesions identified in their retrospective review of 712 arthroscopies were not classifiable using the I-IV terminology previously defined by Snyder. They suggested expanding the classification scale for SLAP lesions to a total of 7 categories, adding descriptions for types V-VII.
  • Type V SLAP lesions are characterized by the presence of a Bankart lesion of the anterior capsule that extends into the anterior superior labrum.
  • Type VI SLAP lesion involve a disruption of the biceps tendon anchor with an anterior or posterior superior labral flap tear.
  • Type VII SLAP lesions are described as the extension of a SLAP lesion anteriorly to involve the area inferior to the middle glenohumeral ligament.

These 3 types typically involve a concomitant pathology in conjunction with a SLAP lesion. Although they provided further classification, this terminology has not caught on and is not frequently used. For example, most people will refer to a Type V SLAP as a Type II SLAP with a concomitant Bankart lesion.

Since then there have been even more classification types described in the literature, up to at least 10 that I know of, but don’t worry, nobody really uses them.

Top 5 things you need to know about classifying SLAP lesions

Here’s all you need to know about classifying SLAP tears:

  1. Just worry about Type I-IV SLAP lesions and realize that any classification system above Type IV just means that there was a concomitant injury in addition to the SLAP tear.
  2. You can break down and group Type I and Type III lesions together. Both involved degeneration of the labrum but the biceps anchor is attached. Thus, these are not unstable SLAP lesions and are not surgically repaired. This makes surgery (just a simple debridement) and physical therapy easier.
  3. You can also break down and group Type II and Type IV lesions together. Both involve a detached biceps anchor and require surgery to stabilize the biceps anchor. Type IV SLAP tears are much more uncommon and will involve the repair and a debridement of the bucket handle tear.
  4. Type II lesions are by far the most common that you will see in the clinic and are almost always what a surgeon is referring to when speaking of a “SLAP repair.”  That being said, we are seeing trends towards NOT repairing SLAP II lesions, as they may be more common than once expected.  This is especially true in overhead athletes.
  5. We all may have a Type I lesion, it is basically just fraying and degeneration of the labrum.

Learn Exactly How I Evaluate and Treat the Shoulder

mike reinold shoulder seminar

If you want to learn even more about the shoulder, my online course at will teach you exactly how I evaluate and treat the shoulder.  It is packed with tons of educational content that will help you master the shoulder, including detailed information on the clinical examination and treatment of SLAP tears.

Which is the Best Position to Immobilize the Shoulder After a Dislocation?

Immobilization is commonly performed after acute first time shoulder dislocations.  The goal of immobilization is to protect the shoulder and allow healing in an attempt to minimize recurrent instability down the road, which isn’t uncommon.

Unfortunately, once you dislocate your shoulder, you have a decent chance of it happening again.


Traditionally, immobilization has occurred with the shoulder in a sling by the person’s side.  This puts the shoulder in adduction and internal rotation.  Considering that most anterior dislocations occur with the arm in an abducted and externally rotated position, this seemed to make sense to take stress of the tissue.

However, a study was published in 2001 by Itoi in the Journal of Bone and Joint Surgery discussing a new position of immobilization in shoulder external rotation.  

The authors used MRI to examine the capsule in both the position of shoulder internal rotation and external rotation.  They showed that the anterior capsule tissue was better approximated in the externally rotated position.  Other recent studies have agreed with these results.

which is the best position to immobilize the shoulder after a dislocation

This was an interesting finding and lead to a follow up study by the same group that was published in 2003 in the Journal of Shoulder and Elbow Surgery.  In this study, the authors prospectively assessed the recurrent instability rate in people that were immobilized in either internal or external rotation.

The results showed that there was a 30% recurrent instability rate in those immobilized in the traditional internally rotated sling position, compared to 0% in those immobilized in external rotation.

 

Which Position is Best to Immobilize the Shoulder After a Dislocation?

Based on these two studies, many began immobilizing the shoulder after dislocation in this position of external rotation.  There are now many shoulder immobilization braces on the market that position the shoulder in ER.

shoulder immobilization in external rotation

Since these two studies many have tried to replicate the original results of Itoi with mixed results.  

I must admit that any time a novel technique, clinical test, or approach is introduced in the literature and the original author has a 100% success rate, I proceed a little cautiously until others have replicated their research.

Clinically, there appears to be no difference in recurrence rates when comparing immobilizing the shoulder in either internal or external rotation.  This has been shown in several studies.

A recent meta-analysis was published in the American Journal of Sports Medicine that reviewed 6 randomized control trials and found no significant difference in recurrence rate.  This was consistent with a prior systematic review of the Cochran Database, which agreed.

 

Basic Science Vs. Clinical Studies

This is an interesting situation, where basic science studies appear to show that immobilization in external rotation may be theoretically more beneficial after shoulder dislocations, but clinical studies have not shown any benefit or reduced occurrence of recurrent instability.  It appears anatomically that immobilizing in a position of external rotation would put the labral tissue in the best position to heal.

I personally see this as a challenging study as many people are simply not compliant with immobilization after dislocations, especially once the acute trauma tends to settle down.  One particular study reported a compliance rate between 53-72%.  

That’s not great.

As of now, it seems like we need more research to make a more definitive decision.  However, keep in mind that these studies have not shown immobilization in internal rotation to be MORE beneficial, they just showed no difference between the two.  So as of now, if I dislocated my shoulder tomorrow, I would probably immobilize myself in external rotation based on the anatomical studies that show better tissue approximation.

For those out there, what are you seeing clinically in your area?  I would imagine this varies a lot based on your location and physicians you work with each day.  Are docs still immobilizing people in external rotation?  Have you found outcomes to differ from those immobilized in internal rotation?  Comment below and let me know.

 

How Rehab Differs Between Traumatic and Atraumatic Shoulder InstabilityHow Treatment Differs Between Atraumatic and Traumatic Shoulder Instability

If you are interested in learning more on this topic, I have an Inner Circle presentation on How Treatment Differs Between Atraumatic and Traumatic Shoulder Instability.  We discuss this topic, plus a lot more, in much greater detail.

Nonoperative Treatment of Anterior Shoulder Dislocations – 25 Year Follow-Up

Bankart2 For this short holiday week, I have a guest post from my Friend and frequent contributor, Dan Lorenz.  This time, Dan talks about a couple of recent studies that assess the success of nonoperative treatment following anterior shoulder dislocations over a 25-year period. 

 

RESEARCH UPDATE: LONG TERM FOLLOW-UP ON NON-OPERATIVE MANAGEMENT OF PRIMARY ANTERIOR SHOULDER DISLOCATIONS AT 25 YEAR FOLLOW-UP

Dan Lorenz, PT, DPT, ATC/L, CSCS

In the last two years, Hovelius et al have published two studies that examined the long term sequelae of primary anterior shoulder dislocations. Both studies were in patients that were managed non-operatively. Interestingly, both groups of patients were followed for twenty-five years.

First, a prospective, multi-center study analyzed 257 shoulders in 255 patients aged 12-40 years followed for 25 years. After 25 years, 229 shoulders were available for follow-up. Radiographic imaging was performed in 97% of those. Researchers found that 44% of the shoulders were normal radiographically. Arthropathy was mild in 29%, moderate in 9%, and severe in 17%. Of shoulders without recurrence, 18% had moderate/severe arthropathy. 39% of shoulders suffered a recurrence once or more without surgery, and 26% for surgically stabilized shoulders. Shoulders that did not recur had less arthropathy than shoulders that recurred or stabilized over time. Shoulders surgically stabilized had less arthropathy than those that became stable over time. Factors correlated with moderate/severe arthropathy were: alcoholism (all 7 with severe were alcoholics), age > 25 years old at primary dislocation, dislocation caused by high-energy sports activity, and recurrence of dislocation. Of note, researchers were unclear about how the patients were managed, either with immobilization or activity as tolerated.

The second study was from the same group of patients, but non-operative treatment was discussed and patients were measured via questionnaire and the DASH score. 43% did not redislocate and 7% did once, 14% of recurrent dislocations stabilized over time, and nearly 8% were recurrent. 27% underwent stabilization procedures due to recurrent instability. Women had worse DASH scores than men. Researchers found that immobilization with the arm tied to the torso for three to four weeks did not change the prognosis compared to those who had immediate mobilization. Researchers also propose that the prognosis for younger ages is neither very good nor very bad. They argue that most first-time dislocations should be treated non-operatively and that immediate operation to stabilize shoulders may result in unnecessary operations in up to 30% or up to 50% if shoulders that stabilize over time are included. Regarding athletic activity, they did not identify an association between athletic activity and recurrence, nor was there a difference between males and females.

References:

Hovelius L, Saeboe M. Neer Award 2008: Arthropathy after primary anterior shoulder dislocation – 223 shoulders prospectively followed up for twenty-five years. J Shoulder Elbow Surg. 2009; 18: 339-347.

Hovelius L et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger: a prospective twenty-five year follow up. J Bone Joint Surg Am. 2008; 90: 945-952.

Choosing Which SLAP Special Test to Perform During Your Examination

There are so many different special tests for superior labral, or SLAP tears, how do you chose which to perform?  I have a couple of different ways that I determine which tests to perform, but first, lets see what the evidence has to say regarding all these tests.

Special tests for SLAP tears have come under much scrutiny in recent years as conflicting reports on the accuracy of these tests have been published.  What you will find in research reports regarding these tests is that the original citation for each of these tests seem to have extremely high sensitivity, specificity, and negative and positive predictive values.  A good example is the active compression test.  The original article by O’Brien had shown 100% sensitivity, 98.5% specificity, positive predictive value of 94%, and a negative predictive value of 100%.  These are pretty high numbers, so high that they are actually even better than MRI!  Since then, no other other author has shown values like this.

This is not isolated to the active compression test, almost every SLAP test described is similar.

Dessaur and Magray reviewed 17 peer-reviewed manuscripts and noted that the majority of papers reporting highly accurate tests for SLAP lesions were of low quality with the results not supported by other researchers.  Jones and Galluch agreed and noted that subsequent independent testing of SLAP tests showed much poorer performance that the originally published studies.  There are many other research reviews and meta-analysis studies that agree.

An interesting study from Oh et al in AJSM showed that a combination of tests used together may yield the best results.  They state that if you combine a couple of tests that have shown to have good sensitivity with a couple of tests that show good specificity, they reached sensitivity and specificity values between 70-95%.  This makes sense to me as none of these tests are perfect, think of it as covering your bases with a few tests.

I feel that this may be for multiple reasons.

Different patient populations will present with different mechanisms of injury.  In most studies, several variations of SLAP lesions are grouped together to obtain enough statistical power to analyze the data. It is my opinion that different tests will result in different specificity and sensitivity results based on the variation of SLAP lesion present. For example, overhead athletes with a type II or IV posterosuperior peel back SLAP lesion may be more symptomatic during tests that simulate the aggravating position and mechanism of injury, such as the biceps load II, clunk, crank, pain provocation tests, and pronated load test; whereas patients with type I or III SLAP lesions due to a traumatic type of injury may be more symptomatic during tests that provide compression to the labral complex such as the active-compression, compression-rotation and anterior slide tests.

Further investigation on the diagnostic characteristics of these tests based on the type of SLAP lesion is warranted.

This article is part of a 4-part series on SLAP Lesions

Choosing Which SLAP Test to Perform During Your Examination

I know it sounds cliché, but first and foremost, your subjective examination should lead your clinical tests.  If you patient is a construction worker who fell on an outstretched arm, you probably don’t need to perform any tests that simulate a peel-back lesion.  And vice-versa, if your patient is a recreational tennis player with a desk job that only feels pain while serving in tennis, you can probably jump straight to the peel-back tests.

For simplicity sake, lets divide SLAP tears into three categories (for more information read my post on classifying SLAP lesions):

  • Overhead Athletes that present with peel-back lesions
  • Compression injuries from someone that falls onto an outstretched arm or on the side of the shoulder.  This will compress and sheer the labrum, similar to a meniscus tear.
  • Traction injuries from a sudden eccentric biceps contraction.  This one is the least common and I even have some mild doubts of this mechanism.

Special tests for SLAP tears

Choosing a SLAP Test Based on The Mechanism of Injury

Here are the tests I perform based on the type of injury mechanism.  I actually find this to be much more helpful in selecting my tests than by selecting based on research results only.

Remember, we have no idea the exact patient population or injury mechanism for those research reports, you can not go on them alone!  You do, however, have this information for the patient that is sitting in the exam room right in front of you!

For detailed descriptions of each test, please refer back to my article on special tests for SLAP lesions.

Peel-Back Injury (Overhead Athlete):

  • Pronated load
  • Resisted Supination ER
  • Biceps Load

Compression Injury:

  • Active compression
  • Compression rotation
  • Clunk

Traction Injury:

  • Dynamic Speed’s
  • Active compression

Choosing a Test Based on The Type of SLAP Tear

If you want to try to determine the type of SLAP tear, Type I, Type II, Type III, or Type IV, this is more challenging but you can try to give it a shot based on the below table.  This is definitely more of guess work, but the more information we can try to obtain the better.

Remember that each of the tests described will try to reproduce symptoms in different ways, you should try to correlate the pathology of the different types of SLAP lesions with specific special tests.  Use this as a grain of salt, it may be helpful but hasn’t been backed by research to show how well this classification works (this more for just a game I play against myself!)

Type I SLAP:

  • Compression rotation

Type II SLAP:

  • Pronated load
  • Resisted Supination ER
  • Biceps Load

Type III and IV SLAP:

  • Clunk and Crank
  • Compression Rotation

In summary, the research results of the numerous SLAP tests are extremely variable and should not be relied on solely to determine which test to perform on your patient.  In contrast, I propose that you:

  • Use the patient’s mechanism of injury to lead your decision on which group of tests to perform.  The subjective exam is important!
  • Perform a cluster of a few tests for that group that have shown decent sensitivity and specificity to enhance your results using a group of tests rather than just one.
  • Don’t hang your hat on one test.  It may be good for a specific patient population and not another
  • Don’t get frustrated, SLAP lesions are difficult to detect on clinical examination.  When in doubt refer back to the doctor for a MRI.

When Do You Perform These Tests?

Now that you know the real key is understanding “when” to pick each test, I want to walk you through all these in one of my Inner Circle webinars.  In my mind, they all are slightly different and may even be better at detecting different types of SLAP lesions.  This Inner Circle webinar discusses this and shows you my clinical algorithm on how and why I perform special tests to diagnose a SLAP tear:

Learn Exactly How I Evaluate and Treat the Shoulder

shoulder seminarIf you want to learn even more about the shoulder, my online course will teach you exactly how I evaluate and treat the shoulder.  It is packed with tons of educational content that will help you master the shoulder, including detailed information on the clinical examination and treatment of SLAP tears.