CHAPTER 47 • SHOULDER SUPERIOR LABRUM BICEPS AND PEC TEARS 283SUPERIOR LABRAL PATHOLOGIC CONDITIONS
- SLAP tears can be a source of pain and disability
either in isolation or coexistent with other shoulder
pathology (Kim et al, 2003; Morgan et al, 1998).
SLAP tears have been associated with instability, rota-
tor cuff pathology, and ganglion cyst origination. - SLAP tears can result from a single traumatic event. A
fall on an outstretched arm or elbow can create a supe-
rior humeral translation that can avulse or tear the
superior labrum. Shoulder hyperextension, as in an
arm tackle or seat-belt restraint injury, can place trac-
tion on the biceps and capsular attachments avulsing
the superior labrum. Large Bankart avulsions can
include the superior labrum and biceps anchor. SLAP
avulsion can increase inferior translation of the shoul-
der contributing to shoulder instability. - SLAP tears often coexist with other shoulder pathol-
ogy as a result of overuse and developmental condi-
tions. Baseball pitchers develop upper extremity
velocity by placing the arm in maximum extension as
they externally rotate and abduct. Torso forward pro-
jection places additional contact forces on the under-
surface of the rotator cuff against the superior labrum.
Internal impingement occurs when excessive com-
pressive forces occur and may be associated with rota-
tor cuff tears, superior labral tears, posterior capsular
changes, and scapular dyskinesia. - Juxta-articular ganglions adjacent to the glenohumeral
joint have been diagnosed with increasing frequency,
as magnetic resonance imaging of the shoulder has
been utilized. Ganglions often originate from the joint
space and communicate with the ganglion with a
defect or tear in the superior or posterosuperior
labrum. Ganglions may be asymptomatic or cause
neurologic dysfunction due to peripheral pressure on
the suprascapular nerve prior to the supraspinatus
innervation at the scapular notch or adjacent to the
scapular spine prior to the infraspinatus innervation.
SUPERIOR LABRAL DIAGNOSIS
•Patients most often complain of pain in provocative
positions. A painful click may occasionally be repro-
ducible, especially when associated with instability.
- The mechanism of injury can be traumatic and overuse.
Traumatic events include a fall on an outstretched arm,
hyperextension injury, and seat-belt injury. The body
torso projects forward as the shoulder and arm are
restrained. Overuse injuries as in baseball pitching
accentuates internal impingement contact forces. Forced
inferior translation may create superior labral avulsions
due to traction on the biceps and capsular attachments.
•Degenerative changes are commonly found in the
superior labrum, and their significance has not been
established.
•Physical examination has had variable results (Kim
et al,2003; Morgan et al, 1998; McFarland, Kim, and
Savino, 2002). Examination of the biceps with
provocative testing has been helpful in anterior tears
(Speed’s, Yergason) Translation test (load and shift,
jerk tests), provocative position (relocation test,
O’Brien) testing can reproduce pain, but is often asso-
ciated with common complaints exterior to the shoul-
der, i.e., the acromioclavicular joint. Most SLAP
lesions are not diagnosed preoperatively, but rather at
the time of arthroscopic surgery.- Imaging tests can be helpful. Magnetic resonance
imaging(MRI) without contrast can identify ganglion
cysts adjacent to the shoulder. MRI with articular con-
trast may illustrate superior labral tear. Anatomic vari-
ants may contribute to abnormal imaging findings.
SUPERIOR LABRAL TREATMENT- Most common treatment for intersubstance tears of
the superior labrum is debridement (type I and III).
•Tears in young active individuals associated with
shoulder instability, advanced rotator cuff pathology,
ganglion origin, and as isolated source of pain are con-
sidered for repair. These repairs may be done in com-
bination with capsulorrhaphies, cuff repairs, ganglion
decompression, and subacromial decompressions. - Superior labral repairs are most commonly performed
with suture anchors. An anchor is inserted along the
articular margin of an abraded glenoid neck. Sutures
are advanced under the labrum and through the capsule
and tied. Anterior labral repairs include the biceps
anchor. Posterosuperior SLAP repairs may need acces-
sory portals to properly place anchors along the gle-
noid to secure the labrum (Morgan et al, 1998). - Postoperative management should include immobi-
lization and regulated movement, followed by
strengthening. Return to demanding activities take 3 to
6 months.
BICEPS (SHOULDER)- The biceps is susceptible to injury in multiple loca-
tions in the shoulder region. The long head of the
biceps has a twisted pathway before attaching to the
superior labrum and glenoid. As the shoulder is posi-
tioned in abduction and external rotation, additional
stresses are placed on these attachments (Burkhart
and Morgan, 1998).