Conservative treatment for SLAP lesions

A SLAP lesion is a type of shoulder injury that involves the labrum inside the shoulder joint. SLAP stands for Superior Labrum Anterior Posterior. It is most commonly found in athletes who do "overhead" sports, e.g. pitching, tennis, or volleyball. It usually happens when they are throwing a ball or hitting an overhead shot, but you can also sustain it by falling on an outstretched arm or when tackling an opponent in rugby.

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SLAP lesions vary in severity. The long head of biceps’ tendon attaches to the top of the labrum in the shoulder and can sometimes also come away from the bone (Type 2 lesion). Minor labral tears can be managed without surgery through a carefully graded rehab exercise programme. In this article I’ll discuss how the research suggests you do this.

In this article:

• Relative Rest

• Medication

• Rehab exercise programme for SLAP lesions

• Look further than just the shoulder

I've also made a video about this:

Relative Rest

Relative rest forms an important part of any rehab programme. Relative rest means that you reduce your activity and sport to a level that doesn’t aggravate your injury. In other words, you don’t have to stop all activity – only the movements that cause pain.

Medication

You may think that it’s strange that I include a section on medication when the article is about rehab exercises. SLAP lesions, even minor ones, can often be very painful and you can’t really do any meaningful exercise while you’re in pain.

NSAIDS can be useful for pain management and to help reduce swelling and inflammation – especially in the early stages. In some cases the pain may not respond to pain medication, in which case a corticosteroid injection may be appropriate. Steroids can, however, interfere with the healing process so it should only be used if really needed.

Hands-on treatment consisting of soft tissue release and dry needling can be a very effective alternative to using pain medication or injections. It can provide very good pain relief and does not come with so many side effects.

Rehab exercise programme for SLAP lesions

The length of the rehab programme should really be tailored according to your injury, but 16 weeks is a good starting point. You may take longer if your injury is more severe or shorter if you only have a tiny tear in your labrum.

The current theory with regards to why this injury happens is that, due to the high volume of repetitive overhead movements these athletes do, they:

1. develop a tight posterior joint capsule that pushes the head of the humerus forward and up, causing increased strain on the labrum. The tight capsule usually causes the shoulder to have less internal rotation than on the other side, so it is useful to test the total rotation range of motion in the one shoulder vs. the other shoulder.

2. often also develop a muscle strength imbalance between the internal rotators (stronger) and the external rotators (too weak) of the shoulder.

That’s why a rehab programme for SLAP lesions usually have to include stretches to improve internal rotation range of motion and pay special attention to strengthening the muscles that control external rotation.

Early Rehab: Weeks 1 – 4

If you have a Type 2 SLAP lesion, which means that the the biceps tendon is also pulling away from the glenoid, you have to make sure that you choose exercises that DON’T load the biceps during the first 4 weeks. This will allow the tendon time to reattach and settle down.

Your first aim should be to restore full range of motion in the shoulder into all directions. Free active movements, where you move the arm into all directions but stop just short of pain can be useful for this.

The Sleeper stretch is one that is commonly prescribed to help stretch the posterior capsule and increase internal rotation, but it can actually cause a lot of pain during the early stages of this injury. Doing a gentler stretch where you just pull your arm across your body may be a better option to start with.

The focus during this early stage should be on activating and strengthening the stability muscles of the scapula and shoulder, which include the lower trapezius, middle trapezius, serratus anterior and rotator cuff. Choose exercises that are done in relatively low load and stable positions. Use low resistance and high reps, but do the movements slowly while focusing on control.

Examples of exercises that may be useful during the early stages of rehab include:

• Forward flexion in side lying

• Prone extension

• Seated row

• Serratus punch

• Knee push-up plus

• Supported internal rotation in 20 degrees of abduction

• Supported internal rotation in 90 degrees of abduction

• Internal rotation diagonal with pully

• Supported external rotation in 20 degrees of abduction

• Supported external rotation in 90 degrees of abduction

• Forearm supination with arm supported

• External rotation

Mid Rehab: Weeks 5 – 12

Start loading the biceps through using exercises like:

• Forward flexion in external rotation and forearm supination – starting with short levers (elbow bent) and progressing to long levers (arm straight)

• Full can

• Elbow flexion in forearm supination

• Uppercut

Progress your strength training to using heavier loads in more unstable positions. Include fast and/or ballistic exercises e.g. throwing a ball against the wall. You should strengthen the shoulder into all directions and think about what you need to be able to do in your sport.

Late Rehab: Weeks 13 - 16

During this period your exercises should be very sport specific and resemble movements and forces that you would experience when you play your sport. This will obviously vary depending on the sport.

Look further than just the shoulder

Your neck and back posture has a direct influence on your shoulder position and function. When you hit or throw a ball, a large part of the force should be generated lower down in the kinetic chain, through your hips and core. You’ll place extra strain on your shoulder if those areas aren’t playing their part properly.

This is why the person who creates your rehab programme should also consider your posture, strength and movement patterns in the rest of their body.

Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

Best wishes

Maryke

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate, Facebook, Twitter or Instagram.

References:

1. Brukner, P, et. al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon)

2. Abrams, G. D. and M. R. Safran (2010). "Diagnosis and management of superior labrum anterior posterior lesions in overhead athletes." British Journal of Sports Medicine 44(5): 311-318.

3. Cools, A. M., et al. (2014). "Rehabilitation exercises for athletes with biceps disorders and SLAP lesions: a continuum of exercises with increasing loads on the biceps." The American Journal of Sports Medicine 42(6): 1315-1322.

4. Helgeson, K. and P. Stoneman (2014). "Shoulder injuries in rugby players: Mechanisms, examination, and rehabilitation." Physical Therapy in Sport 15(4): 218-227.

5. Manske, R. and D. Prohaska (2010). "Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete." Physical Therapy in Sport 11(4): 110-121.

6. Moore-Reed, S. D., et al. (2017). "Conservative Treatment for Patients with Suspected SLAP Tears: A Case Series." urkiye Klinikleri Journal of Health Sciences 2(2): 121.

7. Wright, A. A., et al. (2018). "Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis." Br J Sports Med 52(4): 231-237.