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Conservative treatment of a rock climber with a SLAP lesion: a case report.

Introduction

The term SLAP (superior labrum anteroposterior) tear was originally introduced by Snyder et al. in 1990 (1) but Andrews was the first to report this type of lesion in 1985 (2). SLAP lesions refer to a tear of the superior labrum (11-to-1 o'clock position), typically at the origin of the long head of the biceps tendon and might extend into the labrum anteriorly or posteriorly and into the adjacent structures. (3-5) The prevalence of SLAP lesions in people seeking orthopaedic care with shoulder pain varies between 6% and 11.8%. (6,7) Although it is difficult to assess the incidence in the population of this type of injury, the incidence of associated number of surgeries was 22.3 / 100,000 inhabitants in the state of New York in 2010. (8) This represents an increase of 464% compared to the year 2002. (8) In the military, the incidence of surgery rates can reach 2.13 cases per 1,000 person-years. (9) Male gender, age and being in the Marine Corps were all significant risk factors. (9) SLAP lesions are also frequently reported in young athletes with 'throw' movements sports (baseball, tennis, swimming, etc.). (10,11) The natural evolution of SLAP lesions and the effectiveness of conservative treatment is unknown since it has only been investigated in the context of a case series. (12) However, the results look promising with a significant decrease in pain, improved quality of life and rates of return to play similar to surgical patients. (12) Nevertheless, half of the patients who start conservative treatment ultimately choose surgery. (12) The latter option seems to produce good results in the general population, but the return to play of athletes (especially baseball) is unpredictable. (13) Treatment modalities used during the conservative care of SLAP lesions are poorly documented. This case report presents in detail the treatments used for a young recreational climber suffering from a SLAP lesion.

Case presentation

A 26 year-old recreational rock climber developed a dull pain in the right shoulder during a bouldering session (difficulty V2-V3). The patient reported that he felt a popping sensation when he tried to reach a distant socket with his shoulder abducted 90[degrees] and in extreme external rotation (ABER position). The patient initially sought chiropractic care at a rate of 1 to 2 treatments per week over a two month period. Although we did not have access to that clinical record, the patient reported that the treatments consisted of transverse friction at the insertion of the rotator cuff tendon; spinal manipulative therapy of the thoracic spine; and prescription of stretching exercise of the pectoralis minor. Since his condition did not improve, the patient then consulted an orthopaedic surgeon and received a prescription for a magnetic resonance arthrography (MRA) examination as well as a reference for physiotherapy. The patient visited the physical therapist only once. During this visit, his shoulder was taped and he received a prescription for stretching exercises of the pectoralis minor and major, as well as strengthening exercises of the internal and external rotators using an elastic band.

Not feeling any improvement after performing the exercises for two weeks, the patient obtained an appointment for the MRA examination in a private clinic. The MRA examination revealed an isolated posterosuperior glenoid labral tear associated with a paralabral cyst without injury to the tendon of the long head of the biceps. All other structures including the rotator cuff tendons and bursae appeared normal (Figure 1 and 2).

Consequently, the patient consulted an orthopaedic surgeon to evaluate surgical options. Awaiting the preoperative consultation, the patient decided to consult another chiropractor for a second opinion 5 months after his initial injury because the pain was still intense (5/10) during exercise. During this clinical examination all the orthopedic tests of the shoulder (Neer, Jobe, Sulcus sign, Hawkins, Speed, Apprehension manoeuvre) were inconclusive and the ranges of motion (active, passive and resisted) were normal. Trigger point pains were identified in the following muscles: supraspinatus, subscapularis, infraspinatus, teres minor, biceps (long head), rhomboids and serratus anterior. In addition, postural analysis showed a slight winging of the right scapula. Conservative care consisted of soft tissue mobilization of muscles, tendons, ligaments and joint capsule using Active Release Techniques[R] and Graston Technique[R]. Strengthening exercises of the external shoulder rotator (with an elastic band) and the serratus anterior (scapular "push-up") were also prescribed. After four treatments, the patient cancelled his appointment with the orthopaedic surgeon because he was pain free. He then gradually returned to his sport, performing today at a more advanced level than before (bouldering V4-V5).

Discussion

This case report is a good example of positive outcomes following the conservative treatment of a SLAP lesion. Having tried several conservative approaches, it is likely that using manual therapies (Active Release[R], Graston Technique[R]) was a key component of the treatment of this patient, along with the inclusion of scapular stabilization exercises. The diagnosis of SLAP requires a high level of clinical suspicion to wisely prescribe imaging. There is little literature on the natural history of this condition and the effectiveness of conservative care. We will now discuss the anatomy, clinical presentation, imaging and treatment of SLAP lesions.

Anatomy

The labrum is a ring of fibrocartilage based on the glenoid cavity. It increases the shoulder's depth, stability and shock absorption capacity. (4) The labrum is also a site of attachment of the joint capsule, the glenohumeral ligaments, and the long head of the biceps tendon. (4) Approximately 50% of the biceps tendon fibers attach to the superior labrum and the other 50% on the supra-glenoid tubercle. (14) The superior and anterior region of the labrum has the poorest blood supply, and it is hypothesized that contributes to a slower healing process. (14) The 11-to-3-o'clock position is a common site of anatomic variants of the labrum and glenohumeral ligament (sublabral recess, sublabral foramen, Buford complex and mobile glenoid labrum). (4) These normal variants are associated with a higher incidence of SLAP lesions. (15-17) Ten distinct types of SLAP lesion, based on the extent of the labral tear and involvement adjacent structures, have been reported in the literature. Type II SLAP lesion (superior labral tear and biceps tendon stripping) is the most common type. 90% of type II SLAP lesions have associated shoulders abnormalities like: rotator cuff tendinosis and/or tear, acromioclavicular and/or glenohumeral arthritis, adhesive capsulitis. (18)

Clinical Presentation

It is difficult to clinically diagnose SLAP lesions, because it does not have a specific presentation and associated conditions are frequent. During the initial interview, the patient may report non-specific anterior shoulder pain aggravated by overhead activity. (3) Clicking, popping, stiffness and glenohumeral instability might also be present. (3,19) Clinicians should also investigate the plausibility of the following potential mechanisms of injury (3) :

* sudden traction on the arm and forceful contraction of the biceps muscle which can peel back the labrum from the glenoid (20) during activity that involves overhead motion with the arm in the abducted and externally rotated (ABER) position (ex: baseball, tennis, swimming);

* the superior migration of the humeral head resulting from a rotator cuff tear, might also cause a lifting of the superior labrum and biceps tendon from the glenoid; (21)

* a fall on an outstretched hand (FOOSH) or a direct blow to the shoulder;

* an internal impingement syndrome that results from the impingement of the soft tissues of the rotator cuff and joint capsule on the glenoid or between the glenoid and the humerus. (22)

The physical examination should begin by a careful evaluation of the glenohumeral and scapulothoracic ranges of motion. (5,10) The glenohumeral ranges of motion are better assessed in the supine position with the shoulder positioned at 90[degrees] of abduction and the elbow in flexion. This position stabilises the scapula and it is easier to detect side-to-side difference in internal and external gleno humeral rotation. SLAP lesions could be associated with an increase of external rotation and a decrease of internal rotation, particularly in the throwing athlete. (10) This glenohumeral internal rotation deficit (GIRD), is characterize by a decrease of 20[degrees] when compared with the opposite side. (23) The evaluation of scapular kinematics is also an important component of the physical examination. Alteration of the scapular position or motion might produce greater stress to the glenohumeral joint (10,24) as in the present case report. Clinicians should also keep in mind that atrophy of the periscapular muscles might be secondary to a cervical pathology. (5,10) Despite the initial enthusiasm regarding particular orthopaedic shoulder tests (Biceps load II test and Active-Compression test (O'Brien's test)), a recent meta-analysis demonstrated that none of the studied tests had sufficient psychometric propriety (sensibility, specificity, positive and negative predictive value) to provide the clinician with useful information. (25) Test combinations represent a promising area of research, but none of the studied combinations were actually satisfactory. (25)

Imaging

Given the limitations of the clinical evaluation, imaging remains the key to diagnosing SLAP lesions. Plain radiographs of the shoulder are typically normal unless there are associated co-existing conditions such as glenohumeral subluxation, acromioclavicular deformation and/or outlet impingement. (5,10) Bankart lesions (anterior inferior fracture of the glenoid) and Hills-Sachs defect (posterior superior fracture of the humeral head) might also be signs of previous shoulder trauma and potential instability. (10) MRA is an examination where intra-articular Gadolinium is administered with a 18- to 25- Gauge needle into the shoulder joint under fluoroscopic or ultrasound guidance followed by magnetic resonance imaging (MRI). It is more sensitive than non-arthrographic MRI and ultrasound scans as Gadolinium distends the joint space allowing for improved visualization of the labral and joint capsular structures. (26,27) Unfortunately, false positives are frequent when compared to arthroscopy. (27) Since computed tomography arthrography demonstrated similar psychometric properties to MRA, it might be used in the context of limited access to MRA. (28) Clinicians might consider prescribing advanced imaging after failure of a course of conservative care if the mechanism of injury is consistent with a SLAP lesion.

Treatment

The evidence regarding the conservative treatment of SLAP lesions is very limited and the treatment recommendations are based on a case series and expert opinions. (5,10,12) Treatment recommendations include: rest from painful activities, nonsteroidal anti-inflammatory drugs and rehabilitation. (5,10,12) Rehabilitation care is oriented towards stabilizing muscles of the shoulder and shoulder girdle in order to regain normal muscle strength, neuromuscular activation and adequate proprioception. (10,12) In the presence of a GIRD, stretching exercises of the posterior capsule might also be prescribed. (10) The present case report suggests that manual therapy (Active Release[R], Graston Technique[R]) might also play an important role in the treatment of SLAP lesions. In the case series reported by Edwards, 49% of patients treated conservatively avoided the surgery. (12) Conservative care significantly improved pain, function and quality of life of patients in 49% of cases. (12) The return to play rate at the pre-injury level of activity was 71% (66% in the overhead athletes). (12) The rate of return to play of conservative care was also comparable to surgical treatment. (12) Edwards recommended that patients should be referred for surgical interventions if significant pain and functional limitations were still present after 3 months of conservative care. (12) Orthopaedic surgeons will consider: the type of SLAP lesions (ie: the extent of the labral tear and the involvement of adjacent structures), the age, and the level of functionality of the patient before recommending surgical options. (5,10,13,29) Since surgical procedures vary widely (debridement, repair, fixation, partial or total resection of the tendon, etc.), it is difficult to assess the prognosis of SLAP lesion repairs. (5,13) A recent systematic review concluded that type II SLAP repairs produced excellent results for patients not involved in overhead throwing sports. (13) Baseball players had less predictable results with return to sport rates (at a similar level) ranging from 22% to 64%. (13)

Conclusion

This case report demonstrates that it is difficult to diagnose SLAP lesions without high clinical suspicion. It also illustrated that conservative treatment might provide an optimal recovery with a return to sport activities at the previous level (or higher). Manual therapies seemed to play an important role in the treatment of this patient. Future research should help to better understand the natural history of SLAP lesions and identify effective modalities of conservative care.

Acknowledgement

The authors would like to thank Dr. Mathieu Paquin for the linguistic revision of the manuscript.

References

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Marc-Andre Blanchette, DC, MSc [1]

Ai-Thu Pham, DC [2]

Julie-Marthe Grenier, DC, DACBR/FCCR(C) [3]

[1] Public Health PhD Program, School of Public Health, University of Montreal, Montreal, QC, Canada

[2] Private practice, Momentum Chiropratique, Vaudreuil-Dorion, QC, Canada

[3] Associate Professor, Department of Chiropractic, Universite du Quebec a Trois-Rivieres, Trois-Rivieres, QC, Canada

Corresponding author: Marc-Andre Blanchette marc-andre.blanchette@umontreal.ca

Public Health PhD Program, School of Public Health, University of Montreal, Montreal, QC, Canada

Disclosures: Dr. Marc-Andre Blanchette receives a PhD fellowship award from the CIHR. Dr. Julie-Marthe Grenier and Dr. Ai-Thu Pham declare no competing interests.
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Author:Blanchette, Marc-Andre; Pham, Ai-Thu; Grenier, Julie-Marthe
Publication:Journal of the Canadian Chiropractic Association
Article Type:Report
Date:Jul 1, 2015
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