30 Muscles involved in the Shoulder
Who is this?
What record did he set?
How many yards?
2, 383 ?
Passing Yards in a Career
Peyton Manning (35)
Warren Moon+ 49,325 1984-2000
Fran Tarkenton+ 47,003 1961-1978
Vinny Testaverde 46,233 1987-2007
Kerry Collins (39) 40,922 1995-2011
Drew Brees (32) 40,742 2001-2011
Joe Montana+ 40,551 1979-1994
Johnny Unitas+ 40,239 1956-1973
Tom Brady (34) 39,979 2000-2011
Throwing Injuries - Shoulder
Hint? They named an award after
4 Phases of Throwing
• Painful popping, clicking, or
“catching” in the shoulder
• Pain when attempting to
extend the arm overhead
or reach behind the back
• Pain when throwing a ball
• An aching pain felt deep in
What is the Diagnoses?
• Superior Labrum from
Anterior to Posterior.
• The SLAP tear occurs at
the point where the
tendon of the biceps
muscle inserts on the
• A SLAP tear is an injury to a part
of the shoulder joint called the
• similar to the hip; however, the
socket of the shoulder joint is
extremely shallow, and thus
• To compensate for the shallow
socket, the shoulder joint has a
cuff of cartilage called a labrum
that forms a cup for the end of
the arm bone (humerus) to move
• Fall onto an outstretched hand
• Repetitive overhead actions (throwing)
• Lifting a heavy object
• The area of the labrum where the SLAP tear occurs is susceptible
to injury because it is an area of relatively poor vascularity. Other
parts of the labrum often heal more easily because the blood
supply delivers a healing capacity to the area of the tear.
• In the area of SLAP tears this is not the case, and chronic shoulder
pain can result.
• a slip and fall onto an
outstretched arm, or
falling on a shoulder
may cause a SLAP tear.
• Even bracing oneself,
outstretched, in a car
• catching sensation
• pain with shoulder movements, most often overhead
activities such as throwing.
• pain deep within the shoulder or in the back of the
• It is often hard to pinpoint symptoms, unless the biceps
tendon is also involved. In cases of SLAP tears with
associated biceps tendonitis, patients may complain of
pain over the front of the shoulder
• SLAP tears tend to be
seen best on MRI when
the study is performed
with an injection of
Anterior Slide Test
• involves the arm to be examined is positioned with the hand on the
ipsilateral hip with the thumb forward.
• The examiner then stabilizes the scapula with one hand and provides an
anterosuperiorly directed axial load to the humerus with the other hand.
• The test is considered positive if there is a click or deep pain in the
shoulder during this maneuver
• Sensitivity: 8-78%, Specificity: 84%, PPV: 5%, NPV: 90% (These results are
from a combination of many different studies, you can see the large
Biceps Load and Biceps Load II Tests
during this test, the shoulder is placed in 90 degrees of abduction and maximally externally
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.
• Sensitivity: 91%, Specificity: 97%, PPV: 83%, NPV: 98% for
Biceps Load I; Sensitivity: 90%, Specificity: 97%, PPV: 92%, NPV:
96% for Biceps Load II
Pain Provocation Test
• During this maneuver, the shoulder is passively abducted to 90-100
degrees and passively externally rotated with the forearm in full
pronation and then full supination.
• SLAP lesion was present if pain was produced with shoulder external
rotation with the forearm in the pronated position or if the severity of
the symptoms was greater in the pronated position.
• The authors note that positive symptoms with this test are due to the
additional stretch placed on the biceps tendon when the shoulder is
externally rotated with the forearm pronated.
• Sensitivity: 100%, Specificity: 90%
SLAP tears into three categories
• 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.
Basic types are Type I-IV.
• Type I –
fraying/degeneration of labrum edge
• Type II – defect (fray/degeneration) into the labrum;
commonest type; requires surgical repair
• Type III - bucket handle tear; uncommon; requires
• Type IV - bucket handle tear AND biceps tendon
tear; uncommon; requires surgical repai
Type I SLAP:
Type II SLAP:
Tests for a PeelBack Injury
Type III & IV SLAP: Crank
• Most patients with SLAP tears will respond to conservative
(meaning non-surgical) treatments.
• Any patient with a SLAP tear will be advised to rest after the
injury to allow the injured tissue to cool down.
• A period of rest will allow inflammation to subside and may
help to alleviate symptoms.
• The therapy is designed to restore range of
motion and strength to the shoulder.
Debridement of the SLAP tear
• When a SLAP tear is debrided, the torn
portion of the labrum is shaved away to leave
a smooth edge.
• This option is only suitable for minor tears
that do not involve the biceps tendon.
• procedure that cuts the biceps tendon from where it attaches to
the labrum, and reinserts it in another area.
• The idea behind a biceps tenodesis is that by decreasing the forces
that pull on the SLAP region, the symptoms will be alleviated.
• A biceps tenodesis is most often performed on patients over 40
years of age or patients with associated biceps tendonitis or
• A biceps tenodesis can either be performed arthroscopically, or
through a small incision over the top of the shoulder.
• A SLAP repair is an arthroscopic procedure
that uses sutures with anchors attached to
resecure the torn labrum down to the
• A SLAP repair is best suited to patients with
an otherwise healthy shoulder who want to
remain athletically active.
Advantages of a SLAP repair?
• Restores the normal anatomy of the shoulder by reattaching the
labrum in its normal position.
• Once healed, the SLAP repair allows normal function of the
previously damaged labrum and biceps attachment.
• What are the advantages of other treatments such as
debridement or tenodesis?
• The rehabilitation is often not as restrictive as is the case with a
• The results of surgery are usually more predictable, as healing of a
SLAP repair is not as reliable.
Rehab after a SLAP repair
Rehabilitation varies depending on factors such as the strength of the SLAP
repair, and the preference of the surgeon.
Most often, a period of time of restricted motion is maintained for about six
weeks following a SLAP repair.
During this first phase of rehabilitation, some passive motion is allowed to
prevent shoulder stiffness. In the first phase, the torn labrum is healing into its
Once healed, patients enter the second phase of rehabilitation and can begin
more motion at about six weeks.
Physical therapy continues to help maintain motion and regain strength of the
shoulder. The final phase of rehabilitation involves more active strengthening of
the muscles that surround the shoulder joint, and full recovery is expected
between 3 to 4 months.
What is this?
Return to Sports?
• 6 months after surgery. You must have good
motion, strength, and control of your
shoulder and arm.
• Overall, the success rate for SLAP repair
ranges from 85 to 95%.
• The goal is to achieve a shoulder with no pain
for throwing or overhead activity.