Brian Schiff’s Blog

Over the past few weeks I have had numerous questions and comments on the blog about SLAP tears.  So, I thought I would add another post with more in depth information on classification of tears, typical treatment and outcomes.  This is a relatively common injury that many know so little about.  To see a diagram, click here.

Different types of SLAP tears

1. Type I – Fraying of the edge fo the superior labrum
2. Type II – detachment of the biceps anchor from the glenoid labrum (most common)
3. Type III – Bucket handle tear of the superior labrum with otherwise normal biceps anchor
4. Type IV – Bucket handle tear of the superior labrum extending into biceps tendon causing detachment of the biceps anchor

Other surgeons have expanded on these classifications as well, but i will not go into that depth here.  You should know that some sub classify type II tears into anterior, posterior and combined anterior and posterior lesions.  In effect a SLAP tear can cause a microinstability thereby leading to articular sided rotator cuff tears.  In plain terms, a posterior labral tear could create a posterior partial thickness rotator cuff tear and an anterior labral tear could create an anterior cuff tear.

The shoulder exam itself often reveals pain with passive external rotation at 90 degrees of abduction (picture the cocking phase of throwing here).  Weakness and instability may also be present depending on the type of tear and if there is already a cuff injury present as well.  There are a number of diagnostic clinical tests done including the O’Brien test, Speed’s test, crank test and biceps load test to name a few.  Many have been successful at confirming labral pathology.  In the end, the MRI is the gold standard in confirming an injury.

Non-operative treatment is often unsuccessful in most cases.  Patients with Type I tears may do better than most (JOSPT February 2009).  Therapeutically, we often see GIRD.   GIRD stands for glenohumeral internal rotation deficit, meaning the affected shoulder has significant posterior capsule tightness and decreased internal rotation (common among overhead athletes and throwers).  Restoring this motion may prevent injury that often occurs between the supraspinatus tendon and the posterior superior labrum.  Research is unclear if GIRD increases risk for a labral tear.

In addition to this stretching the posterior capsule, it is critical to strengthen the scapular muscles and rotator cuff to restore optimal mechanics and motion between the humerus and scapula.  Due to poor posture, flexibility issues and muscular imbalances, the average person may have an altered scapulo-humeral rhythm.  If non-operative treatment fails, one typically opts for surgery.

Arthroscopic surgery is the standard procedure today with debridement of the labrum and reattachment via sutures.   In many cases, surgeons debride rotator cuff tears with less than 50% torn, while opting for primary repair if greater than a 50% tear.  According to a leading surgeon, David Altchek, he will excise a longitudinal biceps tear that is less than 1/3 of the diameter of the tendon, while optiong to repair one that is greater in size back to the major portion of the tendon.

Common rehab timetable 

• Max protection for 0-3 weeks in sling with limited external rotation and overhead activity
• No biceps strengthening for 2 months
• Focus on motion restoration in weeks 3-8
• More aggressive strengthening begins at week 8
• Return to throwing begins at month 4 in most cases

These are some rough guidelines and progressions vary based on each case and the type of tear and associated damage as well as desired activity level.  About 90% of patients experience good to excellent results with Type II repairs in the short to mid term follow-up, but there is not extensive long term data out there.  It should also be noted that throwers and overhead athletes tend to exhibit lower satisfaction with repsect to return to pre-injury levels after surgery.  Recent studies also seem to indicate throwers with an overuse related injury do not do as well as those with a specific traumatic injury resulting in a type II tear.

I hope this post is helpful for those suffering from labral tears or who suspect they may have one.  It is an intricate injury but quite disabling to function with long term implications for the health and function of the shoulder.

Ever have a persistent ache in the shoulder with certain exercises in the gym?  I am talking about a nagging pain along the top or end of the shoulder with bench press, flies, dips, military press or even pull-ups?

Well, one of my staff members has just this type of pain.  He first asked me to look at his shoulder about 6 weeks ago.  I felt there was nothing substantially wrong with the rotator cuff or labrum and recommended he work on rotator cuff and scapular strengthening while backing off the heavy strength training (he is a natural body builder preparing for a show).

He told me about 2 weeks ago that it was still not better.  He complained of more site specific pain along the AC joint.  There was no obvious subluxation present but he was tender right along the end of the clavicle.  I suggested he see a shoulder specialist I know.

The AC joint below (joined by ligaments not visible on x-ray)

His MRI results revealed a micro fracture of the distal clavicle.  Doc says he can continue to train but needs to back off the weight on bench press and avoid pull-ups.  I also suggested he skip dips and he has been now for some time.  So, what caused it?  Good question as he only recalled pain when doing flies during a workout a few months back. 

Could this have caused it?  Maybe.  Pulling the arm across or toward the mid line of the body brings the clavicle into close approximation with the acromion of the shoulder.  There may have been a loading moment (especially with heavy dumbbells) where he strained the joint.  Or, perhaps it was the result of repetitive micro-trauma as the result of lots of heavy chest work.

Regardless, the take away points here are:

• Repetitive upper body lifts (especially those requiring lots of clavicle spinning, elevation and rotation like pressing, dips, pull-ups, and upright rows) may cause stress to the AC joint. 
• Flies do cause approximation and in people with any AC joint arthritis mild compression of the AC joint as the arm comes toward mid line
• Chest movements are likely to affect pain as the pecs attach directly to the clavicle
• Obscure chronic shoulder pain may be related to AC joint irritation that does not show up on an X-ray
• Shoulder pain with lifting may be related to AC joint pain rather than rotator cuff dysfunction in some cases

As a general rule, I caution all my clients over the age of 35 to go easy on the dips for sure as I find this one exercise more than any other tends to flare up an arthritic AC joint fast.  That is the double edged sword of strength training – repetition is necessary to get results but the repetitive nature is capable of taking good exercises and wreaking havoc on the body long term.  Form matters as does avoiding harmful range of motion with lifting.

In the end, let your shoulder guide your decision making in the gym.  In my staff member’s case, he will be fine and recover 100%, although he will likely have to modify his lifting and endure some pain as he pushes on toward his competition.

Okay, today I am going to rant just a bit about two fundamental problems in modern America with repsect to medicine.  Before I get started, let me first say this blog post is not a universal generalization or assessment of all people or all physicians.  With that said, here is the email I received from a customer today that has spurred this post:

“I’ve started on the rotator cuff muscle exercises and my right shoulder is already feeling better. The left shoulder, which has been torn for the longest, is not yet showing a noticeable improvement. Considering my doctor told me I’d have to ‘put up and shut up’ I am feeling very pleased.“

So here are the 2 problems:

1. MD’s are typically trained to prescribe pills and operate as opposed to encouraging and trusting the human mind and body to heal itself with the proper intervention
2. Too many people just blindly accept the physician’s treatment approach without considering other qualified opinions or asking “why” the MD feels that way

In the case of my client above, the MD obviously told the patient if she chose not to undergo an operation that she would continue to suffer and needed to shut up and quit complaining.  While one shoulder has yet to improve, in less than one week on my program she is already seeing positive improvement.  Hmmm.  Surgery or exercise to relieve shoulder pain.  What would you choose out of the gate?  This is a no brainer in my mind.

Now, this client has a backbone and chose to look at other options.  Thankfully, she believes there is another way.  She did not just say okay and get in line for surgery.  She is optimistic that she can use conservative means to achieve pain resolution and restore function.  Trust me when I tell you the human body is remarkably resilient.  It will generally heal on its own if we simply get out of its way.  Too often, we ignore what it tells us and just do more damage until there is no choice aside from cortisone, pain pills or surgery to allow us to return to what we need to do as soon as possible.  Perhaps we simply need to practice patience over instant gratification.

 So, I want to encourage you to critically analyze what people tell you to do when it comes to your body.  Ask this magic one word question: “Why?”  Always know the “why” behind what you do when it comes to exercise, medication, surgery, etc.  I always have a “why” for every exercise I prescribe and implement in a client’s program.  There is no room for mindless prescription in exercise or medicine.  We need to treat every person differently based on their specific injury, needs, goals, work and life demands, and past medical history. 

My intention in sharing this post is not to bash physicians.  There are lots of excellent docs who practice case by case decision making and serve as true patient advocates.  However, there are also many who need to take a step back and recognize that pills and surgery are not always the answer despite what statistics and tendencies tell us.  If you or someone you know is suffering, be sure to ask their health care professionals “why.”

I get daily email from people suffering shoulder injuries all over the world. Many have questions regarding their MRI reports that somehow go unanswered by the MD or just are not explained clearly enough. Sound familiar?

One such email yesterday described an injury as a slat tear. I knew the customer probably meant SLAP tear even though he did not know the true description. Face it – deciphering MRI reports is like reading a foreign language unless you have medical training. Many people suffering from rotator cuff tears/tendonitis may also be suffering from a SLAP injury as well.

What does SLAP stand for? Superior Labrum Anterior to Posterior to be exact. Even more confusing, right? Think of it simply as an injury to the long head of your biceps tendon as it joins with the glenoid labrum (shoulder cartilage) in the top of your shoulder. This is actually more common than you may think. It can occur through a traumatic injury (fall for example) or through gradual stress/degeneration.

The long head of the biceps tendon assists the rotator cuff in depressing the humerus during elevation of the arm and overhead activities like throwing. In my experience, SLAP tears often require arthroscopic surgery to repair them in order to restore function and eliminate pain. If you have a torn labrum, minimize overhead stress or extending the arm fully beyond the plane of your body, especially with a straight arm under resistance.

Exercises in the gym that would place harmful stress on the labrum include full range bench press, military press, incline biceps curls, dips, upright rows above 90 degrees, and deep push-ups or flies and pull-ups. To rehab this injury conservatively, you should focus on scapular stabilization and rotator cuff strengthening, always taking care not to load the shoulder joint with significant weight at end ranges of motion.

I included a screenshot from one of my webinars of a few scapular strengthening exercises guaranteed to improve your shoulder function if you have such an injury. It includes a prone serratus punch progression (starts on the knees and advances to the toes) to increase serratus anterior strength, a muscle often shown to be weak and lacking endurance in those suffering from shoulder pain.  You will also see some quadruped rocking and advanced progressions of the serratus push-up using a BOSU trainer and BOSU ballast ball.

I offer an on demand webinar on SLAP tears at www.alliedhealthed.com.  It includes anatomy, rehab, surgery and current research updates on the treatment of SLAP tears.