142. Shoulder SLAP tear assessment, diagnosis and treatment. Physio Edge Shoulder Success podcast with Jo Gibson

You're listening to the Physio Edge podcast episode 142 with David Pope. Hey and welcome to the Physio Edge podcast. I'm your host David Pope in Australian sports and muscular skeletal physio and on the Physio Edge Shorter Success podcast, Joe Gibson, who's an upper limb rehabilitation specialist physio, takes you through how to assess and treat your shoulder pain patients so you get great results with shoulder pain. And on this particular podcast, Joe's talking all about a topic that we get a lot of questions about and that slap tears. Traumatic slap tears can occur in your contact athletes and your other patients that land on their arm or their shoulder. It can occur in throws and other athletes and often in that initial assessment and even if they've had an MRI, it can miss or misdiagnose their injuries and then they can go on to have shoulder long head of biceps tendon or ac joint pain. So in this podcast, Joe's going to take you through how to identify which of your patients have slap tears. You're going to explore the assessment tests you can use to diagnose and differentiate your slap tears from other causes of shoulder pain and which imaging modalities are actually going to help you identify your slap tears. So tons of great info and if you'd like a couple of free resources to go along with the podcast, we've got some great free video series on shoulder pain with Joe Gibson. If you want to find out more about diagnosis of acute shoulder pain or if you'd like to improve your assessment and treatment of frozen shoulder, Joe's got a couple great video series there you can get access to and that's over at clinicaledge.co/shoulder and if you'd like to improve your treatment results with all the other areas of the body, your other musculoskeletal and sports injuries that you're going to see with your patients in your clinic, then you're going to love clinical edge membership. It's designed to give you the practical information that you need with your patients so you can get great results. So head on over, grab your free trial clinical edge membership so you can dive into it whenever you've got a spot in your clinic if you've got a patient cancellation or you've got a gap in between patients or you just want to dive into it on the way to work while you're commuting. Tons of opportunities there for you to take advantage of and really get stuck into some practical tips that'll help you with your patients. So grab your free trial membership over at clinicaledge.co/free trial and now it's time to dive into this podcast with Joe Gibson. Hi, my name is Joe Gibson and I am an upper limb rehabilitation specialist and a consultant in private practice working in Liverpool in the UK. I've got quite a few things lined up for the next few weeks based on questions I've been asked on the courses about specific tools in rehabilitation, about some challenging cases, all sorts of things to wet your appetite. I thought I'd just pop on and just share with you a patient that I was asked to review this week who had had what sounded like really good physiotherapy but was really struggling to thrive. So really just to bring up a kind of condition that kind of comes in and out of trend, what gives us best value in terms of diagnosis and importantly where things perhaps had gone wrong with this particular chap. Now this was a 24 year old rugby player, recreational rugby player, not playing any particularly high level but plays every weekend, loves it, has only got into it in the last couple of years. He reports an injury about 12 months ago, he plays as a front row prop so obviously he's going into contact situations and he describes an original mechanism where essentially he had the ball, he was going into contact and he took a direct kind of force through his elbow really into his shoulder and he felt like it's sub-luxed. Now it didn't come out of joint, he didn't have to stop playing, he managed to finish the game but kind of since that particular instance he's had some ongoing symptoms in his shoulder. Now when you ask him what the problems that he's had he describes deep anterior superior shoulder pain somewhere between the AC joint and the coracoid, he can't really localize it, it's very deep down in the joint, he doesn't report any ongoing feeling of instability or apprehension, he doesn't feel like he's going to get that sub-luxation again, he does say that when he's trying to do his weights in the gym particularly in a kind of abduction external rotation position, if he drops into extension or he doesn't really kind of set himself before he does his weights, he can get a click if he moves too quickly from one position to another but if he controls it and really thinks about what he's doing he can actually make the click better. The click is uncomfortable but not horribly painful, he doesn't get any symptoms at night, the other thing he does describe as he feels that if he's trying to create power at speed like throwing a ball, doing stuff in training that he doesn't have the same power or the same distance that he had before but importantly this guy has actually had an MR scan to a plane MR after six months of actually having symptoms not doing so well with rehabilitation, struggling back to get back to play at the previous level, he tolerate training but again as soon as he went into full contacts those things were causing him problems again. The MR scan was reported as normal so he was sent back for more rehabilitation but it's got very frustrating for both him and the physiotherapist because despite throwing everything at it that they can think of in terms of cuff work, scapular work, strength work, proprioceptive work, every tool you can think of this guy just isn't seeing any translation either into his high-alow gym work or when he goes back on the pitch into contact. So what are you thinking because I'm sure some of you out there already have got some ideas, I've given you some clues in terms of where his pain is, how his problems started and the sorts of things that are causing him problems so I'm sure that you've got some suspicions already. Now for me as soon as I have somebody that's had some sort of either traction, compression or direct blow to the shoulder particularly in rugby, one of the things that I have to put in my kind of diagnostic toolbox if you like, something to rule in or rule out has to be a slap lesion so a superior label tear and tear and posterior. So what are the things that we need to think about in terms of slap tears? Well absolutely there's no doubt that trauma can be relevant and if we look at the typical reported mechanisms, any forceful traction on the long head of biceps, a fall onto an outstretched hand probably accounts for up to 50% of traumatic injuries, bracing in a motor vehicle accident so people holding the steering wheel knowing that there's about to be an impact or that big concentric e-centric load seems to result in slap lesions, it's recognised in medical legal literature now, direct blows to the shoulder so either through the elbow indirect or direct actually to the shoulder itself. But clearly that's our traumatic group. Now another group that I've seen who have presented with symptomatic slap lesions and we'll talk about when we can be confident that perhaps that's causing the symptoms, patients who in the gym heavy loading abduction external rotation, little bit too heavy, lose control and get forced into extension rather than that hyper external rotation position which is more likely to potentially take off that anterior inferior labrum so that extension mechanism also seems to have some credibility in creating a slap lesion. Now again what's really interesting, I think particularly in something like rugby hide, adrenaline sports where lots going on, generally we say with any trauma of it's relevant then it causes symptoms and that player has to stop immediately but as I say rugby players that seem a specific group that often they continue and yet then when they after the match and when they start get back to their training these things show up. Now interestingly in horses done some lovely work looking specifically at the rugby cohort, looking at patients who had ongoing pain and instability despite physiotherapy and found in over 50% of them that related to direct tackling then followed by a fall on the arm but there were 30% of cases that couldn't actually recall a definitive injury even though they found clear evidence of label pathology when they scan their shoulder. Now of course what we have to be clear about is when this is relevant because if we look at the different causes of slap lesions we clearly have the traumatic sporting group which is probably the easiest group both in terms of diagnosis and identifying a management plan if they haven't done well with rehab but clearly we have the overuse we have the throwers where again slap lesions can just be a feature of the fact that you've thrown a long time it's a question of does that then become a cause of symptoms or is it just an anomaly in a normal finding as a response to load and then we have the group that are probably massively over treated and over 40 cohort where we see slap type ones that are probably just a degenerative phenomenon just some fraying in that superior labrum. Now if you look at classification systems for slaps I'm not going to go through them all tonight and there's so many different ones there's about 10 different descriptions of slap tears but Perkarts was the original one which was just a nice simple four but it's expanded to include all sorts of things with the work of people like Moffitt as clinicians what matters to us is whether or not that long head of biceps attachment is stable or not so if you imagine well there's a big issues with slap tears and why they're so inconsistent and difficult to make sense of the evidence is that there is a big variation in attachment of the long head of biceps into the superior labrum some it's more anterior some it's more posterior some it is generally all the way across the superior labrum some have a more mobile attachment some have a more fixed attachment so you can see that depending on the same mechanism of trauma it can potentially have a very different effect in different athletes. Now as I say from our point of view those degenerative fray tears really are probably just a consequence of loading or perhaps of ongoing cuff pathology but generally don't need anything doing but in some Mae'n gwneud gweithio'n gweithio gweithio'n gweithio o'r gweithio'r gweithio'n gweithio'r gweithio'r gweithio'r gweithio'r gweithio'r gweithio'r gweithio'r gweithio'r gweithio'r gweithio a gweithio'r ysgwyrdd yn ysgwyrdd o'r oesgwyrdd yn ysgwyrdd yn ysgwyrdd yn ysgwyrdd oesgwyrdd oesgwyrdd oesgwyrdd oesgwyrdd oesgwyrdd oesgwyrdd oesgwyrdd oesgwyrdd o yn yng Nghymru yn yng Nghymru sy'r gwyllwyr yng Nghymru sy'r gwyllwyr yng Nghymru sy'r gwyllwyr y a'r ffordd i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w Mae'r ymwch ymwch ywch ywch ywch ywch ywch ywch ywch ywch ywch y ac mae'r gwaithio'r gweithio'r gwaithio'r gwaithio'r gwaithio'r gwaithio'r gwaithio'r gwaithio'r gwaithio'r gwaithio'r gwaithio' i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'w i'n yng Nghymru, maen nhw'n gweithio yng Nghymru'r gyda'r llwyddiad i'r gweithio yng Nghymru'r gweithio i'r gweithio yng Nghymru'r gweithio yng Nghymru'r gweithio yng Nghymru'r gweithio yng Nghymru'r gweithio ac i'n dod i'r iawn i'n gweithio gweithio i'n gweithio gweithio. Mae'r gweithio gweithio gweithio gweithio gweithio. Mae'r gweithio gweithio gweithio gweithio. Mae'r gweithio gweithio gweithio. Mae'r gweithio gweithio. ac mae yng Nghymru yn ymwch yn ymwch yn gweld ymwch yn ymwch yn ymwch yn gweld ymwch yn gweld ymwch yn gweld ymwch yn gweld ymwch yn gweld ymwch yn gweld ymwch yn gw Mae'r gwaith i'n hynny, mae'r hynny'r hynny'r hynny'r hynny'r hynny'r hynny'r hynny'r hynny'r hynny'r hynny'r hynny'r hynny'r hynny i'n gweithio'r unrhyw i'n gweithio'r unrhyw i'n gweithio. Mae'r unrhyw i'n gweithio'r unrhyw i'n gweithio. Mae'r unrhyw i'n gweithio. Mae'r iawn i'n gwybod, mae'n gwybod, mae'n gwybod, mae'r gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n g 'byseps tina deisys' Now, part of the issue with this is often if the long head of biceps is very very irritable and particularly if they've had symptoms for a long period of time, when you try and repair that type 2 slack lesion and we tension that long head of biceps, that in itself can cause some problems. So you now have a super stable superior labrum, but now you've got a very unhappy biceps. But of course this has got to be weighed up according to the age of the patient and what they're going back to. There's no doubt that if you look at something like Major League Baseball and Baseball's increasing in popularity in the UK, they're actually patients who have Major League Baseball pictures, who have a tina deisys, only 17% of them get back to their previous level of throwing. So for them, that long head of biceps contribution, sustainability and strength really seems to matter. And certainly in younger rugby players who present earlier more acutely, so potentially with less creep or changing that long head of biceps, again, a lot of surgeons would try and do a primary repair. So age, how long they've had it, the state of the long head of biceps, particularly that intraticular portion, will all influence decision making. So what can we learn from this guy? Well, I think as ever, that trauma and searching out that mechanism can be really important. Remember, most of the evidence about label pathology is about anterior instability and we can be confident in somebody who's under 25, dislocates, has to have it put back in, continues to have apprehension. They're highly likely to have a bank art lesion. But remember, particularly in our contact athlete population, actually they don't need a frank dislocation to get label pathology. Where do they get their pain? What positions do they perhaps feel they're lacking power or weakness? Do they get any creptors? Yes, well, no, not essential, but it adds to the story. And importantly, how does it behave? So you can see how, again, we build that story in terms of our clinical reasoning, but don't be deceived in patients who might have had a history that's one year or longer. Because remember, we also know the sequirley of traumatic slap lesions, is they develop some AC joint stiffness and they get an unhappy rotator cuff. So it's all about going back to the very beginning, peeling away the layers of that onion and trying to make sense of what they say. So I think this is a really good example of how plain NMR is not infallible when we look at label pathology. As I say in somebody like this, and our throscopy is really the gold standard, how our history really matters. And this is an example that structured does matter sometimes. So guys, I hope that was interesting and shared with you some interesting things. Let me just have a wee look here or some questions. Tim says, "Tim's always here with great questions." Tim says, "Should biceps tina-deces be considered in slap lesions when traumatic instances arm to parent?" Yes, absolutely. And I think the important thing, Tim, is putting it together with that feeling of weakness or those feelings of instability and low extension positions or those loss of power. And of course, somebody with tendonitis is an interesting one. We can have a whole argument about when it's tendonitis and when it's tendonopathy. Let's just call it tendonopathy to make life easier. But there's absolutely no doubt that patients who have an unstable type 2 slap lesion, where basically we've got every time we tug on biceps, it pulls on that superior labrum. Because it's lost its normal stability, the biceps can get very unhappy. And as we know from the evidence, biceps tendonopathy is generally secondary, not primary, only about 5% of all biceps tendonopathy is primary. And that, actually, people who might have moved house over the weekend, or suddenly done a load of biceps curls. But otherwise, it's quite rare. It's usually the victim, not the culprit. So there's absolutely no doubt that slap lesions would have to be part of my differential diagnosis. And if we look at the groups that that might be relevant, then young overhead manual workers, as I say, throwers, absolutely for sure. But again, it's fitting with that subjective picture of a gradual loss of power, and the inability to create strength, perhaps some mechanical symptoms. But again, all the things I've talked about that would help you weigh up, whether it's just a cuff that's got a bit tired, and that's why my biceps isn't happy, or whether there is actually something structural that's precipitating that. So I hope that answers you question. So lots to pack in there tonight. I know there's loads of other different sluptares out there. I've just shared with you the best of what we've currently got in terms of the evidence. Good methodological research. Now, I'm very aware that clustering is not without its flaws and is potentially questionable. So the key thing about this was really MR is in plain MR is in sufficient when we're querying label pathology. There may be ways of making our MR after-gram even more reliable in terms of positioning. So having a radiologist who is offay with the recent evidence that shows how to make it more reliable is very, very useful. Remember, mechanism on set is everything. Don't be sustained in patients who have long-term symptoms, but as ever, it's about putting that whole picture together. So guys, I hope you've enjoyed that. As ever, try to give you some useful clinical tips and tricks to take away. I'll post you the link to that National Athletics Trainer's Position Statement because it's got a really lovely summary of a lot of the stuff that's out there. Guys, I hope you've enjoyed it. As ever, I'll be back for some more shoulder geeking. Bye for now. Thanks Joe. That was awesome. Hope you enjoyed that podcast and you've got lots of good ideas. Next time you have a patient in that you think has a traumatic slap to your. Remember, go and grab your access to those shoulder resources. You've got your acute shoulder pain diagnosis video series and also your frozen shoulder assessment and treatment video series. And that's over at clinicaledge.co/shoulder. The other resource we've got is your free trial clinical edge membership. If you want to take a new approach to your treatment of musculoskeletal and sports injuries and you want to boost your treatment results, jump on over, grab your free trial membership and dive straight into it now. You have a great week and I'll catch you on the next Physio Edge podcast.