SLAP Lesion Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program following a Superior Labrum Anterior Posterior (SLAP) lesion, either after surgical repair or conservative management. It is crucial to remember that progression through phases is based on individual patient progress, pain levels, and tissue healing rather than strictly adhering to a timeline. Communication between the physical therapist, physician, and patient is essential for optimal outcomes. This protocol assumes a right shoulder involvement; adapt accordingly for left shoulder.

Pathophysiology

A SLAP lesion involves a tear of the superior labrum, the fibrocartilaginous rim that surrounds the glenoid fossa of the shoulder joint. This tear often occurs near the attachment of the long head of the biceps tendon. Mechanisms of injury include repetitive overhead activities (throwing, swimming), a fall onto an outstretched arm, or a direct blow to the shoulder. SLAP lesions are classified into different types (Type I-VII) based on the extent and location of the tear. Common symptoms include pain with overhead activities, a clicking or catching sensation in the shoulder, and a feeling of instability.

Common Special Tests

• O'Brien's Active Compression Test: Assesses for SLAP lesions by evaluating pain with internal rotation and resisted shoulder flexion.
• Biceps Load II Test: Evaluates the integrity of the superior labrum through resisted elbow flexion and supination at 90 degrees of shoulder abduction.
• Anterior Slide Test: Assesses for anterior instability and SLAP lesions by stressing the anterior labrum with a posterior force applied to the humerus.
• Crank Test: Assesses for labral tears by rotating and compressing the humerus within the glenoid fossa.
• Yergason's Test: Assesses for biceps tendonitis and SLAP lesions by resisting supination with the elbow flexed at 90 degrees.

Phase I: Protection Phase (0-4 weeks post-op or initial conservative management)

Goals: Protect the healing tissues, control pain and inflammation, prevent muscle atrophy, and restore passive range of motion (PROM).

• Immobilization: Shoulder sling worn at all times (except for bathing and exercise).
• Pain and Inflammation Management: Ice packs applied 3-4 times daily for 15-20 minutes. Consider modalities like electrical stimulation or ultrasound as indicated.
• PROM Exercises:
  • Pendulum exercises: 2-3 times daily, 5-10 minutes each session.
  • Supine PROM flexion, abduction, and external rotation (within physician's prescribed limits, usually limited external rotation initially): 2-3 times daily, 10-15 repetitions each.
• Scapular Stabilization Exercises: Focus on scapular protraction, retraction, elevation, and depression. Gentle isometric contractions can be initiated in a pain-free range.
• Elbow, Wrist, and Hand Exercises: Active range of motion (AROM) to maintain strength and flexibility.
• Activity Restrictions: Avoid lifting, pushing, pulling, and repetitive overhead activities.

Phase II: Loading Phase (4-12 weeks post-op or following pain reduction in conservative management)

Goals: Gradually restore active range of motion (AROM), improve muscle strength and endurance, and normalize scapulohumeral rhythm.

• AROM Exercises: Progress from PROM to AAROM (Active Assisted Range of Motion) and then AROM in all planes. Avoid pain.
• Strengthening Exercises:
  • Isometric exercises for shoulder internal rotation, external rotation, abduction, flexion, and extension. Progress to light resistance using theraband or light weights.
  • Scapular strengthening exercises: Rows, scapular squeezes, shrugs, and push-ups against a wall.
  • Biceps strengthening: Begin with isometric contractions and progress to light dumbbell curls.
  • Triceps strengthening: Begin with isometric contractions and progress to light dumbbell extensions.
• Proprioceptive Exercises: Closed kinetic chain exercises such as weight shifting on a stable surface and rhythmic stabilization exercises.
• Cross-Body Adduction Stretch: Gentle stretching to improve posterior capsule flexibility.
• Continue pain and inflammation management as needed.

Phase III: Return to Function Phase (12+ weeks post-op or as strength and function improve in conservative management)

Goals: Restore full AROM, strength, power, and endurance. Return to sport or desired functional activities.

• Advanced Strengthening Exercises:
  • Progress to higher resistance exercises using dumbbells, therabands, or weight machines.
  • Plyometric exercises: Begin with controlled plyometrics (e.g., wall dribbles) and progress to more advanced exercises (e.g., medicine ball throws).
  • Continue scapular stabilization exercises with increased resistance.
• Sport-Specific Training:
  • Gradually introduce sport-specific activities, such as throwing, swimming, or overhead reaching.
  • Focus on proper technique and biomechanics.
  • Monitor for any signs of pain or re-injury.
• Interval Training: Gradually increase the intensity and duration of activities.
• Continue proprioceptive training to improve shoulder stability and coordination.
• Criteria for Return to Activity:
  • Full, pain-free AROM.
  • Strength and endurance at least 80% of the uninvolved side.
  • Successful completion of sport-specific functional testing.

Disclaimer: This protocol is a general guideline and should be modified based on the individual patient's needs and progress. Consult with a qualified healthcare professional for personalized rehabilitation recommendations.