SLAP - Hayden's Comprehensive Guide To SLAP Tears, For Shannon

UpToDate articles and Haydens summary of
SLAP (Superior labrum anterior posterior)

tears and shoulder stability rehab
Contents of this document:

Haydens handwritten notes on SLAP tears
Full UpToDate article on SLAP (Page 5)
Full UpToDate article on SIS, for shoulder rehab exercises (Page 21)
Hayden Lee
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Written 11 July 2015 for Shannon Denley
Hayden Lee
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Hayden Lee
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UpToDate article
INTRODUCTION Superior labrum anterior posterior (SLAP) tear refers to a specific injury
of the superior portion of the glenoid labrum that extends from anterior to posterior in a curved
fashion. These tears are common in overhead throwing athletes and laborers involved in
overhead activities.
The pathophysiology, diagnosis, and nonsurgical management of SLAP tears are reviewed
here. The general approach to patients with shoulder pain, the shoulder examination, and
rotator cuff injuries are discussed separately. (See "Evaluation of the patient with shoulder
complaints" and "Physical examination of the shoulder" and"Shoulder impingement
syndrome" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff
tears".)
ANATOMY AND BIOMECHANICS General shoulder anatomy and biomechanics are
discussed separately; anatomic details and biomechanical factors related specifically to SLAP
lesions are described here. (See "Evaluation of the patient with shoulder complaints", section
on 'Anatomy and biomechanics'.)
The glenohumeral joint is composed of the glenoid, humeral head, glenoid labrum, and a
surrounding ligamentous complex (figure 1 and figure 2 and figure 3 and figure 4and figure 5).
The labrum is a fibrocartilaginous ring attached to the outer rim of the glenoid that increases
the area of contact between the humeral head and glenoid and provides added depth to the
joint. Given the profound mobility of the shoulder and the shallowness of the bony glenoid, the
increased surface area and depth provided by the labrum serves an important role in
increasing the stability of the glenohumeral joint. In addition, the labrum serves as the
attachment point for the glenohumeral ligaments, as well as the origin of the long head of the
biceps tendon. This attachment can lead to labral injury during shoulder motions in the
abducted and externally rotated positions when the biceps tendon is stretched.
SLAP tears occur from several mechanisms. One mechanism involves forceful eccentric
traction exerted on the biceps tendon. This can occur when someone falls back onto an
outstretched arm, tries to prevent him or herself from falling by grabbing hold of an object, or
suddenly tries to lift a heavy object. Such mechanisms can cause an acute SLAP injury even
in patients without underlying shoulder pathology. Anatomic variations in the structure of the
superior labrum and the attachment of the biceps tendon increase the likelihood of SLAP
tears in a small number of patients.
Many SLAP lesions occur in throwing or overhead athletes. When throwing a ball or other
object, or performing similar motions (eg, swinging a hammer), the shoulder is forcefully
abducted and externally rotated during the cocking phase. This motion performed while the
hand carries a weight places stress on the labrum. Shear forces created by the movement of
the humeral head anteriorly and superiorly must be resisted by the anterior joint capsule,
which inserts partially into the superior anterior labrum. These forces can produce labral tears.
In addition, shoulder positions that involve 90 degrees or more of external rotation and
abduction cause increased contact between the posterior-superior rotator cuff and the
posterior-superior glenoid labrum. This is due to the increased forces exerted at the posterior
glenohumeral joint when there is any damage to the stability of the anterior capsule. When
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the biceps tendon has some degree of injury or subluxation or the anterior labrum shows any
significant degenerative tearing, the anterior shear forces of the humeral head increase. In
addition, constraints against posterior motion of the humeral head are diminished. The
increase in shear forces leads to increased motion of the humeral head posteriorly whenever
the humeral head returns to a neutral position from action of rotator cuff muscles and
glenohumeral ligaments trying to reset the humeral head within the glenoid. This increased
translational force exerted on the posterior glenohumeral joint causes microtrauma and some
fibrosis of the posterior capsule. If this becomes significant, the result is posterior shoulder
capsule tightness and a greater degree of glenohumeral internal rotation deficit (GIRD).
Combined shoulder abduction and external rotation causes the biceps tendon to twist,
increasing the stress placed on the tendon and its attachment, and thereby increasing the risk
of a labral tear. When powerful traction forces are applied through the biceps tendon to the
superior labrum during the cocking phase of throwing, the tendons attachment can tear the
labrum from the glenoid. The different stresses placed on the shoulder joint during different
activities likely account for the different types of SLAP lesions sustained.
EPIDEMIOLOGY, CLASSIFICATION, AND RISK FACTORS The term SLAP ("superior
labrum anterior posterior") was initially coined by Snyder and his colleagues while performing
a retrospective review of a large sample of shoulder arthroscopies [1]. While the true overall
incidence of SLAP tears is unknown, the incidence among patients undergoing arthroscopy is
reported to be between 6 and 26 percent [1-3]. Four types of SLAP injuries were described
initially:
Type I demonstrated degenerative fraying with intact biceps insertion
Type II, detachment of the biceps insertion
Type III, a bucket-handle tear with intact biceps tendon attachment to bone
Type IV, an intrasubstance tear of the biceps tendon with bucket-handle tear of the
superior labrum
In a prospective observational study of 544 consecutive shoulder arthroscopies that included
139 SLAP tears, different tear types were associated with particular conditions or activities.
Type I tears were associated with increased age, rotator cuff disease, and osteoarthritis; Type
II tears were associated with overhead sports; and Type III and IV tears were associated with
high-demand occupations [2]. The authors of the study did not define high-demand
occupations or speculate why such occupations were associated with Type III or IV lesions,
as few such injuries were identified in the study.
Given these associations, different types of SLAP injuries likely involve different mechanisms
of injury. According to a retrospective review of 84 arthroscopically diagnosed labral tears, the
most common mechanism involved an inferior traction-type injury either from a fall or a
sudden pull when lifting a heavy object [3]. Other common mechanisms included traumatic
glenohumeral dislocation or repetitive shoulder abduction and external rotation (eg, throwers
and other overhead athletes). A direct blow to the shoulder or a fall onto an outstretched hand
may also cause a SLAP tear. A predisposition to sustaining certain types of SLAP injuries may
stem from underlying shoulder comorbidities, such as multidirectional instability or chronic
degenerative changes.
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According to some researchers, the "peel-back" mechanism accounts for Type II labral
injuries [4]. In this mechanism, excessive stress on the biceps tendon attachment when the
shoulder is placed in abduction and maximal external rotation leads to separation and tearing
of the superior posterior labrum from the glenoid. Overhead throwing athletes (eg, baseball
pitchers, cricket bowlers) and laborers who swing tools overhead frequently assume this
position.
During repetitive overhead motions that involve abduction to 90 degrees and maximal
external rotation, increases in external rotation range can be seen over time. Often, this
increase is associated with a loss of internal rotation, a pattern termed glenohumeral internal
rotation deficit (GIRD) [5]. While it remains unclear how GIRD develops, it can lead to
tightening of the posterior capsule, which in turn changes the translational mechanics of the
humeral head within the glenoid. These changes can lead to internal impingement and
posterior labral injury.
CLINICAL FEATURES
History The history provided by the patient ultimately diagnosed with a SLAP lesion is
often vague. SLAP tears may stem from chronic overuse or acute injury. Typically in cases of
repetitive overuse, the patient complains of anterior shoulder pain. The athlete or laborer may
complain of episodic clicking or comparable mechanical symptoms, particularly when their
arm is placed in the cocking position of throwing (ie, abduction and external rotation) (figure 6)
[6]. In patients with a history of glenohumeral dislocation, subluxation, or a shoulder sprain,
persistent anterior shoulder pain after returning to normal activities should raise suspicion for
a SLAP tear and prompt an assessment of labral stability. However, no particular activity of
daily living consistently elicits pain in the patient with a SLAP lesion. Night pain is an
uncommon symptom and suggests a rotator cuff tear or other pathology. Shoulder instability
with normal activity is not common, nor is swelling or paresthesias, which can occur with
multidirectional shoulder instability [3]. (See "Presentation and diagnosis of rotator cuff
tears" and "Multidirectional instability of the shoulder".)
Overhead athletes, such as tennis, baseball, and volleyball players, may complain of a
decline in function or throwing velocity [7]. A classic complaint of baseball pitchers with an
acute labral tear is that their arm feels like it went dead. Initially, pitchers are often able to
continue throwing in spite of the pain. Some researchers describe throwers or overhead
workers initially experiencing dull shoulder tightness, which then progresses to pain and
mechanical symptoms as tears develop in those who play or work through the initial tightness
[5]. The diagnosis should be entertained in laborers who routinely swing a hammer overhead
and complain of anterior shoulder painand/or mechanical symptoms such as clicking or
catching. (See "Throwing injuries: Biomechanics and mechanism of injury" and "Throwing
injuries of the upper extremity: Clinical presentation and diagnostic approach".)
In a patient complaining of new onset shoulder symptoms after an acute event, the clinician
should review the history to see if the mechanism is consistent with the traumatic SLAP injury.
Typically, this involves patients who receive a direct blow to the shoulder or fall onto an
outstretched hand and complain of anterior shoulder pain immediately following the trauma.
Injuries involving sudden traction of the arm, which may occur while lifting a heavy object with
a sudden jerking motion, also suggest labral injury. SLAP tears are typically not associated
with acute anterior shoulder dislocations, although they may be present in patients with a
history of shoulder dislocation and subsequent instability.
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Concomitant injury SLAP tears are frequently accompanied by other shoulder pathology.
Rotator cuff impingement or tears, Bankart lesions, biceps tendon injury, and glenohumeral
osteoarthritis are common findings during arthroscopic evaluation of patients with SLAP tears.
If a SLAP tear is suspected, clinicians should assess for other shoulder pathology.
(See "Shoulder impingement syndrome" and "Presentation and diagnosis of rotator cuff
tears" and "Biceps tendinopathy and tendon rupture" and"Multidirectional instability of the
shoulder" and "Glenohumeral osteoarthritis".)
Examination
Overall approach As noted above, patients with SLAP lesions often have sustained
additional shoulder and upper extremity injuries, and thus a careful examination of the
involved shoulder and upper extremity should be performed, including assessments of
motion, strength, and basic neurovascular function. To a large extent, the examination is
guided by the differential diagnosis that is generated through the history. Assessment of the
rotator cuff and biceps tendon are often indicated. Our approach to the adult with shoulder
pain and a review of the shoulder examination are provided separately. (See "Evaluation of
the patient with shoulder complaints"and "Physical examination of the shoulder".)
Examination begins with observation. Posture and shoulder position should be assessed. In
throwing athletes, it is helpful to look for asymmetries in the upper extremities. Many athletes
have hypertrophy of the throwing arm and malposition of the shoulder of the dominant arm. In
particular, imbalances in muscle strength may lead to scapular protraction and a rolled
forward shoulder appearance. Significant muscular atrophy is unusual in patients with SLAP
tears and suggests neurologic problems or other injuries leading to disuse.
Whenever possible, the examination should include an assessment of shoulder motion.
Clinicians should look for scapular dyskinesis as well as any hesitancy or catch as the patient
moves their shoulder in normal arcs of abduction and elevation or forward flexion and
elevation. Symptoms or abnormal motion that manifests during basic mobility testing suggests
some underlying pathology and the need for more careful examination of the scapular
stabilizers and rotator cuff. The portions of the examination of particular relevance to SLAP
pathology are discussed below.
In addition to specific tests for SLAP lesions (described below), we suggest clinicians perform
the following maneuvers:
Palpate the proximal biceps tendon. The presence of focal tenderness suggests
tendon injury.
Assess the glenohumeral joint for restricted internal rotation and excessive external
rotation. With the patient supine, the shoulder in 90 degrees of abduction, and the elbow
in 90 degrees of flexion, gently determine the degree of maximal external and internal
shoulder rotation compared to both standard measures of the glenohumeral arc and to
the unaffected shoulder. (See "Physical examination of the shoulder", section on 'Range
of motion'.)
Assess scapular motion. Many patients with a SLAP tear have some degree of
unilateral scapulothoracic dysfunction. (See "Physical examination of the shoulder",
section on 'Scapulothoracic motion and strength'.)
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SLAP-specific testing: Suggested approach No single examination maneuver or

combination of tests has been shown to identify superior labral lesions with high sensitivity
and specificity [8-13]. In addition, the plethora of available tests for SLAP lesions can be
overwhelming for the clinician, not to mention the patient who has a painful shoulder and may
become annoyed by all the manipulation. Thus, we limit the number of tests we perform.
Ultimately, the diagnosis of a SLAP lesion is made using the history, imaging studies, and
sometimes arthroscopy in addition to the physical examination. The specific examination
maneuvers for detecting SLAP lesions should be approached with the intention of determining
the need for advanced imaging or surgical intervention. Although there are many different
examination tests for SLAP tears, they essentially fall into one of a few basic categories,
including: maneuvers that elicit pain at the site of the tear (eg, by compressing and rotating
the humeral head into the glenoid), maneuvers that place a strain on the proximal biceps
tendon (which is often affected with SLAP tears), and maneuvers that demonstrate shoulder
instability. Based upon the available evidence and our clinical experience, we perform the
following examination maneuvers in the following order to assess for SLAP injuries:
Anterior glide test
Compression rotation test
Active compression (OBriens) test
Crank test
Speeds test
Performance of these tests is described below. (See 'SLAP-specific testing: Overview and test
descriptions' below.)
Although often described as a test of biceps tendon pathology, Speeds test is useful for
assessing SLAP lesions, and, when performed following the first three tests, it is most specific
[9]. Additional tests for detecting SLAP lesions may be performed for difficult cases that
remain unclear after these tests are performed.
Given the limitations of the available research, it is not surprising that a number of
approaches to the clinical diagnosis of SLAP lesions have been advocated. A prospective
study of several examination tests in a population of overhead throwing athletes with an
expected high prevalence of SLAP lesions concluded that earlier studies of individual tests
were exceedingly optimistic [13]. Its authors suggest that the best approach to the clinical
diagnosis of SLAP lesions would include a combination of tests designed to detect SLAP
lesions and biceps tendon injuries.
One research group suggests that combining two of three sensitive tests (active compression
test, apprehension test, compression-rotation test) with one of the three more specific biceps
tendon tests (Speeds, Yergason's, Biceps load II) yields a sensitivity of 70 percent and a
specificity of 95 percent [14]. Another group suggests that the most useful combinations of
tests to rule in the diagnosis of labral tear, in descending order, are (1) history of popping,
clicking, or catching and positive anterior slide test; (2) positive anterior slide and crank tests;
(3) history of popping, clicking, or catching and positive crank test; and (4) positive anterior
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slide and active compression tests [15]. However, another group reviewed five selected
clinical maneuvers for diagnosing SLAP tears and found that combinations of tests did not
improve diagnostic accuracy compared to stand-alone testing with individual maneuvers [16].
SLAP-specific testing: Overview and test descriptions Many examination tests for
detecting superior labrum anterior posterior (SLAP) lesions have been described, but studies
of individual techniques are extremely limited by methodology, variations among patient
populations, and other factors. Several meta-analyses and systematic reviews have
concluded that no single physical examination technique can accurately diagnose a SLAP
tear. In addition, there are no conclusive studies about which combination of techniques are
most useful [8,9,17]. Several of the more commonly used techniques and studies of their
accuracy are described here; our suggested approach to assessing possible SLAP lesions is
discussed separately. (See 'SLAP-specific testing: Suggested approach' above.)
Active compression test (OBriens sign) The active compression test has two
parts and is performed with the patient standing (picture 1). To prepare, the patient
flexes their shoulder 90 degrees with the elbow in full extension. Then, they adduct the
arm 10 degrees (ie, move it slightly toward the midline). Once properly positioned, the
patient internally rotates their arm until the thumb points downward. The examiner then
pushes the arm toward the floor while the patient resists by maintaining their arm in the
starting position. This first part of the test may elicit deep shoulder pain or a clicking
sensation in the glenohumeral region. The maneuver is then repeated with the patients
arm fully supinated. The test is positive if the pain or click is reduced or eliminated during
the second part of the test.
Crank test To perform the crank test, the patient stands and abducts their shoulder
160 degrees while keeping the arm in the plane of the scapula [18]. The elbow is flexed
90 degrees. The examiner then applies an axial load to the humerus with one hand
while rotating the arm internally and externally with the other (movie 1). Pain, a clicking
sensation during the maneuver, or reproduction of symptoms similar to those
experienced at work or sport indicates a positive test. The test may be performed with
the patient prone.
Compression-rotation test For the compression-rotation test, the patient lies supine
with their shoulder abducted 90 degrees directly to the side and their elbow flexed at 90
degrees (movie 2) [1]. Laying supine with the back against the examination table
stabilizes the scapula. The examiner pushes the humerus into the glenoid by applying
an axial load and then rotates the humerus internally and externally. A positive test
produces discomfort and a catching, popping, or snapping sensation. This test is
analogous to the McMurrays test for meniscus lesions of the knee.
Speeds and Yergason's tests Given the frequent association between biceps
pathology and SLAP tears, performing these two tests can be helpful in a patient with a
suspected SLAP tear. In Speeds test, the patients elbow is extended and their forearm
fully supinated with the shoulder slightly flexed. In this position, the patient is asked to
elevate the arm against a resisted isometric force applied by the examiner (picture
2 and movie 3) [19]. A test that elicits pain in the anterior shoulder is considered positive.
Yergason's test is performed with the patient's forearm pronated and elbow flexed to 90
degrees (picture 2). The patient then attempts to supinate their arm against a resisted
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isometric force applied by the examiner (movie 4). Pain localized to the long biceps
tendon marks a positive test. Yergason reasoned this test would isolate biceps tendon
injury from rotator cuff pathology. A study of 50 patients, using arthroscopy as the gold
standard, found Yergason's test to have a sensitivity of 43 percent, specificity of 79
percent, and positive likelihood ratio of 2.05 [20].
The studies described here reflect the general surgical literature, which suggests that
neither Speeds test nor Yergason's test provide much help in distinguishing biceps
tendon pathology from other causes of anterior shoulder pain [20,21]. In other words,
these tests increase the post-test probability of biceps pathology only slightly when
positive and when negative do not aid diagnosis.
However, the results of such surgical studies may be limited. These studies include only
patients selected for arthroscopy and may not reflect the broader patient population that
presents to primary care and sports medicine clinics with shoulder complaints.
Furthermore, surgical studies generally focus on the presence of tendon tear to assess
the accuracy of physical examination tests. The presence of tendinopathy is more
difficult to assess.
One study using MRI as the gold standard for biceps pathology found a sensitivity of
68.5 percent and specificity of 55.5 percent for Speeds test and sensitivity of 37 percent
and specificity of 86 percent for Yergason's test [22]. This study is consistent with
surgical studies and suggests that physical examination tests have limited accuracy for
diagnosing biceps tendon pathology.
Biceps load test (Kim 1) The first biceps load test is intended to detect SLAP
injuries in patients with chronic shoulder dislocation [23]. The test is performed with the
patient supine and the examiner seated alongside holding the patients wrist and elbow.
The patients arm is positioned with the shoulder abducted 90 degrees to the side, the
elbow flexed 90 degrees, and the arm fully supinated. The examiner then steadily
rotates the shoulder externally in a manner similar to the apprehension test (movie 4).
Rotation is stopped when the patient feels as if the shoulder will dislocate. The patient
then flexes the elbow while the examiner resists. The test is positive if the last maneuver
provokes pain or continued apprehension about dislocation.
Biceps load test (Kim 2) The second biceps load test is intended for patients
without recurrent dislocation [24]. The patient and examiner positions are the same as
for the first biceps load test. However, in the second test, the shoulder is abducted 120
degrees before the shoulder is maximally externally rotated, again with the elbow flexed
to 90 degrees, and the arm is supinated. The patient is then asked to flex the elbow
while the examiner resists (movie 5). The test is positive if pain develops when the
patient flexes their elbow or if pain increases when the examiner applies resistance.
Pain provocation test This test is similar to the biceps load tests (movie 6) [25]. The
patient sits with the examiner standing behind them. The examiner holds the patients
wrist with their ipsilateral hand while the contralateral hand gently braces the patients
shoulder. The shoulder is abducted 90 to 100 degrees directly to the side with the elbow
flexed 90 degrees. The arm is then maximally externally rotated and, while maintaining
this position, the arm is then maximally pronated and supinated. The test is positive if
maximal pronation elicits or worsens pain.
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Anterior glide test For the anterior glide test, the patient lies supine and their arm is
abducted a bit less than 90 degrees (movie 7). The examiner stands next to the patient
between their torso and the affected upper extremity. Next, the examiner wraps the hand
closest to the patient around the patients superior trapezius and clavicle to provide
stability. With the other hand, the examiner grasps just distal to the patients humeral
head, with the thumb anterior and the remaining fingers wrapped around the proximal
humerus. Next, the examiner distracts the humerus slightly and then translates the
humeral head anteriorly. A positive test produces notable anterior laxity when compared
to the unaffected side.
DIAGNOSTIC IMAGING
Overview All imaging techniques used to diagnose superior labrum anterior posterior
(SLAP) tears have limitations, making definitive diagnosis of these injuries challenging
[26,27]. In addition, depending upon the clinical scenario and prospective treatment, it may
not be necessary to obtain advanced imaging studies to establish the diagnosis. As one
important example, since patients older than 35 are often poor surgical candidates, it is
generally best to obtain consultation with an experienced shoulder surgeon before ordering
advanced imaging studies for such patients, who are unlikely to need them. (See 'Indications
for orthopedic consult or referral' below.)
Currently, magnetic resonance arthrogram (MRA) is the most accurate imaging study for
diagnosing SLAP tears. Plain radiographs cannot delineate soft tissue injuries such as SLAP
tears but remain important for identifying concomitant injuries and are obtained in most
patients. Computed tomography (CT) arthrography can help to diagnose SLAP tears but is
typically reserved for patients with contraindications to MRI.
Plain radiography When a SLAP tear is suspected, plain radiographs of the shoulder are
used to assess other potential causes of shoulder pain. Given how frequently SLAP tears are
associated with other injuries, plain radiographs are typically the first studies performed.
Anteroposterior, scapular Y, and axillary views are generally obtained. Acromioclavicular (AC)
and glenohumeral (GH) joint osteoarthritis, calcific tendinopathy, osteochondral lesions of the
glenoid or humerus, fractures, dislocations, and bony tumors can be seen using plain
radiographs.
Computed tomography In patients who are unable to obtain a MRI due to implanted
medical devices (eg, Pacemaker) or other reasons, CT arthrography may be used to assess
possible SLAP tears. According to a retrospective review that included 161 imaging studies,
CT demonstrated a sensitivity and specificity of 94 to 97 percent and 72 to 76 percent,
respectively, compared to arthroscopy [28].
Musculoskeletal ultrasound Although useful for identifying some shoulder pathology
such as supraspinatus tear, musculoskeletal ultrasound (MSK US) is not useful for examining
SLAP tears [29]. The labrum is surrounded by multiple osseous structures, which makes it
difficult to assess using ultrasound. Labral tears may be associated with paralabral cysts or
biceps tendon abnormalities that can be evaluated reliably using ultrasound. Biceps tendon
subluxation can be demonstrated on dynamic US and this finding may raise suspicion of a
Type II SLAP lesion.
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Magnetic resonance imaging Magnetic resonance arthrogram (MRA) is the most

accurate available imaging technique for diagnosing SLAP tears, but has limitations and is
most useful in patients younger than 35 years. In addition, quality varies greatly with these
studies and the ordering physician (usually the shoulder surgeon assuming care) should
make certain that the imaging facility can provide the appropriate, high quality study.
According to several observational studies that used findings at arthroscopy or open surgery
as the gold standard, the sensitivity of MRA falls between 89 and 95 percent [30-32]. The
specificity of MRA reported in these studies was between 50 and 91 percent. A meta-analysis
of six imaging studies found similar results with a marginally improved sensitivity and
specificity of MRA of 88 percent and 93 percent respectively when compared with magnetic
resonance imaging (MRI) (sensitivity 76 percent, specificity 87 percent) [33]. Positioning the
patients shoulder in an externally rotated or abducted and externally rotated (ABER) position
during the MRA can improve diagnostic accuracy [34,35].
Standard MRI of the shoulder performed without contrast demonstrates much lower
sensitivity, with one research group reporting 38 percent [36]. In this study, accuracy improved
when musculoskeletal fellowship-trained radiologists interpreted the images. Additional
studies have corroborated the limited sensitivity of conventional MRI [37]. As with any test,
MRI must be interpreted in light of the clinical presentation and examination findings [38]. One
likely reason for the limitations of MRI is the relatively wide variation of the normal
appearance of the glenoid labrum.
Since patients older than 35 are often poor surgical candidates, MRI and MRA studies
generally should not be ordered by the primary care physician. As described above, MRA and
MRI show a range of sensitivity and specificity and most likely will be abnormal in patients
older than 35. These studies rarely change management in this age group so it is generally
best to obtain consultation with an experienced shoulder surgeon before ordering advanced
imaging studies for such patients. (See 'Indications for orthopedic consult or referral' below.)
Imaging and intra-articular injection Guided intra-articular anaesthetic (eg, lidocaine)
injection can be helpful in the diagnostic workup. Given that SLAP tears are an intra-articular
process, anesthetizing the glenohumeral joint to see if a patients pain resolves suggests that
the labrum may be involved. Such injections can be performed in the office or clinic under
ultrasound guidance or added to the contrast dye when performing an MRA. Pain from extraarticular pathology, especially in the subacromial space such as rotator cuff tears or
tendinopathy, will not improve with such an injection.
DIAGNOSIS SLAP tears can be difficult to diagnose, as the mechanism of injury varies
and symptoms can be vague. Initial suspicion for a SLAP injury arises from the patients
history. Any overhead throwing athlete or laborer who performs repetitive overhead swinging
motions and develops anterior shoulder pain may have a SLAP tear. A baseball pitcher with
anterior shoulder pain that persists despite correct throwing mechanics, appropriate rest, and
completion of a well-designed rehabilitation program is likely to have a SLAP injury. In
addition, patients with a history of shoulder trauma, such as a glenohumeral dislocation or
instability or a shoulder sprain, who continue to experience pain or intra-articular symptoms
(eg, clicking, catching) despite a return to normal activities may have a SLAP tear. A
combination of several positive tests designed to elicit the symptoms associated with a SLAP
tear along with the absence of evidence consistent with other causes of shoulder pain further
suggest the diagnosis. (See 'SLAP-specific testing: Suggested approach' above.)
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Ultimately, a definitive diagnosis of SLAP tear is made using either advanced imaging,
preferably MRA, or by performing diagnostic arthroscopy. Arthroscopy is the gold standard for
SLAP tear diagnosis given the occasional limitations of MRA. Musculoskeletal ultrasound
(MSK US) can be useful for evaluating concomitant rotator cuff or biceps tendon pathology. In
the authors experience, the diagnosis of SLAP tear is likely in patients with a suggestive
history and anterior shoulder pain without evidence of rotator cuff pathology on examination
and MSK US. It is important to note that the effectiveness of surgical treatment is limited,
particularly in patients 35 years or older, and therefore, many patients do not need advanced
imaging to establish a definitive diagnosis of SLAP tear if the diagnosis is likely based upon
the clinical evaluation and common alternative diagnoses have been ruled out. In most cases,
only good surgical candidates warrant advanced imaging (eg, MRA), and this determination is
best made by an orthopedist with advanced training in shoulder surgery.
INDICATIONS FOR ORTHOPEDIC CONSULT OR REFERRAL SLAP tears can be difficult
to diagnose definitively by history and physical examination. Even magnetic resonance
arthrogram (MRA) has limitations and is often unnecessary in patients over 35 years and
others who may be poor surgical candidates. Given the complexities of establishing the
diagnosis of SLAP tear and determining the best approach to management, in most cases we
suggest obtaining orthopedic referral prior to performing advanced imaging studies (eg, MRA)
when a SLAP injury is suspected. Ideally, the consulting surgeon should be an orthopedist
with advanced training in shoulder surgery.
Refraining from obtaining advanced imaging is particularly important in patients who are
unlikely to be suitable surgical candidates. This approach minimizes unnecessary studies and
the possibility of false-negative tests. It also enables the surgeon to correlate MRA results with
the history and examination findings, and then to determine which SLAP tears are most
amenable to surgical repair. Of course, local practice varies and in some cases obtaining an
MRA prior to surgical consultation may be suitable. As an example, this approach may be
appropriate for a younger patient who is a good surgical candidate and likely to have a SLAP
tear based upon the clinical evaluation but for whom visiting a shoulder surgeon requires
significant travel.
In addition to patients likely to have a SLAP tear based on their initial clinical evaluation,
patients who have completed a comprehensive nonoperative rehabilitation program and
continue to struggle with shoulder pain that affects their work or athletic performance should
obtain surgical consultation.
Orthopedic referral is indicated for any overhead throwing athlete or repetitive overhead
laborer with anterior shoulder pain, particularly if the pain increases when the shoulder is
placed in the cocking position of throwing or working, and the overall clinical evaluation
suggests the presence of a SLAP tear.
DIFFERENTIAL DIAGNOSIS Shoulder pain is common in the general population and the
differential diagnosis is extensive. This differential and a discussion of how to approach the
patient with undifferentiated shoulder pain are provided separately; the diagnoses most likely
to be confused with a SLAP tear are discussed briefly below. (See "Evaluation of the patient
with shoulder complaints".)
SLAP tears can occur in isolation but are frequently associated with other shoulder pathology.
This can make identifying SLAP tears difficult. A few common shoulder diagnoses that may be
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confused with SLAP tears include the following, listed in order of decreasing likelihood, along
with important features to differentiate them from SLAP tears. Key historical and examination
features that suggest a SLAP tear rather than other shoulder pathology include participation in
a sport or occupation that involves extensive overhead activity, pain that is worst in the
cocking phase of shoulder motion, and intra-articular mechanical symptoms such as crepitus
or catching.
Rotator cuff tendinopathy or partial tear Patients may have rotator cuff pathology
and SLAP tears simultaneously. However, patients with rotator cuff pathology typically
have signs of anterior shoulder impingement and night pain, which are generally absent
in patients with isolated SLAP tears. Intra-articular symptoms, such as clunking or
catching, are uncommon with isolated rotator cuff pathology. Weakness with shoulder
abduction or external rotation and a positive painful arc test occur more consistently with
rotator cuff problems. However, articular-side supraspinatus tears lie close to the biceps
tendon and as such, can mimic SLAP tears. Ultrasound provides an excellent method
for identifying tendinopathy and partial or complete rotator cuff tears. A normal
ultrasound with significant shoulder symptoms makes SLAP lesion a strong possibility.
(See "Physical examination of the shoulder", section on 'Examination for rotator cuff
pathology' and"Presentation and diagnosis of rotator cuff tears" and "Rotator cuff
tendinopathy".)
Shoulder impingement syndrome (SIS) SIS generally causes persistent, vague
anterior shoulder pain with overhead motions but like rotator cuff pathology, typically
does not cause intra-articular symptoms. Patients with suspected SIS who do not
improve with comprehensive rehabilitation may have an underlying SLAP tear.
(See "Shoulder impingement syndrome".)
Biceps tendinopathy or tear The close proximity of the proximal biceps tendon
insertion and the glenoid labrum make it possible for patients to have bicipital tendon
pathology and SLAP tears simultaneously. Anterior shoulder pain is a common
complaint with both conditions. Isolated biceps tendon pathology typically does not
cause intra-articular symptoms. Proximal biceps tendon tears are rare in younger
patients and create a notable deformity of the muscle (Popeye deformity (picture 3)).
Complete or partial tears of the biceps tendon are easily identified on ultrasound as the
tendon is superficial. Maneuvers commonly used to elicit pain from a SLAP tear (eg,
Active compression and compression-rotation tests) typically do not cause pain in those
with isolated biceps tendon pathology. However, patients who continue to experience
anterior shoulder pain despite appropriate rehabilitation of the biceps tendon may have
an associated SLAP tear. (See "Biceps tendinopathy and tendon rupture".)
While uncommon, entrapment of the long head of the biceps tendon, due to an anatomic
variant called an hourglass biceps, can produce the symptoms and signs of a SLAP tear
[39]. In such cases, a hypertrophic intra-articular portion of the biceps tendon becomes
entrapped in the glenohumeral joint when the shoulder is abducted and the elbow flexed
simultaneously. This can cause a mechanical block within the glenohumeral joint
producing signs that mimic intra-articular labral pathology. This condition can only be
seen during arthroscopy and the intra-articular portion of the long head of the biceps
tendon must be excised to prevent recurrence.
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Glenohumeral osteoarthritis SLAP tears and glenohumeral osteoarthritis can both

cause anterior shoulder pain. Patients with either condition may experience reduced
shoulder motion and pain with overhead activities. Night time pain is common with
osteoarthritis but not SLAP lesions. Glenohumeral osteoarthritis is easily identified on
plain radiographs of the shoulder (image 1 and image 2), whereas patients with an
isolated SLAP tear typically have normal radiographs. (See"Glenohumeral
osteoarthritis".)
Multidirectional shoulder instability A SLAP tear can cause symptoms of shoulder
instability, particularly after a traumatic dislocation. However, in general patients with
SLAP tears do not complain of shoulder instability symptoms or transient neurologic
symptoms. Multidirectional instability involves laxity in all directions of humeral motion
(anterior, inferior, and posterior) whereas SLAP tears may in rare instances be
associated with anterior laxity only. (See "Multidirectional instability of the shoulder".)
MANAGEMENT
Patient categories and overview of management Appropriate classification of patients
and the demands they place on their shoulder joint help to determine the best approach to the
management of superior labrum anterior posterior (SLAP) tears. In our experience, the
categories listed below provide a useful framework.
High-level throwing or overhead athletes These patients are typically referred to
an orthopedic surgeon experienced in treating athletes with SLAP lesions. When referral
poses difficulty, diagnostic testing with MRA (preferred) or MRI, depending upon
institutional experience, is warranted. While awaiting surgical evaluation, the patient can
begin a home exercise program. Exercises that emphasize biceps and rotator cuff
strengthening performed with light weights may be performed within a pain free range of
motion.
Patients with high occupational demands involving frequent overhead activity
For patients younger than 35 years who fall into this category, we follow the same
approach used for high level athletes. We refer patients over 35 years to physical
therapy for a comprehensive rehabilitation program and see them periodically in followup. If patients do not improve with physical therapy, we refer them to an orthopedic
surgeon.
Recreational athletes and individuals with limited occupational demands Care
of these patients begins with physical therapy and periodic follow-up. Orthopedic
consultation can be obtained if rehabilitation is ineffective, but these patients are not
likely to be surgical candidates.
Individuals over 60 years Patients over 60 years with a SLAP tear are likely to have
concomitant shoulder pathology. We perform a careful evaluation that includes
musculoskeletal ultrasound and plain radiographs looking for rotator cuff pathology or
osteoarthritis. These patients are treated with physical therapy and symptom
management of their SLAP tear and any associated shoulder conditions. These patients
rarely benefit from surgical intervention.
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Initial treatment Initial management of SLAP tears involves reducing pain by avoiding
aggravating activities, such as overhead throwing or work where the shoulder is placed
repeatedly in abducted and externally rotated positions. Nonsteroidal antiinflammatory drugs
(NSAIDs) or acetaminophen can be taken to help reduce pain in the acute setting. Once pain
is adequately controlled, patients begin a rehabilitation program with the goals of improving
glenohumeral and scapulothoracic motion and increasing the strength and endurance of the
rotator cuff and scapulothoracic muscles [26]. Specific exercises to accomplish these goals
are described separately. (See"Rehabilitation principles and practice for shoulder
impingement and related problems", section on 'Rehabilitation program'.)
Nonoperative treatment Typically, nonoperative management of SLAP tears is preferred
whenever possible given the long recovery required following surgical repair (typically 6 to 12
months) and the limitations of surgical treatment [38]. Rehabilitation programs focused
specifically on addressing scapular dyskinesia and posterior capsule contractures associated
with glenohumeral internal rotation deficits (GIRD) enable approximately 40 percent of
professional baseball players to resume playing without surgery [40]. Although studies are
limited primarily to retrospective case series, evidence suggests that most patients are able to
resume pre-injury activity levels following participation in a well-designed physical therapy
program. As an example, a retrospective study of 39 patients involving a rehabilitation
protocol similar to that described above for baseball players reported improved pain and
quality of life scores in 71 percent of patients, and 67 percent of overhead athletes returned to
their sport at preinjury levels [41].
The standard of care for rehabilitation of SLAP lesions includes addressing the following
principles and biomechanical deficits [7,42]:
Reduce pain and inflammation.
Restore pain free range of motion (ROM), including identifying and resolving any
glenohumeral internal rotation deficits (GIRD). Specific stretches and exercises help
improve internal rotation in these patients.
Improve function and strength of scapular stabilizers Exercises to accomplish this
goal are described separately. (See "Rehabilitation principles and practice for shoulder
impingement and related problems", section on 'Step one: Improve scapular stability'.)
Improve rotator cuff strength Exercises to accomplish this goal are described
separately. (See "Rehabilitation principles and practice for shoulder impingement and
related problems", section on 'Step two: Strengthen the rotator cuff'.)
Given the complexity of SLAP tears, patients are best served by participating in a
rehabilitation program under the supervision of a knowledgeable physical therapist. Proper
technique is important to effective treatment, and knowledge of when it is safe to advance to
more challenging exercises is essential for maximizing progress and avoiding further injury.
While there is no gold standard SLAP tear rehabilitation protocol, as patients start from a
range of functional baselines, following a standardized protocol that incorporates proven
exercises is helpful. Such a protocol provides direction about which exercises to use, how to
use them, when to advance to the next stage of rehabilitation, and approximately how much
time will be required to achieve recovery [43].
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SLAP tears are often accompanied by other pathology, such as rotator cuff or biceps
tendinopathy. In such cases, treatment of these associated conditions should be performed, in
part to determine the extent to which the SLAP tear is contributing to the patients symptoms.
Many times resolving rotator cuff or biceps tendon-related pain is sufficient. In patients with
persistent shoulder pain despite appropriate treatment of associated conditions, treatment of
the SLAP tear is often warranted. (See "Rotator cuff tendinopathy" and "Biceps tendinopathy
and tendon rupture".).
Persistent anterior shoulder pain, especially associated with overhead motions, or failure to
regain prior function despite compliance with a well-designed rehabilitation program suggests
the SLAP tear is not amenable to conservative treatment and surgical referral should be
made. In patients who are not surgical candidates, activity modifications, such as limiting
throwing or repetitive overhead activities, may be necessary to reduce chronic symptoms.
Some number of patients with SLAP tears will experience chronic pain and possibly instability
with particular activities or shoulder movements.
Surgical treatment Surgical treatment for SLAP tears may be considered in cases where
nonoperative management fails to reduce pain and improve shoulder function. A number of
surgical techniques exist, and there is some controversy about the most effective technique
for each major type of injury. Factors that inform technique selection include patient age and
whether the patient is an overhead laborer or throwing athlete. Surgical success rates are
lower in older patients according to observational studies and the clinical experience of many
shoulder surgeons. A systematic review of surgery for SLAP tears included several studies
that reported higher failure and complication rates in patients over age 40 [44]. As an
example, one prospective observational study of 179 patients with Type II SLAP tears
reported a statistically significant increase in the failure of surgical treatment among patients
older than 36 years [45]. Approximately 37 percent of patients in the study met the criteria for
surgical failure.
Overall, experienced shoulder surgeons are performing fewer SLAP repairs and becoming
more selective about which patients warrant surgery [46]. According to the review cited above,
biceps tenodesis or debridement provides a reasonable alternative. A review of SLAP repairs
performed by young surgeons applying for certification from the American Board of
Orthopedic Surgery found that only 26 percent of patients reported being pain-free and 13
percent reported normal shoulder function following SLAP repair [47]. The study authors
expressed concern over the relatively large number of repairs being performed by these
younger surgeons.
The standard repair of SLAP tears involves placing bioabsorbable anchors into the glenoid
and then securing the labrum to the glenoid with nonabsorbable sutures [48]. Performing a
biceps tenodesis (moving the biceps tendon insertion from the glenoid to the humerus)
simultaneously, particularly with overhead throwing athletes and laborers, may improve the
likelihood of the patient returning to their prior level of function, which is achieved by
approximately 60 to 70 percent of patients. However, patients with an acute traumatic SLAP
tear may do better with arthroscopic repair than patients whose SLAP tear was sustained
from repetitive injury [49].
Controversy persists about whether to repair SLAP tears in patients over 40 years with
associated rotator cuff tears (RTC). One observational study reported improved outcomes in
patients over 45 years with rotator cuff tears when SLAP tears were repaired as well, but a
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randomized trial of 63 patients over 50 years of age reported no difference in outcome in

patients whose SLAP and rotator cuff tears were repaired compared to those treated with
rotator cuff repair and biceps tenotomy [50,51]. In patients with concomitant rotator cuff injury,
labral debridement or biceps tenotomy may be preferable to labral repair [44].
Postoperative treatment and results It typically requires six months and often as long as
12 months to return to throwing after surgical repair of a SLAP lesion. Healing must not be
rushed. The patient should work through the appropriate stages of rehabilitation gradually and
clinicians must guard against the patient progressing prematurely. Given the complexity and
importance of post-operative rehabilitation, patients are best served by participating in a
rehabilitation program under the supervision of a knowledgeable physical therapist, athletic
trainer, or comparable clinician.
The post-operative rehabilitation program is typically divided into three stages:
Phase 1 Maximal protection phase (approximately six weeks duration)
Phase 2 Moderate protection phase (approximately six weeks duration)
Phase 3 Minimum protection phase (approximately 14 weeks duration)
The maximal protection phase begins the day after surgery until around six weeks. During this
phase the primary goal is to protect the surgical repair from re-injury and to minimize pain and
inflammation. The patient is typically in a sling for the full six weeks; avoiding any motion that
loads the biceps tendon is critical. The patient begins to perform passive and active assisted
range of motion (ROM) exercises during this phase but these are limited. Protected motion
begins with passive motion below 90 degrees of shoulder flexion and abduction, and
progresses gradually after the first two weeks. Limited active motion is introduced gradually.
Toward the end of this stage, the patient begins to perform some basic isometric strength
exercises.
The moderate protection phase begins at approximately week seven and continues through
week 12. During this phase, one major goal is to regain full active range of motion. Around
week 10, active loading of the biceps tendon can begin. If full ROM is not obtained with the
basic program, additional focused stretching and mobilization exercises may be required.
Increasing levels of resistance are used for scapular and rotator cuff exercises. Exercises for
developing core strength are performed during this phase.
The minimum protection phase begins at approximately week 13 and continues through week
26. During this phase, the patient may gradually resume throwing or overhead occupational
activities until full function is restored. Throwing from a mound may begin around 24 to 28
weeks after surgery in most cases. It is critical that full shoulder mobility is achieved. Full
strength and motion of the scapular stabilizers and rotator cuff muscles should be achieved
before full activity is resumed. To prevent reinjury, it is important that a pitchers throwing
mechanics be assessed and any problems resolved, and that appropriate guidelines
regarding the type and number of pitches thrown be followed [52].
For the patient who follows up with a primary care or sports medicine physician, failure to
progress through the phases in a reasonable time frame (approximately three months for
phases 1 or 2 and six months for phase 3) merits consultation with the orthopedic surgeon
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who completed the repair. Similarly, if the patient develops unexpected pain or dysfunction
during the post-operative rehabilitation, the patient should return to their orthopedic surgeon
for evaluation. The surgeon should have the final say about whether the patient is ready to
resume full activity.
A systematic review of studies of the management of Type 2 SLAP tears (506 patients
included) found that 83 percent of patients reported good-to-excellent results following
operative repair [53]. However, only 73 percent of patients returned to their prior level of
function, while only 63 percent of overhead throwing athletes returned to their previous level
of play. Should primary repair fail, biceps tenodesis often relieves pain. About 40 percent of
patients report an excellent outcome with this surgery, while approximately 4 percent
experience significant complications [47]. Common long-term disabilities after a failed surgical
repair include pain and instability with overhead or abducted and externally rotated shoulder
positions. It is unclear whether SLAP tears increase the risk for glenohumeral osteoarthritis.
SUMMARY AND RECOMMENDATIONS
Superior labrum anterior posterior (SLAP) tear refers to a specific injury of the superior
portion of the glenoid labrum that extends from anterior to posterior in a curved fashion.
These tears are common in overhead throwing athletes and laborers involved in
overhead activities. SLAP tears are caused by forceful eccentric traction exerted on the
biceps tendon and in throwers by the chronic stress placed on the labrum when the
shoulder is forcefully abducted and externally rotated (eg, cocking position of throwing).
(See 'Epidemiology, classification, and risk factors' above and 'Anatomy and
biomechanics' above.)
The history provided by the patient ultimately diagnosed with a SLAP lesion is often
vague. In cases related to overuse, the patient typically complains of anterior shoulder
pain. The athlete or laborer may complain of episodic clicking or comparable mechanical
symptoms, particularly when their arm is placed in the cocking position of throwing.
Overhead athletes may complain of a decline in function or throwing velocity. Cases
involving acute trauma may involve falling onto an outstretched arm or sudden traction
of the arm, which may occur while lifting a heavy object with a sudden jerking motion.
SLAP tears are frequently accompanied by other shoulder pathology.
(See 'History' above.)
A careful examination of the involved shoulder and upper extremity should be
performed, including assessments of motion, strength, and basic neurovascular
function. The proximal biceps tendon should be palpated; focal tenderness suggests
tendon injury. Specific examination maneuvers for detecting SLAP lesions should be
approached with the intention of determining the need for advanced imaging or surgical
intervention. Many tests for SLAP tears are used; we suggest performing the following
such maneuvers:
Anterior glide test
Compression rotation test
Active compression (OBriens) test
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Crank test
Speeds test (see 'Examination' above)
All imaging techniques used to diagnose SLAP tears have limitations, making definitive
diagnosis challenging. Depending upon the clinical scenario and prospective treatment,
it may not be necessary to obtain advanced imaging studies to establish the diagnosis.
Currently, magnetic resonance arthrogram (MRA) is the most accurate imaging study for
diagnosing SLAP tears. Plain radiographs cannot diagnose SLAP tears but remain
important for identifying concomitant injuries and are obtained in most patients.
(See 'Diagnostic imaging' above.)
Definitive diagnosis of a SLAP tear requires arthroscopy or MRA, but these are often
unnecessary and a clinical diagnosis is adequate if the patient is not a good surgical
candidate, the history and clinical findings strongly suggest the diagnosis, and other
important alternative diagnoses such as rotator cuff tear can be ruled out by examination
and ultrasound. (See 'Diagnosis' above.)
Given the complexities of establishing the diagnosis of SLAP tear and determining the
best approach to management, in most cases we suggest obtaining orthopedic referral
prior to performing advanced imaging studies (eg, MRA) when a SLAP injury is
suspected. Ideally, the consulting surgeon should be an orthopedist with advanced
training in shoulder surgery. Refraining from obtaining advanced imaging is particularly
important in patients who are unlikely to be suitable surgical candidates.
(See 'Indications for orthopedic consult or referral' above.)
SLAP tears are frequently associated with other shoulder pathology, which can make
identifying SLAP tears difficult. A few common shoulder diagnoses that may be confused
with SLAP tears are discussed in the text, along with important features to differentiate
them from SLAP tears. These diagnoses include rotator cuff tear or tendinopathy,
shoulder impingement, and biceps tendinopathy or tear. (See 'Differential
diagnosis' above.)
The management of SLAP tears depends upon patient age and activity, and the type of
tear. Nonoperative management of SLAP tears is preferred whenever possible given the
long recovery required following surgical repair (typically 6 to 12 months) and the
limitations of surgical treatment, particularly in older patients. High-level throwing or
overhead athletes and patients with high occupational demands involving frequent
overhead activity should be referred to an orthopedic surgeon. For such referrals and
whenever surgery is contemplated, it is best to consult an orthopedic surgeon
experienced in treating SLAP lesions. Management is discussed in greater detail in the
text. (See 'Management' above.)
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Exercises/rehab for shoulder

INTRODUCTION Shoulder impingement syndrome (SIS) refers to a combination of
shoulder symptoms, examination findings, and radiologic signs attributable to the
compression of structures around the glenohumeral joint that occurs during shoulder
elevation. Such compression causes persistent pain and dysfunction. SIS is a common cause
of shoulder pain among patients presenting to primary care clinics.
The principles of rehabilitation and a physical therapy program for the treatment of SIS are
discussed here. The risk factors, pathophysiology, diagnosis, and general management of SIS
and other shoulder problems are reviewed separately. (See "Shoulder impingement
syndrome" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff
tears" and "Frozen shoulder (adhesive capsulitis)" and "Evaluation of the patient with shoulder
complaints" and "Physical examination of the shoulder".)
DEFINITION AND CLASSIFICATION Glenohumeral or shoulder impingement syndrome
(SIS) is a chronic condition that develops when soft tissues are repeatedly compressed
between the humeral head and the acromion when the arm is actively raised. SIS refers to a
combination of shoulder symptoms, examination findings, and radiologic signs, rather than
injury to a specific structure. However, shoulder impingement predisposes to rotator cuff
tendinopathy and tears.
Most often SIS results from overuse in middle-aged adults. Throwing athletes suffer from a
unique form of SIS: Impingement of the superior and posterior labrum and rotator cuff occurs
with external rotation, extension, and abduction of the shoulder (ie, the cocking phase of
throwing). The different types of SIS and their pathophysiology are reviewed separately.
(See "Shoulder impingement syndrome", section on 'Pathophysiology'.)
ANATOMY AND BASIC BIOMECHANICS The anatomy and basic biomechanics of the
shoulder are reviewed separately (figure 1 and figure 2 and figure 3 andpicture 1).
(See "Evaluation of the patient with shoulder complaints", section on 'Anatomy and
biomechanics'.)
PATHOPHYSIOLOGY Given the nature of contemporary life in developed nations, the
pervasiveness of shoulder pain is not surprising. Many of us sit most of the day and many of
our activities (eg, working at a computer) require spending significant periods in a posture that
predisposes us to shoulder impingement: head forward, thoracic spine flexed, shoulders
rounded and internally rotated, and scapula protracted (picture 2). In addition, the average
person has relatively tight and strong muscles in the anterior torso and upper extremities
(pectoralis major and minor, anterior deltoid, subscapularis, and biceps) and relatively weak
muscles in the back and posterior shoulder (rhomboids, mid trapezius, shoulder external
rotators, and posterior deltoid), which further contribute to this problematic posture. In
addressing shoulder impingement syndrome (SIS), rotator cuff pathology, and many other
shoulder problems, we must take into account the effects of this posture upon shoulder
function [1-5].
PRINCIPLES OF REHABILITATION The normal biomechanics of any joint can be
disrupted by problems intrinsic to the joint or in related structures. Muscles, tendons, or
ligaments that are relatively tight or loose, weak or strong can contribute to such problems. To
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understand and rehabilitate injuries properly we need to understand the requirements of the
involved joint complex and how imbalances in strength and flexibility affect its function. Once
the fundamental problems are recognized, a progressive program can be designed to
address them.
Proper rehabilitation makes use of the overload principle, which involves providing a
progressive stimulus (or stress) to which the body must adapt [6]. According to this principle, a
muscle will only become stronger if resistance is increased. Each exercise program starts with
simple movements involving light resistance. Over time, depending upon the muscle group
involved, more complex exercises using greater resistance are added, as the patient can
tolerate them. In other words, as soon as the patient can perform an exercise without
difficulty, the amount of weight or the tube tension being used should be increased. Such
increases in resistance should be gradual but steady.
It is important to maintain the patients confidence during rehabilitation. If a program is too
easy and provides little benefit, patient compliance may fall; if a program is too difficult, pain
may increase and the patient may quit rehabilitation. Increasing the stimulus by an
appropriate amount and at an appropriate rate leads to steady improvement.
All therapeutic exercise programs follow the basic steps of rehabilitation:
Decrease pain and inflammation
Restore normal range of motion (ROM)
Improve individual muscle function
Restore overall functional capacity
Educate and direct injury prevention exercises to avoid re-injury
Often the pace of recovery is determined by pain and inflammation. As an example, shoulder
pain can inhibit the primary movers of the shoulder (ie, the rotator cuff). When the rotator cuff
is not working properly the head of the humerus migrates superiorly impinging on structures in
the subacromial space [7,8]. Therefore, decreasing pain and inflammation must be the first
step in treating shoulder dysfunction. With shoulder impingement syndrome (SIS), this is
accomplished in part by improving scapular stability. Improved scapular stability contributes to
better rotator cuff function, and as the rotator cuff becomes better able to hold the head of the
humerus against the glenoid fossa during arm elevation, impingement decreases and overall
shoulder function improves [9]. In addition, exercises specifically for improving rotator cuff
function are necessary to treat SIS.
Each muscle group performs specific actions in a particular manner, and rehabilitation of each
muscle group involves different exercises and workout volumes (ie, number of exercises,
sets, and repetitions). In general, we prefer to use several different exercises to ensure that
every major movement for each involved muscle is appropriately trained. Another benefit of
using a range of exercises is the ability to modify a program based upon the patients abilities
and limitations, for example when a patient is unable to perform a particular exercise. For the
rotator cuff, the major movements are internal rotation (subscapularis), external rotation (teres
minor, infraspinatus), and abduction (supraspinatus), and for the muscles that provide
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scapular stability, the major movements are retraction, elevation, and depression-rotation (or
protraction) of the scapula.
In addition, researchers in rehabilitation have identified the need to create specific training
regimens for postural muscles versus phasic muscles [10]. Postural, or tonic, muscles are
primarily involved in endurance functions and contract over longer periods while phasic
muscles primarily perform in short bursts of activity and exert greater power. The number of
repetitions used for a particular exercise will vary depending upon the muscle type. As an
example, a high number of repetitions (50 to 100) is necessary to improve the endurance of
postural muscles, while phasic muscles become stronger when performing fewer repetitions
(10 to 20) using greater resistance.
Proper exercise technique and posture are essential for effective physical therapy. During
rehabilitation, exercises for the shoulder complex should be performed in a deliberate,
controlled manner; patients must avoid using momentum to make exercises easier. The
muscles involved in executing a particular movement should move smoothly. If a patient is
unable to complete the prescribed number of repetitions in a controlled manner, it is better to
stop as soon as the form starts to break down, rather than risk injury, and build up to the
desired number over time. Our goal is to improve muscle function, not just to complete the
sets and repetitions.
Appropriate exercise technique depends in part on whether a muscle is contracting
concentrically or eccentrically. When a muscle is contracting and the lever arm is shortening,
this is called a concentric contraction. One example is the biceps muscle when a person is
pulling their body up to the bar during a chin up. Concentric exercises during physical therapy
are generally performed to a 2 second count. When a muscle is contracting and the lever arm
is lengthening, this is called an eccentric contraction (sometimes referred to as a negative
repetition by weightlifters). An example would be the biceps muscle when a person is lowering
their body down from the bar during a chin up. Eccentric exercises during physical therapy
are generally performed to a 4 second count.
These second counts reflect the importance of using controlled deliberate movements to
perform resisted rehabilitation exercises and the relative strength of eccentric movement
generally. This approach ensures that the appropriate muscles are doing the work and the
role of momentum is minimized. In addition, an eccentric contraction can generate forces up
to one and a third times that of a concentric contraction involving the same muscle. By
increasing the duration of the eccentric contraction, a suitable challenge is created for the
muscle without changing the load.
Of note, eccentric contraction involves the breaking actin-myosin cross-bonds in muscle
sarcomeres, while concentric contraction involves the creation of such cross-bonds. The
breaking of cross-bonds is associated with the delayed onset muscle soreness associated
with weight lifting and other intense athletic activities involving significant eccentric contraction
under a load [11].
Posture has a large effect on muscles and movement, and this is particularly true of the
shoulder. If exercises are performed with slumped, internally rotated shoulders and poor
spinal posture, anterior muscles, such as the pectoralis major (which in most patients are too
tight and too strong relative to the muscles of the upper back and rotator cuff) can
overcompensate for deficiencies elsewhere and physical therapy will be ineffective.
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Once rehabilitation is completed and healthy shoulder function is achieved, it is crucial that
patients not resume the postures and practices that predispose to disability. Therefore, it is
important that patients continue to perform a few times each week a subset of exercises
prescribed by the physical therapist that will maintain the strength of the scapular stabilizers
and rotator cuff muscles and overall shoulder function. In addition, proper posture and
ergonomics at home, work, and play are essential to avoiding a recurrence of shoulder
impingement. Techniques for improving and maintaining proper posture and ergonomics are
reviewed separately. (See "Overview of joint protection", section on 'The principles of joint
protection'.)
REHABILITATION PROGRAM
Overview Rehabilitation of any injury requires a specific plan and exercise progression.
With shoulder impingement syndrome (SIS), there are three primary goals of rehabilitation
[3,12,13]:
Strengthen the muscles that stabilize the scapula: By strengthening the scapular
stabilizers, greater stability is provided for the rotator cuff muscles, which originate on
the scapula. This stability allows for greater efficiency and muscular endurance of the
rotator cuff, and improved overall shoulder function. This is a critical first step in
rehabilitation.
Correct imbalances in strength among the rotator cuff muscles: Typically, before
rehabilitation, the muscles at the front of the shoulder complex (anterior deltoid, internal
rotator (ie, subscapularis)) are 1.5 to 2 times stronger than those at the posterior
(posterior deltoid, external rotators).
Stabilize the secondary movers of the shoulder complex: Once the primary muscles of
the shoulder are strong and functional, the next step is to rehabilitate the secondary
shoulder muscles in order to improve coordination of the entire shoulder complex.
In addition to these three primary goals, a fourth goal for many athletes is to improve sportspecific biomechanics and function. This may entail performing exercises that simulate key
movements in their sport using resistance or other techniques to improve performance.
Proper technique is an essential component of this phase.
Patients should be made aware that successful completion of such a program generally
requires from 8 to 16 weeks, but that some improvement is usually noted within the first three
to four weeks. A patient who has successfully completed a rehabilitation program for SIS
should have complete, pain-free motion of the glenohumeral joint and should be able to
perform all functional movements and exercises in the program without pain. Several months
following the completion of rehabilitation may be needed before pain during sleep completely
resolves.
It is important to maintain the patients confidence during rehabilitation. If a program is too
easy and provides little benefit, patient compliance may fall; if a program is too difficult, pain
may increase and the patient may quit rehabilitation. To avoid such problems when
rehabilitating patients with shoulder pain, it is important to distinguish between SIS and rotator
cuff tears at the outset, and to refer patients back to their referring primary care or sports
medicine clinician to discuss possible surgical evaluation as soon as the need is recognized
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(eg, patient demonstrates significant weakness consistent with a substantial rotator cuff tear).
A discussion of how to work through the differential diagnosis of the adult with shoulder pain
and specific discussions of how to diagnose a rotator cuff tear are provided separately.
(See "Evaluation of the patient with shoulder complaints" and "Presentation and diagnosis of
rotator cuff tears".)
Step one: Improve scapular stability Scapular instability is common in patients with SIS
and improving the stability of the scapula is the first goal in rehabilitating these patients. The
scapula is the origin for the rotator cuff muscles and thus, if it is unstable, rotator cuff
contractions are weaker and less efficient. Strengthening the muscles that stabilize the
scapula allows for better rotator cuff function [1-4,14]. The muscles targeted in this phase of
physical therapy are, in order of importance, the rhomboid and mid-trapezius, lower trapezius,
upper trapezius and levator scapulae, and the serratus anterior.
The key to success in this step is getting the patient to focus on the scapula. This is often
accomplished by having the patient exaggerate squeezing the shoulder blades together.
Initially, it may help for the clinician or therapist to place a finger or object in the space
between the scapulae while this is done. The most common mistakes that patients make
when performing these exercises are overemphasizing arm movement and neglecting
scapular movement.
The muscles providing scapular stability contract continuously during the day to help maintain
posture. Thus, the patient must perform exercises using relatively low resistance but many
repetitions in order to improve the endurance of these muscles. In one randomized trial of
patients with chronic SIS, the group assigned to rehabilitation involving exercises performed
with high repetitions (three sets of 30) demonstrated significantly greater improvements in
pain and function than the group treated with low repetitions (two sets of 10) [15].
The authors preferred exercises for scapular stabilization include:
Row Use tubing anchored to a doorknob, table leg, or sturdy stair banister. While
standing, hold the tubing in each hand at about waist height. Pull the tubing back by
letting the elbows bend and squeezing the shoulder blades together as much as
possible, as if you are trying to hold a pencil between your shoulder blades (picture
3 and movie 1). Pull back while slowly counting to two, and then return to the starting
position while slowly counting to four. Perform two sets of 20 to 25 repetitions with 30
seconds rest between sets.
Shoulder extension Use tubing anchored to a doorknob, table leg, or sturdy stair
banister. While standing, hold the tubing in each hand at about waist height. Keeping the
elbows straight, pull the tubing back and squeeze the shoulder blades together as much
as possible, like you are trying to hold a pencil between your shoulder blades (picture
4 and movie 2). Pull back while slowly counting to two, and then return to the starting
position while slowly counting to four. Perform two sets of 20 to 25 repetitions with 30
seconds rest between sets.
Scapular downward rotation and depression (Supermans) Lay on your stomach
with your arms straight and directly overhead. Lift your arms off the floor and hold the
position while slowly counting to two, and then slowly lower your arms while counting to
four. Perform two sets of 20 to 25 repetitions with 30 seconds rest between sets.
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Horizontal shoulder abduction Use tubing anchored to a doorknob, table leg or sturdy
stair banister. While standing, hold the tubing in each hand at about shoulder height.
Keeping the elbows straight, pull the tubing back and squeeze the shoulder blades
together as much as possible. Your arms and body will form a T shape. Pull back while
slowly counting to two, and then return to the starting position while slowly counting to
four. Perform two sets of 20 to 25 repetitions with 30 seconds rest between sets. The
exercise can also be performed from a prone position (picture 5).
The author prefers to have patients begin performing these exercises using rubber tubing for
resistance and performing a moderate number of repetitions (eg, 15 to 20). Gradually, the
patient works up to three sets of 50 to 100 repetitions [3]. For most patients, it is reasonable to
increase the number of repetitions by five each session. It is generally safe for the patient to
increase the resistance of an exercise (eg, use tubing with greater tension) when he or she
can successfully perform two to three sets of 50 repetitions without an increase in pain. For
each group of exercises, it usually takes two to three weeks for a patient to achieve the full
number of repetitions and progress to more difficult tubing.
Tubing is made by a number of manufacturers and different tubes or bands have variable
resistance. As an example, Thera-Band tubing has resistance as follows: yellow tubing 2.4 to
3.4 lbs (1.1 to 1.5 kg); red 3.7 to 5.5 lbs (1.7 to 2.5 kg); green 4.6 to 6.7 lbs (2.1 to 3 kg); blue
5.8 to 8.6 lbs (2.6 to 3.9 kg); black 7.3 to 10.2 lbs (3.3 to 4.6 kg); silver 10.2 to 15.3 lbs (4.6 to
6.9 kg).
Once an appropriate number of repetitions can be performed for each exercise above using
more difficult tubing, patients begin using weighted resistance. Suitable exercises to perform
once this stage is reached include:
Seated rows While seated, grasp the handle of a pulley bar directly in front of you
and, while maintaining an erect posture, gradually pull the bar straight to your belly, hold
for one second, and then return the bar to the starting position (picture 6). Do three sets
of 15 repetitions with a weight that does not cause pain but challenges the muscles.
Work up to three sets of 20 repetitions without pain, while maintaining proper form,
before increasing the weight. Each time the weight is increased, begin with three sets of
15 repetitions and work up to 20 repetitions.
Close-grip pull-downs While seated, grasp the handle of an overhead pulley bar and,
while maintaining good posture, gradually pull the bar straight to your chest, hold for one
second, and then return the bar to the starting position (picture 7). Do three sets of 15
repetitions with a weight that does not cause pain but challenges the muscles. The
progression is identical to that for seated rows.
I-T-Ys with dumbbells I-T-Ys can be performed in different positions and one or both
arms can be used; the authors preferred approach is described here. Begin by lying
prone with your upper torso extended beyond the edge of a stable flat surface. An
examination table, bed, weight bench, or stability ball can be used. Initially, perform each
exercise without weight for two sets of 15 to 20 repetitions. As the exercises become
easier, add resistance in one pound (0.45 kg) increments until the exercises can be
performed using 8 to 10 pound (3.6 to 4.5 kg) dumbbells.
I exercises begin with the involved arm hanging straight down from the shoulder.
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26
Keeping the elbows straight, extend your shoulders until the arms are pointing straight
down and are adjacent to your torso (picture 8). Hold this position for one second, and
then slowly return the arms to the starting position.
T exercises begin from the same starting position. Keeping the elbows extended, raise
your arms straight to the side (combination of shoulder extension and abduction) until
they are perpendicular to the torso (if both arms are used, the arms and torso form a T)
and in line with the body (picture 9 and picture 10). Hold the position for one second,
and then slowly return the arms to the starting position.
Y exercises begin from the same starting position. With the elbows extended and the
thumbs pointing up, flex your shoulders in a plane approximately at a 45 degree angle
from the body until the arms are in line with the body (if both arms are used, the arms
and torso form a Y) (picture 11). Hold the position for one second, and then slowly return
the arms to the starting position.
Shoulder shrugs Holding a dumbbell in each hand, gradually shrug your shoulders
completely, hold the top of the shrug for a second, and then gradually lower them to the
starting position. Do three sets of 15 repetitions with a weight that does not cause pain
but challenges the muscle. The progression is identical to that for seated rows.
In the final stages of rehabilitation, more complex exercises are performed. These exercises
may involve the use of suspension training (eg, TRX), free weights, or other equipment.
However, regardless of the complexity of the movement or the equipment used, the exercises
should involve relatively low resistance but steadily build to a high number of repetitions (50 to
100). With each new group of more challenging exercises, the patient should begin with
lighter resistance and perform two to three sets of 15 repetitions. Gradually the number of
sets and repetitions are increased until the patient can perform three sets of 50 to 100
repetitions. Then, resistance is gradually increased and the process begins anew. Repetitions
can be increased for as long as there is no shoulder pain.
Stretching Many patients with SIS have inadequate flexibility in the muscles of their
anterior shoulder and chest, and tightness in the posterior capsule of their glenohumeral joint.
These problems contribute to shoulder impingement and thus an important part of
rehabilitation for SIS is a stretching program. Stretching exercises are performed throughout
rehabilitation.
The author prefers the following stretching exercises:
Corner stretch (for chest and anterior deltoid) (picture 12)
Posterior capsule stretch (movie 3 and picture 13)
Sleeper stretch (movie 4 and picture 14)
Pectoralis minor stretch (picture 15)
Each stretch is held for 30 seconds and repeated three times. A rest interval of about 60
seconds between sets is generally adequate. For exercises that involve one extremity at a
time, both sides should be stretched.
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27
During the initial stages of rehabilitation, pain may limit the patients ability to perform
stretches. Thus, early on, patients stretch once a day to the extent that they can without
causing pain. However, improving flexibility generally requires more frequent training than
improving strength. Therefore, as pain subsides and patients are able to perform physical
therapy exercises, we tell patients to stretch twice daily. When patients reach the final phase
of shoulder rehabilitation, and are preparing to resume their usual activities, we tell patients to
stretch two to three times daily, and have them continue this regimen until they achieve full,
pain-free shoulder movement. Thereafter, they can stretch following exercise to maintain
flexibility.
Step two: Strengthen the rotator cuff There are four rotator cuff muscles involved in
three distinct shoulder movements (although the coordinated action of all four muscles is
essential for healthy shoulder function). To address strength imbalances among the rotator
cuff muscles, it is necessary for patients to perform exercises that isolate particular muscles.
Although rotator cuff muscles perform postural functions during some activities of daily living
(ADL), the rotator cuff muscles are primarily phasic and most often perform short bursts of
activity. Phasic muscles become stronger when performing exercises with 10 to 20
repetitions. Thus, the best rehabilitation volume consists of two to three sets of 10 to 20
repetitions. As soon as the patient can perform a workout without difficulty, the amount of
weight or the tube tension being used should be increased. Increases in resistance should be
gradual but steady. (See 'Principles of rehabilitation' above.)
It is important that the patient perform the rotational exercises described below in a deliberate,
controlled manner, thereby forcing the muscles involved to rotate the arm and stabilize the
glenohumeral joint simultaneously.
Supraspinatus SIS often involves weakness or dysfunction of the supraspinatus muscle,
which is involved in abduction of the arm. Therefore, exercises to strengthen this muscle are
generally included in the rehabilitation program.
Abduction exercises performed with the thumbs pointed upwards are the safest way to train
the supraspinatus, according to a systematic review of biomechanical and clinical studies
performed to identify the most effective rehabilitation exercises for rotator cuff and
scapulothoracic muscles [12,16]. These exercises are sometimes referred to as full can
exercises because the patients hands are positioned as if they are holding a full can of liquid
they do not want to spill. Exercises that isolate the supraspinatus but are performed with
alternative positioning have been found to compress subacromial structures.
The progression of exercises used to strengthen the supraspinatus consists of the following:
Isometric holds in the mid-range of abduction using the full can position (movie 5).
Start with your arms hanging straight down from your body. With your arm in a thumbsup position, lift your arm in a plane at approximately 45 degrees of shoulder external
rotation (ie, arm in front of your body) to waist height so that it engages the counter or a
wall and then maintain it at this height for five seconds. Perform two sets of 10 to 15
repetitions. When this exercise can be performed without pain, progress to the next
exercise.
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Active abduction using the full can position (movie 6). Start with your arms hanging
straight down from your body. With your arm in a thumbs-up position, lift your arm in a
plane at approximately 45 degrees of shoulder external rotation to shoulder height, hold
this position for one second, and then slowly return to the starting position (picture 16).
Perform three sets of 15 repetitions.
Active abduction using the full can position against resistance (tubing or free weights)
(picture 17 and movie 7). Start with your arms hanging straight down from your body
while holding a 1 lb (0.45 kg) dumbbell. Alternatively, you can use light resistance tubing
attached at about waist height to a fixed object behind you. With your arm in a thumbsup position, lift your arm in a plane at approximately 45 degrees of shoulder external
rotation to shoulder height. Perform three sets of 15 repetitions. Each time the patient is
able to perform three sets of 20 repetitions without pain, add 1 lb (0.45 kg) to the load
being raised. A reasonable goal for the average patient is to perform the exercise with
10 to 12 lbs (4.5 to 5.5 kg) for three sets of 20 repetitions.
Avoid elevating the arm too much in these exercises.
External rotators (infraspinatus and teres minor) The infraspinatus and the teres minor are
the rotator cuff muscles responsible for external rotation of the shoulder. In addition, the
external rotators decelerate the humerus during overhand throwing and racquet sports. These
muscles are trained together during rehabilitation.
Several exercises can be used to strengthen the external rotators and selection is sometimes
based upon the specific activities in which the patient participates. The author prefers to begin
with isolated movements and then progress to more complex movements designed to help
the patient improve performance in their chosen activity.
A typical progression of exercises used to strengthen the external rotators consists of the
following:
Isometric holds in neutral position (movie 8). Standing with your body perpendicular to
a wall, flex your elbow to 90 degrees and make sure that your posture is erect. While
keeping your elbow tight to your side throughout the exercise, push your forearm into
the wall by externally rotating your shoulder. Maintain the contraction for 5 seconds and
then relax for 2 to 5 seconds. Perform two sets of 10 to 15 repetitions. When this can be
done without pain, progress to the next exercise.
Active external rotation with the arm held in neutral position. While standing or sitting,
flex your elbow to 90 degrees. Keeping your elbow tight to your side throughout the
exercise, externally rotate your shoulder so your forearm travels approximately 90
degrees; your forearm will move from touching your abdomen until it points directly in
front of your torso. Perform three sets of 15 repetitions.
Active external rotation while lying on the side. While lying on the uninvolved side, rest
your affected arm on the side of your torso and flex the elbow to 90 degrees, allowing
your forearm to rest against your abdomen. Keeping your elbow tight to your side
throughout the exercise, externally rotate your shoulder such that your forearm moves a
little beyond 90 degrees (ie, forearm is just beyond parallel to the floor). Perform three
sets of 15 repetitions.
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Active external rotation against resistance, using either tubing or free weights (movie
9). Stand with your body perpendicular to the wall or to the site to which the tubing is
anchored. Hold the weight or tubing in the hand furthest from the wall or anchor site and
flex your elbow to 90 degrees. If you are using tubing, move away from site to which the
tubing is anchored until there is no slack and your forearm is resting against your
abdomen (picture 18). Keeping your elbow tight to your side throughout the exercise,
externally rotate your shoulder until the forearm is slightly more than 90 degrees from
your body. The goal is to perform three sets of 20 repetitions with 10 to 15 lbs (4.5 to 6.8
kg), or at least 50 percent of the resistance used for internal rotation exercises.
In order to isolate the rotational component of these exercises, it is often helpful to have the
patient pinch a towel between their body and the arm involved in performing the exercise.
Subscapularis Internal rotation of the shoulder is performed by the subscapularis, a
relatively large muscle that originates on the undersurface of the scapula. The subscapularis
is generally quite responsive to exercise and rarely limits the rehabilitation potential of the
patient with SIS, or other shoulder problems. Therefore, beginning isometric exercises are
usually unnecessary, unless the shoulder has sustained acute trauma involving an anterior
glenohumeral force moment (eg, anterior glenohumeral dislocation). In such circumstances,
rehabilitation would begin with isometric holds in a neutral position, with the patient
performing two sets of 15 repetitions with five second holds for each repetition (movie 10).
In most circumstances, a typical progression of exercises used to strengthen the
subscapularis consists of the following:
Active internal rotation with the arm held in neutral position. Stand or sit and flex the
elbow of your involved arm to 90 degrees. Keeping your elbow tight to your side
throughout the exercise, begin with your forearm pointing straight in front of your body
and then internally rotate your shoulder, moving your forearm until it rests against your
abdomen. Perform three sets of 15 repetitions.
Active internal rotation while lying on the side (movie 11). While lying on your involved
side, position your bottom (ie, affected) arm under your body and flex the elbow to 90
degrees, allowing your forearm to rest against the floor or table. Keeping your elbow
tight to your side throughout the exercise, internally rotate your shoulder until your
forearm touches your abdomen. Perform three sets of 15 repetitions.
Active internal rotation against resistance, using either tubing or free weights (movie
12 and movie 13). Stand with your body perpendicular to the wall or to the site to which
the tubing is anchored with the affected arm closest to the wall. Hold the weight or tubing
in the hand closest to the wall or anchor site and flex your elbow to 90 degrees. If you
are using tubing, move away from site to which the tubing is anchored until there is no
slack and the forearm arm is rotated a little more than 100 degrees from your body
(picture 19). Keeping your elbow tight to your side throughout the exercise, internally
rotate your shoulder until the forearm touches your abdomen. The goal is to perform
three sets of 20 repetitions with 15 to 25 lbs (6.8 to 11.3 kg).
Step three: Improve overall strength and coordination of shoulder complex Gaining
strength in isolated movements is essential for proper rehabilitation, but exercises to improve
Hayden Lee
30
coordinated shoulder movement are a critical, and often overlooked, final step in treatment
that is necessary to attain maximal function.
As symptoms and shoulder function improve, patients gradually resume their usual daily
activities. These activities often include manipulating an object overhead at arms length (eg,
removing or replacing a dish from a high shelf). Thus, the final stages of SIS rehabilitation
should include more challenging functional exercises that develop the scapular stability and
rotator cuff strength necessary to counteract the torque created at the end of the lever arm
when they perform such activities. Incorporating more complex movements, like combined
internal and external rotation or diagonal pulls across the body, and more difficult exercises,
such as plyometric and closed kinetic chain exercises, helps to achieve these functional
goals.
Two exercises suitable for the general patient population that help to improve overall shoulder
strength and coordination are the following:
Active internal rotation against resistance in a 90-90 position (movie 14). Attach
appropriate tubing to a stationary object at about waist height. Stand facing away from
the object while holding the tubing at head height with the arm in a 90-90 position (90
degrees of elbow flexion and 90 degrees of arm abduction). Internally rotate the
shoulder until the forearm is parallel to the ground (picture 20). The goal is to perform
three sets of 20 repetitions with blue or black tubing (or 20 to 30 lbs [9.0 to 13.6 kg]
resistance).
Active external rotation against resistance in a 90-90 position (movie 15). Attach
appropriate tubing to a stationary object at about waist height. Stand facing the object
while holding the tubing at head height with the arm in a 90-90 position (90 degrees of
elbow flexion and 90 degrees of arm abduction). Externally rotate the shoulder until the
forearm is perpendicular to the ground (picture 21). The goal is to perform three sets of
20 repetitions with blue or black tubing (or 10 to 15 lbs [4.5 to 6.8 kg]), or 50 percent of
internal rotation resistance.
Exercises involving more complex movements are used for patients with specific needs, such
as athletes preparing for a particular sport, but these are beyond the scope of this topic.
WHERE TO BEGIN When deciding how to begin a rehabilitation program for the patient
with SIS, it is important to determine the type and stage of their shoulder pathology. Is the
problem acute inflammation or chronic overuse? Is there a history of shoulder problems in the
affected extremity? Is a significant rotator cuff tear suspected?
Whenever SIS is suspected but there is doubt about the precise nature of the problem, it is
best to begin treatment with simple isometric exercises. The patient can then progress to
active range of motion (ROM) exercises as tolerated, and finally to resisted exercises.
(See 'Principles of rehabilitation' above.)
The management of rotator cuff tears is debated, and most patients with a suspected tear can
be assessed by any physician experienced in the management of shoulder disorders. Active
patients with a suspected rotator cuff tear associated with significant shoulder weakness or
instability who present acutely following an injury should be referred immediately to an
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31
orthopedic surgeon. (See "Management of rotator cuff tears", section on 'Surgical indications
for rotator cuff tears'.)
A discussion of how to work through the differential diagnosis of the adult with shoulder pain
and specific discussions of how to diagnose rotator cuff tendinopathy and rotator cuff tear are
provided separately. (See "Evaluation of the patient with shoulder complaints" and "Rotator
cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears".)
EVIDENCE SUPPORTING THIS APPROACH Much of the evidence supporting the
approach to physical therapy for shoulder impingement syndrome (SIS) described in this topic
consists of clinical experience, biomechanical studies, and observational data [3,12,17-19].
However, further support can be found in a small number of controlled trials, including the
following:
In a controlled trial of 102 patients with chronic SIS (symptoms >6 months), the group
randomly assigned to treatment with a specific physical therapy program for SIS showed
significantly greater improvements in shoulder function and patient satisfaction than the
group managed with general exercises for the shoulder and neck [13]. The mean
change in the Constant-Murley shoulder assessment score was 24 points for patients in
the specific program (95% CI 19-28) and 9 points in the general exercise group (95% CI
5-13). The specific program consisted of eccentric strengthening exercises for the
rotator cuff and both concentric and eccentric exercises for the scapula stabilizers
performed with progressive resistance, along with manual mobilization.
In addition to the rehabilitation program described in this topic, manual manipulation of the
involved shoulder to improve mobility, when performed by experienced physical therapists,
appears to improve outcomes in patients with SIS [20,21].
SUMMARY AND RECOMMENDATIONS
Glenohumeral or shoulder impingement syndrome (SIS) is a chronic condition that
develops when soft tissues are repeatedly compressed between the humeral head and
the acromion when the arm is actively raised. A specific subtype of SIS is seen in
overhead athletes (eg, pitchers, tennis players) (See "Shoulder impingement
syndrome".)
Rehabilitation of SIS requires a specific plan that includes appropriate exercises and
progressions. Our suggested plan for general rehabilitation of SIS is described in the
text. This plan is organized around the three primary goals of rehabilitation
(see 'Principles of rehabilitation' above and 'Rehabilitation program' above):
Strengthen the muscles that stabilize the scapula: By strengthening the scapular
stabilizers, greater stability is provided for the rotator cuff muscles, which originate
on the scapula. This stability allows for greater efficiency and muscular endurance
of the rotator cuff, and improved overall shoulder function. (See'Step one: Improve
scapular stability' above.)
Correct imbalances in strength among the rotator cuff muscles: Typically, before
rehabilitation, the muscles at the front of the shoulder complex (anterior deltoid,
internal rotator (ie, subscapularis)) are disproportionately stronger than those at the
Hayden Lee
32
posterior (posterior deltoid, external rotators). (See 'Step two: Strengthen the
rotator cuff' above.)
Stabilize the secondary movers of the shoulder complex: Once the primary
muscles of the shoulder are strong and functional, the next step is to rehabilitate
the secondary shoulder muscles in order to improve coordination of the entire
shoulder complex. (See 'Step three: Improve overall strength and coordination of
shoulder complex' above.)
Appropriate stretching is another important element of the rehabilitation program.
Suggested stretches are described in the text. (See 'Stretching' above.)
Successful completion of the SIS rehabilitation program generally requires from 8 to 16
weeks, but some improvement is usually noted within the first three to four weeks. A
patient who has successfully completed a rehabilitation program for SIS should have
complete, pain-free motion of the glenohumeral joint and should be able to perform all
functional movements and exercises in the program without pain. It is important to
instruct patients about proper posture, movement, and ergonomics to reduce the risk of
recurrence.
Sources:
UpToDate: Superior labrum anterior posterior (SLAP) tears (Mar 20, 2015),
Rehabilitation principles and practice for shoulder impingement and related
problems (Jan 12, 2015)
http://www.uptodate.com.ezproxy.library.uq.edu.au/contents/superior-labrumanterior-posterior-slap-tears
http://www.uptodate.com.ezproxy.library.uq.edu.au/contents/rehabilitationprinciples-and-practice-for-shoulder-impingement-and-related-problems
Also useful: http://radiopaedia.org/articles/superior-labral-anterior-posteriortear
Hayden Lee
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UpToDate articles and Haydens summary of

SLAP (Superior labrum anterior posterior)

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SLAP-specific testing: Suggested approach No single examination maneuver or

Magnetic resonance imaging Magnetic resonance arthrogram (MRA) is the most

Glenohumeral osteoarthritis SLAP tears and glenohumeral osteoarthritis can both

randomized trial of 63 patients over 50 years of age reported no difference in outcome in

Exercises/rehab for shoulder

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