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Non-operativeRehabilitationForSLAPTearsHowtoKnowwhenRehab“Fails”?ChuckThigpen,PT,PhD,ATC

April22,2017AnnualOrthopaedic Meeting

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2017AnnualOrthopaedic MeetingApril22nd

Non-operativeRehabilitationForSLAPTears

HowtoKnowwhenRehab“Fails”?

ManagementofSuperiorLabralAnterior-to-Posterior(SLAP)LesionsoftheShoulder

InpressJournalofAthleticTraining

Lori Michener, PT, PhD, SCSTim Uhl, PhD, PT, ATCKellie Bliven, PhD, ATCSue Falsone, PT, ACT, SCSJeff Abrams, MDJames Tibone, MDEd McFarland, MD�ƌ

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WĞƌĨŽƌŵ�ƚŚĞ�ƐƚƌĞƚĐŚĞƐ�ĚĂŝůǇ͘��ůƚĞƌŶĂƚĞ�ďĂŶĚ�ĂŶĚ�ǁŝŐŚƚ�ĞǆĞƌĐŝƐĞƐ͘Sleeper Stretch: 3/4 side lying; upper arm position 60-90˚ of Abduction; forearm at 90˚ to upper arm

Cross Body Stretch: 3/4 side lying; upper arm position 60-90˚ of abduction; pull across body

Lat Stretch: Shoulder blade back & down with + Upper Quarter position

Foam Roll Stretch: 3/4 side lying; upper arm position 60-90˚ of Abduction; forearm at 90˚ to upper arm IR/ER rotate arm; 2nd stretching overhead

Hand Taps: Start with arms just wider than your shoulders. Press blades apart then move hands side to side. Goal is 45 to 30 secs.

Prone Robbers: Elbows bent at 90˚; shoulder blades down & back; then rotate the forearmout to side while keeping elbow at 90˚

Prone Superman: Arms above head; thumbs point skyward; first, pull shoulder blades down, then raise arms

Prone T’s: Arms raised even with shoulders; thumbs skyward; first, pull shoulder blades down & back, then raise arms

Low ER: Squeeze blades down & back, then pull cord across your body keeping your elbow at your side and elbow bent

High ER: Do not shrug shoulders. Squeeze blades down & back, then pull cord back like throwing

Lower Trap: Keep arms straight by the side; palms up, thumbs pointed out; keep hands in front of body at all times

Band ER @ 45˚: Elbows bent at 90˚; shoulder blades down & back; rotate the forearm out to side while keeping elbow at 90˚

If you have any questions about your program ask your Athletic Trainer or email:

Typical Clinical Relevance ¨ Dominant arm¨ Male¨ Under age of 40¨ High performance overhead activity

- Decreased velocity & control¨ Shoulder Trauma History

- Fall on outstretched hand- MVA with seatbelt

¨ Shoulder Instability¨ Incidence 3 - 11.7%

(Snyder, Stetson, Maffet, Handelberg)

Incidence¨ Kim et al (JBJS 2003) –

n Onset during sport (OR 9.7)n High demand job (OR 8.66)n Biceps Load II- SLAPn Jerk Test- Posteroinferior Labral Tear

Clinically:- 139 SLAP lesions of 544 scopes (26%)- Type I (74%), II (21%), III (0.7%), IV (4%)Pathology:- Over 40 à Supraspinatus tear &/or OA- Under 40 à Bankart Lesion



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SLAP Type I/II

Snyder SJ, et al, Arthroscopy 1990; 6(4):274-9

I

SLAP Type III or >

Snyder SJ, et al, Arthroscopy 1990; 6(4):274-9

X

SLAP lesion¤ 22% incidence w/ Bankart

(Snyder et al JSES ‘95)

¤ +/ Instability

This talk is NOT about patients w/ instability

What/Who are these Patients?

XSLAP Repair in Throwers

Poor Outcomes – in all 3Systematic Review Articles

Gorantla Arthroscopy 2010

Sayde CORR 2012

Osti Musc Lig Tend J 2013

Baseball Return to Play22-64%

SLAP + biceps tenodesis…. 38% AOSSM Speciality Day 2017



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SLAP is Not the Problem?48% Asymptomatic MLB pitchers had an SLAP lesion

45% Asymptomatic mature pitchers had MRI Labrum Tear

Lesniak et al AJSM 2013

Miniaci et al AJSM 2001

Do “SLAP’s” Hurt?

➔ Biceps tenodesis or tenotomy may be considered if the biceps iso Synovitico hypertrophiedo Frayedo unstable biceps anchor

➔ Failed SLAP repair may consider a combined repair of the SLAP tear combined with biceps tenodesis or tenotomy (Boileau et al. ‘09; Gupta et al. ‘13; Werner et al ‘14; McCormick et al ‘14 )

Biceps Outcome? When does a non-op program fail?

Right Patient: Key Considerations for Differential¨ How long do you have?

¤ Athlete vs. Worker’s comp vs. Crossfitter vs. “Dad”¨ Mechanism of injury

¤ Acute event¤ Hyper ER/ABD vs. Traction

¨ What is functional complaint?¤ Loading vs. End ROM

¨ What are other impairments?¤ Irritability level; Magnitude of deficits



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UE Sport Demands Physical Exam to Drive Treatment

¨ History¤ Overhead activity¤ Pain post/deep & often

“biceps”¨ ROM

¤ ER- painful? Click?¤ IR- pain?¤ HA- pain?

¨ Joint end feel¤ Post/inferior

¨ Muscle Performance¤ ER @ 0 & 90/90

n If they need > 90 of ER can they actively get there?

¨ Special tests¤ r/o instability

n Especially posterior¤ If overhead athlete

n O’Briensn + for intrarticular injection

AJSM 2008

¨ Overhead athletes with SLAP tears should undergo non-operative management with the goals to ¤ decrease pain ¤ improve function, ¤ return to previous activity levels

(Neri, Owsley et al. 2009; Edwards, Lee et al. 2010; Neri, ElAttrache et al. 2011; Gupta, Bruce et al. 2013; Fedoriw, Ramkumar et al. 2014)

#1 Match Treatment:Patient Presentation, Goals, and Expectations

¨ 3-6 months of non-operative management prior to undergoing surgery

¨ Failure of non-operative management is characterized by the inability to¤ regain pain free ROM (abd/ER)¤ near normal rotator cuff strength (ER)¤ inability to return to their desired level of activity

(Neri, Owsley et al. 2009; Edwards, Lee et al. 2010; Neri, ElAttrache et al. 2011; Gupta, Bruce et al. 2013)

How Long !!???



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Pain

0 2wks 6wks 12wks 16wks 24wks Time

10

5

0

High Level Throwers

Weekly Tennis

¨ Modifiers¤ Pain intensity¤ Tissue(s) involved¤ Age¤ Goals/Sport¤ Psychosocial

When Will I “know”?

High Irritability

Low Irritability

¨ Range of Motion-not specific to SLAP¤ IR ROM¤ HA ROM¤ Total Arc(Edwards, Lee et al. 2010; Fedoriw, Ramkumar et al. 2014)

#2 Restore Shoulder ROM

¨ Deficits in external rotation range of motion are the most consistent complaints associated with poor outcomes after surgery.

¨ Surgical considerations include:¤ anchor placement- anterior to “12

O’clock”¤ anatomical variants (e.g., fovea)¤ over constraining repair(Neri, Owsley et al. 2009; Neri, ElAttrache et al. 2011; McCulloch, Andrews et al. 2013)

Preservation of ER ROM- SORT B

¨ Ant translation-17%¨ ER reduced by 10-37°¨ FE 16°(Plausinis ’06, Gerber ‘03, Harryman ‘92)

Scapular Adaptations?Lost 30° of total arc and 20° of IR



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Extensibility NOT Flexibility

(Tsai et al ‘99; McClure et al, 2007; Borstadet al 2008)(Borstad et al, ‘12; Seitz et al ‘13)

(Kebaetse et al ‘99, Finley et al ‘03 & Thigpen et al ’08)

Flexibility & Extensibility

(Borstad et al, ‘12; Seitz et al ‘13)

(Tsai et al ‘99; McClure et al, 2007; Borstad et al 2008)

(Kebaetse et al ‘99, Finley et al ‘03 & Thigpen et al ’08)

Posterior RTC

Sports Health April 2017

GH Joint kinematics



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¨ ↓ ER strength associated ¤ ↓ AHD and ↑ disability ¤ Symptoms

n Resolve with ↑ ER strengthn Similar deficits observed w/ induced pain

(Mura ’00; Hurschell ‘03; McClure et al ‘04 &’06; MacDermoid et al ’04; Seitz et al ’12; Stackhouse et al ‘12 )

¨ Scapular Muscle Function¤ UT:LT & UT:SA imbalance

(Ludewig et al ’96; Cools et al ‘ ‘04)

¨ All Level 1 evidence includes muscle performance exercises

(Michener et al JHR ‘04; Kuhn et al JSES ‘09)

#3 Restore Muscle Performance

(Edwards, Lee et al. 2010; Fedoriw, Ramkumar et al. 2014)

“Posterior Chain”

What is Patient’s Load?

Gabbett & Jenkins, J Sci Med Sport, 2011;Foster et al, J Str Cond Res, 2001

Athletic Performance

Likelihood of Injury (%)

Chr

onic

Loa

d (%

of n

orm

al a

vg)

110 4.7 4.1 3.6 3.4 3.2 3.3 3.5

100 4.3 3.7 3.4 3.3 3.3 3.6 4

90 3.9 3.5 3.3 3.3 3.6 4.2 4.9

80 3.5 3.3 3.3 3.7 4.3 5.3 6.6

70 3.3 3.3 3.7 4.6 5.8 7.5 9.5

60 3.3 3.8 4.9 6.6 8.8 11.6 14.9

50 4 5.5 7.9 11 14.9 19.6 25.1

40 6.6 10.1 14.9 20.9 28.2 36.7 46.5

30 14.9 23.2 33.7 46.5 61.4 78.6 98

60 70 80 90 100 110 120

Acute Load (% of normal avg)

How much time/week last week?

How much time/week when healthy or goal?

Systematically Monitor & Progress Load

Gabbett & Jenkins, J Sci Med Sport, 2011;Foster et al, J Str Cond Res, 2001

AthleticPerformance

Likelihood of Injury (%)

Chr

oni

c Lo

ad (%

of n

orm

al a

vg) 110 4.7 4.1 3.6 3.4 3.2 3.3 3.5

100 4.3 3.7 3.4 3.3 3.3 3.6 4

90 3.9 3.5 3.3 3.3 3.6 4.2 4.9

80 3.5 3.3 3.3 3.7 4.3 5.3 6.6

70 3.3 3.3 3.7 4.6 5.8 7.5 9.5

60 3.3 3.8 4.9 6.6 8.8 11.6 14.9

50 4 5.5 7.9 11 14.9 19.6 25.1

40 6.6 10.1 14.9 20.9 28.2 36.7 46.5

30 14.9 23.2 33.7 46.5 61.4 78.6 98

60 70 80 90 100 110 120

Acute Load (% of normal avg)

¨ TherEx Load¤ Sets x Reps x Weight¤ 15% increase/week



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Phased Periodization

Phase I Phase II Phase III/IV

Periodization ConsiderationsLinear

¨ Predictable sequence¨ Useful for transition to

gym and HEP¨ Difficult to overlap

strength/power/ endurance phases

Non-Linear¨ Volume and load altered

more frequently¨ Allows more frequent

changes in stimuli¨ May produce greater

neuromuscular effects¨ Can address strength and

power at same time

Within/Between Session

Progressive Resistance

Videos by Bryce Gaunt

#4 Progressive, Functional Return

¨ Rotator Cuff Performance¤ IR/ER @ 90/90 for 30

secs w/ green sport cord

¤ Prone endurance testn “t’s” w/ 5-7lb >20 reps

¨ Scapula¤ < subtle scapular

dyskinesis w/ 3# or 5# weight for 10 reps

¤ 60 secs w/ 90 reps of CKC stability test



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#5 Kinetic Chain

Significantly altered thoracic rotation patterns after SLAP repair

Pitchers with SLAP repair vs BT Tenodesis

Chalmers et al AJSM 2016

Kinetic Chain and Trunk Rot Specificity

≠

≠Palmer et al JAT 2015; Oliver G JSCR 2010; Lehman G et al JSCR 2013; Oliver GD et al JSCR 2015

¨ Non op program effective for 60-70% of athletes¤ Key maybe getting rid of bad treatment

not improving the “average” treatment

¨ Still 30-40% of patients will need other intervention

¨ “other” factors including patient expectations, beliefs and preferences drive outcomes

Fundamentals Win…..

Treat these… Don’t Treat these… ¨ A program might be effective but if it doesn’t demonstrate efficacy it is irrelevant.

¨ What decreases efficacy?¤ Time¤ Complexity¤ Resources

¨ Stick to what is most likely to work 1st

¤ Appropriate manual therapy¤ Match exercise¤ Dose exercise¤ Progress exercise

Fundamentals Win…..

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