Clinical Presentation, Etiology and Physical Exam of SLAP Lesions

In this article, we will discuss the Clinical presentation, etiology and physical exam of SLAP lesions. So, let’s get started.

Clinical Presentation, Etiology and Physical Exam

The clinical diagnosis of SLAP lesions is difficult. Non-specific shoulder pain, particularly with over-head or cross-body motion, is the most common clinical presentation. Additional symptoms include popping, clicking, catching, weakness, stiffness and instability. The majority of patients present with concurrent shoulder injuries. In a retrospective review of 140 arthroscopically-proven SLAP lesions by Snyder et al, the reported incidence of associated intra-articular disease included 29% with partial rotator cuff tears, 11% of full rotator cuff tears, 22% with Bankart lesions and 10% with glenohumeral chondromalacia.

Clinical history may involve a traction injury, direct trauma to the shoulder or fall on an outstretched hand. Frequently, no antecedent injury or activity is reported. On physical exam, patient may have increased shoulder laxity and positive findings with many shoulder provocative tests. No single test or sign is specific for SLAP lesions and physical findings can be confusing due to associated lesions (e.g. rotator cuff tears). The clinical diagnosis of SLAP lesions is difficult and imaging plays a key role in diagnosis.

Recently, a cadaveric study has confirmed the peel-back theory of SLAP lesions. In the abducted and externally rotated shoulder, the biceps tendon assumes a more vertical and posteriorly directed orientation, which transmits a force to the superior labrum, causing it to peel off the glenoid. Common mechanism of injury include microtrauma secondary to repetitive overhead arm motion and direct trauma due to fall on an outstretched hand. Repetitive overhead motion such as throwing and swimming are thought to cause injury secondary to traction on the arm due to sudden pulling, throwing or other overhead motion. Additional findings in repetitive overhead motion injury include, undersurface rotator cuff tears, cystic change in the humeral head related to posterosuperior impingement and capsular laxity. Falling on an outstretched hand usually causes injury secondary to a compressive force applied to the shoulder, usually with the shoulder abducted and slightly anteriorly flexed. This mechanism can result in marrow edema secondary to impaction of the humeral head against the glenoid. If an associated anterior dislocation is present, a Hill-Sachs deformity and a Bankart lesions may occur.


Causes of Shoulder Pain

Shoulder Pain is a very common problem among athletes, middle aged and elder individuals especially diabetics. It is the 3rd most common Musculoskeletal Pain.

More than 50% individuals suffer from shoulder pain at some point of time in their life. Following are the causes of shoulder pain listed below:

Frozen Shoulder

Rotator cuff Tendinopathy and Rotator cuff Tear

Shoulder Impingement Syndrome or Swimmer’s Shoulder

Shoulder Dislocation

Supraspinatus Tendinitis

Subacromial Bursitis

Osteoarthritis of Shoulder

Polymyalgia Rheumatica

Cervical Radiculopathy

Avascular Necrosis of Shoulder

Bicipital Tendinitis

Thoracic Outlet Syndrome

SLAP Labrum Tear

Calcific Tendinitis

Brachial Plexus Injury

Rheumatoid Arthritis

Shoulder Instability

AC joint Injury

Referred Pain of Acidity, Heart Attack , Diaphragm phrenic nerve irritation (Kehr Sign)

Fracture of Humerus, Clavicle and Scapula

Biceps Tendinopathy

Pain, tenderness and inflammation around long head of biceps tendon often caused due to overuse injury among older patients especially older athletes ( 30+ age athletes and old aged patients 60+ age).

Pain often resembles Shoulder impingement syndrome, Rotator cuff tendinopathy.



Occurs more commonly while performing or after sporting activities like lifting, throwing, overhead movement.

In UK prevalence rate of biceps tendon rupture is 0.53/100,000 over 5 years, with male:female ratio 3:1.


Repetitive irritation friction leads to swelling of tendon initially.

Continued irritation, traction, friction makes tendon thicker.

Eventually long term irritation leads to adhesion formation around surrounding structures.


Patients with biceps tendinopathy often complain of a deep, throbbing pain in the anterior shoulder that is intensified when lifting.

Patients are likely to present with a chief complaint of anteromedial shoulder pain The pain is usually localized to the bicipital groove and may radiate toward the insertion of the deltoid muscle or along radial distribution

Pain may be aggravated by overhead reaching, pulling and lifting activities. The pain usually worsens at night when sleeping on the affected shoulder.

Pain with palpation over the bicipital groove is another physical exam finding in patients with biceps tendinopathy. Active elbow flexion may also provoke pain. Cases associated with biceps instability, the patient may complain of an anterior shoulder “clicking” or “popping” sensation associated with throwing motions.


Physical examination includes Active And Passive ROM testing, Palpation, Clinical Screening and Specific tests

Biceps Tendon tests


Resisted shoulder flexion with elbow extended and forearm supinated

Positive if pain felt in bicipital groove


Elbow flexed at 90°. Initially pronated

Active Supination and flexion against resistance

Pain at bicipital groove yields positive result





SLAP Lesion

Glenohumeral Instability


Sub-Acromial Impingement

Scales used to measure is

DASH (Disability of Arm, Shoulder and Hand)


Physical therapy has been commonly used for the treatment of tendinopathies, especially eccentric training.

Intervention should include restoration of pain free range of motion, trunk and core stability and ensuring stable scapulothoracic rhythm. Pain free range can be achieved with such activities as Passive Range of Motion, Active Assisted Range of Motion, and mobilization. Painful activities such as abduction and overhead activities should be avoided in the early stages of recovery as it can exacerbate symptoms.

Initial Conservative Management includes application of ice to the affected area for 10-15 minutes, 2-3 times per day for the first 48 hours. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are used for 3-4 weeks to treat inflammation and pain

Stretching and strengthening regimes are a common aspects of most therapy protocols. Therapists also use other modalities like ultrasound, iontophoresis, deep transverse friction massage, low-level laser therapy, Hot fermentation.

Rehabilitation Exercise Regime includes

Active Elbow Flexion and Extension

Biceps Stretch

Biceps Curl

Single arm Shoulder flexion

Resisted Shoulder Internal Rotation

Resisted Shoulder External Rotation

Sleeper Stretch

Side lying External Rotation

Supraspinatus Tendonitis And Shoulder Examination

Supraspinatus Tendonitis is often associated with Shoulder impingement syndrome impingement and inflammation of Supraspinatus Tendon is called Supraspinatus Tendonitis


Mostly affects sports athlete often result from overuse injury with sporting activities like throwing and overhead motion apart from this it also affects age group of 50-60 years with prevalence more in patients with diabetes

Factors affecting listed below




Subdeltoid pain is the most highlighting feature which aggravates with abduction movement Pain also felt while reaching,overhead activity, sleeping on affected shoulder It become worse during night and often disturbs sleep

Painful and limited range of motion and painful arc 70°-120°

Their is anterior instability along with posterior tightness


Following physical examination used to evaluate Supraspinatus Tendonitis


Neer test

Hawkins Kennedy Test

Empty Can Test

Drop Arm Test

Impingement test

Complete description on how to perform following tests along with other important physical examination of shoulder injury is given below

Shoulder Examination

X-ray Radiography shows calcified lesion around Supraspinatus tendon later cases shows degenerative and sclerotic changes Ultrasound reveals thickening of subacromial bursa


AC Joint Injury

Clavicle injury

Rotator Cuff tear

Swimmer’s Shoulder

Impingement Syndrome


Biceps Tendinitis or Tendinopathy


Simple shoulder test questionnaire

Oxford Shoulder Score


Medical management includes Corticosteroid injection, NSAIDS that alleviates pain and surgical procedures include subacromial decompression, sometimes acromioplasty, bursal resection. Physiotherapy management includes Rest, Ice, pain relieving modalities like ultrasound, cryotherapy, Electrical Modalities Stimulation. Their are three phases of Supraspinatus Tendonitis management which includes (a) Immobilisation (b) Assitive range of motion (c) Progressive resistance exercise

ROM exercise, Strengthening exercise, Stretching techniques, Isometric exercises, Codmans classic pendullar exercise and Kinesiotaping, soft tissue manipulation like MFR, IASTM are also prescribed and found to be very effective in pain relief and regaining range of motion. Along with these Home exercise programs, self exercise regimes are also advised

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