Page ContentSLAP Repair ProtocolArthroscopic Labral Repair Protocols(Type II, IV and Complex Tears)This protocol has been modified and is being used with permission from the BWH Sports and Shoulder Service.The purpose of this protocol is to provide the physician/therapist/patient with a GUIDELINE of the postoperative rehabilitation course for a patient with arthroscopic SLAP repairs.Briefly, SLAP lesions have been classified as the following:Type I SLAP lesions consist of degenerative fraying of the superior labrum, but the biceps attachment to the labrum is intact. The biceps anchor is intact.Type II SLAP lesions are created when the biceps anchor has pulled away from the glenoid attachment.Type III SLAP lesions involve a bucket-handle tear of this superior labrum with an intact biceps anchor.Type IV SLAP lesions involve a bucket-handle tear of the superior labrum in which the tear extends into the biceps tendon. The torn biceps tendon and labrum are displaced into the joint.Complex SLAP lesions involve a combination of two or more SLAP types, usually II and III or II and IV. Phase I (Weeks 1-7)Immediate Post Surgical Phase – Protected motion phaseWeeks 1-4GoalsProtect the anatomic repairPrevent/minimize the side effects of immobilizationDiminish pain and inflammationSling for 6 weeksWrist/hand active range of motion (AROM)/ Active Assisted Range of Motion (AAROM)Hand-gripping exercisesPROM/AAROM:Flexion and elevation in the plane of the scapula to 70 degrees, week 2 to 80 degrees, week 3 to 90 degrees External rotation(ER)/internal rotation (IR) with arm in scapular planeER to 20-30 degreesIR to 45°No AROM ER, extension, or abductionSubmaximal isometrics for all rotator cuff, periscapular, and shoulder musculatureNo isolated biceps contractions (i. e. no active elbow flexion)Cryotherapy, modalities as indicatedDiscontinue use of sling at 4 weeksInitiate rhythmic stabilization drills within above ROMWeeks 5-6Begin AROM of shoulder (all planes, gravity eliminated positions then gravity resisted position once adequate mechanics):Gradually improve PROM and AROMFlexion and elevation in the plane of the scapula to 145°Abduction to 145°External rotation 45-50° at 45° abductionInternal rotation 55-60° at 45° abductionExtension to toleranceMay initiate gentle stretching exercisesGentle Proprioceptive Neuromuscular Facilitation (PNF) manual resistanceInitiate prone exercise program for periscapular musculatureBegin AROM elbow flexion and extensionNO biceps strengthening Phase II - (Weeks 7-14)Intermediate Phase-Moderate Protection Phase GoalsGradually restore full AROM and PROM (week 10)Preserve the integrity of the surgical repair Restore muscular strength and balanceWeeks 7-9GoalsGradually progress P/AROMFlexion, elevation in the plane of the scapula, and abduction to 180°External rotation 90-95° at 90° abduction o Internal rotation 70-75° at 90° abduction o Extension to toleranceBegin isotonic rotator cuff, periscapular, and shoulder strengthening programContinue PNF strengtheningInitiate “Thrower’s Ten” program except resisted biceps exercise (see protocol)Type II repairs: begin submaximal pain-free biceps isometricsType IV and complex repairs: continue AROM elbow flexion and extension, no biceps isometric or isotonic strengtheningWeeks 10-12GoalsProgress ER P/AROM to thrower’s motionER 110-115 at 90° abduction in throwersProgress shoulder isotonic strengthening exercises as aboveContinue all stretching exercises as needed to maintain ROMProgress ROM to functional demands (i.e., overhead athlete)Type II repairs: begin gentle resisted biceps isotonic strengthening at week 12Type IV and complex repairs: begin gentle submaximal pain free biceps isometrics Phase III (Weeks 14-20)Minimal Protection Phase GoalsEstablish and maintain full ROMImprove muscular strength, power, and enduranceGradually initiate functional exercisesWeeks 14-16GoalsContinue all stretching exercises (capsular stretches)Maintain thrower’s motion (especially ER) Continue rotator cuff, periscapular, and shoulder strengthening exercisesType II repairs: progress isotonic biceps strengthening as appropriateType IV, and complex repairs: progress to isotonic biceps strengthening as appropriate“Thrower’s Ten” program with biceps exercise or fundamental exercisesPNF manual resistanceEndurance trainingInitiate light plyometric programRestricted sports activities (light swimming, half golf swings)Weeks 16-20GoalsContinue all exercises listed aboveContinue all stretchingContinue “Thrower’s Ten” programContinue plyometric programInitiate interval sport program (e.g., throwing). See interval throwing program Phase IV (Weeks 20-26)Advanced Strengthening Phase GoalsEnhanced muscular strength, power, and enduranceProgress functional activitiesMaintained shoulder stabilityWeeks 20-26GoalsContinue flexibility exercisesContinue isotonic strengthening program PNF manual resistance patterns Plyometric strengtheningProgress interval sports programs Phase V (Months 6-9)Return to Activity PhaseGoalsGradually progress sport activities to unrestrictive participationContinue stretching and strengthening program 1Wilk K, et all. Current Concepts in the Recognition and Treatment of Superior Labral (SLAP) Lesions. JOSPT 2005;35:273-291.Protocol adopted from Brotzman & Wilk, published in Brotzman SB, Wilk KE, Clinical Orthopeadic Rehabilitation. Philadelphia, PA: Mosby Inc; 2003.