0:00

The third concept with which we deal is the concept

0:04

of slap lesions.

0:05

Their importance, they're common in throwing athletes

0:08

and their effects it's been shown can be devastating.

0:12

And career ending.

0:14

The controversy is in what phases it occurs

0:19

and what is the mechanism.

0:21

Some people believe it is purely a tensile injury

0:24

to the biceps anchor as a result

0:27

of deceleration in the follow through me, uh, phase

0:31

of throwing others counter and I showed this, uh, yesterday.

0:35

Rather, it is a peel back injury

0:38

to the biceps anchor related both to tension and torque.

0:42

And it occurs as an acceleration mechanism in the late

0:47

cocking phase of throwing.

0:48

So there is some disagreement about the pathogenesis

0:53

of this particular problem,

0:55

but I think most people would agree it can be

0:59

devastating and career ending.

1:01

This is the diagrams that I showed you, uh, yesterday,

1:05

showing you that in abduction

1:06

and external rotation that there is rolling up of the biceps

1:11

that leads to peeling away of the superior labrum.

1:15

And most of the labral tears will in fact start post

1:20

superiorly and proceed, uh,

1:23

antho superiorly over time.

1:25

So this is the, what I believe is the basic mechanism

1:29

for these superior labral tears.

1:32

So the injury often begins as a separation

1:35

or tear of the, uh, of the biceps labral anchor

1:39

that begins post row superiorly.

1:42

If you like Roman numerals, that would be classified

1:45

as a slap two B beginning B uh,

1:49

means post row superior.

1:52

And then over time, here's what it looks like.

1:54

The bottom image shows you it.

1:56

And then over time that lesion proceeds anteriorally

2:00

and anter superiorly.

2:02

And I'm showing you another transverse graphic image in this

2:06

patient to show you that the superior aspect

2:09

of a labrum is involved.

2:11

And then eventually you can see involvement

2:13

of the post rose, superior, superior,

2:16

and anterosuperior portions of the labrum.

2:19

In this particular case, this is a labral detachment.

2:23

So this is the pattern of slap lesions

2:26

that we see in the throwing shoulder.

2:29

Now one of the interesting findings that has a funny name

2:34

is the pitcher's mound.

2:36

And it is suggested over time

2:38

because of tension in placed upon the superior labrum

2:42

that a bone expressions may occur called a pitcher's mound.

2:47

This is what the pitcher's mound looks like in baseball.

2:50

If you haven't seen it,

2:52

it's an elevated area from which the pitcher

2:55

throws the baseball.

2:56

And this is the appearance. I haven't seen a lot

2:58

Of these, but this is the bone expressions typically

3:02

associated with a slap lesion

3:04

generally occupying the region from about 10

3:07

o'clock to 12 o'clock.

3:09

Sometimes a little bit more extensive than that.

3:12

So this is the appearance of

3:14

what is designated a pictures mount.

3:18

And then as we mentioned yesterday, a variety of chondral

3:21

and osteochondral abnormalities may occur.

3:25

Terms such as the chondral print

3:28

or the slapped fracture have been used to describe these.

3:32

There usually is erosion of cartilage depression

3:35

of the subc chondral bone plate

3:38

marrow edema as shown here.

3:40

The overlying biceps may be abnormal as in this case.

3:45

So it may relate to friction of the bone

3:49

and cartilage with the biceps tendent.

3:52

I also mentioned yesterday there's a bit of a controversy is

3:56

how reliable is this to tell you there's a slap lesion.

4:01

I don't think it's totally reliable,

4:03

but it may be present in certain slap lesions.

4:07

And then as I mentioned yesterday,

4:09

the slap lesions may extend in a variety of directions.

4:14

Posteriorly, anteriorly,

4:16

they may extend into a variety of structures.

4:18

Here's one involving the attachment

4:22

of the longhead of the biceps.

4:24

And again, if you like Roman numerals, uh,

4:26

these are generally when it gets to this,

4:29

they are Roman numerals.

4:31

Three and four come to mind.