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Orthopedics & Traumatology

SLAP Lesion, Type II, Left Shoulder, Initial Encounter

ICD-10 Code
S43.432A_1

Type II tear of the superior labrum anterior to posterior (SLAP) lesion in the left shoulder.

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents with left shoulder pain localized to the superior/posterior aspect, exacerbated by overhead activities and throwing motions. Reports mechanical symptoms including clicking, popping, and occasional catching. Onset is [acute/insidious] following [mechanism of injury]. Pain is rated [X]/10, interfering with ADLs and sleep. No associated numbness, tingling, or radiating neck pain.

Clinical Examination Findings

Left shoulder inspection reveals no gross deformity or atrophy. Palpation demonstrates tenderness at the superior glenoid rim. Range of motion is full but painful at end-range abduction and external rotation. Strength is 5/5 in rotator cuff musculature. Provocative testing: Oโ€™Brienโ€™s test positive, Biceps Load II test positive, and Crank test positive. Neurovascular status is intact distally.

Treatment Protocol

Initial management includes activity modification, avoidance of overhead lifting, and a structured physical therapy program focusing on scapular stabilization and rotator cuff strengthening. Prescribed NSAIDs for inflammation control. Discussed potential for surgical intervention (arthroscopic SLAP repair) if conservative management fails after 3-6 months. Follow-up scheduled in [X] weeks.

Detailed clinical guide coming soon.