What is a SLAP tear?
A SLAP tear is an injury to a part of the shoulder joint called the labrum. The shoulder joint is a ball and socket joint, similar to the hip; however, the socket of the shoulder joint is extremely shallow, and thus inherently unstable. To compensate for the shallow socket, the shoulder joint has a cuff of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move within.
A specific type of labral tear is called a SLAP tear; this stands for Superior Labrum from
Anterior to Posterior. The SLAP tear occurs at the point where the tendon of the biceps muscle inserts on the labrum.
How does a SLAP tear occur?
Common mechanisms of a SLAP tear include:
- Fall onto an outstretched hand
- Repetitive overhead actions (throwing)
- Lifting a heavy object
- The area of the labrum where the SLAP tear occurs is susceptible to injury because it is an area of relatively poor vascularity.
Other areas of the labrum often heal more easily because the blood supply delivers a healing capacity to the area of the tear. In the area of SLAP tears this is not the case, and chronic shoulder pain can result.
What are the symptoms of a SLAP tear?
Typical symptoms of a SLAP tear include a catching sensation and pain with movement, most typically overhead activities such as throwing. Patients usually complain of pain deep within the shoulder or in the back of the shoulder joint. It is often hard to pinpoint symptoms, unless the biceps tendon is also involved. In cases of SLAP tears with associated biceps tendonitis, patients may complain of pain over the front of the shoulder.
How is a SLAP tear diagnosed?
There are several tests a skilled examiner can perform to detect for SLAP tears. These tests are part of a shoulder physical examination. In addition, careful questioning of the patient can help the examiner identify symptoms consistent with a SLAP tear.
Diagnosis of a SLAP tear can be quite difficult, as these injuries may not show up well on MRI scans. SLAP tears tend to be seen best on MRI when the study is performed with an injection of contrast. A contrast MRI is performed by injecting a fluid called gadolinium into the shoulder; the gadolinium helps to highlight tears of normal structures, including SLAP tears. Sometime the diagnosis of a SLAP tear is made at the time of surgery.
What is the treatment of a SLAP tear?
Most patients with SLAP tears will respond to conservative (meaning non-surgical) treatments. Any patient with a SLAP tear will be advised to rest after the injury to allow the injured tissue to cool down. A period of rest will allow inflammation to subside and may help to alleviate symptoms.
Other treatments that are often used in cases of a SLAP tear include:
- Physical therapy
- Anti-inflammatory medication
- Cortisone injections
What if these treatments do not work? In patients who have continued symptoms despite these treatments, arthroscopic surgery of the shoulder may be recommended. There are several specific surgical procedures that may be performed, and it is important to understand that SLAP tears often occur in conjunction with other shoulder problems such as rotator cuff tears, and even shoulder arthritis.
In these cases, surgical treatment will have to take into account these factors.
The primary treatment options for the SLAP tear are:
Debridement of the SLAP tear. When a SLAP tear is debrided, the torn portion of the labrum is shaved away to leave a smooth edge. This option is only suitable for minor tears that do not involve the biceps tendon.
SLAP repair. A SLAP repair is an arthroscopic procedure that uses sutures with anchors attached to resecure the torn labrum down to the shoulder socket. A SLAP repair is best suited to patients with an otherwise healthy shoulder who want to remain athletically active.
Biceps tenodesis. A biceps tenodesis is a procedure that cuts the biceps tendon from where it attaches to the labrum, and reinserts it in another area. The idea behind a biceps tenodesis is that by decreasing the forces that pull on the SLAP region, the symptoms will be alleviated. A biceps tenodesis is most often performed on patients over 40 years of age or patients with associated biceps tendonitis or tearing.
A biceps tenodesis can either be performed arthroscopically, or through a small incision over the top of the shoulder. Determining how to best perform a biceps tenodesis depends primarily on other conditions being treated within the shoulder joint.
When is a SLAP repair an appropriate treatment?A SLAP repair is considered for treatment when the attachment of the labrum (the so-called biceps anchor) is unstable. In these cases, debridement would not be adequate to alleviate the symptoms of the SLAP tear.
How is a SLAP repair performed? A SLAP repair is performed arthroscopically using sutures to reattach the torn labrum back to the bone.
The steps of a SLAP repair are:
1. The SLAP tear is identified and excess tissue is removed.
2. A small hole is drilled into the bone where the labrum has torn off (the SLAP tear).
3. An anchor is placed into this hole; attached to the anchor is a strong suture.
4. The suture is used to tie the torn labrum snuggly against the bone.
What are the advantages of a SLAP repair?
A SLAP repair restores the normal anatomy of the shoulder by reattaching the labrum in its normal position. Once healed, the SLAP repair allows normal function of the previously damaged labrum and biceps attachment.
What are the advantages of other treatments such as debridement or tenodesis?
The rehabilitation is often not as restrictive as is the case with a SLAP repair.
The results of surgery are usually more predictable, as healing of a SLAP repair is not as reliable.
What is the rehab after a SLAP repair?Rehabilitation varies depending on factors such as the strength of the SLAP repair, and the preference of the surgeon. Most often, a period of time of restricted motion is maintained for about six weeks following a SLAP repair. During this first phase of rehabilitation, some passive motion is allowed to prevent shoulder stiffness. In the first phase, the torn labrum is healing into its proper position.
Once healed, patients enter the second phase of rehabilitation and can begin more motion at about six weeks. Physical therapy continues to help maintain motion and regain strength of the shoulder. The final phase of rehabilitation involves more active strengthening of the muscles that surround the shoulder joint, and full recovery is expected between 3 to 4 months.
Kim TK, et al. "Clinical features of the different types of SLAP lesions" Journal of Bone Joint Surgery Am. 2003 Jan;85-A(1):66-71.
Choi NH, Kim SJ. "Avulsion of the superior labrum"Arthroscopy. 2004 Oct;20(8):872-4.