SLAP tears typically occur after shoulder dislocations, in throwing athletes and those who work overhead repeatedly. The SLAP tear may extend to the labrum at the front or back of the shoulder; or it may even extend into the biceps tendon. Patients with a SLAP tear often report a deep ache in the shoulder joint and pain exacerbated with particular activities, such as throwing or overhead work.
The Shoulder is the most mobile joint in the body. This allows you great function but increased risk of dislocations. When the Shoulder dislocates, the Labrum (ring of cartilage) around the glenoid (socket) may tear (this is called a bankart lesion) – this can happen either at the front, back or at the top of the glenoid.
The Labrum is a soft tissue ring around the glenoid (socket) that deepens the shoulder joint and keeps the humeral head (ball) in joint. After shoulder dislocations (especially recurrent episodes) the Labrum may tear off the socket and no longer function in stabilising the shoulder joint.
The labrum can tear at the:
Front – Anterior
Back – Posterior
Top – SLAP (Superior Labrum Anterior and Posterior)
In a SLAP injury, the top part of the labrum is torn; this top area is where the biceps tendon is attached to the labrum. The tear can occur at the top and then move to the front (anterior) and back (posterior). Depending on the type of SLAP tear, tissue may flip into the joint, and in more severe cases the biceps tendon itself may be damaged (biceps tendon tear). In some cases, patients may have a 360-degree labrum tear (front, back, and top).
Injuries to the superior labrum can be due to acute trauma or overuse with repetitive shoulder movement. Typical cases that cause a SLAP tear are:
SLAP tear may also occur in older patients (>40) who have had repeated small episodes of trauma over the years. In these cases a SLAP tear may be incidental and not the cause for their shoulder pain.
Anterior Labral tear, Posterior Labral tear, and SLAP tears can present in different ways. SLAP tears may present with the following symptoms:
Dr Pant will take a detailed history about your shoulder symptoms. He will ask about when they first began and whether there was any particular injury that caused your shoulder pain. Many patients may not recall a particular event. In some cases work or sport may aggravate your symptoms. It is important to describe the location of pain, whether you have had any physiotherapy and injections to your shoulder.
Dr Pant will conduct a physical examination and check your shoulder range of motion, strength, and stability of your shoulder function. He will then perform specific tests to isolate the biceps tendon and SLAP area to see if this reproduces your symptoms.
X-rays – Show the bones of the shoulder joint in clear detail. It is a good screening test to look for any damage to the humeral head and glenoid (ball and socket). The labrum will not be seen on the plain X-ray; however, if you have a bony bankart (fracture) or a Hill Sachs on the humeral head this may be seen on a plain X-ray.
MRI (Magnetic Resonance Imaging) scans – Improve the visibility of soft tissues such as the labrum. In some cases, a dye may be injected into the shoulder to help show the labrum tear (MRI arthrogram).
For most patients with a SLAP tear – the treatment is non-surgical. A period of rest, activity modification, and NSAIDs may be useful to treat shoulder pain.
Physiotherapy may be suggested to restore movement and strengthen your shoulder. Range of motion, rotator cuff strengthening, scapula stabilising exercise may be useful as guided by your physiotherapist. Keeping up the therapy may relieve your pain, restore your shoulder function, and prevent further injury. It may be necessary to continue this exercise program for 3-6 months in some cases.
If you have not improved with non-surgical treatment or if you have a high grade SLAP tear (with either anterior or posterior extension) then you may do better with surgery. In some cases this is the best option from the outset. Dr Pant will review your case (and your MRI scan) to determine if this is the right course of action to provide you with the best shoulder outcome. If surgery is required this is done keyhole (arthroscopic) and the rehabilitation is using the JPL method.
There are several different types of SLAP tears and Dr Pant will determine how best to treat your SLAP injury; in some cases this final decision is made at the time of arthroscopic surgery. The treatment options are to:
The factors that are considered in the treatment choices are your age, occupation, type of sport, level of sporting participation, quality of your tissue, and associated injuries in the shoulder. All of these factors need to be considered in combination to achieve the best outcome for your shoulder injury repair.
Repeat anterior instability/dislocations can lead to a fear of using the shoulder (not “trusting” it) and reduction in function. Patients may avoid positions of “apprehension”.
A labral tear at the back of the shoulder (Posterior) may cause ongoing shoulder pain and difficulty sleeping on the affected side. Posterior labral tears usually do better with surgery. Tears of the Anterior Labrum usually lead to “apprehension” and loss of “trust” for fear of dislocation (more than pain per se). Tears at the top (SLAP) in young patients may cause biceps related pain within the shoulder joint; in some cases this SLAP tear may extend down the front or back of the socket causing further symptoms.
Patients will have apprehension with the hand in the upper outer quadrant
Inability to play overhead contact sports without instability +/- pain
Patients will have pain +/- apprehension with hand in the upper inner quadrant
Particularly an issue in younger patients, throwing athletes, and those who work overhead.
Arthroscopic shoulder surgery is very safe and routine. Most patients do not experience any complications from surgery. As with any surgery, however, there are some risks associated with the procedure and these are usually minor and treatable. The risks during arthroscopic shoulder surgery include but are not limited to:
Dr Pant will discuss the possible complications in your particular situation with you prior to your repair surgery.
After the surgery you will be in a sling and protect your shoulder to allow the repair to heal. At two weeks after the surgery Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery. You will be in a sling after your SLAP repair for 6 weeks. Dr Pant will liaise with your physiotherapist to commence strengthening exercises at 3 months post surgery.
The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the repair begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Rotator cuff strengthening is commenced at 3 months post surgery. Dr Pant will discuss when it is safe to return to your chosen sports. Generally, contact sports and throwing athletes need more time to allow for healing.
Most patients report that their shoulder strength improves and they have less pain after SLAP repair surgery. The final outcome does depend on the severity of your injury and the level of sport participation. Dr Pant will individualise your treatment and outline the chances of success after SLAP repair to your particular case.
This 19 year old tennis player sustained shoulder trauma with an instability episode. Over the following weeks, he was unable to play tennis and presented with night pain and difficulty undertaking overhead tasks.
His examination findings were consistent with a SLAP tear and this was confirmed to be a high-grade tear on MRI. Given his young age, functional demands, overhead sport, and high-grade SLAP tear surgery was the prefered option.
He underwent an Arthroscopy and SLAP repair. At the time of surgery anterior labral extension was noted and repaired at the same time. He used the JPL method for shoulder rehabilitation. At six weeks he had full range of motion and commenced strengthening at 3 months. He returned to playing tennis at five months pain-free with full shoulder function.
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