SLAP (Superior Labrum Anterior to Posterior) Lesion Repair

Understanding SLAP Lesions

The shoulder is a complex and mobile joint, stabilized by a ring of cartilage called the labrum. The long head of the biceps tendon attaches to the top (superior) part of the labrum. When this area is damaged—specifically from the front (anterior) to the back (posterior)—the condition is known as a SLAP tear, short for Superior Labrum Anterior to Posterior lesion.

SLAP tears are especially common among overhead athletes such as baseball pitchers, swimmers, and tennis players, as well as in individuals who engage in heavy labor. These injuries can lead to persistent pain, clicking sensations, weakness, and reduced shoulder function.

Anatomy: Why the Labrum Matters

To understand a SLAP lesion, one must appreciate the anatomy of the shoulder joint. The labrum deepens the glenoid cavity (shoulder socket) and helps stabilize the humeral head (upper arm bone) during movement. It also plays a crucial role in anchoring the biceps tendon, which helps control shoulder motion.

The vascular supply (blood flow) to the labrum is limited—especially in its upper front part—which makes healing more difficult after injury.

Several anatomical variants exist, such as:

• Sublabral recess: a normal gap under the labrum that may mimic a tear on imaging.
• Buford complex: absence of the front-upper labrum with a cord-like ligament instead.

Recognizing these variants is essential to avoid misdiagnosis.

Classification of SLAP Lesions

SLAP lesions were first described by Snyder et al., and are now classified into several types:

• Type I: Fraying of the labrum without detachment.
• Type II: Most common. The labrum and biceps tendon detach from the glenoid.
• Type III: Bucket-handle tear of the labrum with intact biceps.
• Type IV: Bucket-handle tear extending into the biceps tendon.

Later expanded classifications include:

• Type V to VII: Involve combinations with other injuries like Bankart lesions or instability.
• Type VIII to X: More complex tears, including full circumferential or reverse Bankart tears.

Causes: The Pathophysiology Behind SLAP Tears

SLAP lesions result from a mix of repetitive stress and biomechanical imbalance:

• Overhead throwing leads to extreme shoulder rotation, placing tension on the labrum and biceps.
• The “peel-back” mechanism: During external rotation, the biceps tendon twists and pulls the labrum off the bone.
• Internal impingement: The upper rotator cuff and labrum get pinched during arm elevation and rotation.

Another contributor is scapular dyskinesis—improper movement of the shoulder blade—which disrupts shoulder mechanics and increases stress on the labrum.

Diagnosis: From Symptoms to Imaging

Clinical Evaluation

SLAP lesions can be difficult to diagnose because they often occur alongside other conditions like rotator cuff tears or shoulder instability. Common symptoms include:

• Clicking or popping during overhead motion
• Weakness
• Night pain

Physical examination tests include:

• O’Brien’s Test
• Biceps Load Test II
• Speed’s Test
• Dynamic Labral Shear Test

These tests are helpful but none are completely specific, meaning imaging is usually needed.

Imaging Studies

• X-rays: Rule out other issues but do not detect labral tears.
• MRI with arthrogram (MRA): Best for SLAP lesions. It uses injected contrast to show the labrum and biceps tendon more clearly.
• CT arthrogram: Sometimes used but generally less effective.

MRA can distinguish real tears from normal variants like the sublabral recess, but false positives are possible. Thus, interpretation must be combined with clinical exam and history.

Treatment Options

Non-Surgical Treatment

For Type I lesions or in older patients, initial treatment is conservative:

• Rest and activity modification
• Physical therapy focused on restoring motion and scapular mechanics
• Anti-inflammatory medications

Rehabilitation goals include improving:

• Strength of the rotator cuff and scapular muscles
• Range of motion
• Neuromuscular control

However, returning to high-level overhead sports is unlikely with non-operative treatment alone.

Surgical Management

Surgery is often needed for:

• Persistent symptoms after conservative care
• Athletes or younger patients with Type II or higher-grade lesions

Procedures include:

• Debridement (Type I and III): Damaged tissue is cleaned out.
• SLAP Repair (Type II and IV): Torn labrum and biceps anchor are reattached to the glenoid using sutures and anchors.
• Biceps Tenodesis or Tenotomy: The biceps tendon is detached and reattached lower down the arm, often preferred in older or lower-demand patients.

Outcomes and Considerations

• Younger patients generally have good outcomes from SLAP repair.
• Elite throwers, however, may not return to their prior level of performance.
• In patients over 35–40 years, some studies suggest biceps tenodesis yields better results, while others find no age-based difference.
• The choice of anchor (metallic vs bioabsorbable vs knotless) impacts complication risk and surgical technique.

Complications can include:

• Synovitis
• Cartilage damage
• Anchor migration

Knotless anchors are now favored for reduced irritation and comparable strength.

Final Thoughts

SLAP lesion repair is a nuanced decision based on:

• Type of lesion
• Patient age and activity level
• Coexisting shoulder conditions

With proper diagnosis and personalized treatment, most patients can experience substantial pain relief and functional improvement.

 

Do you have more questions?

Q. What is a SLAP tear?
A. A SLAP tear is an injury to the superior part of the labrum in the shoulder, where the biceps tendon attaches to the labrum.

Q. What does SLAP stand for?
A. SLAP stands for Superior Labrum Anterior to Posterior.

Q. What are the common causes of a SLAP tear?
A. SLAP tears can be caused by trauma such as a fall on an outstretched arm, repetitive overhead activity, or a sudden pull on the arm.

Q. What are the symptoms of a SLAP tear?
A. Symptoms include pain with overhead activity, a sensation of locking or catching, decreased shoulder strength, and a feeling of instability.

Q. How is a SLAP tear diagnosed?
A. Diagnosis involves a physical exam, patient history, and imaging studies such as an MRI or MR arthrogram.

Q. What nonsurgical treatments are available for a SLAP tear?
A. Nonsurgical treatments include rest, anti-inflammatory medications, physical therapy, and activity modification.

Q. When is surgery recommended for a SLAP tear?
A. Surgery is recommended when nonsurgical treatments fail to relieve symptoms or if the tear is severe and affects shoulder function.

Q. What does SLAP repair surgery involve?
A. SLAP repair surgery involves reattaching the torn labrum to the bone using sutures and anchors, usually performed arthroscopically.

Q. How long does SLAP repair surgery take?
A. The surgery typically takes about one hour and is usually performed on an outpatient basis.

Q. What is the recovery time after SLAP repair surgery?
A. Recovery typically takes several months, with physical therapy starting soon after surgery and full activity resuming around 4 to 6 months.

Q. Will I need physical therapy after SLAP repair surgery?
A. Yes, physical therapy is crucial for regaining range of motion, strength, and function.

Q. Are there risks associated with SLAP repair surgery?
A. Risks include infection, stiffness, nerve injury, or failure of the repair.

Q. Can a SLAP tear heal without surgery?
A. Some SLAP tears can heal or become asymptomatic with conservative treatment, depending on the type and severity of the tear.

Q. What are the types of SLAP tears?
A. There are multiple types, with Type II being the most common and often requiring surgical repair.

Q. Is SLAP repair surgery effective?
A. Yes, many patients experience significant pain relief and improved shoulder function after SLAP repair surgery.

Q. Who is most at risk for a SLAP tear?
A. Athletes involved in overhead sports, such as baseball or tennis, and individuals with traumatic shoulder injuries are at higher risk.