The shoulder has the most range of motion of any joint in the body. Maintaining stability in this highly mobile joint requires a finely tuned combination of many structures including the socket (glenoid), the cartilaginous rim around the socket (labrum), the capsular ligaments, and the rotator cuff muscles.
A frequent cause of pain or instability of the shoulder is a labral tear. A particular kind of labral tear involving the superior labrum, the site where the biceps tendon originates inside the shoulder, is a SLAP (Superior Labrum Anterior to Posterior) tear.
SLAP tears can be attritional (degenerative) or traumatic. Common mechanisms of injury include blows to the shoulder, a fall on an outstretched arm, seatbelt/shoulder harness injuries, or heavy lifting. Also, repetitive forces such as those seen with overhead and/or throwing athletes are frequently responsible for SLAP lesions. The most frequent symptom experienced with a SLAP tear is a deep-seated pain often referred to the back of the shoulder but occasionally anterior also, depending on the extent of actual biceps involvement. Sudden movements or extremes of motion, especially outwards and upwards as in throwing, often bring on the pain. Occasionally, catching sensations will be encountered. Instability symptoms are also described in some cases.
MRI slap tear
DIAGNOSIS – Most important in making the diagnosis of a SLAP tear is having an index of suspicion for this lesion based on a history of trauma and also the nature of the symptoms described. There are no physical exam tests that can totally accurately diagnose a SLAP tear, but often maneuvers that stress or load the biceps/labral complex and cause pain strongly suggests this diagnosis. Typically, it may be difficult to detect any tenderness given the depth of the structures involved. If one suspects the possibility of a SLAP tear, further imaging with an MRI is often done. Depending on the strength of the magnet and the experience and preferences of the radiologist interpreting the images, dye may occasionally be injected into the joint prior to the MRI to help clarify the anatomy. Even MRI is not foolproof and often a definitive diagnosis of a clinically significant SLAP lesion requires shoulder arthroscopy.
SLAP Tear-labrum torn from approximately 10:00 to 1:00
TREATMENT – Many minor tears will respond to conservative treatment including rest, anti-inflammatory medications and physical therapy. However, it is frequent for larger tears brought on by significant trauma to require arthroscopic surgery in order to heal. In patients who experience continued symptoms despite conservative treatment, arthroscopic surgery may be recommended. Several specific procedures may be performed and it is important to understand that SLAP tears are often seen in conjunction with other shoulder problems, such as instability or rotator cuff tears. If this is the case, these other conditions may influence how the SLAP lesion is dealt with.
Debridement – For minor tears that do not involve the biceps tendon, torn or frayed portions of the labrum are trimmed away in order to leave a smooth edge, which is less likely to cause catching or irritation in the joint.
Repair – In younger, healthy patients with traumatic labral lesions who wish to remain athletically active, a labral repair is typically performed. This involves the use of bio-absorbable suture anchors to which sutures are attached being imbedded in the edge of the socket (glenoid.) These sutures are placed through the labrum with specially designed tools and the sutures are then snugly tied, securing the torn labrum back to the glenoid rim.
SLAP Repair – suture anchors placed into rim of glenoid
SLAP Repair – three anchor repair of labrum to glenoid rim
Biceps Tenodesis – In situations where significant tearing or degeneration of the biceps is also seen, biceps tenodesis is often done. This involves excising the diseased portion of the tendon and re-attaching the remaining healthy tendon in a location slightly more distal, either to adjacent soft tissue (rotator cuff/rotator interval) or bone (proximal humerus.) This also has the beneficial effect of removing a tethering force from the abnormal labrum, thereby reducing pain. Recovery and rehabilitation from a biceps tenodesis is typically less lengthy than that following a labral repair.
RECOVERY – Depending on many factors, including the presence or absence of concomitant injuries/procedures, recovery from a SLAP repair typically involves the use of a sling/immobilizer for approximately six weeks to protect and rest the repaired tissues. Gentle range of motion and stretching exercises are prescribed to discourage stiffness. After approximately six weeks and once the initial healing has taken place, a therapy program is instituted which concentrates on gradually increasing range of motion and strength. Sport-specific exercises are usually started at around three to four months postoperatively, with full recovery possible by six months postoperatively.
If you are bothered with a painful, weak, or unstable shoulder the experienced professionals at Longview Orthopedic Associates are able to help. Call 360-501-3400.
One Mention of “Slap Tears”
- Dexter W. Sasser
April 16th, 2009 at 10:43 am