The superior labrum is the upper portion of the cartilage rim that attaches to the edge of your shoulder socket (glenoid. This upper part of the socket and labrum is also the attachment for the long head of biceps tendon. Occasionally a SLAP tear extends into the biceps tendon itself. The term SLAP means - Superior Labrum Anterior and Posterior to biceps. The area marked in red below is the SLAP region. The arthroscopic photograph below shows an unstable SLAP tear.
The superior labrum can be injured either in isolation, or as part of a more widespread shoulder instability picture. SLAP tears in young patients tend to be traumatic or sport-related, but in those over 40, these are normally degenerate, rather than traumatic tears.
Traction injuries, where the arm is forcefully pulled out in front of you, pull through the biceps tendon into the superior labrum and can rip it off the glenoid. Intensive strength training programmes (e.g. Crossfit) can cause superior labral problems through repetitive faulty technique or overwhelming loading. Throwing sports exert repeated twisting forces on the superior labrum. Eventually, this can peel off the superior labrum. Throwers are also prone to posterior capsule tightness. This may cause rubbing against the superior labrum (internal impingement) and SLAP problems. Significant direct blows to the shoulder (landing heavily on the side of the arm) can also cause complex labral tears that may include the superior labrum.
Face on view of shoulder socket (glenoid). Labral cartilage rim with superior labrum and long head of biceps tendon in red
Arthroscopic photograph of an unstable SLAP tear. The long head of biceps tendon is sometimes destabilised by this injury. This patient's injury was repaired.
Most patients have not suffered a complete shoulder dislocation, but patients often say their shoulder ‘isn’t right’. Patients may well recall a precipitating traumatic event, often a sudden pulling event on the arm or a heavy landing onto the shoulder. Patients describe deep-seated pain in their shoulder, sometimes with pain in front and behind. Crossing the arm in front of your body often makes it worse and using the biceps muscle (screwdriver, heavy lifting) can also exacerbate pain. Some patients describe intermittent pins and needle or a ‘dead arm’ sensation
Most patients try the usual combination of rest, activity modification, painkillers and anti-inflammatories to see how things settle.
Physiotherapy helps to restore your range of motion, stretch any tight capsule and to optimise the co-ordination of your muscles. This may offload your biceps and reduce your SLAP symptoms.
Cortisone (steroid) injections may be helpful to relieve pain and enable your physiotherapist to work with you.
If your SLAP tear is a result of an overuse problem, and you continue the sport without correcting your technique or posture, it may get worse. As shoulders rarely dislocate with SLAP tears alone, it is unlikely to cause significant joint damage beyond the superior labral area although your symptoms of pain and clicking may persist. This is often the reason why patients want surgery.
If you are recommended for surgery for a SLAP tear there are two main options:
Arthroscopic SLAP repair
Biceps tenotomy or tenodesis
Your surgeon will explain which options would work best for you based on you and your specific injury pattern. In general, results from clinical studies suggest improved outcomes with biceps tenodesis, rather than a SLAP repair if you are over 35years old.
You will require a period of protection in a sling, with restrictions on movement and function. Whatever surgery you have, you will require a physiotherapy rehabilitation programme. Return to sport will vary with procedure, associated injuries and by individuals, but is unlikely before 5 months after SLAP repair or biceps tenodesis. Contact and overhead sports usually take a bit longer (approx. 7 to 9) months.
Some patients’ shoulders will settle with activity modification and a physiotherapy programme. Of those who need surgery, 85% will be happy with their outcome by 6 months, but a few patients will continue to experience pain during certain activities.
If a SLAP repair fails to help your pain, revision surgery is feasible, but it may be better to perform a tenodesis of the biceps tendon if the tissue quality of the superior labrum is poor.
Making the right choice about the best treatment for you means getting the right information. During your consultation, please do feel free to ask Mr Granville-Chapman to explain anything that you do not fully understand, and for his advice about the pros and cons of any treatment.