Labral and SLAP Tears

A SLAP (Superior Labrum Anterior and Posterior) tear is a specific type of shoulder injury affecting the labrum, the cartilage ring surrounding the shoulder socket. This injury is particularly prevalent among athletes engaged in overhead throwing activities, such as baseball pitchers, tennis players, and swimmers.

Although SLAP tears, which are labrum tears at the top or superior aspect of the glenoid (socket of the shoulder), were thought to be the core pathologic lesion of the shoulder, we now understand that there is a spectrum of disease that occurs in the shoulder in repetitive-use athletes. This broader pathology is known as internal impingement.

What is a SLAP tear?

The labrum serves as a stabilizing structure for the shoulder joint, providing attachment points for ligaments and the biceps tendon. A SLAP tear occurs at the top (superior) part of the labrum, where the biceps tendon attaches, and extends from the front (anterior) to the back (posterior) of this attachment point. This tear can compromise shoulder stability and function, leading to pain and decreased performance. In addition, SLAP tears can extend to the front and back of the glenoid, causing further instability and pain. Lastly, these tears are commonly associated with other pathologies in the joint, such as the long-head biceps and rotator cuff.

Causes of SLAP tears

SLAP tears can result from both acute injuries and repetitive stress:

• Repetitive Overhead Motion: Athletes involved in sports requiring frequent overhead movements, such as baseball, tennis, and swimming, are at increased risk due to the repetitive stress placed on the shoulder joint.
• Trauma: A sudden injury, such as falling onto an outstretched arm or a direct blow to the shoulder, can cause a SLAP tear.
• Degeneration: Age-related wear and tear can weaken the labrum, making it more susceptible to injury.
• Internal Impingement: During repetitive rotation motion of the shoulder in an overhead position, the labrum and rotator cuff come into contact, the biceps are placed under tension, and the capsule of the shoulder is placed on stretch to maintain the ball centered within the socket. As a result, each of these structures is placed under stress repeatedly, which can lead to failure. Commonly, labrum tears with associated undersurface rotator cuff tears progressively occur, causing pain. In addition, the capsule can become stretched or torn further, resulting in instability of the shoulder joint.

Symptoms of a SLAP tear

Individuals with a SLAP tear may experience:

• A deep, aching pain in the shoulder, often in the cocking position
• A sensation of catching, locking, or grinding
• Decreased range of motion and strength
• Difficulty performing overhead activities

In throwing athletes, these symptoms often manifest as decreased velocity, control, and endurance.
In addition, patients report that their shoulders feel tight, they have difficulty getting warmed up, and they have trouble recovering after an outing.

Diagnosis

Diagnosing a SLAP tear involves:

Physical Examination

Assessing shoulder stability, range of motion, and areas of tenderness. This is critical in identifying a suspicion of labrum pathology and evaluating other possible causes of shoulder pain, such as biceps tendinitis or rotator cuff tendinitis.

• Imaging Studies: MRI scans are the mainstay of evaluating the structure of the shoulder. Included is a specific view called an ABER view in which the arm is positioned in a cocked position (abduction and external rotation). This also involves visualization of the structures to detect pathology in the dynamic phase of throwing. Most throwing athletes have adaptive changes on MRI scans. Hence, an experienced surgeon familiar with throwing or overhead athletes must evaluate a patient and perform a physical exam to correlate the findings with the MRI scan to determine an accurate diagnosis.
• Arthroscopy: In some cases, a minimally invasive surgical procedure may be performed to visualize the tear directly. This is typically done after conservative care fails, with the expectation that a repair will be performed.

Treatment options

Non-Surgical Treatment

Initial management may include:

• Rest and Activity Modification: Avoiding activities that exacerbate symptoms. Rest period from throwing is typically 2-6 weeks.
• Physical Therapy: Important principles are to restore range of motion and resolve any inflammation in the shoulder, as well as to perform exercises to strengthen shoulder muscles and improve stability. Lastly, a gradual return to throw is initiated.
• Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation.
• Injections: A cortisone injection to reduce inflammation is performed to reduce inflammation in the joint and around the rotator cuff. Your surgeon can discuss any option for other orthobiologic injections, such as PRP, with you.

Surgical Treatment

If conservative treatments fail, surgical options may be considered:

• Arthroscopic SLAP Repair: Reattaching the torn labrum to the shoulder socket using sutures. This is an outpatient procedure whereby the shoulder is first examined with an arthroscope (camera). The labrum tear can be evaluated and smoothed (debrided) to remove any loose or unstable segments. Finally, a decision is made as to whether the labrum requires a formal repair, which is performed with suture anchors.
• Other aspects of the shoulder are evaluated, and the rotator cuff may require debridement or, in rare cases, repair.
• Biceps Tenodesis: Detaching the biceps tendon from the labrum and reattaching it to the upper arm bone may be preferred in certain cases, especially for older patients or those with biceps tendon involvement.
  The choice between these procedures depends on factors such as age, activity level, and specific injury characteristics, as well as your surgeon’s examination of the shoulder to determine where your pain is coming from.

Rehabilitation and return to sport.

Post-surgical rehabilitation is crucial for recovery:

• Physical Therapy: Initially, the shoulder is placed in a sling to protect the repair and facilitate healing. Next, the range of motion is recovered. By 12 weeks, a structured program focusing on restoring strength and function is initiated. Typically, players may begin a structured throwing program 4-5 months post-surgery once the surgeon clears them and completes a pre-return to throw physical therapy analysis performed at our performance center.
• Finally, we take a phased approach, starting with basic movements and advancing to sport-specific drills. For throwing athletes, this includes a specific interval throwing program developed in collaboration between our surgeons, therapists, strength and conditioning coaches, and throwing experts.

Recovery timelines vary, but throwing athletes may require several months before returning to competitive play.

Prevention strategies for throwing athletes

To minimize the risk of SLAP tears:

• Proper Mechanics: Ensure correct throwing techniques to reduce shoulder strain.
• Strength Training: Focus on shoulder and core strengthening exercises.
• Flexibility: Maintain adequate flexibility in the shoulder and surrounding muscles
• Rest: Incorporate adequate rest periods to prevent overuse injuries.

Expert care at Midwest Orthopaedics at Rush

At Midwest Orthopaedics at Rush, w3 specializes in diagnosing and treating SLAP tears, particularly in throwing athletes. Go where the pro’s go! As the head team physician for the Chicago White Sox for over twenty years, we have extensive experience in managing shoulder pain in overhead athletes! We offer comprehensive care, from advanced imaging and accurate diagnosis to personalized treatment plans and rehabilitation programs.

Schedule a Consultation Today

If you’re experiencing shoulder pain or suspect a SLAP tear, contact us to schedule an appointment today. We’re committed to helping you return to your sport and daily activities with confidence.