Procedure can be performed at our Seattle Location
The labrum is a rim of cartilage that surrounds the glenoid or shoulder socket. A tear of the labrum that occurs along the top of the socket is called a SLAP tear or SLAP lesion. SLAP stands for Superior Labrum Anterior Posterior and involves the portion of the labrum that the biceps tendon attaches to.
SLAP tears or SLAP lesions can occur from a traumatic event or from repetitive overhead activities such as throwing a baseball, hitting volleyball, or swimming. Labral tears have a poor blood supply and therefore a limited capacity to heal. Not all labral tears require surgery, even if they do not heal. An initial course of physical therapy should be attempted in most cases, especially in throwing athletes. SLAP tears are common in throwing athletes, especially in pitchers and don’t always cause symptoms or require surgery.
Those SLAP tears that occur due to a traumatic event or those that fail nonoperative treatment are usually best treated with arthroscopic labral repair or debridement (shaving torn labrum).
Normal Superior Labrum and Biceps Tendon
Signs and Symptoms of a SLAP Tear
SLAP tears usually cause pain in the front and top of the shoulder and may be associated with clicking or catching. Overhead activity such as throwing, lifting weights or swimming can aggravate these symptoms. The onset of the symptoms may be gradual as it often is in baseball throwing injuries or it may occur during a single event such as a shoulder dislocation. Some of these tears can be found in association with rotator cuff tears. Examination of the shoulder may reveal tenderness over the biceps tendon, pain and clicking with compression and rotation of the shoulder, or pain in the front of the shoulder while performing biceps resistance exercises.
Diagnosis of SLAP Tears
Although the signs and symptoms may lead to a probable diagnosis, there is not one single exam finding or group of symptoms that are specific for a SLAP tear. Many of these findings overlap with other shoulder problems. Xrays and an MRI combined with an arthrogram (injection of dye into the shoulder joint) are recommended to confirm the diagnosis and rule out other conditions.
SLAP Tear (white arrow)
Many SLAP tears may be treated nonoperatively with relative rest and physical therapy. Icing the shoulder and anti-inflammatory medications can help with pain. If nonoperative treatment is not successful or in cases where there has been a traumatic event, surgical treatment may be considered. The indications for surgery should be based on an individual basis considering the patient’s age, activity level, functional needs, response to treatment, and time in season for athletes.
Surgery consists of arthroscopic repair of the labrum if it is an unstable tear or debridement (shaving) if it is a stable tear. Arthroscopy uses small incisions and allows the surgeon to view the shoulder joint on a TV monitor to use small instruments to perform the surgery. Repair involves creating bleeding of the bone on the edge of the socket where the labrum tore away and placing suture anchors in the bone to tie the labrum down to it. Debridement involves shaving the frayed edges of a stable tear and can be done if the labrum is attached to the socket but the tear is away from the attachment site. The surgery is done as an outpatient procedure allowing patients to go home the same day.
SLAP Tear viewed from the back of the shoulder (head toward the left, feet to the right
Close up of SLAP Tear (Labrum is to left, Glenoid is to right)
Glenoid is prepared by shaving the bone to make it bleed and create a healing response
Suture anchor has been placed and suture passing device is being positioned to go under the labrum and retrieve one limb of the suture
Suture passer placed under the labrum
Suture passed under labrum, ready to tie
Sutures tied and labrum repaired
Rehabilitation of SLAP Tears
The rehabilitation following a SLAP repair is much different than a debridement. If a SLAP repair is done, patients are placed in a shoulder immobilizer with a small pillow next to the side to protect the repair for six weeks. Physical therapy is started 1 week after surgery and involves passive range of motion where the therapist moves the shoulder within a specified range. Active motion where the patient starts moving the shoulder without assistance begins at 6 weeks after surgery. There is a progression to more aggressive strengthening at three to four months after surgery and return to some sports at four to six months after surgery. Return to pitching typically takes ten to twelve months and swimming eight to ten months after surgery. It is important to recognize that return to sport is based on multiple factors including biologic healing, return of strength and endurance, subjective improvement, and a gradual/incremental return to sport specific activities. Therefore, return to sport timeframes may vary.
If a debridement or shaving is done, patients are placed in a sling for several days to a week. Physical therapy begins approximately one week after surgery. Range of motion is allowed as tolerated and strengthening is started 1-2 weeks after surgery. Return to sports or full activity is allowed when pain allows, full range of motion and strength return. This may be as soon as 4-6 weeks after surgery for some sports or activities. For a repair, there is protected range of motion for the first six weeks followed by active motion and gentle strengthening.
Dr. Khalfayan’s Tip: Sleeping is difficult after surgery. It’s helpful to sleep in a semi-reclining position propping yourself up on pillows behind your head, neck, and upper back or in a recliner until you are comfortable sleeping flat in bed.