SLAP Lesion / Superior Labrum Tear | Diagnosis & Treatment
The glenoid labrum is a fibrocartilagenous structure that runs circumferentially around the rim of the shallow bony glenoid fossa, deepening the socket and acting as a passive stabilizer to prevent humeral head subluxation. The labrum also serves as an attachment site for capsuloligamentous structures, such as the glenohumeral ligaments and the long head of the biceps (Calcei et al. 2018).
SLAP stands for Superior labral tear, anterior to posterior, and comprises four major injury patterns as a cause of pain and instability, particularly in the overhead athlete (Ahsan et al. 2016).
Snyder et al. (1990) first described four injury patterns in 27 patients:
- Type I: Degenerative fraying of the superior labrum free edge with intact peripheral attachment and stable biceps tendon anchor. This pattern is very common amongst middle-aged and elderly populations, suggesting that it may be a degenerative finding that is not a definitive source of pain
- Type II: Degenerative fraying with an additional detachment of the superior labrum and biceps from the glenoid resulting in an unstable labral-biceps anchor (marked with red in the illustration)
- Type III: Bucket-handle tear of the superior labrum with an intact biceps tendon anchor (marked with blue in the illustration)
- Type IV: Lesions include a displaced bucket-handle labral tear with extension into the biceps tendon root
Ahsan et al. (2016) stress that the original description by Snyder lacks adequate reproducibility, which might partly be attributable to the difficulty in understanding even normal superior labral anatomy and age-related changes that can occur.
There are two main theories on the pathogenesis of type II SLAP lesions in athletes (Change et al. 2016):
- Cadaveric and arthroscopic demonstrations of impingement of the posterosuperior labrum between the greater tuberosity and glenoid with the shoulder in abduction and external rotation (ABER) led to the hypothesis that posterosuperior impingement causes SLAP and cuff tears.
- Other investigators favor a peel-back mechanism, wherein humeral hyper-external rotation in the late cocking phase generates a posteriorly directed torsional force on the biceps tendon, leading to twisting and peel-back and detachment of the biceps root and posterosuperior labrum from the underlying glenoid cartilage.
Given how often posterosuperior impingement, SLAP lesions, and rotator cuff undersurface tears occur concurrently, both of these proposed mechanisms likely contribute to the pathogenesis of SLAP lesions.
Acute injuries can be caused by a fall by a fall onto the outstretched arm or an unexpected pull on the arm, e.g., when losing grip of heavy objects or sudden traction (e.g., high bar exercises, hold off bodyweight in dropping rock climbers). Furthermore, injury can occur following direct contact of the adducted shoulder which an opposing player (in e.g. rugby) or to the surface (Popp et al. 2015).
Schwartzberg et al. (2016) report a prevalence of up to 72% diagnosed by MRI in the asymptomatic population between 45 and 60 years of age.
Landsdown et al. (2018) retrospectively analyzed shoulder MRIs performed in patients with shoulder pain and found that the prevalence of SLAP tears increases with age. In the study, MRIs from patients between 51-65 were twice as likely to show a SLAP tear and in patients older than 65 the chance of a SLAP tear increased fourfold compared to 35-50 years of age.
On the other hand, Pappas et al. (2013) investigated the prevalence of labrum tears in 102 cadavers with an average age of 80.6 (range 57 – 96) and found a low prevalence of 9.8% with 8.8% classified as type I and 0.98% classified as type II lesions.
Weber et al. (2012) report that SLAP repairs made up 9.4% of all arthroscopic surgeries for the shoulder in the United States between 2003 and 2008 with increasing numbers.
Of those SLAP repairs, 78.4% were performed in men (mean age 36.4) and 21.6% in women (mean age 40.9).
Clinical Picture & Examination
Signs & Symptoms according to Calcei et al. (2018) are:
- Anterior shoulder pain
- Repetitive trauma through overuse
- Throwers complain about velocity and report clicking, popping during the late cocking phase of the throwing motion
- Tennis and volleyball players may complain of pain during cocking phase of the serve
- Concomitant injuries such as rotator cuff pathology and instability
Ahsan et al. (2016) state that given the difficulties in reliably classifying SLAP lesions based on arthroscopic videos, it is not surprising that physical examination maneuvers and MRI findings are reported to be unreliable in correctly diagnosing SLAP lesions.
Mathew et al. (2018) point out that a key aspect of patient history-taking is to look at the provocative phase or phases of pitching throwing in an overhead athlete.
The reason is that posterior pain in the late cocking phase could indicate a posterior superior labral tear and supraspinatus-infraspinatus junction due to internal impingement.
Posterior pain during the release or follow-through on the other hand might be indicative of the eccentric failure of the rotator cuff. Anterior pain during the cocking phase is associated with some degree of anterior instability of multifactorial origin. At last, anterior pain during the terminal phase of the throw might indicate mechanical impingement of the biceps or coracoid impingement.
Overhead throwers often present with glenohumeral internal rotation deficit (GIRD), which should be assessed first. On top of that, scapular dyskinesis is often present and should be evaluated in a second step. While we mentioned in the “Scapular Dykinesis” unit that scapular dyskinesis might actually be a sport-specific adaption, it might be a risk factor for the development of shoulder pain in athletes performing at elite levels.
Two possibly helpful clusters have been evaluated in order to exclude a SLAP lesion:
1) The “3-Pack” Examination consists of O’Brien’s Active Compression Test (ACT), resisted throwing test, and palpation of the bicipital tunnel described by Taylor et al. (2017).
The author describes that both a negative ACT (with sensitivity values ranging from 88-96% and specificity ranging from 46-64%) and/or a negative palpation test (Sensitivity: 92-98%/ Specificity: 52-73) are helpful in the exclusion of lesions to the biceps-labrum-complex.
2) The cluster described by Schlechter et al. (2009) consists of the Active Compression Test and the Passive Distraction Test (PDT). In the case of 2 positive tests, the cluster yields a LR+ of 7.0 and a negative LR- of 0.33 in the case of two negative outcomes.
Rosas et al. (2017) have conducted a literature review and have come up with a test cluster. They found that the uppercut test combined with tenderness to palpation of the long head of the biceps had the highest accuracy to diagnose pathology of the proximal biceps with a sensitivity of 88.3% and a specificity of 93.3%. Although accuracy seems to be high, this combination has not been confirmed by other studies or reviews yet, which is why we give it a moderate clinical value in practice.
Nonoperative management has demonstrated success, including in overhead athletes, and therefore should be the first line of treatment for athletes with biceps and superior labral-complex injuries (Calcei et al. 2018). Physiotherapy should focus on functional impairments like range of motion (thereby focusing on possible concomitant GIRD), glenohumeral and scapulothoracic strength, and coordination. Mathew et al. (2018) report a higher success rate in professional baseball players with directed rehabilitation that focuses on the flexibility of the posterior capsule and scapula positioning compared to surgical treatment.
Schrøder et al. (2016) compared two common surgery techniques (labrum repair and biceps tendon arthrodesis) with sham surgery in 118 surgical candidates with SLAP II lesions. At six months and two-year follow-up, neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied. On top of that, post-operative stiffness occurred in five patients after labral repair and in four patients after tenodesis.
Gismervik SØ, Drogset JO, Granviken F, Rø M, Leivseth G. Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance. BMC musculoskeletal disorders. 2017 Dec;18(1):41.
Jang SH, Seo JG, Jang HS, Jung JE, Kim JG. Predictive factors associated with failure of nonoperative treatment of superior labrum anterior-posterior tears. Journal of shoulder and elbow surgery. 2016 Mar 1;25(3):428-34.
Lansdown, D. A., Bendich, I., Motamedi, D., & Feeley, B. T. (2018). Imaging-Based Prevalence of Superior Labral Anterior-Posterior Tears Significantly Increases in the Aging Shoulder. Orthopaedic journal of sports medicine, 6(9), 2325967118797065.
Mathew, C. J., & Lintner, D. M. (2018). Suppl-1, M6: Superior Labral Anterior to Posterior Tear Management in Athletes. The open orthopaedics journal, 12, 303.
Moore-Reed SD, Kibler WB, Sciascia AD, Uhl T. Preliminary development of a clinical prediction rule for treatment of patients with suspected SLAP tears. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2014 Dec 1;30(12):1540-9.
Rosas, S., Krill, M. K., Amoo-Achampong, K., Kwon, K., Nwachukwu, B. U., & McCormick, F. (2017). A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps. Journal of shoulder and elbow surgery, 26(8), 1484-1492.
Schlechter JA, Summa S, Rubin BD. The passive distraction test: a new diagnostic aid for clinically significant superior labral pathology. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2009 Dec 1;25(12):1374-9.
Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. High prevalence of superior labral tears diagnosed by MRI in middle-aged patients with asymptomatic shoulders. Orthopaedic journal of sports medicine. 2016 Jan 5;4(1):2325967115623212.
Smith R, Lombardo DJ, Petersen-Fitts GR, Frank C, Tenbrunsel T, Curtis G, Whaley J, Sabesan VJ. Return to play and prior performance in major league baseball pitchers after repair of superior labral anterior-posterior tears. Orthopaedic Journal of Sports Medicine. 2016 Dec 28;4(12):2325967116675822.
Taylor SA, Newman AM, Dawson C, Gallagher KA, Bowers A, Nguyen J, Fabricant PD, O’Brien SJ. The “3-pack” examination is critical for comprehensive evaluation of the biceps-labrum complex and the bicipital tunnel: a prospective study. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2017 Jan 1;33(1):28-38.
Weber SC, Martin DF, Seiler III JG, Harrast JJ. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery part II candidates. The American journal of sports medicine. 2012 Jul;40(7):1538-43.
- Barbara Fasol05/09/23Rotator Cuff Related Shoulder Pain THE BEST COURSE SO FAR
I really enjoyed this course, so much it felt like a pleasure instead of a work. The explanations are very clear and the content is well documented and complete. Thank you!Alvin Chi24/06/23Rotator Cuff Related Shoulder Pain OVERALL A QUALITY COURSE THAT SUMMARIZES THE EVIDENCE WELL.
Overall a good course. I found the scapula dyskinesis section the most helpful, as it taught helpful physical exam findings that I could not find elsewhere. I also found the discussion on various tissue irritability helpful. I removed one star because this course has large sections of text, and relatively little videos and helpful diagrams. In comparison to the PFPS course by Claire Robertson, there was too much text and too little videos. I do appreciate how evidence based the course was, but summary diagrams and additional videos would have been helpful. Despite this, I would still recommend this course.Lynn Tastenhoye21/06/23Rotator Cuff Related Shoulder Pain REVIEW RC RELATED SHOULDER PAIN
Naar mijn gevoel werd het theoretische te weinig gekoppeld aan de praktische toepassing ervan
- Tristan Bard05/02/23Rotator Cuff Related Shoulder Pain REVIEW
Very interesting course, which allows you to improve your knowledge and your care with the patient, I highly recommend!Maud Silvertand12/01/23Rotator Cuff Related Shoulder Pain RCRSP COURSE REVIEW
A great course guided by up to date knowledge. It provides a good overview of rotator cuff related shoulder pain and the best research and treatment options following the latest evidence. In addition there is a lot of exercise and practice material to test your knowledge.Joscha Kaspar26/11/22Rotator Cuff Related Shoulder Pain AMAZING COURSE
Can highly recommend this course. Step by step you will be guided towards up to date knowledge about rotator cuff related shoulder pain. The Information is very well presented, not to long not to short. It helped me allready to make better treatment descisions in practice with patients. They often come with “impingement” diagnosis and ideas of their subacromial space being to small. Thanks to this course not only my communication is better towards those patients but also my clinical reasoning goes better and I am able to make better treatment plans within a realistic time frame. Thank you!
- Ivo Nieuwenhuis25/11/22Rotator Cuff Related Shoulder Pain GOOD COURSE TO LEARN AND UNDERSTAND MORE ABOUT THE SHOULDER
I liked this course because it is connecting evidence based with the practical understanding of cuff related problems. The way the course is given suits me because mr Struyf is not dictating he is explaining with an open mind.Janneke de Groot03/11/22Rotator Cuff Related Shoulder Pain ERG FIJNE PRAKTIJK GERICHTE CURSUS
Goede state of the art schouder cursus met fijne focus op het praktische aspect van het vak! Goede duidelijke instructie filmpjes en mooi voorbeeld materiaal wat meteen in de praktijk te gebruiken is!Jelter Wahlen05/10/22Rotator Cuff Related Shoulder Pain RCRSP COURSE!
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Een heel praktisch gerichte cursus om rotatorcuff gerelateerde schouderklachten aan te pakken. Heeft mij echt nieuwe inzichten en motivatie gegeven om met schouderklachten aan de slag te gaan! Je kan de cursus op je eigen tempo thuis volbrengen met regelmatig een quiz en leuke praktische video’s.Pavel Samsonov13/07/22Rotator Cuff Related Shoulder Pain Perfect course with uptodate knowledge and fine quizes.
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Test in the end of the course is great idea to check your knowledge.Remy03/06/22Rotator Cuff Related Shoulder Pain Very good course, up to date background information, skilled instructor. Highly recommended
- Khaled Mohi03/09/21Rotator Cuff Related Shoulder Pain His course is excellent one . here you will find true understanding to this very common misunderstanded syndrome . how to treat without causig injury to the patient . i said it is truly excellent courseJanneke de Groot01/01/70Rotator Cuff Related Shoulder Pain ERG FIJNE PRAKTIJK GERICHTE CURSUS
Goede state of the art schouder cursus met fijne focus op het praktische aspect van het vak! Goede duidelijke instructie filmpjes en mooi voorbeeld materiaal wat meteen in de praktijk te gebruiken is!