SLAP Tear
A Superior Labrum, Anterior to Posterior tear is commonly known as a SLAP tear. Per the Cleveland Clinic it is estimated that 4-8% of all shoulder injuries involve SLAP tears. Before we dive into the causes and treatment of a SLAP tear, it is important to understand the anatomy.
This image is courtesy of the American Academy of Orthopaedic Surgeons and it highlights the relevant structures involved in a SLAP tear. The labrum is the primary structure involved in a SLAP tear, and it is the inert lining that increases the stability of the shoulder joint. The shoulder joint is one of the most unstable joints in the body, which allows for our significant mobility. However, additional support is required, and this is what the labrum provides. It creates a larger surface area for the head of the humerus (your upper arm bone) to adhere to.
The biceps tendon is another important structure in a SLAP tear. There are actually two heads to your biceps, one inserts directly into your scapula, while the other actually inserts into your labrum. The tendon that inserts into your labrum provides security to prevent your humerus from dislocating superiorly, or upwards. There are many other muscles including your rotator cuff that provide stability in the region, but the biceps is the most important in this case.
A SLAP tear describes a superior tear of the labrum, meaning the top of the labrum is torn. Remember, the biceps tendon is partially responsible for stability in this area, and it can be torn in some cases with SLAP tears. Diagnosing a SLAP tear can involve several special tests, but an MRI is the gold standard. X-rays are not very beneficial because they only observe bone, and there is usually no bony involvement in a SLAP tear. Instead, MRIs, particularly those with contrast enhancement, can show the quality of the labrum.
SLAP Tear Causes
SLAP tears can occur from acute or chronic loads. An example of an acute tear is from a fall, motor vehicle accident, or some other significant trauma. Oftentimes, the stress will result in a shoulder dislocation as seen below on an x-ray.
For the shoulder to be dislocated, the labrum has to be torn and not provide support. This is a situation where x-rays can be beneficial, as a significant dislocation can lead to a diagnosis of a SLAP tear. However, the extent of the tear is not known until an MRI or surgery is performed.
Chronic SLAP tears are typically a result of repeated loads in an overhead position. This can be from manual labor, weightlifting, or overhead sports like baseball. Repeated microtraumas to the area can gradually peel away the labrum until there is a significant tear. As with many other injuries, a lot of people do not realize that they have a SLAP tear until they have symptoms. Many baseball pitchers probably have SLAP tears as part of their adaptation to throwing. In order to move their shoulder in such extreme positions, some tearing has to occur. This may be a helpful development if you are a major league pitcher throwing 100 miles per hour, but it is still something that requires monitoring.
SLAP Tear Symptoms
Symptoms of SLAP tears can be difficult to determine, as the nature of the tear and the individual can play a large role. Pain can be a primary symptom, particularly when lifting something overhead or assuming certain shoulder positions. The position of “layback” when pitching provides particular stress to the labrum, as it is stretched while also loading the biceps to create further stress as shown below.
Clicking or grinding in the shoulder joint is also a possible symptom of SLAP tears. If the labrum is torn in such a way that a portion of it is floating, it can even cause “catching” in the shoulder where mobility is limited temporarily in certain positions. Some clicking and grinding is common in baseball pitchers’ shoulders and these symptoms by themselves are normally not of significant concern.
Limited mobility can be a result of catching as described above or muscle guarding of the shoulder. If there is pain in an area, the body will typically tighten the muscles around it to provide support and guarding for the painful area. This can limit mobility of the shoulder, leading to other stresses. Research has shown that limited shoulder motion in pitchers can lead to elbow pathologies, so any loss of motion in the shoulder is important to assess. There can also be a feeling of hypermobility as if the shoulder is going to dislocate with certain movements. This can lead to limited mobility as a person may be fearful of putting himself in positions that could cause a dislocation.
Shoulder strength can also decrease from muscular guarding in the area and this may limit daily activities as well as lifting tolerance. Baseball players may see a loss of velocity or accuracy depending on their body’s response to the SLAP tear.
SLAP Tear vs Rotator Cuff Tear
Oftentimes, people assume that any shoulder injury is a rotator cuff tear. It is important to differentiate between that and a SLAP tear, as treatment is different. The rotator cuff refers to four muscles that provide stability to the shoulder, similar to the labrum. However, the rotator cuff is made up of contractile muscles. Rotator cuff tears typically cause a significant decrease in strength and mobility, while SLAP tears can cause these symptoms but usually manifest in clicking and popping. SLAP tears can eventually progress in symptoms if untreated.
Passive and active tissues require different timelines for recovery. All rehabilitation should be based on the individual, but rotator cuff surgery typically results in longer recovery times due to the healing and guarding of muscles. Even lower intensity activities at lower arm angles can stress the rotator cuff muscles, while SLAP tear rehabilitation has to avoid overhead activities for a period of time.
If you think that you have suffered either injury, it is beneficial to see a healthcare provider who can give you an individualized diagnosis and rehabilitation plan.
SLAP Tear Treatment
Treatment for a SLAP tear can be complicated, as every individual is different. There are many grades of SLAP tears and they involve different severities of injury. Typically, SLAP tears are treated non-surgically at first to determine if conservative treatment will allow for healing. Physical therapy can take several months for significant SLAP tears, and a full return to activity can take even longer. However, it is important to try conservatie rehabilitation if possible, as outcomes are typically faster and better compared to surgical interventions.
Surgical options can depend on the nature of the tear. In smaller tears, the surgeon may simply trim the portion of the labrum that is damaged, resulting in a faster healing time. Sometimes, the portion of the labrum that is torn requires repair and it has to be sewn into place. This significantly increases the rehabilitation timeline, as it takes several weeks for the labrum to heal from the procedure, and you want to ensure full healing before progressing physical therapy. Finally, some surgeons will cut the biceps tendon if they find that to be the aggravating factor. In certain populations, the biceps tendon will not be as crucial and healing can be faster and safer if it is severed or relocated. All of these options depend on individual factors and the surgeon’s preference.
SLAP Tear Recovery
As I mentioned before, recovery timelines vary based on non-surgical and surgical options. However, conservative treatment can take anywhere from 6 weeks to 3 months depending on symptoms. After surgery you may be placed in a sling for 2-6 weeks depending on what technique was performed. This allows for healing, but it also decreases strength and mobility. Most surgeons will clear a patient for throwing at 3-4 months following surgery, but it will take a couple months of throwing to build up strength and workload if everything goes well. Surgical SLAP repairs can require 6 months or more to get back on the field if you are a baseball player, particularly if you are a pitcher.
SLAP Tear Exercises
Early exercises for SLAP tears will avoid putting the shoulder in stressful positions such as overhead or in significant rotation. Light weights will also be used to avoid stressing the surrounding musculature, particularly the biceps. Band exercises are helpful as you can stress the shoulder from different directions while controlling the load. Rows and other exercises to strengthen the back muscles can be helpful, as you want to limit pulling from the front to avoid using the biceps.
Rotator cuff exercises are crucial, as they provide stability for the injured or repaired labrum. Light exercises can give way to closed-chain exercises which involve your hand being fixed on something, usually the ground, and you having to stabilize around it. A basic example of this would be holding a pushup position as shown below.
This requires you to utilize your rotator cuff to maintain position while not putting your shoulder in threatening movements such as overhead or behind your back. You can progress to one arm and rotations or other movements as you are able.
Biceps strengthening is often overlooked in SLAP tear rehabilitation. While you need to protect the biceps early on in physical therapy, the muscle does need to get stronger, particularly eccentrically in throwers. Eccentric strengthening occurs when the muscle is lengthening. In biceps curls this is when you are lowering the weight down after you have curled it up. Strengthening the biceps muscle and tendon can prevent future injury by strengthening the area.
Finally, a return to throwing program is crucial if you are a baseball player. If you had surgery or took a break from throwing for conservative physical therapy, it can take longer than expected to build your workload to return to the field. A couple of months are the minimum amount of time that you typically need, and pitchers often need more time. It is important to progress your exercises during this time and monitor your workload so that your shoulder is not overly stressed.
As always, if you are suffering from pain, nerve symptoms (numbness, tingling, or weakness), or anything else significant, please see a healthcare provider. This blog is meant to be educational and is not a substitute for medical advice.
Hopefully you learned something about SLAP tears and how they are diagnosed, what symptoms are typically felt, what treatment options are a possibility, and how physical therapy typically progresses. If you have interest in other shoulder injuries, check out our shoulder page. If you found this blog helpful, please share it with someone. We hope to continue to grow and help people better understand how our bodies move and work. If you are in the Sterling, Virginia area and would like to work with me or you have any questions, please email me at danny@eclipsewellnessnova.com or follow me on Instagram or Twitter @drdannydpt.