SLAP TEAR
(Superior Labrum Anterior-to-Posterior Tear)
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related talks: rotator cuff tear; biceps tendon tear; adhesive capsulitis; biceps tendonitis
What is a SLAP tear?
SLAP tear stands for Superior Labrum Anterior-Posterior Tear. This is a type of tear to the shoulder labrum.
Lets quickly review some shoulder anatomy to better understand this condition.
The shoulder is where the arm (humerus) meets the shoulder blade (scapula). The shoulder joint kinda looks like a golf ball sitting on a golf tee. The shoulder is our most mobile joint, it moves so far in so many directions. And while this is great for so many things, this type of flexibility comes at the sacrifice of stability. Our shoulder is the most unstable (easy to dislocate) joint in our body (see talk). The shoulder tries to compensate for the lack of stability by relying on muscles (like the rotator cuff) and soft tissue (like the labrum!) to provide additional stability.
The labrum is soft tissue thats part of the shoulder joint and it helps to stabilize the shoulder. The superior labrum is located where the bicep tendon attaches to the shoulder (it actually fuses with the superior labrum). This means that abnormal forces on the bicep tendon or at the shoulder joint can tear the superior labrum, or the bicep tendon, or both.
These injuries are all described as SLAP tears. The injury is often caused by a fall onto an outstretched arm, or it can occur in pitchers whose repetitive throwing puts too much strain on the shoulder eventually causes a tear.
Diagnosing a SLAP tear:
A SLAP lesion can be challenging to diagnose.
People with this injury are either over-head throwing athletes that complain of gradually worsening, chronic shoulder pain, or they occur someone after a recent fall onto their outstretched arm with persistent pain.
The symptoms are often vague. A dull, deep shoulder pain. Maybe occasional clicking or popping within the joint. Increased shoulder fatigue. All of these symptoms help point your doctor in the right direction, but an MRI is the most useful test to diagnose this tear. Sometimes a special MRI, called an MRI arthrogram, where dye is injected into the shoulder joint before the MRI is ordered to improve visualization of any abnormal tissue in the shoulder.
X-ray isn’t useful for this injury because it only shows changes to the bone (like a fracture) but it wont show soft tissue injury. X-rays are often ordered however to rule out other causes of shoulder pain, like a small fracture or shoulder arthritis.
There are different types of SLAP tears and they are classified based on their appearance on MRI.
A Type 1 tear is only fraying (degeneration) of the bicep tendon and labrum (think of an old sweater that frays after being used too much). Type 2 is a tear of the bicep tendon but the labrum is ok. A Type 3 the labrum is torn but the bicep muscle is ok, and a Type 4 the labrum and bicep is torn. There are other more advanced stages of tearing beyond this but they are too technical for this talk.
Treating a SLAP tear:
Treatment can be non-surgical or surgical.
Non-surgical treatment emphasizes shoulder strengthening with physical therapy and anti-inflammatories.
Oftentimes however the tear will only heal when fixed with arthroscopic surgery (using a camera and mini-tools inside the joint). The torn labrum is reattached to the shoulder bone (glenoid) using small anchors. After this repair, people need to follow a strict rehabilitation protocol to insure the tissue heals. A sling and passive motion (not flexing your shoulder muscles) is all that you are allowed in the first 4 weeks after surgery, then slowly active motion is started. Different surgeons have variations of this protocol.
What is the long term outcome?
Overall the treatment of SLAP tears has had mixed success. A recent study showed that overall, surgical repair of the injury leads to significantly improved pain and function as compared with nonsurgical treatment. The concern with this surgery is the relatively high rate of failure over the long term. Some estimates of up to 35% of surgeries either require re-operation or fail to allow people to return to their sport/work or fail to significantly improve symptoms. Of note, the risk of failed surgery increases with age, and 35 years old is about the cut-off point where people really have to start to accept a higher risk of failure.
Re-tear rates certainly increase of someone tries to rehab their shoulder too aggressively and does not following the correct rehab protocol. In general, some people lose a small amount of shoulder motion, however this rarely affects daily function. vThe physical therapists know best and will guide you to a speedy recovery.
References
1) Provencher MT, et al. A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med 2013; 41: 880-6. full article.
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