SLAP TEARs © Dr Mary Obele ANZSOM 5 March 2018

labrum - ring of fibrocartilage which: Increases the surface area and depth of the glenohumeral (shoulder) joint. Helps stabilise the glenohumeral joint.

SLAP = Superior Labrum Anterior Posterior Labral tears diagnosed by MRI in individuals between age of 45 and 60 years may be normal age-related findings. 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;4(1).

classification Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6(4):274-9.

SLAP 2 tears The superior labrum is completely torn off the glenoid. The biceps anchor is detached. This leaves a gap between the articular cartilage and the labral attachment to the bone. These can be anterior, posterior or both. Approximately half of all clinically relevant SLAP lesions are Type 2. Most are degenerative.

Diagnosis The history and presentation are non-specific: Locking, popping, grinding or catching. Deep, dull ache. Difficulty with certain movements or positions e.g. going down during a bench press. Reduced ROM and strength. Difficulty sleeping on that side. Feeling of a “dead arm” after throwing. Decline in sports performance. Physical examination tests have variable accuracies. The most definitive tests are MRI arthrogram and shoulder arthroscopy.

treatment Reduce pain. Restore a pain-free range of motion (ROM). Manage glenohumeral internal rotation deficits (GIRD) with exercises to improve internal rotation, and to correct scapular stabiliser function and strength.

Young overhead athletes Avoid aggravating activities. Home exercise program – biceps and rotator cuff strengthening with light weights within a pain free range of motion. Refer to a sports physician or orthopaedic surgeon experienced in treating athletes with SLAP lesions.

Older patients Older patients with a SLAP tears often have other non-traumatic shoulder pathology. Refer to a physiotherapist or sports physician for exercise therapy and periodic follow- up. These patients with SLAP 1 and 2 tears are unlikely to be surgical candidates, because surgery can lead to post-operative stiffness, a long delay in return to previous activities and pain.

Surgery Surgical treatment for SLAP tears may be considered in cases where nonoperative management fails to reduce pain and improve shoulder function. Higher failure and complication rates of surgery for SLAP tears in older patients. Patients with an acute traumatic SLAP tear do better with arthroscopic repair than patients whose SLAP tear is degenerative or related to repetitive microtrauma.

Schroder et al BJSM 2017 Sham surgery versus labral repair or biceps tendinosis for type II SLAP lesion of the shoulder: a three-armed randomised clinical trial. Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied.

Acute SLAP tears A motor vehicle accident. Shoulder dislocation (usually anterior). Compression - a fall onto an outstretched arm. Forceful eccentric traction - forceful pulling on the arm, such as an arm being pulled into moving machinery or when trying to catch an unexpectedly heavy object.

Non-traumatic tears Most SLAP 1 and 2 tears are age-related: They result from wearing down of the labrum slowly over time. In patients over 40 years of age, tearing or fraying of the superior labrum is a normal process of aging (usually type 1 and 2).

SLAP tears occur in repetitive overhead athletes and labourers Frequent, repetitive and forceful abduction and external rotation, or activities that require the biceps muscle to contract sharply against the labrum Cricket and baseball pitchers, swimmers, weightlifters, gymnasts, golfers and hammering labourers.