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INTRODUCTION — Superior labrum anterior posterior (SLAP) tear refers to a specific injury of the superior portion of the glenoid labrum that extends from anterior to posterior in a curved fashion. These tears are common in overhead throwing athletes and laborers involved in overhead activities.
The pathophysiology, diagnosis, and nonsurgical management of SLAP tears are reviewed here. The general approach to patients with shoulder pain, the shoulder examination, and rotator cuff injuries are discussed separately. (See "Evaluation of the patient with shoulder complaints" and "Physical examination of the shoulder" and "Shoulder impingement syndrome" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears".)
ANATOMY AND BIOMECHANICS — General shoulder anatomy and biomechanics are discussed separately; anatomic details and biomechanical factors related specifically to SLAP lesions are described here. (See "Evaluation of the patient with shoulder complaints", section on 'Anatomy and biomechanics'.)
The glenohumeral joint is composed of the glenoid, humeral head, glenoid labrum, and a surrounding ligamentous complex (figure 1 and figure 2 and figure 3 and figure 4 and figure 5). The labrum is a fibrocartilaginous ring attached to the outer rim of the glenoid that increases the area of contact between the humeral head and glenoid and provides added depth to the joint. Given the profound mobility of the shoulder and the shallowness of the bony glenoid, the increased surface area and depth provided by the labrum serves an important role in increasing the stability of the glenohumeral joint. In addition, the labrum serves as the attachment point for the glenohumeral ligaments, as well as the origin of the long head of the biceps tendon. This attachment can lead to labral injury during shoulder motions in the abducted and externally rotated positions when the biceps tendon is stretched.
SLAP tears occur from several mechanisms. One mechanism involves forceful eccentric traction exerted on the biceps tendon. This can occur when someone falls back onto an outstretched arm, tries to prevent him or herself from falling by grabbing hold of an object, or suddenly tries to lift a heavy object. Such mechanisms can cause an acute SLAP injury even in patients without underlying shoulder pathology. Anatomic variations in the structure of the superior labrum and the attachment of the biceps tendon increase the likelihood of SLAP tears in a small number of patients.
Many SLAP lesions occur in throwing or overhead athletes. When throwing a ball or other object, or performing similar motions (eg, swinging a hammer), the shoulder is forcefully abducted and externally rotated during the cocking phase. This motion performed while the hand carries a weight places stress on the labrum. Shear forces created by the movement of the humeral head anteriorly and superiorly must be resisted by the anterior joint capsule, which inserts partially into the superior anterior labrum. These forces can produce labral tears.
In addition, shoulder positions that involve 90 degrees or more of external rotation and abduction cause increased contact between the posterior-superior rotator cuff and the posterior-superior glenoid labrum. This is due to the increased forces exerted at the posterior glenohumeral joint when there is any damage to the stability of the anterior capsule. When the biceps tendon has some degree of injury or subluxation or the anterior labrum shows any significant degenerative tearing, the anterior shear forces of the humeral head increase. In addition, constraints against posterior motion of the humeral head are diminished. The increase in shear forces leads to increased motion of the humeral head posteriorly whenever the humeral head returns to a neutral position from action of rotator cuff muscles and glenohumeral ligaments trying to reset the humeral head within the glenoid. This increased translational force exerted on the posterior glenohumeral joint causes microtrauma and some fibrosis of the posterior capsule. If this becomes significant, the result is posterior shoulder capsule tightness and a greater degree of glenohumeral internal rotation deficit (GIRD).
Combined shoulder abduction and external rotation causes the biceps tendon to twist, increasing the stress placed on the tendon and its attachment, and thereby increasing the risk of a labral tear. When powerful traction forces are applied through the biceps tendon to the superior labrum during the cocking phase of throwing, the tendon’s attachment can tear the labrum from the glenoid. The different stresses placed on the shoulder joint during different activities likely account for the different types of SLAP lesions sustained.
EPIDEMIOLOGY, CLASSIFICATION, AND RISK FACTORS — The term SLAP ("superior labrum anterior posterior") was initially coined by Snyder and his colleagues while performing a retrospective review of a large sample of shoulder arthroscopies . While the true overall incidence of SLAP tears is unknown, the incidence among patients undergoing arthroscopy is reported to be between 6 and 26 percent [1-3]. Four types of SLAP injuries were described initially:
●Type I demonstrated degenerative fraying with intact biceps insertion
●Type II, detachment of the biceps insertion
●Type III, a bucket-handle tear with intact biceps tendon attachment to bone
●Type IV, an intrasubstance tear of the biceps tendon with bucket-handle tear of the superior labrum
In a prospective observational study of 544 consecutive shoulder arthroscopies that included 139 SLAP tears, different tear types were associated with particular conditions or activities. Type I tears were associated with increased age, rotator cuff disease, and osteoarthritis; Type II tears were associated with overhead sports; and Type III and IV tears were associated with high-demand occupations . The authors of the study did not define high-demand occupations or speculate why such occupations were associated with Type III or IV lesions, as few such injuries were identified in the study.
Given these associations, different types of SLAP injuries likely involve different mechanisms of injury. According to a retrospective review of 84 arthroscopically diagnosed labral tears, the most common mechanism involved an inferior traction-type injury either from a fall or a sudden pull when lifting a heavy object . Other common mechanisms included traumatic glenohumeral dislocation or repetitive shoulder abduction and external rotation (eg, throwers and other overhead athletes). A direct blow to the shoulder or a fall onto an outstretched hand may also cause a SLAP tear. A predisposition to sustaining certain types of SLAP injuries may stem from underlying shoulder comorbidities, such as multidirectional instability or chronic degenerative changes.
According to some researchers, the "peel-back" mechanism accounts for Type II labral injuries . In this mechanism, excessive stress on the biceps tendon attachment when the shoulder is placed in abduction and maximal external rotation leads to separation and tearing of the superior posterior labrum from the glenoid. Overhead throwing athletes (eg, baseball pitchers, cricket bowlers) and laborers who swing tools overhead frequently assume this position.
During repetitive overhead motions that involve abduction to 90 degrees and maximal external rotation, increases in external rotation range can be seen over time. Often, this increase is associated with a loss of internal rotation, a pattern termed glenohumeral internal rotation deficit (GIRD) . While it remains unclear how GIRD develops, it can lead to tightening of the posterior capsule, which in turn changes the translational mechanics of the humeral head within the glenoid. These changes can lead to internal impingement and posterior labral injury.
History — The history provided by the patient ultimately diagnosed with a SLAP lesion is often vague. SLAP tears may stem from chronic overuse or acute injury. Typically in cases of repetitive overuse, the patient complains of anterior shoulder pain. The athlete or laborer may complain of episodic clicking or comparable mechanical symptoms, particularly when their arm is placed in the cocking position of throwing (ie, abduction and external rotation) (figure 6) . In patients with a history of glenohumeral dislocation, subluxation, or a shoulder “sprain,” persistent anterior shoulder pain after returning to normal activities should raise suspicion for a SLAP tear and prompt an assessment of labral stability. However, no particular activity of daily living consistently elicits pain in the patient with a SLAP lesion. Night pain is an uncommon symptom and suggests a rotator cuff tear or other pathology. Shoulder instability with normal activity is not common, nor is swelling or paresthesias, which can occur with multidirectional shoulder instability . (See "Presentation and diagnosis of rotator cuff tears" and "Multidirectional instability of the shoulder".)
Overhead athletes, such as tennis, baseball, and volleyball players, may complain of a decline in function or throwing velocity . A classic complaint of baseball pitchers with an acute labral tear is that their arm feels like it “went dead.” Initially, pitchers are often able to continue throwing in spite of the pain. Some researchers describe throwers or overhead workers initially experiencing dull shoulder tightness, which then progresses to pain and mechanical symptoms as tears develop in those who play or work through the initial tightness . The diagnosis should be entertained in laborers who routinely swing a hammer overhead and complain of anterior shoulder pain and/or mechanical symptoms such as “clicking” or “catching.” (See "Throwing injuries: Biomechanics and mechanism of injury" and "Throwing injuries of the upper extremity: Clinical presentation and diagnostic approach".)
In a patient complaining of new onset shoulder symptoms after an acute event, the clinician should review the history to see if the mechanism is consistent with the traumatic SLAP injury. Typically, this involves patients who receive a direct blow to the shoulder or fall onto an outstretched hand and complain of anterior shoulder pain immediately following the trauma. Injuries involving sudden traction of the arm, which may occur while lifting a heavy object with a sudden jerking motion, also suggest labral injury. SLAP tears are typically not associated with acute anterior shoulder dislocations, although they may be present in patients with a history of shoulder dislocation and subsequent instability.
Concomitant injury — SLAP tears are frequently accompanied by other shoulder pathology. Rotator cuff impingement or tears, Bankart lesions, biceps tendon injury, and glenohumeral osteoarthritis are common findings during arthroscopic evaluation of patients with SLAP tears. If a SLAP tear is suspected, clinicians should assess for other shoulder pathology. (See "Shoulder impingement syndrome" and "Presentation and diagnosis of rotator cuff tears" and "Biceps tendinopathy and tendon rupture" and "Multidirectional instability of the shoulder" and "Glenohumeral osteoarthritis".)
Overall approach — As noted above, patients with SLAP lesions often have sustained additional shoulder and upper extremity injuries, and thus a careful examination of the involved shoulder and upper extremity should be performed, including assessments of motion, strength, and basic neurovascular function. To a large extent, the examination is guided by the differential diagnosis that is generated through the history. Assessment of the rotator cuff and biceps tendon are often indicated. Our approach to the adult with shoulder pain and a review of the shoulder examination are provided separately. (See "Evaluation of the patient with shoulder complaints" and "Physical examination of the shoulder".)
Examination begins with observation. Posture and shoulder position should be assessed. In throwing athletes, it is helpful to look for asymmetries in the upper extremities. Many athletes have hypertrophy of the throwing arm and malposition of the shoulder of the dominant arm. In particular, imbalances in muscle strength may lead to scapular protraction and a “rolled forward” shoulder appearance. Significant muscular atrophy is unusual in patients with SLAP tears and suggests neurologic problems or other injuries leading to disuse.
Whenever possible, the examination should include an assessment of shoulder motion. Clinicians should look for scapular dyskinesis as well as any hesitancy or catch as the patient moves their shoulder in normal arcs of abduction and elevation or forward flexion and elevation. Symptoms or abnormal motion that manifests during basic mobility testing suggests some underlying pathology and the need for more careful examination of the scapular stabilizers and rotator cuff. The portions of the examination of particular relevance to SLAP pathology are discussed below.
In addition to specific tests for SLAP lesions (described below), we suggest clinicians perform the following maneuvers:
●Palpate the proximal biceps tendon. The presence of focal tenderness suggests tendon injury.
●Assess the glenohumeral joint for restricted internal rotation and excessive external rotation. With the patient supine, the shoulder in 90 degrees of abduction, and the elbow in 90 degrees of flexion, gently determine the degree of maximal external and internal shoulder rotation compared to both standard measures of the glenohumeral arc and to the unaffected shoulder. (See "Physical examination of the shoulder", section on 'Range of motion'.)
●Assess scapular motion. Many patients with a SLAP tear have some degree of unilateral scapulothoracic dysfunction. (See "Physical examination of the shoulder", section on 'Scapulothoracic motion and strength'.)
SLAP-specific testing: Suggested approach — No single examination maneuver or combination of tests has been shown to identify superior labral lesions with high sensitivity and specificity [8-13]. In addition, the plethora of available tests for SLAP lesions can be overwhelming for the clinician, not to mention the patient who has a painful shoulder and may become annoyed by all the manipulation. Thus, we limit the number of tests we perform.
Ultimately, the diagnosis of a SLAP lesion is made using the history, imaging studies, and sometimes arthroscopy in addition to the physical examination. The specific examination maneuvers for detecting SLAP lesions should be approached with the intention of determining the need for advanced imaging or surgical intervention. Although there are many different examination tests for SLAP tears, they essentially fall into one of a few basic categories, including: maneuvers that elicit pain at the site of the tear (eg, by compressing and rotating the humeral head into the glenoid), maneuvers that place a strain on the proximal biceps tendon (which is often affected with SLAP tears), and maneuvers that demonstrate shoulder instability. Based upon the available evidence and our clinical experience, we perform the following examination maneuvers in the following order to assess for SLAP injuries:
●Anterior glide test
●Compression rotation test
●Active compression (O’Brien’s) test
Performance of these tests is described below. (See 'SLAP-specific testing: Overview and test descriptions' below.)
Although often described as a test of biceps tendon pathology, Speeds test is useful for assessing SLAP lesions, and, when performed following the first three tests, it is most specific . Additional tests for detecting SLAP lesions may be performed for difficult cases that remain unclear after these tests are performed.
Given the limitations of the available research, it is not surprising that a number of approaches to the clinical diagnosis of SLAP lesions have been advocated. A prospective study of several examination tests in a population of overhead throwing athletes with an expected high prevalence of SLAP lesions concluded that earlier studies of individual tests were exceedingly optimistic . Its authors suggest that the best approach to the clinical diagnosis of SLAP lesions would include a combination of tests designed to detect SLAP lesions and biceps tendon injuries.
One research group suggests that combining two of three sensitive tests (active compression test, apprehension test, compression-rotation test) with one of the three more specific biceps tendon tests (Speeds, Yergason's, Biceps load II) yields a sensitivity of 70 percent and a specificity of 95 percent . Another group suggests that the most useful combinations of tests to rule in the diagnosis of labral tear, in descending order, are (1) history of popping, clicking, or catching and positive anterior slide test; (2) positive anterior slide and crank tests; (3) history of popping, clicking, or catching and positive crank test; and (4) positive anterior slide and active compression tests . However, another group reviewed five selected clinical maneuvers for diagnosing SLAP tears and found that combinations of tests did not improve diagnostic accuracy compared to stand-alone testing with individual maneuvers .
SLAP-specific testing: Overview and test descriptions — Many examination tests for detecting superior labrum anterior posterior (SLAP) lesions have been described, but studies of individual techniques are extremely limited by methodology, variations among patient populations, and other factors. Several meta-analyses and systematic reviews have concluded that no single physical examination technique can accurately diagnose a SLAP tear. In addition, there are no conclusive studies about which combination of techniques are most useful [8,9,17]. Several of the more commonly used techniques and studies of their accuracy are described here; our suggested approach to assessing possible SLAP lesions is discussed separately. (See 'SLAP-specific testing: Suggested approach' above.)
●Active compression test (O’Brien’s sign) – The active compression test has two parts and is performed with the patient standing (picture 1). To prepare, the patient flexes their shoulder 90 degrees with the elbow in full extension. Then, they adduct the arm 10 degrees (ie, move it slightly toward the midline). Once properly positioned, the patient internally rotates their arm until the thumb points downward. The examiner then pushes the arm toward the floor while the patient resists by maintaining their arm in the starting position. This first part of the test may elicit deep shoulder pain or a clicking sensation in the glenohumeral region. The maneuver is then repeated with the patient’s arm fully supinated. The test is positive if the pain or click is reduced or eliminated during the second part of the test.
●Crank test – To perform the crank test, the patient stands and abducts their shoulder 160 degrees while keeping the arm in the plane of the scapula . The elbow is flexed 90 degrees. The examiner then applies an axial load to the humerus with one hand while rotating the arm internally and externally with the other (movie 1). Pain, a clicking sensation during the maneuver, or reproduction of symptoms similar to those experienced at work or sport indicates a positive test. The test may be performed with the patient prone.
●Compression-rotation test – For the compression-rotation test, the patient lies supine with their shoulder abducted 90 degrees directly to the side and their elbow flexed at 90 degrees (movie 2) . Laying supine with the back against the examination table stabilizes the scapula. The examiner pushes the humerus into the glenoid by applying an axial load and then rotates the humerus internally and externally. A positive test produces discomfort and a catching, popping, or snapping sensation. This test is analogous to the McMurray’s test for meniscus lesions of the knee.
●Speeds and Yergason's tests – Given the frequent association between biceps pathology and SLAP tears, performing these two tests can be helpful in a patient with a suspected SLAP tear. In Speeds test, the patient’s elbow is extended and their forearm fully supinated with the shoulder slightly flexed. In this position, the patient is asked to elevate the arm against a resisted isometric force applied by the examiner (picture 2 and movie 3) . A test that elicits pain in the anterior shoulder is considered positive.
Yergason's test is performed with the patient's forearm pronated and elbow flexed to 90 degrees (picture 2). The patient then attempts to supinate their arm against a resisted isometric force applied by the examiner (movie 4). Pain localized to the long biceps tendon marks a positive test. Yergason reasoned this test would isolate biceps tendon injury from rotator cuff pathology. A study of 50 patients, using arthroscopy as the gold standard, found Yergason's test to have a sensitivity of 43 percent, specificity of 79 percent, and positive likelihood ratio of 2.05 .
The studies described here reflect the general surgical literature, which suggests that neither Speeds test nor Yergason's test provide much help in distinguishing biceps tendon pathology from other causes of anterior shoulder pain [20,21]. In other words, these tests increase the post-test probability of biceps pathology only slightly when positive and when negative do not aid diagnosis.
However, the results of such surgical studies may be limited. These studies include only patients selected for arthroscopy and may not reflect the broader patient population that presents to primary care and sports medicine clinics with shoulder complaints. Furthermore, surgical studies generally focus on the presence of tendon tear to assess the accuracy of physical examination tests. The presence of tendinopathy is more difficult to assess.
One study using MRI as the gold standard for biceps pathology found a sensitivity of 68.5 percent and specificity of 55.5 percent for Speeds test and sensitivity of 37 percent and specificity of 86 percent for Yergason's test . This study is consistent with surgical studies and suggests that physical examination tests have limited accuracy for diagnosing biceps tendon pathology.
●Biceps load test (Kim 1) – The first biceps load test is intended to detect SLAP injuries in patients with chronic shoulder dislocation . The test is performed with the patient supine and the examiner seated alongside holding the patient’s wrist and elbow. The patient’s arm is positioned with the shoulder abducted 90 degrees to the side, the elbow flexed 90 degrees, and the arm fully supinated. The examiner then steadily rotates the shoulder externally in a manner similar to the apprehension test (movie 4). Rotation is stopped when the patient feels as if the shoulder will dislocate. The patient then flexes the elbow while the examiner resists. The test is positive if the last maneuver provokes pain or continued apprehension about dislocation.
●Biceps load test (Kim 2) – The second biceps load test is intended for patients without recurrent dislocation . The patient and examiner positions are the same as for the first biceps load test. However, in the second test, the shoulder is abducted 120 degrees before the shoulder is maximally externally rotated, again with the elbow flexed to 90 degrees, and the arm is supinated. The patient is then asked to flex the elbow while the examiner resists (movie 5). The test is positive if pain develops when the patient flexes their elbow or if pain increases when the examiner applies resistance.
●Pain provocation test – This test is similar to the biceps load tests (movie 6) . The patient sits with the examiner standing behind them. The examiner holds the patient’s wrist with their ipsilateral hand while the contralateral hand gently braces the patient’s shoulder. The shoulder is abducted 90 to 100 degrees directly to the side with the elbow flexed 90 degrees. The arm is then maximally externally rotated and, while maintaining this position, the arm is then maximally pronated and supinated. The test is positive if maximal pronation elicits or worsens pain.
●Anterior glide test – For the anterior glide test, the patient lies supine and their arm is abducted a bit less than 90 degrees (movie 7). The examiner stands next to the patient between their torso and the affected upper extremity. Next, the examiner wraps the hand closest to the patient around the patient’s superior trapezius and clavicle to provide stability. With the other hand, the examiner grasps just distal to the patient’s humeral head, with the thumb anterior and the remaining fingers wrapped around the proximal humerus. Next, the examiner distracts the humerus slightly and then translates the humeral head anteriorly. A positive test produces notable anterior laxity when compared to the unaffected side.
Overview — All imaging techniques used to diagnose superior labrum anterior posterior (SLAP) tears have limitations, making definitive diagnosis of these injuries challenging [26,27]. In addition, depending upon the clinical scenario and prospective treatment, it may not be necessary to obtain advanced imaging studies to establish the diagnosis. As one important example, since patients older than 35 are often poor surgical candidates, it is generally best to obtain consultation with an experienced shoulder surgeon before ordering advanced imaging studies for such patients, who are unlikely to need them. (See 'Indications for orthopedic consult or referral' below.)
Currently, magnetic resonance arthrogram (MRA) is the most accurate imaging study for diagnosing SLAP tears. Plain radiographs cannot delineate soft tissue injuries such as SLAP tears but remain important for identifying concomitant injuries and are obtained in most patients. Computed tomography (CT) arthrography can help to diagnose SLAP tears but is typically reserved for patients with contraindications to MRI.
Plain radiography — When a SLAP tear is suspected, plain radiographs of the shoulder are used to assess other potential causes of shoulder pain. Given how frequently SLAP tears are associated with other injuries, plain radiographs are typically the first studies performed. Anteroposterior, scapular Y, and axillary views are generally obtained. Acromioclavicular (AC) and glenohumeral (GH) joint osteoarthritis, calcific tendinopathy, osteochondral lesions of the glenoid or humerus, fractures, dislocations, and bony tumors can be seen using plain radiographs.
Computed tomography — In patients who are unable to obtain a MRI due to implanted medical devices (eg, Pacemaker) or other reasons, CT arthrography may be used to assess possible SLAP tears. According to a retrospective review that included 161 imaging studies, CT demonstrated a sensitivity and specificity of 94 to 97 percent and 72 to 76 percent, respectively, compared to arthroscopy .
Musculoskeletal ultrasound — Although useful for identifying some shoulder pathology such as supraspinatus tear, musculoskeletal ultrasound (MSK US) is not useful for examining SLAP tears . The labrum is surrounded by multiple osseous structures, which makes it difficult to assess using ultrasound. Labral tears may be associated with paralabral cysts or biceps tendon abnormalities that can be evaluated reliably using ultrasound. Biceps tendon subluxation can be demonstrated on dynamic US and this finding may raise suspicion of a Type II SLAP lesion.
Magnetic resonance imaging — Magnetic resonance arthrogram (MRA) is the most accurate available imaging technique for diagnosing SLAP tears, but has limitations and is most useful in patients younger than 35 years. In addition, quality varies greatly with these studies and the ordering physician (usually the shoulder surgeon assuming care) should make certain that the imaging facility can provide the appropriate, high quality study.
According to several observational studies that used findings at arthroscopy or open surgery as the gold standard, the sensitivity of MRA falls between 89 and 95 percent [30-32]. The specificity of MRA reported in these studies was between 50 and 91 percent. A meta-analysis of six imaging studies found similar results with a marginally improved sensitivity and specificity of MRA of 88 percent and 93 percent respectively when compared with magnetic resonance imaging (MRI) (sensitivity 76 percent, specificity 87 percent) . Positioning the patient’s shoulder in an externally rotated or abducted and externally rotated (ABER) position during the MRA can improve diagnostic accuracy [34,35].
Standard MRI of the shoulder performed without contrast demonstrates much lower sensitivity, with one research group reporting 38 percent . In this study, accuracy improved when musculoskeletal fellowship-trained radiologists interpreted the images. Additional studies have corroborated the limited sensitivity of conventional MRI . As with any test, MRI must be interpreted in light of the clinical presentation and examination findings . One likely reason for the limitations of MRI is the relatively wide variation of the normal appearance of the glenoid labrum.
Since patients older than 35 are often poor surgical candidates, MRI and MRA studies generally should not be ordered by the primary care physician. As described above, MRA and MRI show a range of sensitivity and specificity and most likely will be abnormal in patients older than 35. These studies rarely change management in this age group so it is generally best to obtain consultation with an experienced shoulder surgeon before ordering advanced imaging studies for such patients. (See 'Indications for orthopedic consult or referral' below.)
Imaging and intra-articular injection — Guided intra-articular anaesthetic (eg, lidocaine) injection can be helpful in the diagnostic workup. Given that SLAP tears are an intra-articular process, anesthetizing the glenohumeral joint to see if a patient’s pain resolves suggests that the labrum may be involved. Such injections can be performed in the office or clinic under ultrasound guidance or added to the contrast dye when performing an MRA. Pain from extra-articular pathology, especially in the subacromial space such as rotator cuff tears or tendinopathy, will not improve with such an injection.
DIAGNOSIS — SLAP tears can be difficult to diagnose, as the mechanism of injury varies and symptoms can be vague. Initial suspicion for a SLAP injury arises from the patient’s history. Any overhead throwing athlete or laborer who performs repetitive overhead swinging motions and develops anterior shoulder pain may have a SLAP tear. A baseball pitcher with anterior shoulder pain that persists despite correct throwing mechanics, appropriate rest, and completion of a well-designed rehabilitation program is likely to have a SLAP injury. In addition, patients with a history of shoulder trauma, such as a glenohumeral dislocation or instability or a “shoulder sprain,” who continue to experience pain or intra-articular symptoms (eg, clicking, catching) despite a return to normal activities may have a SLAP tear. A combination of several positive tests designed to elicit the symptoms associated with a SLAP tear along with the absence of evidence consistent with other causes of shoulder pain further suggest the diagnosis. (See 'SLAP-specific testing: Suggested approach' above.)
Ultimately, a definitive diagnosis of SLAP tear is made using either advanced imaging, preferably MRA, or by performing diagnostic arthroscopy. Arthroscopy is the gold standard for SLAP tear diagnosis given the occasional limitations of MRA. Musculoskeletal ultrasound (MSK US) can be useful for evaluating concomitant rotator cuff or biceps tendon pathology. In the authors’ experience, the diagnosis of SLAP tear is likely in patients with a suggestive history and anterior shoulder pain without evidence of rotator cuff pathology on examination and MSK US. It is important to note that the effectiveness of surgical treatment is limited, particularly in patients 35 years or older, and therefore, many patients do not need advanced imaging to establish a definitive diagnosis of SLAP tear if the diagnosis is likely based upon the clinical evaluation and common alternative diagnoses have been ruled out. In most cases, only good surgical candidates warrant advanced imaging (eg, MRA), and this determination is best made by an orthopedist with advanced training in shoulder surgery.
INDICATIONS FOR ORTHOPEDIC CONSULT OR REFERRAL — SLAP tears can be difficult to diagnose definitively by history and physical examination. Even magnetic resonance arthrogram (MRA) has limitations and is often unnecessary in patients over 35 years and others who may be poor surgical candidates. Given the complexities of establishing the diagnosis of SLAP tear and determining the best approach to management, in most cases we suggest obtaining orthopedic referral prior to performing advanced imaging studies (eg, MRA) when a SLAP injury is suspected. Ideally, the consulting surgeon should be an orthopedist with advanced training in shoulder surgery.
Refraining from obtaining advanced imaging is particularly important in patients who are unlikely to be suitable surgical candidates. This approach minimizes unnecessary studies and the possibility of false-negative tests. It also enables the surgeon to correlate MRA results with the history and examination findings, and then to determine which SLAP tears are most amenable to surgical repair. Of course, local practice varies and in some cases obtaining an MRA prior to surgical consultation may be suitable. As an example, this approach may be appropriate for a younger patient who is a good surgical candidate and likely to have a SLAP tear based upon the clinical evaluation but for whom visiting a shoulder surgeon requires significant travel.
In addition to patients likely to have a SLAP tear based on their initial clinical evaluation, patients who have completed a comprehensive nonoperative rehabilitation program and continue to struggle with shoulder pain that affects their work or athletic performance should obtain surgical consultation.
Orthopedic referral is indicated for any overhead throwing athlete or repetitive overhead laborer with anterior shoulder pain, particularly if the pain increases when the shoulder is placed in the cocking position of throwing or working, and the overall clinical evaluation suggests the presence of a SLAP tear.
DIFFERENTIAL DIAGNOSIS — Shoulder pain is common in the general population and the differential diagnosis is extensive. This differential and a discussion of how to approach the patient with undifferentiated shoulder pain are provided separately; the diagnoses most likely to be confused with a SLAP tear are discussed briefly below. (See "Evaluation of the patient with shoulder complaints".)
SLAP tears can occur in isolation but are frequently associated with other shoulder pathology. This can make identifying SLAP tears difficult. A few common shoulder diagnoses that may be confused with SLAP tears include the following, listed in order of decreasing likelihood, along with important features to differentiate them from SLAP tears. Key historical and examination features that suggest a SLAP tear rather than other shoulder pathology include participation in a sport or occupation that involves extensive overhead activity, pain that is worst in the cocking phase of shoulder motion, and intra-articular mechanical symptoms such as crepitus or catching.
●Rotator cuff tendinopathy or partial tear – Patients may have rotator cuff pathology and SLAP tears simultaneously. However, patients with rotator cuff pathology typically have signs of anterior shoulder impingement and night pain, which are generally absent in patients with isolated SLAP tears. Intra-articular symptoms, such as clunking or catching, are uncommon with isolated rotator cuff pathology. Weakness with shoulder abduction or external rotation and a positive painful arc test occur more consistently with rotator cuff problems. However, articular-side supraspinatus tears lie close to the biceps tendon and as such, can mimic SLAP tears. Ultrasound provides an excellent method for identifying tendinopathy and partial or complete rotator cuff tears. A normal ultrasound with significant shoulder symptoms makes SLAP lesion a strong possibility. (See "Physical examination of the shoulder", section on 'Examination for rotator cuff pathology' and "Presentation and diagnosis of rotator cuff tears" and "Rotator cuff tendinopathy".)
●Shoulder impingement syndrome (SIS) – SIS generally causes persistent, vague anterior shoulder pain with overhead motions but like rotator cuff pathology, typically does not cause intra-articular symptoms. Patients with suspected SIS who do not improve with comprehensive rehabilitation may have an underlying SLAP tear. (See "Shoulder impingement syndrome".)
●Biceps tendinopathy or tear – The close proximity of the proximal biceps tendon insertion and the glenoid labrum make it possible for patients to have bicipital tendon pathology and SLAP tears simultaneously. Anterior shoulder pain is a common complaint with both conditions. Isolated biceps tendon pathology typically does not cause intra-articular symptoms. Proximal biceps tendon tears are rare in younger patients and create a notable deformity of the muscle (“Popeye” deformity (picture 3)). Complete or partial tears of the biceps tendon are easily identified on ultrasound as the tendon is superficial. Maneuvers commonly used to elicit pain from a SLAP tear (eg, Active compression and compression-rotation tests) typically do not cause pain in those with isolated biceps tendon pathology. However, patients who continue to experience anterior shoulder pain despite appropriate rehabilitation of the biceps tendon may have an associated SLAP tear. (See "Biceps tendinopathy and tendon rupture".)
While uncommon, entrapment of the long head of the biceps tendon, due to an anatomic variant called an hourglass biceps, can produce the symptoms and signs of a SLAP tear . In such cases, a hypertrophic intra-articular portion of the biceps tendon becomes entrapped in the glenohumeral joint when the shoulder is abducted and the elbow flexed simultaneously. This can cause a mechanical block within the glenohumeral joint producing signs that mimic intra-articular labral pathology. This condition can only be seen during arthroscopy and the intra-articular portion of the long head of the biceps tendon must be excised to prevent recurrence.
●Glenohumeral osteoarthritis – SLAP tears and glenohumeral osteoarthritis can both cause anterior shoulder pain. Patients with either condition may experience reduced shoulder motion and pain with overhead activities. Night time pain is common with osteoarthritis but not SLAP lesions. Glenohumeral osteoarthritis is easily identified on plain radiographs of the shoulder (image 1 and image 2), whereas patients with an isolated SLAP tear typically have normal radiographs. (See "Glenohumeral osteoarthritis".)
●Multidirectional shoulder instability – A SLAP tear can cause symptoms of shoulder instability, particularly after a traumatic dislocation. However, in general patients with SLAP tears do not complain of shoulder instability symptoms or transient neurologic symptoms. Multidirectional instability involves laxity in all directions of humeral motion (anterior, inferior, and posterior) whereas SLAP tears may in rare instances be associated with anterior laxity only. (See "Multidirectional instability of the shoulder".)
Patient categories and overview of management — Appropriate classification of patients and the demands they place on their shoulder joint help to determine the best approach to the management of superior labrum anterior posterior (SLAP) tears. In our experience, the categories listed below provide a useful framework.
●High-level throwing or overhead athletes – These patients are typically referred to an orthopedic surgeon experienced in treating athletes with SLAP lesions. When referral poses difficulty, diagnostic testing with MRA (preferred) or MRI, depending upon institutional experience, is warranted. While awaiting surgical evaluation, the patient can begin a home exercise program. Exercises that emphasize biceps and rotator cuff strengthening performed with light weights may be performed within a pain free range of motion.
●Patients with high occupational demands involving frequent overhead activity – For patients younger than 35 years who fall into this category, we follow the same approach used for high level athletes. We refer patients over 35 years to physical therapy for a comprehensive rehabilitation program and see them periodically in follow-up. If patients do not improve with physical therapy, we refer them to an orthopedic surgeon.
●Recreational athletes and individuals with limited occupational demands – Care of these patients begins with physical therapy and periodic follow-up. Orthopedic consultation can be obtained if rehabilitation is ineffective, but these patients are not likely to be surgical candidates.
●Individuals over 60 years – Patients over 60 years with a SLAP tear are likely to have concomitant shoulder pathology. We perform a careful evaluation that includes musculoskeletal ultrasound and plain radiographs looking for rotator cuff pathology or osteoarthritis. These patients are treated with physical therapy and symptom management of their SLAP tear and any associated shoulder conditions. These patients rarely benefit from surgical intervention.
Initial treatment — Initial management of SLAP tears involves reducing pain by avoiding aggravating activities, such as overhead throwing or work where the shoulder is placed repeatedly in abducted and externally rotated positions. Nonsteroidal antiinflammatory drugs (NSAIDs) or acetaminophen can be taken to help reduce pain in the acute setting. Once pain is adequately controlled, patients begin a rehabilitation program with the goals of improving glenohumeral and scapulothoracic motion and increasing the strength and endurance of the rotator cuff and scapulothoracic muscles . Specific exercises to accomplish these goals are described separately. (See "Rehabilitation principles and practice for shoulder impingement and related problems", section on 'Rehabilitation program'.)
Nonoperative treatment — Typically, nonoperative management of SLAP tears is preferred whenever possible given the long recovery required following surgical repair (typically 6 to 12 months) and the limitations of surgical treatment . Rehabilitation programs focused specifically on addressing scapular dyskinesia and posterior capsule contractures associated with glenohumeral internal rotation deficits (GIRD) enable approximately 40 percent of professional baseball players to resume playing without surgery . Although studies are limited primarily to retrospective case series, evidence suggests that most patients are able to resume pre-injury activity levels following participation in a well-designed physical therapy program. As an example, a retrospective study of 39 patients involving a rehabilitation protocol similar to that described above for baseball players reported improved pain and quality of life scores in 71 percent of patients, and 67 percent of overhead athletes returned to their sport at preinjury levels .
The standard of care for rehabilitation of SLAP lesions includes addressing the following principles and biomechanical deficits [7,42]:
●Reduce pain and inflammation.
●Restore pain free range of motion (ROM), including identifying and resolving any glenohumeral internal rotation deficits (GIRD). Specific stretches and exercises help improve internal rotation in these patients.
●Improve function and strength of scapular stabilizers – Exercises to accomplish this goal are described separately. (See "Rehabilitation principles and practice for shoulder impingement and related problems", section on 'Step one: Improve scapular stability'.)
●Improve rotator cuff strength – Exercises to accomplish this goal are described separately. (See "Rehabilitation principles and practice for shoulder impingement and related problems", section on 'Step two: Strengthen the rotator cuff'.)
Given the complexity of SLAP tears, patients are best served by participating in a rehabilitation program under the supervision of a knowledgeable physical therapist. Proper technique is important to effective treatment, and knowledge of when it is safe to advance to more challenging exercises is essential for maximizing progress and avoiding further injury. While there is no gold standard SLAP tear rehabilitation protocol, as patients start from a range of functional baselines, following a standardized protocol that incorporates proven exercises is helpful. Such a protocol provides direction about which exercises to use, how to use them, when to advance to the next stage of rehabilitation, and approximately how much time will be required to achieve recovery .
SLAP tears are often accompanied by other pathology, such as rotator cuff or biceps tendinopathy. In such cases, treatment of these associated conditions should be performed, in part to determine the extent to which the SLAP tear is contributing to the patient’s symptoms. Many times resolving rotator cuff or biceps tendon-related pain is sufficient. In patients with persistent shoulder pain despite appropriate treatment of associated conditions, treatment of the SLAP tear is often warranted. (See "Rotator cuff tendinopathy" and "Biceps tendinopathy and tendon rupture".).
Persistent anterior shoulder pain, especially associated with overhead motions, or failure to regain prior function despite compliance with a well-designed rehabilitation program suggests the SLAP tear is not amenable to conservative treatment and surgical referral should be made. In patients who are not surgical candidates, activity modifications, such as limiting throwing or repetitive overhead activities, may be necessary to reduce chronic symptoms. Some number of patients with SLAP tears will experience chronic pain and possibly instability with particular activities or shoulder movements.
Surgical treatment — Surgical treatment for SLAP tears may be considered in cases where nonoperative management fails to reduce pain and improve shoulder function. A number of surgical techniques exist, and there is some controversy about the most effective technique for each major type of injury. Factors that inform technique selection include patient age and whether the patient is an overhead laborer or throwing athlete. Surgical success rates are lower in older patients according to observational studies and the clinical experience of many shoulder surgeons. A systematic review of surgery for SLAP tears included several studies that reported higher failure and complication rates in patients over age 40 . As an example, one prospective observational study of 179 patients with Type II SLAP tears reported a statistically significant increase in the failure of surgical treatment among patients older than 36 years . Approximately 37 percent of patients in the study met the criteria for surgical failure.
Overall, experienced shoulder surgeons are performing fewer SLAP repairs and becoming more selective about which patients warrant surgery . According to the review cited above, biceps tenodesis or debridement provides a reasonable alternative. A review of SLAP repairs performed by young surgeons applying for certification from the American Board of Orthopedic Surgery found that only 26 percent of patients reported being pain-free and 13 percent reported normal shoulder function following SLAP repair . The study authors expressed concern over the relatively large number of repairs being performed by these younger surgeons.
The standard repair of SLAP tears involves placing bioabsorbable anchors into the glenoid and then securing the labrum to the glenoid with nonabsorbable sutures . Performing a biceps tenodesis (moving the biceps tendon insertion from the glenoid to the humerus) simultaneously, particularly with overhead throwing athletes and laborers, may improve the likelihood of the patient returning to their prior level of function, which is achieved by approximately 60 to 70 percent of patients. However, patients with an acute traumatic SLAP tear may do better with arthroscopic repair than patients whose SLAP tear was sustained from repetitive injury .
Controversy persists about whether to repair SLAP tears in patients over 40 years with associated rotator cuff tears (RTC). One observational study reported improved outcomes in patients over 45 years with rotator cuff tears when SLAP tears were repaired as well, but a randomized trial of 63 patients over 50 years of age reported no difference in outcome in patients whose SLAP and rotator cuff tears were repaired compared to those treated with rotator cuff repair and biceps tenotomy [50,51]. In patients with concomitant rotator cuff injury, labral debridement or biceps tenotomy may be preferable to labral repair .
Postoperative treatment and results — It typically requires six months and often as long as 12 months to return to throwing after surgical repair of a SLAP lesion. Healing must not be rushed. The patient should work through the appropriate stages of rehabilitation gradually and clinicians must guard against the patient progressing prematurely. Given the complexity and importance of post-operative rehabilitation, patients are best served by participating in a rehabilitation program under the supervision of a knowledgeable physical therapist, athletic trainer, or comparable clinician.
The post-operative rehabilitation program is typically divided into three stages:
●Phase 1 – Maximal protection phase (approximately six weeks duration)
●Phase 2 – Moderate protection phase (approximately six weeks duration)
●Phase 3 – Minimum protection phase (approximately 14 weeks duration)
The maximal protection phase begins the day after surgery until around six weeks. During this phase the primary goal is to protect the surgical repair from re-injury and to minimize pain and inflammation. The patient is typically in a sling for the full six weeks; avoiding any motion that loads the biceps tendon is critical. The patient begins to perform passive and active assisted range of motion (ROM) exercises during this phase but these are limited. Protected motion begins with passive motion below 90 degrees of shoulder flexion and abduction, and progresses gradually after the first two weeks. Limited active motion is introduced gradually. Toward the end of this stage, the patient begins to perform some basic isometric strength exercises.
The moderate protection phase begins at approximately week seven and continues through week 12. During this phase, one major goal is to regain full active range of motion. Around week 10, active loading of the biceps tendon can begin. If full ROM is not obtained with the basic program, additional focused stretching and mobilization exercises may be required. Increasing levels of resistance are used for scapular and rotator cuff exercises. Exercises for developing core strength are performed during this phase.
The minimum protection phase begins at approximately week 13 and continues through week 26. During this phase, the patient may gradually resume throwing or overhead occupational activities until full function is restored. Throwing from a mound may begin around 24 to 28 weeks after surgery in most cases. It is critical that full shoulder mobility is achieved. Full strength and motion of the scapular stabilizers and rotator cuff muscles should be achieved before full activity is resumed. To prevent reinjury, it is important that a pitcher’s throwing mechanics be assessed and any problems resolved, and that appropriate guidelines regarding the type and number of pitches thrown be followed .
For the patient who follows up with a primary care or sports medicine physician, failure to progress through the phases in a reasonable time frame (approximately three months for phases 1 or 2 and six months for phase 3) merits consultation with the orthopedic surgeon who completed the repair. Similarly, if the patient develops unexpected pain or dysfunction during the post-operative rehabilitation, the patient should return to their orthopedic surgeon for evaluation. The surgeon should have the final say about whether the patient is ready to resume full activity.
A systematic review of studies of the management of Type 2 SLAP tears (506 patients included) found that 83 percent of patients reported good-to-excellent results following operative repair . However, only 73 percent of patients returned to their prior level of function, while only 63 percent of overhead throwing athletes returned to their previous level of play. Should primary repair fail, biceps tenodesis often relieves pain. About 40 percent of patients report an excellent outcome with this surgery, while approximately 4 percent experience significant complications . Common long-term disabilities after a failed surgical repair include pain and instability with overhead or abducted and externally rotated shoulder positions. It is unclear whether SLAP tears increase the risk for glenohumeral osteoarthritis.
SUMMARY AND RECOMMENDATIONS
●Superior labrum anterior posterior (SLAP) tear refers to a specific injury of the superior portion of the glenoid labrum that extends from anterior to posterior in a curved fashion. These tears are common in overhead throwing athletes and laborers involved in overhead activities. SLAP tears are caused by forceful eccentric traction exerted on the biceps tendon and in throwers by the chronic stress placed on the labrum when the shoulder is forcefully abducted and externally rotated (eg, cocking position of throwing). (See 'Epidemiology, classification, and risk factors' above and 'Anatomy and biomechanics' above.)
●The history provided by the patient ultimately diagnosed with a SLAP lesion is often vague. In cases related to overuse, the patient typically complains of anterior shoulder pain. The athlete or laborer may complain of episodic clicking or comparable mechanical symptoms, particularly when their arm is placed in the cocking position of throwing. Overhead athletes may complain of a decline in function or throwing velocity. Cases involving acute trauma may involve falling onto an outstretched arm or sudden traction of the arm, which may occur while lifting a heavy object with a sudden jerking motion. SLAP tears are frequently accompanied by other shoulder pathology. (See 'History' above.)
●A careful examination of the involved shoulder and upper extremity should be performed, including assessments of motion, strength, and basic neurovascular function. The proximal biceps tendon should be palpated; focal tenderness suggests tendon injury. Specific examination maneuvers for detecting SLAP lesions should be approached with the intention of determining the need for advanced imaging or surgical intervention. Many tests for SLAP tears are used; we suggest performing the following such maneuvers:
•Anterior glide test
•Compression rotation test
•Active compression (O’Brien’s) test
•Speeds test (see 'Examination' above)
●All imaging techniques used to diagnose SLAP tears have limitations, making definitive diagnosis challenging. Depending upon the clinical scenario and prospective treatment, it may not be necessary to obtain advanced imaging studies to establish the diagnosis. Currently, magnetic resonance arthrogram (MRA) is the most accurate imaging study for diagnosing SLAP tears. Plain radiographs cannot diagnose SLAP tears but remain important for identifying concomitant injuries and are obtained in most patients. (See 'Diagnostic imaging' above.)
●Definitive diagnosis of a SLAP tear requires arthroscopy or MRA, but these are often unnecessary and a clinical diagnosis is adequate if the patient is not a good surgical candidate, the history and clinical findings strongly suggest the diagnosis, and other important alternative diagnoses such as rotator cuff tear can be ruled out by examination and ultrasound. (See 'Diagnosis' above.)
●Given the complexities of establishing the diagnosis of SLAP tear and determining the best approach to management, in most cases we suggest obtaining orthopedic referral prior to performing advanced imaging studies (eg, MRA) when a SLAP injury is suspected. Ideally, the consulting surgeon should be an orthopedist with advanced training in shoulder surgery. Refraining from obtaining advanced imaging is particularly important in patients who are unlikely to be suitable surgical candidates. (See 'Indications for orthopedic consult or referral' above.)
●SLAP tears are frequently associated with other shoulder pathology, which can make identifying SLAP tears difficult. A few common shoulder diagnoses that may be confused with SLAP tears are discussed in the text, along with important features to differentiate them from SLAP tears. These diagnoses include rotator cuff tear or tendinopathy, shoulder impingement, and biceps tendinopathy or tear. (See 'Differential diagnosis' above.)
●The management of SLAP tears depends upon patient age and activity, and the type of tear. Nonoperative management of SLAP tears is preferred whenever possible given the long recovery required following surgical repair (typically 6 to 12 months) and the limitations of surgical treatment, particularly in older patients. High-level throwing or overhead athletes and patients with high occupational demands involving frequent overhead activity should be referred to an orthopedic surgeon. For such referrals and whenever surgery is contemplated, it is best to consult an orthopedic surgeon experienced in treating SLAP lesions. Management is discussed in greater detail in the text. (See 'Management' above.)
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