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SLAP tear

A SLAP tear (superior anterior to posterior) is an injury to the superior , a ring of that deepens the socket and stabilizes the joint, often involving the origin of the long head of the biceps tendon. These tears account for 4% to 8% of injuries, with higher rates among overhead athletes and individuals over 40 years old, comprising 80-90% of labral pathologies in stable shoulders and peaking in incidence among those aged 20-29 and 40-49. SLAP tears result from acute trauma, such as falls on an outstretched arm, or chronic repetitive overhead motions in sports like or , which generate shear forces on the . They are classified into types based on extent and involvement, from Type I (fraying) to Type IV (extending into the ), with up to 10 subtypes described. Detailed symptoms, , , and outcomes are covered in subsequent sections.

Anatomy and Pathophysiology

Shoulder labrum anatomy

The is a fibrocartilaginous ring that encircles the of the , attaching firmly to the glenoid rim via a transitional zone that connects to both the and the adjacent articular . This structure deepens the inherently shallow by approximately 50%, thereby increasing the effective depth and surface area of the glenohumeral articulation to enhance joint stability. Composed primarily of type I and II fibers arranged in a layered microstructure—including a superficial multidirectional , a loosely packed middle layer, and a dense circumferential —the exhibits a triangular cross-section, particularly in its superior portion where it reaches an average height of 5.96 mm and thickness of 6.02 mm. The superior , which is meniscoid in shape and more loosely attached compared to other regions, plays a critical role as the anchor for the long head of the brachii . Approximately 40% to 60% of the tendon's fibers insert directly into this superior at the , forming a contiguous biceps-labral complex that integrates with the , including the emerging recognition of the superior glenohumeral ligament's (SGHL) involvement in stability. This attachment site is variable but consistently contributes to the biomechanical linkage between the and the glenoid rim. The labrum's blood supply is limited, deriving primarily from branches of the , including the subscapular, circumflex scapular, and anterior humeral circumflex vessels that penetrate via the . Vascularity is confined largely to the peripheral and outer portions, with the central and articular aspects remaining relatively avascular—often comprising about one-third of the tissue at various positions—which explains the structure's inherently poor intrinsic healing capacity. Functionally, the promotes glenohumeral joint congruence by augmenting the socket's depth and maintaining negative intra-articular pressure, while also resisting anterior-posterior and superior translation of the humeral head during motion. It contributes approximately 10% to overall concavity-compression in the joint and serves as a critical anchor for the long head of the , facilitating coordinated arm elevation and load distribution.

Pathophysiology of SLAP tears

A SLAP tear, or superior labrum anterior to posterior tear, involves injury to the superior extending from approximately the 10 o'clock to 2 o'clock position in the right (or 10 o'clock to 2 o'clock mirrored for the left), often detaching the anchor of the long head of the from the glenoid rim. This detachment disrupts the normal buffering and stabilizing function of the , which deepens the glenoid socket and secures the biceps tendon origin. The primary biomechanical mechanism implicated in SLAP tear development is the "peel-back" phenomenon, particularly in overhead athletes, where torsional forces during the late cocking phase of throwing generate posterior humeral head glide and strain on the biceps-labral complex. In this position of abduction and maximum external rotation, the posterior labrum experiences increased tensile loading, leading to progressive peeling and superior migration of the labral fragment away from the glenoid. Additionally, compressive forces in overhead positions contribute to initial labral fraying by shearing the superior labrum against the humeral head during repetitive glenohumeral contact. Recent studies have also identified the superior glenohumeral ligament (SGHL) as a contributor to pathophysiology, with in this ligament leading to and new proposed subtypes (e.g., involving anterior or bucket-handle along the SGHL), observed in about 5% of cases. At the tissue level, often begin with degenerative fraying of the superior (Type I lesion), characterized by irregular margins without full detachment, which is more prevalent in older patients due to age-related fibrocartilaginous wear and reduced vascularity. Progression to a Type II lesion involves partial or complete detachment of the superior and anchor, potentially extending inferiorly to involve the or contributing to glenohumeral through laxity in the anterior-posterior direction. In response to these insults, the labral tissue may exhibit inflammatory changes and attempted healing via fibrotic scarring, though poor blood supply limits regeneration, often resulting in persistent . Isolated SLAP tears alter glenohumeral by compromising the labrum's role in and humeral head centering, leading to increased translation and forces during , which can exacerbate superior of the humeral head. While frequently coexisting with tears or Bankart lesions, the isolated effects of a SLAP tear primarily manifest as disrupted biceps tensioning, impairing dynamic stability without necessarily causing gross instability. In older patients, degenerative SLAP changes often reflect cumulative microtrauma rather than acute events, with fraying progressing to detachment due to underlying and capsular attenuation.

Causes and Risk Factors

Acute injury mechanisms

Acute injury mechanisms for SLAP tears typically involve sudden, high-force events that disrupt the superior and biceps tendon anchor, often occurring in younger individuals engaged in sports or accidental falls. These traumatic incidents are particularly common among athletes under 40 years old, where immediate deep pain and mechanical symptoms like catching arise post-injury. One primary mechanism is a fall on an outstretched hand (FOOSH) with the shoulder in and external , generating compressive forces that drive the humeral head superiorly against the glenoid, compressing and detaching the superior through and compressive forces. This scenario is reported in about 50% of early SLAP tear series, commonly seen in like , , or where falls are frequent. Direct blows to the , such as those in contact sports like or , represent another key acute pathway, producing eccentric loading on the glenohumeral that shears the labral-biceps complex. In professional players, for instance, up to 83% of SLAP lesions stem from such direct impacts to the adducted against an opponent or surface. Sudden traction forces on the arm also precipitate tears by stretching the biceps-labral anchor, as occurs when abruptly pulling a heavy object, catching a falling body during a slip, or decelerating forcefully in throwing motions. These tensile loads are prevalent in occupational settings or activities like and , stressing the long head of the insertion.

Chronic overuse and risk factors

Chronic overuse injuries to the superior , leading to SLAP tears, primarily arise from repetitive overhead motions that impose cumulative microtrauma on the glenohumeral joint. Activities such as throwing in pitchers, freestyle swimming, and overhead generate high forces and tensile on the biceps-labral during the cocking and follow-through phases of motion. These forces cause progressive attrition of the labral without a single traumatic event, with pitchers particularly susceptible due to the extreme valgus loading and internal rotation velocities exceeding 7000 degrees per second. Degenerative risk factors play a significant role in the development of SLAP tears, especially in individuals over 40 years of age, where age-related labral thinning and chondromalacia contribute to tissue vulnerability. Occupational exposures involving repetitive overhead work, such as , tasks, or manual labor in , accelerate this wear through sustained eccentric loading on the superior . Middle-aged manual laborers exhibit a higher incidence of these degenerative changes, often compounded by underlying glenohumeral or prior subclinical microtrauma. Demographic factors further influence susceptibility, with males demonstrating approximately a 2:1 higher incidence rate compared to females, attributed to greater participation in high-risk overhead sports and occupational activities. Among athletes, those in overhead-dominated disciplines like face elevated risks, with up to 48% of pitchers showing lesions on , indicating a high prevalence of subclinical that may progress with continued exposure. Anatomical variations, such as a shallow or sublabral foramen, can exacerbate these risks by reducing joint congruence and increasing labral stress during repetitive motions. The progression of chronic overuse typically begins with Type I lesions characterized by irregular fraying and degeneration of the superior , which may remain stable for years under moderate load but evolve into Type II detachments with ongoing cumulative stress. This gradual shift occurs as repeated microtrauma weakens the labral attachment to the glenoid rim, potentially leading to and biceps anchor disruption without an acute inciting event.

Clinical Presentation

Symptoms

Patients with SLAP tears typically experience deep pain, often described as aching or sharp, located within the glenohumeral joint and potentially radiating to the anterior or posterior aspects of the or down the . This pain is frequently exacerbated by overhead activities, such as throwing, reaching, or lifting objects, and may worsen with pushing or pulling motions. Mechanical symptoms are common and include sensations of catching, popping, locking, grinding, or clicking during shoulder movements, which can create a feeling of instability or that the shoulder might "pop out of ." In athletes, particularly throwers, a "dead arm" sensation may occur after activity, accompanied by reduced throwing velocity or overall shoulder strength. Functional limitations often involve decreased and difficulty with daily activities or sports requiring arm elevation, leading to that interferes with sleep in more advanced cases. Symptom presentation varies: acute tears following present with sudden, sharp and immediate mechanical issues, while chronic tears from repetitive overhead use develop insidiously as a progressive ache, sometimes mimicking other shoulder conditions.

Physical examination findings

During physical examination for suspected SLAP tears, inspection may reveal asymmetry or in the affected , though these findings are nonspecific. often elicits tenderness over the superior glenohumeral joint line, , or , indicating possible involvement of the long head of the or . In severe cases, active and passive may be reduced, particularly in internal rotation, while overhead athletes may exhibit increased external rotation compared to the contralateral side. Several provocative tests are used to assess for lesions, though none are entirely diagnostic in isolation. The O'Brien active compression test involves flexing the to 90 degrees, adducting 10-15 degrees, and maximally internally rotating the while resisting a downward force; pain deep in the glenohumeral joint that decreases with external rotation suggests a positive result. This test demonstrates moderate sensitivity (approximately 67%) but low specificity (37%), limiting its ability to rule out other pathologies. The crank test is performed with the shoulder in 90 degrees of and 10 degrees of forward flexion, applying an axial load while passively rotating the ; reproduction of pain or a grinding indicates a labral abnormality. It has lower (around 46%) but fair specificity (72%), making it more useful for confirmation when combined with other maneuvers. Speed's test assesses involvement by having the patient flex the to 90 degrees with the elbow extended and supinated against resistance; anterior or bicipital groove pain is considered positive. Its is low (about 20%), though specificity reaches 88%, highlighting its role in supporting rather than confirming SLAP tears. The load and shift test evaluates associated glenohumeral by stabilizing the and applying an anterior or posterior load to the humeral head in the plane of the ; excessive translation or pain suggests labral compromise. While primarily for , it aids assessment with variable sensitivity (17-86% for similar maneuvers like anterior slide) and moderate specificity. Overall, these tests exhibit sensitivities ranging from 20% to 90% for SLAP tears but generally low specificity, with positive findings potentially occurring in asymptomatic overhead athletes due to overlapping biomechanics. Combinations of tests improve diagnostic utility, but clinical correlation with symptoms is essential.

Diagnosis

Imaging and diagnostic tests

Initial imaging for suspected SLAP tears typically begins with plain radiographs (X-rays) to evaluate for associated bony abnormalities such as fractures, Hill-Sachs lesions, or calcific deposits, though X-rays appear normal in isolated SLAP tears since the labrum is a structure not visible on these studies. Ultrasound serves as a non-invasive option for dynamic assessment of the long head of the biceps tendon, which may show instability or in SLAP-related cases, but its utility is limited for direct and confirmation of labral pathology due to challenges in the glenoid labrum's depth and orientation. Magnetic resonance imaging (MRI) is the primary non-invasive modality for evaluating structures in the , including the , with conventional non-contrast MRI demonstrating 85-95% sensitivity for detecting Type II tears, though specificity can vary based on field strength and protocol. MR arthrography, which involves intra-articular contrast injection to distend the and enhance labral contour definition, significantly improves diagnostic accuracy to 90-100% sensitivity and near-perfect specificity for SLAP tears by better delineating tear extent and associated anchor involvement. Higher-field 3-T MRI further enhances compared to 1.5-T systems, reducing partial volume effects in the superior labrum. Diagnostic remains the gold standard for confirming tears, providing direct visualization of the and biceps anchor under intra-articular conditions, with the ability to grade tear severity and assess concomitant ; it is particularly indicated when non-invasive yields equivocal results or in preoperative planning. Despite these advances, diagnostic challenges persist, including high rates of incidental findings on MRI in individuals—studies report 40-72% in middle-aged adults and 46-55% in overhead athletes—leading to potential false positives that necessitate correlation with clinical symptoms and examination findings. Additionally, MR arthrography involves procedural risks like or allergic to contrast, while conventional MRI entails higher costs and longer scan times, limiting accessibility in resource-constrained settings.

Classification of subtypes

SLAP tears are classified primarily using the system developed by Snyder et al. in 1990, which initially described four subtypes based on arthroscopic observations of the superior and biceps tendon anchor. This classification was built upon the initial description by Andrews et al., who identified superior labral injuries in overhead throwing athletes but emphasized posterior extensions in their variant scheme. The Snyder system has since been expanded to ten types by subsequent researchers, including Maffet et al. (1995) and others, to account for more complex anatomical variations. Type I SLAP tears involve degenerative fraying or irregular margins of the superior without detachment from the glenoid rim or involvement of the biceps attachment; these are often incidental and associated with aging. Type II tears, the most common subtype accounting for 41-55% of cases, feature detachment of the superior and the long head of the biceps anchor from the glenoid, creating at the biceps origin; subtypes include anterior-dominant (IIa) and posterior-dominant (IIb) variants. Type III lesions present as a bucket-handle tear of the superior that displaces into the , but with an intact biceps attachment, rendering it relatively stable. Type IV extends the bucket-handle configuration into the biceps itself, potentially causing tendon displacement or partial tearing. Extended classifications include Type V, a Type II tear continuous with an anterior-inferior , often linked to traumatic anterior instability; Type VI, a Type II variant with an unstable labral flap (anterior or posterior); Type VII, a Type II extension into the middle glenohumeral ligament and capsule; Type VIII, a Type II with posterior labral involvement (posterior SLAP); Type IX, a circumferential labral detachment around the glenoid; and Type X, a superior labral tear extending into the rotator interval or associated ligaments, frequently with pathology. Andrews' original scheme highlighted posterior emphasis, classifying isolated posterior superior tears (SLAP I), those extending anteriorly (SLAP II), and isolated anterior tears (SLAP III), influencing later refinements for posterior variants. Clinically, Type II tears are the most symptomatic, frequently requiring surgical intervention due to , , and mechanical symptoms in active patients, while Types I and III are often managed conservatively if . On MRI or MR arthrography, Type II appears as high-signal detachment between the and glenoid, correlating with the "displaced " sign for confirmation. This guides treatment by delineating anatomical involvement and stability, with higher types indicating greater complexity and potential for associated injuries.

Management

Conservative treatment

Conservative treatment serves as the initial approach for managing tears, particularly in cases where surgical intervention is not immediately warranted. It is indicated for type I tears, which involve fraying of the superior without detachment, as well as partial type II tears in non-athletic or low-demand patients who lack significant glenohumeral . This approach may also be considered following failed surgical repair in select patients seeking to avoid revision procedures. Success rates for range from 40% to 60% in low-demand individuals, with higher variability in athletes due to ongoing mechanical stress. Key modalities emphasize symptom control and functional restoration without operative measures. Patients typically begin with rest and short-term immobilization in a for 1 to 2 weeks to reduce acute pain and protect the labral-bicep complex from further irritation. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are commonly prescribed to alleviate pain and during this phase. forms the core of , progressing from passive range-of-motion exercises to targeted strengthening of the muscles and scapular stabilizers, aiming to improve dynamic stability and prevent compensatory patterns. Adjunctive options include intra-articular injections into the glenohumeral joint for refractory symptoms. injections provide short-term relief from inflammation and pain, typically lasting 3 to 6 months, while (PRP) injections may promote tissue healing in partial tears, though evidence for long-term efficacy remains emerging. Throughout treatment, activity modification is essential, with patients advised to avoid overhead or repetitive throwing motions to minimize labral stress and support recovery. A structured of conservative generally spans 3 to 6 months, with regular clinical monitoring to assess progress via levels, function, and . is defined by persistent symptoms, such as ongoing or mechanical , prompting referral for surgical evaluation; up to 50% of patients may ultimately require operative management if conservative efforts prove insufficient.

Surgical interventions

Surgical interventions for SLAP tears are typically indicated following failure of , particularly in patients with persistent pain, mechanical symptoms, or functional limitations despite nonoperative treatment. is the standard approach due to its minimally invasive nature, allowing visualization and treatment within the glenohumeral joint. Arthroscopic is commonly performed for Type I and Type III tears, where the procedure involves smoothing and resecting frayed or unstable labral edges to restore a glenoid rim without reattachment. This technique is suitable for , degenerative, or partial tears not involving significant biceps detachment, with reported success rates of 70-89% in alleviating symptoms and improving function. For Type II SLAP tears, particularly in young, active patients such as overhead athletes, arthroscopic labral repair is preferred to reattach the detached superior and anchor to the glenoid using suture anchors, typically 2-4 in number placed in a strategic . This method aims to restore the labral bumper and stability, with return-to-play rates around 73% in athletes following repair. In contrast, for older patients (>40 years) or cases with irreparable labral damage, tenodesis or is often utilized; tenodesis involves detaching and resecuring the long head of the to the , offloading the , while tenotomy simply releases the .00048-2/fulltext) tenodesis demonstrates high satisfaction rates of 87-93% and reliable pain relief in these populations. Open is rarely indicated for SLAP tears and is generally reserved for complex, multi-type lesions associated with extensive instability or concomitant injuries that cannot be adequately addressed arthroscopically. In such scenarios, biceps tenodesis procedures are integrated to reduce labral stress, achieving success rates of 85-95% in functional outcomes. Indications for emphasize patient-specific factors, including age, activity level, and tear chronicity; acute repairs performed within six months of symptom onset are associated with improved long-term functional outcomes and earlier return to activity compared to delayed interventions. Among overhead athletes, labral repair is favored over tenodesis to better preserve throwing mechanics and high-level performance.

Rehabilitation and Prognosis

Postoperative rehabilitation

Postoperative rehabilitation following SLAP tear surgery follows a phased approach to protect the repair, restore (), and progressively rebuild strength while minimizing the risk of re-injury. The protocol is tailored to the surgical technique, with labral repair requiring more cautious progression than biceps tenodesis, which allows earlier active loading due to reduced concern for labral disruption. Overall, compliance with these guidelines is essential to minimize the risk of re-injury. Phase 1 (0-4 weeks): This initial protective phase emphasizes to safeguard the surgical site, with the maintained in a for 3-4 weeks to prevent stress on the repair. Passive exercises are introduced early, limited to forward elevation below 90° and external rotation less than 30-45° in the scapular plane, to avoid while promoting gentle . and swelling are managed through (ice application) and nonsteroidal anti-inflammatory drugs (NSAIDs), alongside exercises for the scapular stabilizers to maintain muscle activation without active motion. No active or active-assisted is permitted, and patients are educated on avoiding any or reaching activities. Phase 2 (4-8 weeks): Transitioning to active-assisted , this phase focuses on gradually increasing shoulder mobility while continuing to protect the repair, with sling use discontinued by week 6. Exercises include cane-assisted flexion and pulley systems for elevation up to 120°, alongside isometric strengthening for the rotator cuff and scapular muscles to enhance . Resisted overhead activities are strictly avoided until at least 6 weeks postoperatively to prevent undue stress on the biceps-labral complex. Progress is monitored for pain levels below 4/10 and achievement of 120° forward elevation before advancing. Phase 3 (8-12 weeks and beyond): Full is prioritized, with active exercises progressing to resisted strengthening for the and scapular stabilizers using light bands or weights, aiming for symmetric motion compared to the uninvolved side. By 12 weeks, dynamic stability is improved through closed-chain exercises like wall pushes, and sport-specific training—such as interval throwing for overhead athletes—begins at 3-6 months once strength reaches 80-85% of the contralateral side and clearance is obtained. Variations in protocol depend on the surgical approach; SLAP repair typically mandates 6 weeks of and delayed biceps loading to allow labral healing, whereas biceps tenodesis permits earlier progression, with use limited to 3-4 weeks and resisted flexion starting at 6 weeks. Throughout all phases, therapists monitor compliance via regular assessments to mitigate re-tear risks, emphasizing gradual loading and avoidance of provocative maneuvers.

Outcomes and complications

The overall for patients with SLAP tears is favorable with appropriate , with 80-90% of individuals returning to prior levels of activity following surgical intervention such as arthroscopic repair or tenodesis. In athletes, success rates range from 70-85%, with higher return-to-play rates observed when is initiated early and is completed fully. Common complications after SLAP tear management include , which occurs in less than 1% of cases due to the minimally invasive nature of arthroscopic procedures. Postoperative stiffness affects 10-20% of patients and is typically managed with or manipulation under . Re-tear rates following repair range from 5-15%, particularly in overhead athletes, while biceps cramping or pain after tenodesis is reported in approximately 10% of cases. Several factors influence outcomes, including patient age, with poorer results in those over 40 years due to associated degenerative changes and lower tissue healing capacity. For type II tears, repair success is around 75%, compared to 90% with biceps tenodesis, which may offer superior durability in older or less active patients. Adherence to rehabilitation protocols significantly enhances recovery, as incomplete participation correlates with reduced return to prior function. Long-term follow-up reveals residual pain in about 20% of patients, often linked to incomplete or secondary . The need for revision arises in approximately 10% of cases, commonly for persistent symptoms or failure of the initial repair. Recent 2025 studies indicate that (PRP) as an adjunct to labral repairs improves metrics, such as labral and , leading to better functional scores at 12 months.

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