Superior Labral Tear of the Shoulder (Shoulder SLAP tear)

Diagnosis: Superior Labral Tear of the Shoulder (Shoulder SLAP tear) 

Clinical Keywords: labrum, biceps, throwing, tear 

Clinical Problems:  

1. Superior labral tears can be a source of pain, especially in athletes that throw overhead, like baseball players
2. SLAP tears can be difficult to diagnose accurately

What is a SLAP tear? 

The term “SLAP tear” stands for Superior Labrum Anterior to Posterior tear.  

The L in SLAP refers to the labrum in your shoulder, a ring-like, cushioning structure that encircles the cup of the shoulder joint. This cushion helps your upper arm bone remain properly positioned in its socket. 

In addition, one of the two tendons of the biceps attaches to the top of the labrum. 

The S in SLAP stands for superior, referring to the top of your labrum. This is the part of the labrum where the biceps tendon attaches.  When the biceps tendon pulls on the superior part of the labrum, it can pull the labrum off of the part of the shoulder blade where the labrum normally attaches.  This injury can cause pain when the shoulder moves around or when the biceps pulls on the labrum, such as when throwing or doing other overhead activities. 

Shoulder SLAP tears are often the result of sudden injuries sustained during sports, but they can also occur over time as you age.  

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Pathology  

SLAP tears are caused by damage to the superior glenoid labrum, where the tendon of long head biceps attaches. They can extend into the tendon, affecting other areas such as the glenohumeral ligaments or other portions of the labrum. 

Etiology 

They are most frequently seen in people who fall onto an outstretched arm or in athletes participating in throwing sports.  

The age of the patient can be related to the health of the superior labrum, as it becomes less firmly attached to the glenoid in people over 35. And between the ages of 30 and 50, the superior and anterior-superior regions of the labrum are more susceptible to tears. 

Classification  

The different types of shoulder SLAP tears can be classified as follows: 

• type I: fraying along the edge of the superior labrum. 
• type II: complete or partial detachment of the superior labrum from its attachment point on the superior part of the glenoid bone. 
• type III: bucket handle tear of the superior labrum without extension into the bicep tendon. 
• type IV: bucket handle tear of the superior labrum with extension into the bicep tendon.  

Despite the fact that a number of other categories of SLAP tears have been described, these injuries are typically combinations of SLAP tears with injuries to other parts of the labrum or other structures, and these are usually described rather than being given a numerical classification. 

Radiographic Diagnostics  

Best Imaging Study: MRI or MR arthrogram   

Secondary Imaging Study: CT arthrogram 

 Because SLAP tears resemble other shoulder disorders, such as instability and rotator cuff problems, they can be difficult to diagnose. 

The medical history is an important part of the diagnosis and may be suggested by an acute injury such as falling on an outstretched hand, pulling suddenly, or during overhead throwing. Ongoing pain or a loss of velocity during a throwing motion or other overhead activities can also suggest a SLAP tear.   

Physical examination tests have not been shown to be reliable or very accurate in diagnosing SLAP tears. Usually, the diagnosis depends on imaging of the shoulder. 

The investigation of choice is an MR arthrogram, which uses fluoroscopy and SLAP-tear MRI images to specifically diagnose injuries in the joint structures. They have been reported to have an accuracy ranging from 75% to 90% on average, although distinguishing between the subtypes tends to be difficult. 

On an MRI, a SLAP tear is diagnosed when the top part of the labrum appears to be detached from its normal bone attachment. A SLAP-tear shoulder MRI may be performed without or with an injection of contrast material (dye) into the shoulder joint to help highlight the structures. 3T MR imaging allows very high-resolution images and results in more accurate diagnoses of SLAP tears when compared with 1.5T MRI. 

Complications and treatment 

Complications: pain, especially with overhead sports  

Treatment: Over-the-counter pain medications, physical therapy, steroid injections, surgery 

How are SLAP tears treated? 

The course of SLAP-tear treatment is typically determined by first making the diagnosis and then considering the impact that your symptoms have on your desired activities. Your doctor might recommend non-surgical therapies as a first step and only consider surgery if those fail.   

Common treatments include: 

• Resting the shoulder to reduce pain and inflammation. 
• Physical therapy to strengthen the muscles around your shoulder joint and decrease pain. 
• Medications such as anti-inflammatory drugs, which can help reduce swelling and pain. 
• Cortisone shots can also be used to reduce pain, inflammation and swelling. 
• Debridement is a procedure that removes some of the damaged tissue from your shoulder joint. 
• Arthroscopic labral surgery which can be done to reattach/repair a torn labrum to the bone 
• Bicep tenodesis is surgery performed to release the tension of the tendon that connects your biceps muscle to the superior labrum and, in this way, reduce repetitive pulling and pain. 

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