The socket of the shoulder (glenoid) has a cartilage rim that lines the periphery of the glenoid, called the labrum. This structure is important in shoulder stability. The labrum serves as the attachment site of the shoulder capsule, the ligaments, and the long head of the biceps tendon to the glenoid (one of the two upper biceps tendon attachments). The upper cartilage rim (superior labrum) is where the biceps tendon attaches. Injury to the superior labrum is called a SLAP lesion, which stands for Superior Labrum, Anterior to Posterior (front to back). This injury may be degeneration, a tear of the labrum or a pulling of the labrum off the glenoid, with or without the biceps tendon attachment being pulled off or torn. This is relatively common source of shoulder pain.

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How do SLAP lesions occur?

• Repetitive throwing motion
• Falling onto the outstretched arm
• Pulling of the arm
• Sudden force applied to the biceps while contracted
• Direct blow to the shoulder with the arm in a throwing position

What increases the risk?

• Contact sports (e.g., football or hockey)
• Overhead sports (e.g., baseball, tennis or volleyball)
• History of shoulder dislocation or subluxation
• Rotator cuff tear
• Poor physical conditioning (strength and flexibility)
• Inadequate warm-up before practice or play

What are the symptoms of SLAP lesions?

• Pain in the shoulder, worse with overhead activities and especially with follow through (after ball release)
• Usually no pain at rest
• Intermittent locking, clicking or snapping of the shoulder, often associated with pain
• Weakness reaching overhead
• Loss of velocity when trying to throw
• Feeling of the shoulder wanting to dislocate
• Pain, tenderness and weakness in the front of the shoulder with attempted elbow bending or rotation of the wrist, such as while using a screwdriver
• Clicking, popping or snapping sensation with activity

How is a SLAP lesion diagnosed?

• Diagnosis is established by history and physical exam

• Physical exam may be difficult because these lesions often occur in association with other shoulder problems, most commonly of the rotator cuff and/or shoulder instability

• Many tests have been described to detect this lesion, but none are 100percent accurate

• The most widely used is known as the “active compression” or O’Brien’s test, named for the physician who reported this physical exam maneuver. When this test is positive, it is suggestive of a SLAP lesion

Are there any special tests?

• MRI is probably the most widely used diagnostic imaging study to evaluate the superior labrum. However, variability in normal anatomy precludes diagnosis in many patients.
• The addition of contrast dye (Gadolineum) into the shoulder joint prior to imaging improves the sensitivity to detect this lesion, though variants of normal can still prevent accurate detection, with both false positives and false negatives.
• Diagnostic arthroscopy remains the gold standard, permitting direct visualization and probe palpation to discern biceps and superior labral attachment integrity. The importance of a careful history and physical exam however cannot be overstated, as even arthroscopy can challenge an inexperienced examiner due to wide variability in anatomy.

How is a SLAP lesion treated?

Non-operative treatment is indicated for most patients, who are able to successfully resume all pre-injury activities. Initial treatment consists of medication and ice to relieve the pain, stretching and strengthening exercises, and modification of the activity that initially caused the problem. These all can be carried out at home, although referral to a physical therapist or athletic trainer may be recommended. Often pain will persist, especially in throwers.

Operative treatment is performed in those patients whose history, exam and imaging studies suggest that the SLAP lesion is responsible for the patient’s symptoms.

Surgery is recommended if symptoms persist despite non-operative treatment. Surgery is performed arthroscopically to débride (clean and remove torn pieces and fragments) or to reattach the labrum back to the glenoid. Reattachment may be performed with tacks or sutures (thread). If repair is undertaken, immobilization is usually recommended after surgery to allow the labrum to heal to the glenoid.

Sometimes a SLAP lesion occurs in conjunction with other pathology. Arthroscopic evaluation influences the decision as to whether the lesion requires debridement (surgical clean-up) or repair.

What are the complications of treatment?

Possible complications of non-operative treatment include:

• Pain, mechanical symptoms, athletic impairment

Possible complications of operative treatment include:

• Surgical complications not specifically associated with SLAP repair, such as pain, bleeding (uncommon), infection (<1percent), nerve injury (uncommon), stiffness, and problems with anesthesia, are uncommon.

When can you return to your sport/activity?

Symptoms may resolve with conservative treatment and resting of the affected area. Often surgery is necessary. After surgery and immobilization, physical therapy may be recommended to regain shoulder motion and strength.

How can SLAP lesions be prevented?

• Appropriately warm up and stretch before practice or competition
• Maintain appropriate conditioning:
  • Shoulder and elbow flexibility
  • Muscle strength and endurance
  • Cardiovascular fitness
• Use proper technique when throwing or falling