Updated: 1/8/2023

SLAP Lesion

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  • summary
    • A SLAP lesion (Superior Labrum from Anterior to Posterior tear) generally occurs as result of overuse injury to the shoulder in overhead athletes or traumatic falls in older patients and can result in deep shoulder pain and biceps tendonitis. 
    • Diagnosis generally requires MRI studies to assess the superior labrum and the integrity of the biceps tendon.
    • Treatment may be nonoperative or operative depending on patient age, activity levels, severity of symptoms and associated instability. 
  • Epidemiology
    • Incidence
      • uncommon injuries, account for less than 5% of all shoulder injuries
    • Demographics
      • dominant shoulder of overhead and throwing athletes
    • Risk factors
      • glenohumeral internal rotation deficit
  • Etiology
    • Pathophysiology
      • mechanisms of injury
        • repetitive overhead activities (often seen in throwing athletes)
        • fall on outstretched arm with tensed biceps
        • traction on the arm
      • pathoanatomy
        • in throwers may be due to tightness of the posterior-IGHL which shifts the glenohumeral contact point posterosuperiorly and increases the shear force on the superior labrum
        • SLAP lesion increases the strain on the anterior band of the IGHL and thus compromises stability of shoulder
    • Associated conditions
      • internal impingement
      • GIRD
      • rotator cuff tears (usually articular sided)
      • instability (may be subtle)
      • scapular dyskinesis
  • Anatomy
    • Anatomy of glenohumeral joint
    • Variant anatomic anatomy
      • variable anatomic relationships extremely common in the glenohumeral joint
      • recognition of these critical but often challenging
    • Biceps
      • anatomy
        • long head of biceps tendon most commonly has 50% fibers attaching to labrum and 50% to supraglenoid tubercle
          • tubercle located over 6mm medial to glenoid surface
        • biceps tendon attachment on glenoid (Tuoheti classification)
          • Type I - completely posterior
          • Type II - predominantly posterior
            • Type I and II together comprise >70%
          • Type III - anterior + posterior (25%)
          • Type IV - anterior (5%)
        • most common pattern of biceps tendon attachment to the superior labrum is posterior to the 12 o'clock position
      • blood supply
        • poorest tendon blood supply while traversing through joint
      • function
        • contributes to torsional and horizontal stability during late-cocking phase of throwing
    • Glenoid labrum
      • function
        • chock block to subluxation
      • composition
        • composed of fibrocartilaginous tissue
      • blood supply
        • from suprascapular, circumflex scapular, posterior humeral circumflex arteries
        • labrum receives blood from capsule and periosteal vessels and not from underlying bone
        • anterior-superior labrum has poorest blood supply
      • stability
        • superior labrum
          • attaches further (medial) from glenoid rim than rest of labrum
          • anchors biceps tendon and is weak link that leads to SLAP lesion
      • anatomic variants
        • sublabral recess/foramen
          • can be confused with a tear on MRI
        • sublabral recess/foramen with thickened MGHL
        • meniscoid appearance (1%)
        • Buford complex
          • cordlike MGHL with associated bare area of the anterosuperior labrum
          • repair of Buford complex to glenoid will result is significant loss of external rotation
        • superior attachment of MGHL on glenoid
  • Classification
      • SLAP Classification
      • Type
      • Description
      • I
      • Labral and biceps fraying, anchor intact (11% of cases)
      • II
      • Labral fraying with detached biceps tendon anchor (41% of cases)
      • III
      • Bucket handle tear, intact biceps tendon anchor (33% of cases)
      • (Biceps separates from bucket handle tear)
      • IV
      • Bucket handle tear with detached biceps tendon anchor (15% of cases)
      • (Biceps remains attached to bucket handle tear)
      • V
      • Type II + anteroinferior labral extension (Bankart lesion)
      • VI
      • Type II + unstable flap
      • VII
      • Type II + MGHL injury
      • VIII
      • Type II + posterior extension
      • IX
      • Circumferential
      • X
      • Type II + posteroinferior extension (reverse Bankart)
    • Snyder Classification: Original classification which includes Types I-IV
    • Maffet sub-classification: Includes the original I-IV and added Types V-VII
    • Significant inter-and intra-observer varaibility when designating classification for SLAP tears
  • Presentation
    • History
      • feeling "pop" sensation in shoulder during overhead activity or traumtic event
    • Symptoms
      • location
        • vague deep shoulder pain
      • timing
        • often a lag between the time of injury and the onset of symptoms
      • mechanical symptoms of popping and clicking
      • weakness, easy fatigue, and decrease athletic performance
    • Physical exam
      • inspection
        • evaluate scapular position and muscle atrophy
      • palpation
        • bicipital groove tenderness
      • motion
        • pop may be reproduced during overhead range of motion
        • particular attention to internal rotation and total rotational arc of motion
        • always compare to contralateral side
      • neurovascular
        • atrophy of supra- and/or infraspinatus due to suprascapular neuropathy
      • provocative tests
        • there is no one specific test for SLAP lesions
        • biceps provocation tests
          • Speed's test
          • Yergason's test
          • Kim biceps load test
        • SLAP lesion tests
          • active compression test (O'Brien's test)
          • crank test
            • arm placed in full abduction and humerus loaded and rotated
          • dynamic labral shear test
          • Kibler anterior slide test
        • apprehension positive in 85% of patients
  • Imaging
    • Radiographs
      • findings often normal
    • MRI +/- arthrogram
      • indications
        • high suspicion for labral tear
      • findings
        • T2 signal intensity between the superior labrum, lateral to glenoid rim, and posterior to the biceps
        • sensitivity ~50% and specificity ~90% which increases with arthrogram
        • may see an associated paralabral ganglion cyst, which is highly specific for labral tear
          • usually in the spinoglenoid notch
  • Treatment
    • Nonoperative
      • rest from sports followed by physical therapy and NSAIDs
        • indications
          • first line of treatment
          • address GIRD if present
          • rehab focusing on scapular dyskinesia and rotator cuff strengthening for all patients
    • Operative
      • arthroscopic debridement
        • indications
          • Types I, III, and IV tears involving <1/3rd of the biceps tendon, causing severe symptoms that have failed nonoperative management
      • arthroscopic debridement with repair of the labrum/biceps versus debridement with biceps tenotomy/tenodesis
        • indications
          • highly controversial
          • Type 2 tears traditionally repaired in overhead athletes
            • return to play rates after SLAP repairs are significantly lower for pitchers compared to non-pitchers
          • general consensus bodes for tenotomy/tenodesis among those over 40 years of age
      • arthroscopic debridement with repair or debridement of the labrum with biceps tenotomy/tenodesis
        • indications
          • Type IV tears with >1/3rd of the biceps tendon involved, causing severe symptoms that have failed nonoperative management
  • Techniques
    • Arthroscopic debridement versus stabilization of the labrum and biceps tendon versus tenotomy/tenodesis
      • approach
        • standard arthroscopic approach to the shoulder
      • soft tissue
        • look for erythema and tearing under labrum to differentiate from normal recess
        • "peel back" test shows "peel back" of the labrum with 90° of external rotation and abduction
        • debride loose flaps of labrum/biceps
        • decompress any cysts
      • SLAP repair
        • utilize accessory or percutaneous portals as necessary for anchor placement near glenoid rim
        • sutures placed depending on tear anatomy
          • traditionally, sutures placed anterior to biceps anchor place patient at increased risk of stiffness post-operatively
      • biceps tenotomy/tenodesis
        • tenotomize biceps near attachment to labrum with arthroscopic scissors or shaver device
        • tenodesis may be done all-arthroscopically or through mini-open incision
        • variety of tenodesis devices used for biceps fixation into proximal humerus
      • rehabilitation
        • week 1-4
          • passive and active assisted flexion in the scapular plane
          • avoid extremes of abduction and external rotation, and resisted biceps exercises
        • week 4-6
          • progress to active ROM, isometrics
        • week 6-12
          • functional exercise and light strengthening
        • week 12+
          • advance strength and ROM, sport-specifics
          • typical return to sport around 6 months
  • Complications
    • Stiffness
      • incidence
        • most common complication following SLAP repair, around 78% of all patients
      • risk factors
        • incidental SLAP lesions repaired in older patients (>45 years) having arthroscopic rotator cuff repair
      • treatment
        • early passive and active assisted range of motion (pendulum) exercises begun 1 week following repair
        • if stiffness does not resolve with physical therapy, capsular release is indicated
    • Suprascapular nerve injury
      • overdrilling the glenoid can injure the suprascapular nerve
    • Failed SLAP repair and persistent symptoms
      • many causes including articular cartilage injuries, hardware failure and anchor pullout
      • failures associated with age >36 years
        • biceps tenodesis better option in this age group
  • Prognosis
    • Return to Play
      • variable and unpredictable rates of return among elite-level throwers

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Technique Guides (1)
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Questions (16)

(OBQ18.220) A 55-year-old male patient presents with right shoulder pain that is worse with overhead activity. The patient works as a computer programmer and is a recreational swimmer and has noted worsening pain with his breaststroke. Figure A is the coronal T2 MRI arthrogram of the affected shoulder. The patient decides to undergo an arthroscopic repair. What factor is associated with repair failure?

QID: 213116

Recreational swimmer



Age greater than 36 years



Male gender



Sedentary career



Snyder type 2 lesion



L 4 A

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(OBQ13.101) Figure A is the MR image of the left shoulder of an active 47-year-old painter who has been experiencing shoulder pain for 9 months. In addition to the finding shown in Figure A, MRI examination of the intra-articular portion of the biceps tendon shows fraying greater than 50%. He has not obtained relief from an 8 month course of non-operative management including non-steroidal anti-inflammatory medications, physical therapy and corticosteroid injection. What is the best next step in treatment?

QID: 4736

New course of physical therapy



Activity shutdown with 6 weeks sling immobilization



Arthroscopic superior labrum anterior to posterior (SLAP) tear repair



Arthroscopic debridement and possible biceps tenotomy versus tenodesis



Arthroscopic rotator cuff repair and acromioplasty



L 2 B

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(OBQ12.110) Which of the following rehabilitation exercises is most appropriate immediately following the repair of the injury seen in figure A?

QID: 4470

Passive external rotation at 90 degrees of abduction



Isotonic rotator cuff strengthening



Isokinetic resistive elbow flexion



Passive and active assisted flexion in scapular plane



Concentric latissimus pull down exercises



L 3 C

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(OBQ12.1) Figure A is an arthrosopic image from a right shoulder in the lateral decubitus position as viewed from the posterior portal. Which one of the following rehabilitation techniques should be avoided in the patient that is 2 weeks post-operative from the surgical repair shown in Figure A?

QID: 4361

Active assisted elevation in the scapular plane



Passive forearm pronation



Passive external rotation at 90 degrees of abduction



Open chain passive elbow flexion



Passive assisted elevation in the scapular plane



L 3 B

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(SBQ11OS.43.1) A 47-year-old man presents to your clinic with chronic persistent deep-seated right shoulder pain. He is able to perform most daily activities but experiences sharp shooting pain within the anterior aspect of the shoulder whenever he thows a baseball with his son. His primary care physician referred him to physical therapy first, which resulted in limited improvement in his symptoms, but he remains dissatisfied. Examination reveals symmetric rotator cuff strength and no instability. Speed's and O'brien's tests are positive. His MRI is shown in Figure A. Which of the following is correct with respect to the pathologic structure?

QID: 213843

Anchors the biceps tendon in a predominantly anterior position



Supplied by a single arterial source



The anterior superior portion is most susceptible to vascular insufficiency



Degeneration usually leads to cyst formation within the suprascapular notch



Repair should be accompanied by post-operative limitation in abduction and internal rotation



L 1 C

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(OBQ10.46) What percent of shoulders have a posterior or posterior dominant attachment of the long head of the biceps onto the glenoid?

QID: 3134
















L 4 D

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(OBQ10.37) A 26-year-old outfielder undergoes arthroscopic repair of a right shoulder type 2 SLAP tear with two labral anchors in the 11 and 1 o’clock positions. Postoperative rehabilitation for this SLAP repair should include:

QID: 3125

Immediate full active range of motion that simulates sport-specific activities



Full-time sling wear with no active nor passive motion for at least 6 weeks until labral tissues heal



Rotator cuff strengthening by post-operative week two to prevent disuse atrophy and shoulder instability



Limited passive motion for 4 weeks then progressive active motion until 8 weeks followed by sport specific strengthening until at least 12 to 16 weeks postoperatively



Eccentric open chain biceps contraction exercises beginning at postoperative week 2 to retrain the biceps muscle and stimulate SLAP healing at the biceps anchor on the glenoid



L 1 C

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(SAE07SM.81) Medial dislocation of the long head of the biceps tendon in the shoulder is most commonly caused by a

QID: 8743

tear of the subscapularis tendon.



tear of the supraspinatus tendon.



tear of the transverse ligament.



type I SLAP tear.



congenitally shallow bicipital groove.



L 2 E

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(SAE07SM.12) Which of the following is considered an advantage of arthroscopic distal clavicle excision compared with open distal clavicle excision?

QID: 8674

Fewer complications



Lower infection rate



Evaluation of the glenohumeral joint



Preservation of the inferior acromioclavicular ligament



Decreased surgical time



L 3 E

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(OBQ04.40) Which of the following best describes a Buford complex?

QID: 101

Normal anatomic variant characterized by a cord-like MGHL and an absent anterosuperior labrum



Normal anatomic variant characterized by a cord-like SGHL and an absent posterosuperior labrum



Abnormal arthroscopic finding characterized by a cord-like MGHL and an absent anterosuperior labrum



Abnormal arthroscopic finding characterized by a cord-like SGHL and an absent posterosuperior labrum



Normal anatomic variant characterized by a cord-like MGHL and a sublabral foramen at the anterosuperior labrum



L 4 D

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(OBQ04.236) A 32-year-old overhead athlete catches himself with his right hand while slipping on ice and injures his right shoulder. He fails to improve with therapy, anti-inflammatory medicines, and rest. His MRI is demonstrated in Figure A. What is the most likely diagnosis?

QID: 1341




SLAP tear









Loose body



L 3 D

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Evidence (33)
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