Superior Labrum Anterior Posterior Lesions (SLAP lesions)

What is Superior Labrum Anterior Posterior Lesions (SLAP lesions)?

Superior labral anterior to posterior (SLAP) lesions are a type of injury commonly found in patients suffering from complex shoulder pain. This condition is often seen in young people who work in physically demanding jobs, athletes who use their arms overhead, like baseball or tennis players, and middle-aged people who do manual labor. These were first medically recognized by Dr. Andrews in 1985. Dr. Snyder later named them “SLAP lesions” because of where they occur in the shoulder and their typical tear patterns.

Initially, Dr. Snyder divided the SLAP lesions into four categories. Over the years, other medical experts further divided these into ten different types including those that are connected with another type of shoulder injury called Bankart injuries.

In recent times, improvements in diagnoses and surgical techniques have changed the approach to managing SLAP lesions. It is now understood that these injuries are not only limited to young athletes, but also can appear in various people with different relevance to their daily activities. Intriguingly, studies have shown that SLAP tears often show up on the MRI scans of overhead athletes who don’t have any symptoms. Therefore, doctors need to be cautious when diagnosing SLAP lesions, as they could be present with other shoulder conditions.

What Causes Superior Labrum Anterior Posterior Lesions (SLAP lesions)?

SLAP tears, or injuries to a part of the shoulder joint, can be caused by different things, and the exact reasons are still being discussed and studied. Yet, whatever the cause, people with SLAP tears usually tell their doctors about a sudden deep pain in their shoulder that comes with mechanical symptoms. This means that the shoulder might pop, lock, or catch while moving it in certain ways.

Acute Traumatic SLAP Lesions

If someone gets hurt due to a strong or sudden injury, it could cause a SLAP tear. These instances could involve falling onto an extended arm or being jerked suddenly. These are a few examples:

– Compressed injuries often occur with a sudden, blunt hit to the shoulder, like what might be experienced in a fall.
– Traction injuries could happen due to sudden pulling motions or after lifting heavy weights.
– Combined injuries involve a mix of the above.

Attritional SLAP Injuries

An injury called a Peel-back Mechanism might happen to athletes often using overhead motions, like throwers. Here, SLAP tears emerge slowly, with shoulder pain getting worse over time. During throwing, the arm position can cause extra force on a part of the shoulder, the biceps, and make the upper and back parts of a socket in the shoulder gradually peel away.

However, there is a debate on whether it’s the Peel-back Mechanism or the process of slowing down the throwing action that causes the harmful forces leading to the SLAP tears in these athletes.

Degenerative SLAP Lesions

Like your car tires wearing out over time, SNAP tears can happen due to the “wear-and-tear” of life, especially in older people. Workers who frequently use overhead motions might also develop them. These sorts of tears become more common for people over 40.

Then there are different kinds of SLAP tears – Types I to VIII.

– Type I SLAP Tear: Wearing down of a part of the shoulder joint occurs, but the attachment to the upper part of the socket (glenoid) is still okay.
– Type II SLAP Tear: This is usually due to sudden injury. The shoulder joint’s outer rim and a muscle in the upper arm (LHBT) get detached from the cavity of the joint.
– Type III SLAP Tear: This kind of tear doesn’t impact the LHBT and is very rare.
– Type IV: This type combines the pattern of Type III tear and impacts an area of the shoulder joint, leading to instability. Other types of SLAP tears might be related to instability and other injuries in the shoulder.

These are complex topics. So be sure to ask your healthcare providers to clarify anything you don’t understand. They can offer more specific explanations and treatments based on your own health history and situation.

Risk Factors and Frequency for Superior Labrum Anterior Posterior Lesions (SLAP lesions)

Our understanding of SLAP (Superior Labrum Anterior and Posterior) injuries is currently limited, as their diagnosis is still a subject of debate. It’s also been challenging to record their incidence rates, which are further complicated by the fact that a formal diagnosis code was only available from 2001. We have seen the most cases of SLAP injuries in people aged between 20-29 or 40-49. Additionally, we’ve learned that these injuries are prevalent in overhead athletes, like baseball players, even when they don’t have symptoms.

With improved technology, such as magnetic resonance imaging (MRI), we’ve been able to diagnose more SLAP injuries. However, the increase in detections has led to a surge in the number of SLAP repair surgeries due to uncertainty about the best ways to manage these injuries.

• Around the early 2000s, we noticed a rise in the number of SLAP repairs. For example, one study found that these procedures made up about 3% of shoulder cases in a large hospital.
• By 2008, the rate of SLAP repairs exceeded 10% of shoulder cases.
• Another study showed a 464% rise in the number of SLAP repairs in New York State from 2002 to 2010, indicating an increase in case volume from 765 to 4313 annually. The occurrence rate climbed from 4 to 22.3 per 100000 patients.

However, as we gained more knowledge about SLAP injuries from 2010 onwards, we’ve seen a decline in SLAP repair rates. It’s been crucial to distinguish between younger, active patients and older patients with degenerative SLAP tears due to repetitive overhead work. In one study from 2016, a decrease in SLAP repair rates was observed from 2004 to 2014, and the age of patients receiving these procedures also reduced.

In a 2015 study looking at the Defense Medical Epidemiological Database from 2002 to 2009, the adjusted annual incidence rate for SLAP lesions increased from 0.31 cases per 1000 person-years to 1.88 cases per 1000 person-years. This represents an average yearly increase of over 20%.

Despite some limitations in understanding, it’s generally agreed that SLAP tears account for 80% to 90% of labral pathology in the stable shoulder. They rarely occur alone and often accompany other shoulder issues. SLAP tears make up approximately 1% to 3% of injuries in sports medicine referral centers and are found in around 6% of shoulder arthroscopy procedures.

Signs and Symptoms of Superior Labrum Anterior Posterior Lesions (SLAP lesions)

If you’re experiencing continuous or recurring pain in your shoulder, it could be caused by a SLAP tear. SLAP, which stands for Superior Labrum Anterior and Posterior, is a type of shoulder injury. It’s often related to other shoulder conditions and doesn’t always have specific symptoms, which is why a thorough medical history is important to diagnose it.

There are several elements doctors will want to know about when assessing possible SLAP tears:

• Sudden, intense pain deep in the shoulder
• Mechanical symptoms like popping, locking, or catching during movement
• Prior instances of sudden, forceful jerks to the shoulder
• Any previous or current shoulder instability
• Participation in specific sports, especially those involving overhead motion such as volleyball, baseball, javelin, and swimming
• If the patient has manual labor or physically demanding jobs

Another similar condition involves the Long Head Biceps Tendon (LHBT), and might have symptoms like:

• Shoulder pain that starts gradually without a clear cause
• Pain that intensifies with overhead activities
• Pain radiating from the shoulder down the front of the arm
• Clicking or popping sounds near the shoulder
• Painful rest periods or sleep

Doctors also need to know about your job history, dominant hand, and past shoulder or neck injuries or surgeries.

During the physical examination, your doctor will exclude potential neck conditions that can mimic shoulder issues by checking your neck posture, muscle symmetry, tenderness, range of motion and looking for any signs of nerve dysfunction. They’ll also inspect both shoulders for any asymmetry, muscle loss, wounds, previous surgery marks, or skin infections. They’ll also check the movement of your shoulder blade.

Next, they will evaluate the active and passive range of motion in your shoulder, assess the function of the axillary nerve and muscle strengths, perform a detailed sensory examination, and further assess motor function of the elbow, wrist, and hand. In older people and patients with suspected underlying shoulder conditions, additional tests might be needed.

The doctor may also perform various tests based on your symptoms. Most of these tests involve positioning your arm in certain ways while you resist the doctor’s attempts to move it. A positive result in these tests would be pain or discomfort experienced in specific positions or movements. All these tests help in narrowing down the possibilities and arriving at a precise diagnosis.

Testing for Superior Labrum Anterior Posterior Lesions (SLAP lesions)

If you’re experiencing acute or long-term shoulder pain, it’s necessary to use radiographic imaging to diagnose the cause.

Radiographs

A specific type of x-ray called a true anteroposterior (AP) image is used. This scan shows a clear picture of the shoulder joint and is often referred to as the “Grashey” view. To take this image, you will be asked to position yourself at an angle between 30 and 45 degrees. Other positions that may be used for the x-ray include the axillary lateral view and “scapular Y”/outlet views, which provide different angles for assessing your shoulder.

Advanced Imaging

Magnetic Resonance Imaging (MRI) and Magnetic Resonance Arthrography (MRA) are advanced techniques used to detect deeper issues in the shoulder, such as a SLAP lesion, which is a tear in one of the shoulder’s ligaments. These imaging methods use a substance called contrast media and certain positions of the arm to improve their sensitivity and accuracy.

However, it’s important to remember that these advanced techniques may potentially identify SLAP lesions that don’t cause symptoms or contribute to your pain. Therefore, it’s important for doctors to consider carefully before deciding to order these specific imaging methods.

There are common anatomical variations in overhead throwers which appear on MRI but don’t cause any pain. Also, MRI scans often document SLAP lesions in up to 72% of middle-aged people who don’t have any shoulder symptoms. Therefore, doctors should exercise caution and not rush to the conclusion that the labrum (a part of the shoulder joint) is the cause of the patient’s pain.

It’s also important to know that other conditions like shoulder impingement (a condition where the shoulder bones rub together), rotator cuff syndrome (an issue with the group of muscles and their tendons that stabilize the shoulder), tendinitis of the long head of the bicep tendon (LHBT), and arthritis in the acromioclavicular (AC) joint (the joint at the top of the shoulder), are all common causes of pain in the middle-aged population.

Therefore, doctors should avoid focusing solely on the potential presence of a SLAP lesion and consider other potential causes of shoulder pain. This is particularly true for young athletes – a study in 2005 found that 93% of professional handball players had abnormal shoulder appearances on MRI, but only 37% actually had symptoms.

Treatment Options for Superior Labrum Anterior Posterior Lesions (SLAP lesions)

It’s important to recognize that not all SLAP (Superior Labrum Anterior and Posterior) shoulder tears are the same. The relevance of the SLAP tear to the patient’s pain and dysfunction should be the main focus. If the SLAP tear doesn’t cause symptoms, watching and waiting can be the right approach. However, if the tear is contributing to symptoms, surgery may be necessary. The recommended procedure can vary depending on the specifics of the SLAP tear and if there are any other shoulder problems present. Still, it’s crucial to note that non-surgical treatments are usually the first line of action for most SLAP injuries.

Non-surgical treatments may include anti-inflammatory medications, applying cold (cryotherapy), rest and modifying activities. A period of rest should be recommended after the injury. Anti-inflammatory drugs and applying cold, like an ice pack, can help manage pain. Athletes and workers whose jobs involve overhead work should follow a specific program to manage their work or sports activities, and workers should make necessary changes to their work routines.

Physical therapy can be an essential aspect of treatment. The goal is to address any underlying shoulder issues that were present before the injury occurred. Training to improve the sense of joint position and movement (proprioception) can help avoid re-injury. Issues like scapulothoracic dyskinesia, a movement disorder of the shoulder blade and thoracic spine, and shoulder joint capsule tightness, should be addressed with special stretching and strengthening exercises. Using specific physical therapy programs can help ensure the effective management of each SLAP tear, reducing the risk of poor patient outcomes. Studies have shown that high-level athletes can have similar outcomes with surgical and non-surgical treatments when they focus on addressing shoulder blade movement disorders and internal rotation deficits. Surgery could be considered when non-surgical treatments don’t relieve symptoms that interfere with sports activities or daily life routines.

When non-operative treatments don’t offer relief, and symptoms persist, surgical management can be considered, keeping in mind the patient’s age, any concurrent diseases, functional needs, job demands, and sports-specific goals. There are various proposal based on the type of SLAP tear for surgical treatment. Hence, it’s crucial to determine whether the labrum alone is causing the patient’s symptoms and understand how to treat a SLAP tear in light of other associated injuries. For instance, in older patients with or without a torn rotator cuff, repairing the SLAP tear can lead to worse results compared to those who choose not to have surgery or perform a bicep tenodesis/tenotomy due to stiffness, persistent pain, and the need for revision surgery. However, in younger patients who have shoulder instability, the SLAP tear could be a contributing factor to symptoms, especially when there is also a front and/or back labral tear.

There are various proposed surgical treatments according to the specific type of SLAP tear, including (I) type-1 tear — arthroscopic debridement (using a thin tube with a light and camera to clean the joint), (II) type-2 tear — SLAP repair or bicep tenotomy/tenodesis (cutting or reattaching the tendon), (III) type-3 tear — SLAP repair or resection (removing tissue), (IV) type 4-tear with less than 50% biceps involvement can consider SLAP repair/resection, while more than 50% biceps involvement may consider tenotomy/tenodesis, and so on.

Multiple SLAP repair techniques have been previously described with a wide array of options based on the surgeon preference. After diagnosing the SLAP tear by probing, unstable flaps of tissue that are deemed irreparable can be removed using a shaver. The preferred locations for the anchor (a small metal device that provides a mechanism for reattachment) depend on the main areas of instability relating to the superior labral-biceps tendon complex.

What else can Superior Labrum Anterior Posterior Lesions (SLAP lesions) be?

If you have persistent pain in your shoulder, it can be due to a variety of reasons. Here are some potential causes for the pain:

• Impingement: This can be external or internal, due to calcified tendons or conditions like SLAP lesions, GIRD, little league shoulder, or posterior labral tears.
• RC Pathology: It includes different types of tears in the shoulder such as partial or full-thickness tears, and Rotator Cuff Arthropathy (RCA).
• Degenerative Conditions: These include advanced Degenerative Joint Disease (DJD) associated with Rotator Cuff Arthropathy (RCA), arthritis of the glenohumeral joint, adhesive capsulitis, Avascular Necrosis (AVN), or a condition called Scapulothoracic crepitus.
• Proximal Biceps Issues: These can be a subluxation often seen with subscapular injuries, tendonitis, tendinopathy, or SLAP tears.
• AC Joint Conditions: Including AC joint separation, osteolysis of the distal clavicle, or arthritis in AC joint.
• Instability: This can be a unidirectional instability related to a specific injury or dislocation, or a multidirectional instability (MDI). There can be associated labral injuries or pathologies.
• Neurovascular Conditions: Includes conditions like Suprascapular neuropathy which can be associated with a paralabral cyst at the spinoglenoid notch, scapular winging (either medial or lateral), brachial neuritis, Thoracic Outlet Syndrome (TOS), or Quadrilateral Space Syndrome.
• Other Conditions: These can be Scapulothoracic dyskinesia, a condition called Os acromiale, muscle ruptures (like pectoralis major, deltoid, or latissimus dorsi), or fractures due to acute injury or pain arising from long-standing deformities, malunion, or nonunion.

What to expect with Superior Labrum Anterior Posterior Lesions (SLAP lesions)

Although there isn’t a wealth of top-tier research available about the outcomes of type II SLAP (a type of shoulder injury) repairs using arthroscopic surgery (a method of minimally invasive surgery), many studies suggest that the procedure can yield good outcomes in the right patients. Some authors have also reported that athletes, even those whose sports involve a lot of overhead arm motion, have fared well after the procedure.

However, it’s important to be aware that results may not be as positive in circumstances like subsequent repair surgeries or among high-level athletes, such as professional overhead athletes. For instance, professional baseball pitchers have shown less favorable outcomes in terms of returning to the game and to their previous performance level after surgery. In fact, better outcomes have been reported for these specific types of athletes when they opt for non-surgical treatments instead.

Possible Complications When Diagnosed with Superior Labrum Anterior Posterior Lesions (SLAP lesions)

When discussing patient expectations for a surgery, it’s important to talk about some of the risks that could potentially lead to future surgeries. These risks are essential to understand as they may increase the chance of further complications like pain, stiffness, and difficulty moving. A study in 2017 analyzed nearly 5000 patients and found the following risk factors that could lead to an additional surgery after SLAP (superior labral tear from anterior to posterior) repair:

• Being over 40 years old
• Being female
• Being overweight or obese
• Smoking
• Having a type of shoulder inflammation or wear and tear due to aging known as LHBT (long head biceps tendon) tendinitis or tendinosis. Specifically, the likelihood of an additional surgery was 5.1 times higher if there was tearing or fraying of the LHBT, and 3.5 times higher if there was tendinitis alone of the LHBT.

Recovery from Superior Labrum Anterior Posterior Lesions (SLAP lesions)

In the first month after your operation, you will typically need to wear a sling to keep your shoulder steady. During this time you can do some gentle ‘pendulum’ movements with your arm, and some exercises to help the muscles around your shoulder blade. You will also be encouraged to move your arm up and down, but how much you do this may vary depending on your doctor’s advice. However, remember to avoid any extreme stretching or rotating of your arm.

Between your fourth and sixth week after surgery, you should begin including more active range of motion (ROM) exercises, which means you actively move your arm in different directions. Just make sure you still avoid any extreme stretching or rotating of your arm.

From the sixth week to the third month, functional exercises and light strengthening can gradually be included in your routine to rebuild your muscle strength. After the two months mark, it is safe to begin exercises that strengthen your bicep muscles. This could involve flexing your elbow against some resistance or twisting your forearm while resisting the twist.

After three months, you can move on higher levels of strength exercises and sport-specific movements. Typically, you can expect to return to your sport around six months post-surgery.

Preventing Superior Labrum Anterior Posterior Lesions (SLAP lesions)

If a patient is worried about possibly having a SLAP tear – which is damage to the ring of cartilage in your shoulder joint called the labrum – they should be informed about the latest understandings we have about these kinds of injuries. Also, sometimes patients will come to us with an MRI report that says a SLAP tear was found in the scan. In these cases, it’s important to reassure the patient and explain that a lot of the time, these reported SLAP tears are “incidental” or “clinically irrelevant.” This means they might not be the main cause of your shoulder pain.

Meticulous attention should be paid to accurately figure out all possible underlying issues affecting the shoulder girdle – the bones in your body that allow your shoulder and arm to move. This careful scrutiny will help us to develop the best plan for treating your specific situation.