The shoulder has the most range of motion of any of the major joints in the body. Maintaining stability in this highly mobile and versatile joint requires a finely tuned combination of many structures in the athlete. The socket (glenoid), the cartilaginous rim around the socket (labrum), the capsular ligaments, and the rotator cuff muscles all play a role in stability.
A frequent cause of pain or instability of the throwing shoulder is a labral tear. A particular kind of labral tear involving the superior labrum is a SLAP (Superior Labrum Anterior to Posterior) tear. This tear originates where the long head of the biceps tendon attaches to the labrum and glenoid.
SLAP tears can be traumatic, from overuse, or degenerative. Repetitive forces such as those seen with overhead and/or throwing athletes are frequently responsible for SLAP lesions. Other common mechanisms of injury include blows to the shoulder, a fall on an outstretched arm, seatbelt/shoulder harness injuries, or heavy lifting. People with a SLAP tear often feel a deep-seated pain often referred to the back of the shoulder. But depending on the extent of biceps involvement can be felt anteriorly as well. Sudden movements or extremes of motion, especially outwards and upwards as in throwing, often bring on the pain. Occasionally, catching sensations or instability symptoms are also felt.
Diagnosis of a SLAP tear in the Throwing Shoulder
A thorough history and physical exam can usually lead the clinician suspect a SLAP tear. Maneuvers are often performed in clinic that load the biceps/ labral complex to see if the symptoms are reproduced. Often plain x-rays are taken in the office to attempt to identify any abnormality in the architecture of the bone that can lead to pain. If the history and physical exam suggests a SLAP tear, often an MRI is performed. Your doctor may order an MRI with and injection of dye placed in the shoulder to get a better image of the biceps labral complex.
Treatment of a SLAP tear in the Throwing Shoulder
Many SLAP tears will respond to conservative treatment including rest, anti-inflammatory medications and physical therapy. However, it is frequent for larger tears brought on by significant trauma to require arthroscopic surgery in order to get symptom relief. In patients who experience continued symptoms despite conservative treatment, arthroscopic surgery may be recommended.
Different surgical procedures may be performed to treat SLAP tears and it is important to understand that SLAP tears are often seen in conjunction with other shoulder problems, such as instability or rotator cuff tears. If this is the case, these other conditions may influence how the SLAP lesion is dealt with and treated.
Debridement for a SLAP tear
For minor tears that do not involve the biceps tendon, torn or frayed portions of the labrum are trimmed away in order to leave a smooth edge, which is less likely to cause catching or irritation in the joint. This might be performed if the torn area is relatively stable or has a small loose flap.
Repair of a SLAP tear
In younger, healthy patients with traumatic labral lesions who have failed extensive non-operative treatment, a labral repair can be performed. This usually involves the use of suture anchors to reattach the SLAP tear to the edge of the socket (glenoid.)
Biceps tenodesis for a SLAP tear
If significant tearing or degeneration of the biceps is present, biceps tenodesis is often done. This involves excising the diseased portion of the tendon and re-attaching the remaining healthy tendon either to adjacent soft tissue or to bone. This also removes the biceps forces from the superior labrum, thereby reducing pain. Recovery and rehabilitation from a biceps tenodesis is typically less lengthy than that following a labral repair.
Rehabilitation after SLAP tear surgery
Recovery after shoulder surgery depends on many factors, including the presence or absence of concomitant injuries/procedures. Recovery from a SLAP repair typically involves the use of a sling/immobilizer for approximately six weeks to protect and rest the repaired tissues. Gentle range of motion and stretching exercises are prescribed to discourage stiffness. After approximately six weeks and once the initial healing has taken place, a therapy program is instituted which concentrates on gradually increasing range of motion and strength. Sport-specific exercises are usually started at around three to four months post-operatively, with full recovery possible by six to nine months post-operatively.
Final thoughts on SLAP tear surgery
SLAP tear surgery of the shoulder is not to be undertaken lightly, especially in throwers; however, if performed for the right reasons it can result in significant pain relief and an increased quality of life. If you have any further questions please don’t hesitate to schedule an appointment with Dr. Mazoch.