SLAP Tears: Whats happening?

SLAP Tears: What’s happening?

Shoulder injuries, particularly those affecting the superior labrum, are commonplace among athletes and individuals involved in repetitive overhead activities and identified in upto 26% of shoulder arthroscopies. The Superior Labrum Anterior to Posterior (SLAP) tear is among the frequently encountered shoulder injuries in this cohort. For physiotherapists, understanding the intricate anatomy, mechanisms of injury, and early-stage management of SLAP tears is crucial for devising effective rehabilitation strategies.

Anatomy and Function of the Shoulder Joint:

The shoulder joint is a biomechanical complexity. It comprises several key structures, including the 

• Humerus
• Scapula 
• Clavicle

•  The glenohumeral joint, where the humerus articulates with the glenoid fossa of the scapula, is the primary joint responsible for the shoulder's wide range of motion.

• The Labrum, a ring of fibrocartilage, encircles the glenoid's periphery, deepening the socket to provide stability and serve as an attachment point for ligaments and tendons of the capsule. The superior labrum plays a critical role in stabilising the shoulder joint, especially during overhead movements.

Mechanisms of Injury

SLAP tears commonly result from acute trauma, repetitive overhead motions, or a combination of both. Overhead athletes, such as baseball pitchers, volleyball players, tennis players, rugby players, are particularly susceptible due to the extreme forces exerted on the shoulder during their respective activities.

Acute trauma may arise from a fall onto an outstretched hand or direct impact to the shoulder, while repetitive overhead motions, such as throwing, serving, swimming or skilled labour, gradually wear down the labrum. This continual stress can cause fraying or tearing of the superior labrum, resulting in a SLAP lesion.

Clinical Presentation:

Diagnosing a SLAP tear can be challenging due to overlapping symptoms with other shoulder pathologies.

Patients often report:

• Vague shoulder pain 
• A catching sensation
• A feeling of instability during specific movements. 
• Loss of glenohumeral internal rotation range of motion
• Inability to lie on the affected side
• Loss of strength and power in the rotator cuff muscles

Diagnostic tests such as MRI can be helpful but often a specialised MRI arthrogram (where a special “dye” is injected into the shoulder) are essential for accurately identifying SLAP tears.

Early-stage management:

SLAP tears typically involve conservative treatment, including rest, anti-inflammatory measures, and physiotherapy. Physiotherapy aims to restore shoulder strength and improve dynamic stability. Therapeutic exercises focusing on scapular control, rotator cuff strengthening, and proprioceptive training are foundational in rehabilitation.

Initially Protecting the joint to limit further irritation to the labrum and further damage are important and this means resting from activities and ranges of motion that irritate the joint. 

Exercises should focus around Optimal Loading, this will usually involve exercises that are in or up to pain free range of motion and with loads/resistance that isn’t aggravating to the shoulder.

Ice and Compression may be helpful in the early phases but only really if you’re using a cryotherapy or compression therapy machine with a shoulder cuff and this is really due to the depth of any inflammation within the shoulder joint, frozen peas or a compression wrap aren’t really going to have a significant impact. 

Surgical intervention might be considered for certain cases, particularly for athletes or individuals with persistent symptoms that do not respond to conservative management. Arthroscopic procedures, including SLAP repair, can effectively address the tear, promoting optimal healing and functional recovery.

Conclusion

In conclusion, SLAP tears pose a challenge in the realm of shoulder injuries, demanding a comprehensive understanding of shoulder anatomy, injury mechanisms, and effective management strategies. As physiotherapists, a meticulous approach to rehabilitation, encompassing both conservative and surgical options, can aid in restoring optimal shoulder function and facilitating the return to pre-injury activities, the choice of surgical or non-operative should be an informed and carefully considered one between the patient and the surgeon and should be centred around the patients goals and functional needs.

References:

Brockmeier, S. F., Voos, J. E., Williams 3rd, R. J., Altchek, D. W., Cordasco, F. A., Allen, A. A. (2009). Outcomes After Arthroscopic Repair of Type II SLAP Lesions. The Journal of Bone & Joint Surgery, 91(7), 1595-1603.

Dodson CC, Altchek DW. SLAP lesions: an update on recognition and treatment. journal of orthopaedic & sports physical therapy. 2009 Feb;39(2):71-80.Available:https://www.jospt.org/doi/full/10.2519/jospt.2009.2850#_i49 (accessed 11.1.2023)

Edwards, S. L., Lee, J. A., Bell, J. E., Packer, J. D., Ahmad, C. S., Levine, W. N., Bigliani, L. U., & Blaine, T. A. (2010). Nonoperative Treatment of Superior Labrum Anterior Posterior Tears: Improvements in Pain, Function, and Quality of Life. The American Journal of Sports Medicine, 38(10), 2104-2110

LeVasseur, M. R., Mancini, M. R., Hawthorne, B. C., Romeo, A. A., Calvo, E., & Mazzocca, A. D. (2021). SLAP tears and return to sport and work: current concepts. Journal of ISAKOS, 6(4), 204-211.

Maffet, M. W., & Drez Jr, D. (2000). SLAP lesions: An update on recognition and treatment. Journal of Orthopaedic & Sports Physical Therapy, 30(5), 271-288.

Snyder, S. J., Karzel, R. P., Del Pizzo, W., Ferkel, R. D., Friedman, M. J. (1990). SLAP Lesions of the Shoulder. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 6(4), 274-279.