SLAP Tear Shoulder Injury and Treatment

A superior labral anterior to posterior injury, commonly called SLAP tear, refers to the fraying or tearing of the labrum, a rim of fibrous cartilaginous tissue that surrounds the shoulder socket cavity. ¹ Varacallo M, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538284/

SLAP tears are a complex, painful, and debilitating condition. It is most common in people with physically demanding jobs and athletes who play sports that require overhead arm movements. ¹ Varacallo M, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538284/

SLAP tears are initially managed using a conservative approach involving rest, icing, physical therapy, and steroid injections. Surgery is recommended for severe SLAP tears or if the non-surgical approach fails. ² LeVasseur MR, Mancini MR, Hawthorne BC, Romeo AA, Calvo E, Mazzocca AD. SLAP tears and return to sport and work: current concepts. J ISAKOS. 2021;6(4):204-211. doi:10.1136/jisakos-2020-000537

Understanding SLAP tears

There are 3 anatomic components involved in a SLAP tear ³ Chang LR, Anand P, Varacallo M. Anatomy, Shoulder and Upper Limb, Glenohumeral Joint. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537018/ :

• The top part of the upper arm bone (humerus), also called the “ball” or humeral head
• The shoulder socket, also called the glenoid cavity, is a shallow cavity that cradles the ball of the humerus
• The labrum, a layer of fibrous cartilage that surrounds the shoulder socket and provides depth and increased surface area to this cavity

The labrum attaches firmly to the lower portion of the socket but is loosely attached to its upper (superior) portion – the region where a SLAP tear occurs. The tears extend from the front (anterior) to the back (posterior). 

See Guide to Shoulder Anatomy

Some cases of SLAP tears also involve a tear in the biceps tendon (the tendon that attaches the biceps muscle to the labrum). ¹ Varacallo M, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538284/

See Soft Tissues of the Shoulder

Around 88% of SLAP injuries are also accompanied by other shoulder injuries, such as rotator cuff tears and shoulder impingement. ⁴ Fitzpatrick S, Bishop JY, Cvetanovich GL. SLAP Tear Diagnosis and Management. The Management of Biceps Pathology: A Clinical Guide from the Shoulder to the Elbow. 2021 Jan 25:125.

4 Types of SLAP Tears

Depending on the degree of the tear and involvement of the biceps tendon, SLAP tears are categorized into 4 types ¹ Varacallo M, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538284/ ^{, 5} Modarresi S, Motamedi D, Jude CM. Superior labral anteroposterior lesions of the shoulder: part 2, mechanisms and classification. AJR Am J Roentgenol. 2011;197(3):604-611. doi:10.2214/AJR.11.6575 ^{, 6} Ahsan ZS, Hsu JE, Gee AO. The Snyder Classification of Superior Labrum Anterior and Posterior (SLAP) Lesions. Clin Orthop Relat Res. 2016;474(9):2075-2078. doi:10.1007/s11999-016-4826-z : 

1. Type I SLAP tears are characterized by the fraying of the labrum without its detachment from the shoulder socket. Type 1 tears are caused by the gradual degeneration of the labrum with aging or repetitive overhead movements. Fraying of the labrum is common in middle-aged and older individuals.
2. Type II SLAP tears involve the detachment of the labrum and the biceps tendon from the shoulder socket. Type II SLAP tears are also caused by either repetitive overhead movements or acute injuries.
3. Type III SLAP tears are described as bucket-handle tears, which refer to a crescent-shaped tearing or fraying of the labrum. A type III tear does not involve the biceps tendon. This type of injury is rare and typically observed after a fall on an outstretched arm. 
4. Type IV SLAP tears are bucket-handle tears accompanied by detachment of the labrum and biceps tendon. Type IV tears are also observed after a fall on the outstretched arm.

Type II SLAP tears are the most common and account for 55% of SLAP tears. ⁷ Civan O, Bilsel K, Kapicioglu M, Ozenci AM. Repair versus biceps tenodesis for the slap tears: A systematic review. J Orthop Surg (Hong Kong). 2021;29(2):23094990211004794. doi:10.1177/23094990211004794

Hallmark Symptoms and Signs of SLAP Tears

The most prominent symptoms of an acute SLAP tear injury include some combination of the following ⁴ Fitzpatrick S, Bishop JY, Cvetanovich GL. SLAP Tear Diagnosis and Management. The Management of Biceps Pathology: A Clinical Guide from the Shoulder to the Elbow. 2021 Jan 25:125. :

• Deep pain in the shoulder joint while performing arm movements
• A sensation of catching or locking in the shoulder joint when moving the arm
• A clicking or popping sound in the shoulder joint 

There’s usually a history of sudden, jerking force to the shoulder prior to an acute SLAP injury. ¹ Varacallo M, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538284/

If a SLAP injury is accompanied by a biceps tendon injury, additional symptoms are experienced, which include ¹ Varacallo M, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538284/ :

• Radiating pain in the arm on the affected side
• Pain at rest and during nighttime 

SLAP injuries involving the complete rupture of the biceps tendon are associated with a bulge in the biceps muscle near the elbow.

SLAP Tear Causes 

Acute traumatic injury or attritional damage to the labrum are the most common causes of SLAP injury. ⁴ Fitzpatrick S, Bishop JY, Cvetanovich GL. SLAP Tear Diagnosis and Management. The Management of Biceps Pathology: A Clinical Guide from the Shoulder to the Elbow. 2021 Jan 25:125.

Acute injury 

There are 2 ways a traumatic injury causes labral tear:

• A fall on an outstretched arm exerts compressive force on the head of the humerus and pushes it upwards, causing a tear in the labrum. 
• An unexpected pulling force (traction) is applied to the arm, such as hanging onto the step (rung) of a ladder while falling from it or lifting a heavy weight.

Some SLAP tears are also caused by a combination of compressive and pulling forces. 

Attritional injury

Repetitive microtrauma of the labrum is common in overhead athletes and middle-aged individuals involved in physically demanding jobs. ¹ Varacallo M, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538284/

Peel-back mechanism

During the cocking phase of throwing (pulling the arm back and rotating the shoulder backward), the biceps twist and strain the labrum, leading to its peeling. This type of labral detachment is referred to as the ‘peel-back mechanism. ¹ Varacallo M, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538284/

Asymptomatic labrum tears

In some individuals, small tears in the labrum do not produce noticeable symptoms. 

Studies show that asymptomatic, painless labrum tears occur in some individuals over 45 years old. ⁸ Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthop J Sports Med. 2016;4(1):2325967115623212. Published 2016 Jan 5. doi:10.1177/2325967115623212

Risk Factors for SLAP Injuries

Aging and overhead activities are two major risk factors for SLAP injuries.

Athletes aged 20 to 29 years and middle-aged individuals aged 40 to 49, particularly those involved in physical labor, are at the highest risk for SLAP injuries. ⁴ Fitzpatrick S, Bishop JY, Cvetanovich GL. SLAP Tear Diagnosis and Management. The Management of Biceps Pathology: A Clinical Guide from the Shoulder to the Elbow. 2021 Jan 25:125.

The Course of Shoulder Labrum Tears

Symptomatic SLAP tears typically require medical treatment and have the potential to cause chronic pain and limited mobility. ⁹ Dodson CC, Altchek DW. SLAP lesions: an update on recognition and treatment. J Orthop Sports Phys Ther. 2009;39(2):71-80. doi:10.2519/jospt.2009.2850

The recovery period for SLAP tears varies based on factors such as the severity of the tear, accompanying injuries, and the treatment approach. 

Individuals with a SLAP tear are at an increased risk of shoulder osteoarthritis in the long term. ¹⁰ Matsuki K, Sugaya H. Complications after arthroscopic labral repair for shoulder instability. Curr Rev Musculoskelet Med. 2015;8(1):53-58. doi:10.1007/s12178-014-9248-5

How long SLAP tears last

When treated non-surgically, SLAP injuries typically heal in 3 to 6 months. ¹¹ Michener LA, Abrams JS, Bliven KCH, et al. National Athletic Trainers' Association Position Statement: Evaluation, Management, and Outcomes of and Return-to- Play Criteria for Overhead Athletes With Superior Labral Anterior-Posterior Injuries. J Athl Train. 2018;53(3):209-229. doi:10.4085/1062-6050-59-16

If surgical intervention is needed, it usually takes 6 to 9 months for complete recovery. ² LeVasseur MR, Mancini MR, Hawthorne BC, Romeo AA, Calvo E, Mazzocca AD. SLAP tears and return to sport and work: current concepts. J ISAKOS. 2021;6(4):204-211. doi:10.1136/jisakos-2020-000537

When surgery is needed for SLAP tear injury

Surgical treatment is considered for individuals who do not respond to non-surgical treatment and/or have progressive worsening of symptoms and signs. ² LeVasseur MR, Mancini MR, Hawthorne BC, Romeo AA, Calvo E, Mazzocca AD. SLAP tears and return to sport and work: current concepts. J ISAKOS. 2021;6(4):204-211. doi:10.1136/jisakos-2020-000537

A study analyzing data collected between 2003- 2013 estimated that 62.8% of individuals with a SLAP tear need surgical treatment. ¹² Dougherty MC, Kulenkamp JE, Boyajian H, Koh JL, Lee MJ, Shi LL. National trends in the diagnosis and repair of SLAP lesions in the United States. J Orthop Surg (Hong Kong). 2020;28(1):2309499019888552. doi:10.1177/2309499019888552

For SLAP tears that are accompanied by other shoulder injuries, such as rotator cuff tears, surgical repair of the damaged muscles usually restores normal shoulder function. ¹³ Forsythe B, Guss D, Anthony SG, Martin SD. Concomitant arthroscopic SLAP and rotator cuff repair. J Bone Joint Surg Am. 2010;92(6):1362-1369. doi:10.2106/JBJS.H.01632

See Rotator Cuff Tear Symptoms

When Labrum Tears Are Serious

A SLAP tear injury is usually not considered a medical emergency but warrants urgent medical attention in some cases, such as:

• Severe shoulder pain and limited mobility after an acute injury, such as a fall or accident
• Bruising, swelling, and deformity of the shoulder 
• Numbness, tingling, or weakness in the shoulder 
• Fever accompanied by pain and redness in the shoulder region 

These symptoms typically indicate a fracture, dislocation, nerve damage, or infection in the shoulder area. ¹⁴ Rees JL, Kulkarni R, Rangan A, et al. Shoulder Pain Diagnosis, Treatment and Referral Guidelines for Primary, Community and Intermediate Care. Shoulder Elbow. 2021;13(1):5-11. doi:10.1177/1758573220984471

Early initiation of SLAP tear treatment reduces the necessity of surgery. Resting, icing, and using over-the-counter pain-relieving medications are recommended until the time of a doctor’s visit.