SLAP Tears

The shoulder, a highly flexible ball-and-socket joint crucial for arm movement, is prone to injuries like SLAP tears. If left untreated, a SLAP tear can severely restrict motion and cause chronic pain. Early evaluation is essential to determine the right treatment and prevent further damage.

What Is a SLAP Tear?

A SLAP tear, short for superior labrum, anterior, and posterior tear, refers to an injury to the labrum—the fibrocartilaginous ring cushioning the socket portion (glenoid) of the shoulder joint for stability. This type of tear typically occurs in the upper (superior) region of the labrum, specifically at the site where the biceps tendon is attached. A labral tear can also impact both the front (anterior) and back (posterior) areas of the attachment, which can affect the biceps muscle and its tendon.

Symptoms of SLAP Tears

The symptoms of SLAP tears vary with their severity. Generally, individuals with a SLAP tear experience discomfort and limitations in shoulder function, much like other shoulder injuries.

Common SLAP tear symptoms include:

• Acute, penetrating pain within the shoulder or at the back of the joint
• Weakness, particularly when twisting the shoulder or lifting objects overhead
• A clicking, popping, or grinding sensation during shoulder movement
• Reduced range of motion
• Instability or a feeling of looseness or slippage in the shoulder
• A decrease in shoulder strength and endurance

Causes of SLAP Tears

SLAP tears can be caused by various factors, such as:

• Repetitive Overhead Movements - Athletes in sports with repetitive arm motions, like baseball pitchers, swimmers, or volleyball players, are at risk of developing a SLAP tear. Similarly, individuals performing regular physical labour, such as construction workers or painters, can also develop SLAP tears due to continuous strain on the shoulder joint.
• Direct Trauma - A SLAP tear can occur from an impact in the arm area, such as falling and landing on an outstretched arm. It can also result from a rapid or forceful movement of the arm when it is above shoulder level, or from a direct blow to the shoulder.
• Degenerative Changes - As an individual ages, the labrum naturally wears down and leads to a SLAP tear, even without a specific injury. Those over the age of 40 are more prone to degenerative SLAP tears as the shoulder cartilage progressively weakens over time.

Classifications of SLAP Tears

SLAP tears are categorised into different types based on how they form and their severity.

Types 1 and 2

A type 1 tear occurs when the superior labrum shows signs of wearing or fraying, but without significant detachment of the biceps tendon within the shoulder socket. This type of tear is frequently observed in middle-aged and older individuals due to degenerative changes.

On the other hand, a type 2 tear is characterised by the detachment of both the superior labrum and biceps tendon from the glenoid, often due to repetitive overhead activities or acute injuries. This is the most common type of SLAP tear in the shoulder.

Types 3 and 4

A type 3 tear, also called a bucket-handle tear, involves a crescent-shaped tearing or fraying of the labrum but does not impact the biceps tendon. This type of tear is rare and typically develops after a fall on an outstretched arm.

A type 4 tear is characterised by bucket-handle tears along with the separation of both the labrum and the biceps tendon attachment. Without treatment, this tear can progress to further complications, such as shoulder instability.

Types 5 and 6

A type 5 SLAP tear extends to the anterior-inferior portion of the labrum, leading to a Bankart lesion. This tear typically results from a shoulder dislocation.

In contrast, a type 6 tear refers to a tear from the labrum that forms a flap, either on the front or back side of the shoulder. This flap tear is often accompanied by a rupture or detachment of the biceps tendon.

Types 7 and 8

A type 7 tear extends into the capsule and middle glenohumeral ligaments (MGHL), which are fibrous tissues that help stabilise the shoulder joint.

A type 8 injury, on the other hand, is a type 2B tear that extends into the posterior inferior labrum. These tears are common in athletes who perform overhead movements, causing shoulder instability, pain, and limited function.

Types 9 and 10

A type 9 tear occurs when the labrum becomes fully or almost completely detached from the glenoid in a circumferential manner.

Alternatively, a type 10 tear is a variation of a type 2 SLAP tear that extends to the posteroinferior region of the labrum.

Diagnosis of SLAP Tears

Firstly, the doctor will ask about the patient’s symptoms and medical history, focusing on the onset of symptoms, activities that exacerbate pain, prior shoulder injuries, and any traumatic events that may have contributed to the tear.

A combination of physical assessments and imaging studies may then be conducted to confirm the presence of SLAP tears. These include:

• Physical Examination - The doctor assesses the shoulder’s range of motion, strength, stability, and pain points. To further diagnose the injury, specific tests may be performed, such as O’Brien’s test or the crank test, which involve placing the arm in various positions to trigger symptoms and pinpoint the underlying issue.
• MRI Scans - An MRI scan provides detailed images of the soft tissues within the shoulder joint, including the labrum. To enhance the visibility of the labrum tear, a specialised type of MRI, called an MR arthrogram, is performed in which a small amount of dye is injected into the shoulder joint before taking a scan.

SLAP Tear Treatment Options

Treatment for SLAP tears can vary from conservative methods to surgical interventions, depending on the severity of the injury and the patient’s level of activity.

• Rest and Activity Modification - Limit or avoid shoulder movement or activities that can trigger or worsen symptoms, such as shoulder strain. Consider changing work tasks and sports techniques.
• Physiotherapy - A structured exercise programme, focusing on rotator cuff strengthening and correcting muscle imbalances, is often recommended to strengthen shoulder muscles, improve flexibility, and restore range of motion.
• Medications - Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, can help control pain and swelling around the shoulder joint. In some cases, the doctor may prescribe corticosteroid injections to provide temporary pain relief.

For significant SLAP tears, especially those where the labrum is displaced or the tear extends into the biceps tendon, surgical intervention may be necessary. This approach is also considered when conservative treatments don't provide enough relief from symptoms.

Common SLAP tear surgeries include:

• Arthroscopy - During the procedure, a small incision is made around the shoulder area, followed by inserting a thin, tube-like instrument with a small camera (arthroscopy) into the joint. The damaged part of the labrum will then be reattached to the shoulder socket using anchors or sutures.
• Labrum Debridement - When a SLAP tear is debrided, the shoulder surgeon shaves away the torn portion of the labrum to leave a smooth edge behind rather than reattaching it. This procedure is typically performed for small degenerative tears or minor injuries that do not affect the biceps tendon.
• Biceps Tenodesis - A biceps tenodesis for SLAP tear involves detaching the long head of the biceps tendon from its original position in the labrum and reattaching it to the upper arm bone (humerus).

Slap Tear Prevention Tips

Although SLAP tears cannot be entirely prevented, particularly those resulting from trauma, there are several precautions individuals may take to reduce the risk of this shoulder injury. These include:

• Warm Up - It is vital to stretch and warm up the shoulder muscles before participating in any sports or activities involving overhead movements to prevent injuries.
• Strengthening Exercises - Incorporate exercises that target the rotator cuff and scapular muscles to help support shoulder joint stability.
• Proper Technique - Maintaining correct techniques, both for athletes and for workers, is essential when performing overhead movements to avoid jerking motions that may place undue stress on the shoulder joint.
• Rest and Activity Modifications - Avoid sudden increases in the intensity or duration of sports activities to prevent exacerbating symptoms. Additionally, ensure adequate rest periods between intense activities to avoid overuse injuries.
• Monitor Shoulder Health - Pay attention to any pain or stiffness in the shoulders. If you experience unusual symptoms, seek medical advice promptly to prevent potential complications.

About Our Orthopaedic Surgeon

Dr James Tan Chung Hui

Senior Consultant
Orthopaedic Surgery, Sports & Exercise Medicine
MBBS (S’pore), MRCS (Edin), MMed (Orth), FRCS Orth & Tr (Edin)

Dr James Tan graduated from the NUS Faculty of Medicine and obtained a Master of Medicine (Orthopaedics). He is widely recognised as an orthopaedic surgeon in Singapore for his treatment techniques for shoulder pain and other shoulder conditions. With over 10 years of experience, he specialises in minimally invasive (keyhole) tendon and ligament repair, joint replacement, and muscle-tendon transfers of the shoulder joint.