What is SLAP tear?
SLAP tear or SLAP lesion or labral tears stands for Superior Labrum Anterior Posterior. The labrum is a rim of cartilage that surrounds the cup of the shoulder joint (glenoid) as a cup. Many tendons and ligaments attach to the labrum to provide stability to the shoulder. Any lesion or tear to the top of the labrum where the long head of biceps is attached is known as SLAP lesion or SLAP tear. In this condition, the tear happens in the superior part of labrum from front (anterior) to back side (posterior) of the attachments of the labrum to the shoulder.
This tear or lesion in the labrum usually occurs in throwing or overhead athletes, weight lifting, and labourer’s involved in overhead activities. Besides it also can happen in motor vehicle injury, a fall onto an outstretched arm, rapid movement of the arm with force to catch a heavy object, shoulder dislocation and repetitive injuries in overhead sports. Ageing is also one of the leading causes of wear and tear in the labrum. It may be associated with other shoulder ailments such as bicep tendinitis, rotator cuff tears, instability or internal impingement. Most incidences of SLAP tears occur at the age of 20-29 years or in the age 40-49 years.
What are the symptoms of a SLAP tear?
It is represented by typical symptoms i.e. pain is felt only during movement of the arm in certain directions, especially in overhead activities. Pain is not felt at rest. You may feel that the shoulder is loose and unstable. A popping or catching or grinding sensation is also common. There is a significant decrease in the strength and range of motion of the shoulder. Patients also complain of pain when throwing a ball.
How is it diagnosed?
After evaluation of your case through complete medical history and physical examination, your surgeons will identify your ailments as SLAP tear. He will advise you for X-ray and MRI scan. X-ray cannot show the tears or lesions on the labrum but it can detect other shoulder ailments such as arthritis, fractures and dislocation. The damage to the labrum is identified clearly in the MRI scan +/- contrast injected into the shoulder.
What happens if nothing is done?
If it is left untreated, the condition may result in chronic or recurrent instability of the shoulder with persistent pain, clicking and weakness. The change in biomechanics may predispose the joint to arthritis.
How is it treated?
It can be treated with either conservative or surgical methods. Most of the cases improve well with the conservative treatment. It includes rest, analgesics, physiotherapy and in selected cases steroid injections.
Surgery is indicated in
- Failed conservative treatment
- High grade Type III and IV SLAP tear
- Acute SLAP lesion in a throwing/overhead athlete with failed physiotherapy
- Shoulder dislocations
- Rotator cuff tear
- AC joint separation
What are the non-operative treatments?
Most cases of SLAP tears heal well with non-surgical treatment. It involves-
- Rest- the inflammation settles and pain relieves when you rest your shoulder. You should also avoid activities that can cause pain such as overhead activities.
- Physiotherapy – stretching and strengthening exercises as designed by your physiotherapist will assist in restoring the normal range of motion and muscle endurance. They are started with gentle exercises which are progressed to strenuous exercises to maintain flexibility and prevent stiffness. This program continues from 3 to 6 months to ensure full recovery of the shoulder.
- Medications- painkillers like paracetamol or codeine are prescribed to manage pain, anti-inflammatory medicines are given to control swelling and pain.
- Steroids injections- if all the above conservative methods fail, then steroid injections may be used to control inflammation from secondary impingement. However, its effect is temporary will provide short-term relief with a risk of progression of SLAP tear.
What does the operation involve?
The goal of surgery is to repair and reattach the torn part of the labrum to the glenoid cavity (a cavity of shoulder bone where the head of the upper arm fits in). It is usually performed by arthroscopy (keyhole surgery) through two-three cuts.
- It is performed as a day case under general anaesthesia. Two or three cuts are made around the affected shoulder.
- A tiny camera is inserted through one of these cuts to visualize the labrum in a bigger television screen.
- Small surgical tools are used to repair or reattach the labrum through other cuts using stitches (suture anchors). In some cases, bicep tendon is cut and reattached to the upper arm.
- After repairing the labrum, other shoulder ailments are corrected. The skin is then closed by absorbable sutures. The whole procedure may take 1-2hrs to complete. The patient is usually discharged on the same day.
What happens after surgery?
- Local anaesthesia wears off in 4 to 10 hours and the patient is encouraged to consume painkillers in order to get relief from the pain of the surgery before it starts.
- The patient is advised to take proper rest and modify his activities to prevent further injury to the labrum. He is specially instructed to avoid overhead activities.
- A shoulder sling is applied to the shoulder to enable safe healing process and prevent new injury. It may be kept for 6 weeks.
- Before discharge, the patient is taught some passive exercises of shoulder probably for 4 to 6 weeks. It may include pendulum exercises of the shoulder, exercises of elbow, wrist and fingers. This is necessary to prevent stiffness and maintain the strength of the shoulder.
- The patient is reviewed after 2 weeks for the wound check.
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature)
- Gentle ROM exercises are introduced in 4th to the 6th week to achieve the full function of the shoulder. Functional exercise and light strengthening exercises are introduced in 6 -12 weeks. Advance strength and sports specifics are started after 12 weeks of surgery. These exercises can improve your shoulder posture. The exercises are designed in such a way that you can regain the range of motion of the shoulder with the strength of the arm. It should be done under the guidance of your surgeon and physiotherapist.
- The recovery following SLAP repair can take a year or two, full strength of rotator cuff and scapular stabilisers and full range of movement should be achieved before returning to sports.
Are there any risks?
- Repair failure
- Injury to blood vessels or nerves or tendons
- shoulder stiffness
- Frozen shoulder
What are the results of the operation?
The outcome of the surgery is excellent in SLAP tears with minimal complications. However, recovery time is different for each individual. The outcome is more predictable in the author’s experience.
When can I return to driving and work?
Depending on your job, you can return to work in 2 weeks (desk job) to few months (manual labour) and start driving after 6 -10 weeks. You can restart sports after 6 months. Full recovery may take several months depending on the age and health of the individual, clinical nature of the SLAP tears and surgical technique adopted. Your surgeon can guide you for this.