The biceps tendon attaches to the labrum at the top or “superior” zone of the shoulder socket. Because labral tears in this area are unique, in that they are subjected to repeated pulling from the attached biceps, they may be associated with ongoing pain. Orthopedists have called tears in this superior zone SLAP tears. SLAP stands for Superior Labrum Anterior to Posterior. These SLAP tears almost always occur either from some unexpected pull on the arm or by a fall onto an outstretched hand. Because the biceps tendon attaches to the superior labrum the pull or “traction” can detach the labrum. Falls onto an outstretched hand can cause the labrum to be sheared off by the ball passing forcefully over the edge of the superior socket.
Ideal treatment of these SLAP tears remains controversial amongst shoulder experts. Some experts contend that the diagnosis is either not a frequent source of pain or that the diagnosis is “over diagnosed” by treating surgeons. That being said more than 20 years of clinical practice and hundreds of shoulder arthroscopy have convinced me that some patients can have pain from this diagnosis. That being said successful treatment of SLAP tears requires selecting patients who have a mechanism of injury, physical exam, and diagnostic testing all consistent with that diagnosis. As I reviewed earlier this diagnosis can be difficult to make on MRI and even arthroscopy because of normal variability in labral anatomy. Ensuring that all these parts of the puzzle fit together greatly increases the probability of successful treatment if surgery is selected.
Some patients will simply have decreasing pain with time and other conservative measures such as physical therapy and anti-inflammatory medications. This diagnosis is not one that will become more difficult to treat or where surgical treatment will be less successful if surgical intervention is delayed in order to attempt conservative care. Since the diagnosis itself is not thought to cause damage or degeneration of the shoulder, and delay in surgery does not cause more complicated or less successful surgery, virtually all patients will undergo an attempt at non-operative treatment.
For those patients who have a mechanism of injury, physical exam, and MRI all consistent with the diagnosis of SLAP tear surgery becomes a reasonable option. Exactly what gets done at the time of surgical arthroscopy depends upon the intra-operative findings as well as patient specific factors such as age and presence or absence of shoulder stiffness at the time of surgery. The surgical options are essentially between repair of the SLAP tear or what is called “debridement” which is the medical term for cleaning up or trimming smooth. In order to successful repair the SLAP tear the labrum and attached biceps tendon both must be of good quality. If they have been damaged by the injury event then “debridement “becomes a better option.