The world is full of acronyms, LOL, YOLO, the list goes on. The medical field is no exception, from ORIF (open reduction with internal fixation), GERD (gastroesophageal reflux disease) to a SLAP lesion of the shoulder. A SLAP lesion is an acronym to describe a specific injury to your shoulder. Superior Labral tear from Anterior to Posterior of the bicep tendon. Your glenoid is covered by an O-ring seal within which your upper arm can move. SLAP is a tear in this ‘seal’ between your shoulder blade and upper arm. That is a mouthful to describe a specific injured area of the glenoid labrum of your shoulder.

A SLAP shoulder lesion causes poorly localized symptoms like clicking or grinding of the joint on movement, pain when lying on the injured side and loss of strength and endurance, especially with overhead and behind the back activities. SLAP shoulder lesions occur more commonly in throwing athletes because of repetitive movement and happens more frequently in people between the ages of 30 – 50 years.

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What is the shoulder labrum?

The shoulder is a ball and socket joint, similar to the hip. This ball and socket structure allow freedom of movement in a wide variety of angles, which comes in handy when you want to reach behind you in the car, scratch your back or swim freestyle. Because we don’t bear weight on the arms frequently, the shoulder is less stable than the hip joint. The socket is more shallow than that of the hip joint. If we can’t rely so strongly on the socket the body has other strategies to keep the shoulder joint stable, in the form of glenohumeral ligaments, glenoid labrum, and the capsule. The rotator cuff and other stabilizing muscles give us dynamic stability when adequately strong. You can think of the muscles as an extra protective barrier, like paying extra for the thicker refuse bags, that keep everything together, the stronger the muscles the more stable your shoulder joint will be.

What does the shoulder labrum do?

The shoulder labrum increases the depth of the socket and acts as an important attachment site for ligaments and muscles. The shoulder labrum is a ring of fibrous tissue that attaches to the glenoid fossa. This labrum increases the depth and diameter of our fairly shallow socket, which comes in handy when you do overhead sport. The shoulder labrum also plays an important role in maintaining the negative pressure within the shoulder joint. The negative pressure within the joint “sucks” the humeral head into the socket to aid in stability.

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How does a SLAP lesion happen?

Repetitive movements, heavy lifting, or a traumatic incident increases the risk to sustain a shoulder labrum tear. Unfortunately, the risk to sustain a SLAP tear increases with age. The shoulder labrum is less securely attached to the glenoid from age 35. Combine this with poor posture, slumped over a computer most of the day, rounded shoulders, and inactivity, your risk to sustain a SLAP shoulder tear increases even more because of the dynamic stability, that is the stability that the muscles provide, are lacking.

Previous rotator cuff injury or pathology that is not well taken care of, that is not rehabilitated, may also increase your risk to sustain a SLAP shoulder tear. Weakness from the rotator cuff causes the humeral head to “float” up and forward because the muscles of your rotator cuff cannot maintain adequate downward pull. The continuous forward glide of the humeral head weakens the labrum attachment in the top and front. When a repetitive movement occurs injury & pain is fated to follow.

Causes of a shoulder SLAP lesion

The most common way to injure your superior glenoid labrum is repetitive overhead throwing and downward traction, like catching, throwing, and lifting heavy objects, like on a building site.

You can be predisposed to injuring your glenoid labrum if you have:

  1. rounded shoulders, like most of us do when hunched over a computer for long periods
  2. decreased internal rotation, if you struggle to reach behind your back to get to that irritating itch
  3. limited pectorals major and minor mm. length, if you struggle to open your collarbones and keep your spine straight

These 3 factors would cause a “perfect storm” for shoulder labrum injury, because of the way the humeral head is pushed forward when you lift and rotate your arm to catch or throw a ball.

An acute traumatic injury, like falling on an outstretched arm, hyperextension of your shoulder, or direct trauma can cause shoulder SLAP tears. It is especially important to evaluate the glenoid labrum if you dislocated or partially dislocated your shoulder.

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Self tests for shoulder labrum tear

Do you suspect you have a SLAP tear of your shoulder? Try these tests at home.

  • Lie over a foam roller or thick rolled blanket/towel (the roller lies vertically down your back, directly under the spine).
  • Now open your arms out sideways, like you are making a snow angel.
  • Rotate your palms to face up, bend your elbows to 90 degrees, elbows remain in line with shoulders.
  • Rotate your palms to face downward toward your feet now.
  • Slowly rotate your shoulder to aim your palms to the ceiling now, as though you go into a “hands up!” or goal post position.
  • If your shoulder feels unsteady compared to the other side you have shoulder instability, which may indicate a SLAP tear.
  • Sit on a chair behind a desk/table.
  • Bring both hands onto your knee, turn your thumb to aim down.
  • Lift the pinky edge of your fingers to press upwards on the edge of the table.
  • Press onto the surface.
  • Pain on the affected side may indicate a SLAP tear.
  • Do for the unaffected side first.
  • Get into a side plank on the unaffected side on your knee and elbow.
  • Begin with your fingers and forearm aiming the same way you are facing.
  • Then keep your elbow firmly pressed into the ground and lift your forearm.
  • Rotate your shoulder by aiming your fingers and forearm to the crown of your head.
  • Repeat on the affected side.
  • Pain, loss of rotation, clicking/grinding may indicate a shoulder labrum tear.

How bad is my  shoulder SLAP lesion?

Shoulder labrum tears are devided into SLAP lesions and non-SLAP lesions and further classified as being stable or unstable. SLAP shoulder tears are injuries to the glenoid labrum from the front (anterior) to the back (posterior) of the bicep tendon insertion. SLAP shoulder injuries are devided into four types.

Type 1 SLAP shoulder injury

The labrum attachment to the glenoid is intact, but there is fraying and/or degeneration.

Type 2 SLAP shoulder injury

The top (superior) portion of the labrum and the tendon of the bicep have detached from the glenoid attachment site.

Type 3 SLAP shoulder injury

The bicep tendon attachment is in tact, but the superior border of the labrum is torn away from the glenoid and displaced into the joint.

Type 4 SLAP shoulder injury

Like with type 3, the top border of the labrum is torn away from the glenoid and displaced into the joint and a part of the bicep tendon is also torn and displaced.

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Diagnosis of SLAP tear shoulder

As physiotherapists, we are skilled at loading and testing specific structures in and around your shoulder. We can differentiate between joint, muscle, ligament, and nerve pathology, and when a combination of issues co-exist. We know not to rely on a single test to make a diagnosis. If needed we can refer you to get the appropriate imaging to confirm our diagnosis.

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Xray

X-rays allow us to see bone and joint space, but not what is happening inside of the joint. Therefore, X-rays will be of no use to diagnose a SLAP tear of your shoulder.

Sonar

Diagnostic ultrasound enables us to see the soft tissue surrounding your shoulder. The ligaments and tendon attachments would be visible, as well as the bicep long head tendon, which will be valuable to visualize. We cannot see inside of the joint capsule, the labrum lies within, therefore a diagnostic ultrasound will be of little value to diagnose your shoulder labrum tear.

MRI

Magnetic resonance imaging allows us to see within the shoulder joint and visualize the torn labrum. MRI is the gold standard for diagnosing shoulder labrum tears. You will need a specialist referral to get an MRI as this is a costly procedure.

MRA

This procedure is similar to an MRI, but with added contrast solution injection. The contrast will outline the joint structure and it is believed to be more precise.

CT

Computerized tomography combines a series of X-rays, taken from different angles to visualize different cross sectional images. CT scans are realiable at diagnosing shoulder labrum tears.

Why is my shoulder labrum tear not going away?

As explained above there are different types of torn labrum injuries to the shoulder. An acute traumatic incident may cause severe damage to the labrum and bicep long head tendon insertion, which then needs to be surgically repaired. The bicep long head inserts on the labrum. If the labrum is not securely anchored the bicep tendon insertion is also unstable, it’s like sticking your car license disc cover on overused double-sided tape.  Overuse and repetitive strain injuries may be caused by improper training techniques or other muscle imbalances. Even with a surgical repair, if you do not change the way you move, throw, and train your shoulder, your SLAP lesion repair may be unsuccessful. You need to address the cause of your injury and all damaged tissue inside & outside your shoulder joint. We can help you find the root cause and address it effectively.

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What NOT to do

  • Anti-inflammatory medications are not recommended, especially in the first 48 hours after shoulder labrum tear, as they are thought to delay healing.

  • Pushing through the pain when training, any clicking sound associated with pain should not be ignored, it could indicate a loose pieces of cartilage or bone within your shoulder joint.

  • Lift, push or pull during training, through the pain.

  • Do not ignore shoulder pain that gets worse (it could be an sign of a deeper problem).

  • Leave your shoulder untreated, if you are uncertain of the diagnosis, rather call us and be safe.

  • Wear a sling and wait for it to go away.

What you should do

  • Follow a PEACE and LOVE protocol (scroll down to the treatment section to see what you can do at home). We are able to guide you through these extra acronyms for your SLAP lesion.

  • Make an appointment to get to the bottom of your SLAP shoulder lesion.

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Making the injury worse

  • Push ups

  • Overhead shoulder press

  • Pull ups

  • Push/train through the pain

  • Bench press

  • Reach behind your car seat

  • Cart wheels

  • Catch and throw

A big problem we see with a shoulder SLAP tear

Misdiagnosis and playing the waiting game. You cannot live a life of avoiding all aggravating activities, no reaching for a shelf, hanging laundry, trying a new hair style or overhead strength training ever again? You cannot wait to magically heal, you have to put in the work. Everything worthwhile in life takes some effort. Wearing a sling for a prolonged period, more than 3 weeks, will cause more harm than good. Muscles become lazy if they are not required to work. Shoulder labrum tear is already associated with instability, lazy muscles will just add to your feelings of not having control of your shoulder.

Taking medication for longer than 2 weeks without having your shoulder assessed is irresponsible. Medication has to be metabolized to have an effect on your pain. Prolonged use of anti-inflammatories can cause gastrointestinal side effects. If you numb the pain with medication you essentially turn down your body’s alarm system without checking why it is going off.

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Physio treatment for shoulder labrum tear

We have the skills to test all the different structures around your shoulder to establish the cause of your pain and get a diagnosis. From here we can address any contributing factors, muscle imbalance, and faulty movement patterns to get you on the road to recovery. We consider the whole of you and what your life requires of your shoulder, we will get you back to painting, training, or whatever it is you love to do. With physiotherapy treatment, we aim to give your shoulder labrum the right environment to heal. Your body can heal given the right circumstances, resting from aggravating activities while we encourage tissue regeneration of the shoulder labrum.

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Phases of rehabilitation for shoulder labrum tear

1st Phase: Protection and initial healing

Protect

Patients tend to push through their pain, hoping that time will heal them. Rest from aggravating activities will prevent continuous inflammation and pain.

Avoid anti-inflammatory medication

Avoid using anti-inflammatory medication continuously, it delays healing by delaying inflammation. If you have severe pain, try to rather use medication for pain without an anti-inflammatory component. That way, your pain will be under control, you’ll be able to get enough sleep and won’t have pain that constantly bothers you. Once the pain is under control, you can decrease the use of your medication and eventually stop taking it completely.

Strapping

By using strapping or elastic bandage, your shoulder can be supported to facilitate safe movement. Movement controls inflammation and swelling which also relieves your pain.

Information

Make sure that you get information from the person that is treating you. It’s important to understand what you should and shouldn’t do, to hasten your recovery. You can make better decisions if you are informed. Your body knows best, so avoid too many types of treatments at once.

Load

Let pain guide you to gradually return to your normal activities. Initially, it is tricky to know if it is better to rest or to move, but finding a balance between the two is the best you can do. Avoid lifting all your groceries with your affected shoulder, but still, brush your teeth or comb your hair with that hand.

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2nd Phase of shoulder labrum tear: Establish pain free range of movement

During your examination, it will become clear what you are able to do, and what you should avoid. We identify factors that contribute to your pain, specific to your case, and will address these factors as your treatment progresses. When doing a movement, like putting on your shirt, you will be able to lift and turn your arm to a certain degree, before your pain starts. This is your pain-free range of movement. You are safe to move in this range and our exercises will be targeted between these boundaries of your pain.

The aim is that, with time, your pain-free range of movement improves and painful movements become less intense.

3d Phase of shoulder labrum tear: Tissue healing

We monitor the progress of the healing of your shoulder labrum and track the formation of scar tissue at the site of injury. On a cellular level we’re able to accelerate tissue healing using dry needlinglaser and ultrasound. As healing takes place, we want to see not only improvement of your pain, but also improvement in the shoulder labrum’s ability to withstand the load of the muscle contraction that causes the shoulder to move.

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4th Phase of shoulder labrum tear: Full range of movement

To regain full range of motion of your shoulder will be a very important component of your rehabilitation. The surrounding muscles and shoulder capsule will be targeted by massage, stretches, and joint and neurodynamic mobilisations to achieve full range of movement of your shoulder.

At the end of this stage of rehabilitation, you should be able to comfortably lift your shoulder overhead to wash your hair or reach behind you to put on a jacket.

5th Phase of shoulder labrum tear: Muscle strength

During this phase of your rehabilitation, you will work on strengthening all of the stabilizing muscles around your shoulder. Repeated contraction of muscles, improves their strength. Stronger muscles have the capacity to work harder and provide dynamic stability while you move, lift or throw. We will progress your exercises more and more, adding resistance, doing more repetitions and building your overall strength.

Now, you should be able to lift a full kettle or hang washing.

6th Phase of shoulder labrum tear: Muscle control and stability

It is one thing to feel your muscles get stronger, but another thing to feel like you have control when you move. The type of muscle contraction we use during this phase of rehabilitation is called eccentric muscle contractions. Muscles are able to contract and shorten concentrically, but they are also able to slowly lengthen eccentrically. Controlling the descend of your arm with a weight in your hand, or slowly lowering your body in a pushup position will enable you control your shoulder movement.

7th Phase of shoulder labrum tear: Testing for return to activity

A big part of your recovery is to gradually return to your routine. This way, we can determine if you are ready to return to fully working and training without any flare-ups of pain. Your physiotherapist will guide you to re-engage in safe increments, and make adjustments where necessary. During this phase we will start throwing movements and add resistance.

8th Phase of shoulder labrum tear: Balance, high speed and power

Now that you’ve worked through the different phases of your shoulder labrum tear rehabilitation, we want to improve the power and speed of your shoulder contractions. You need to be able to do precise activities with high load, and speed to ensure that your shoulder complex can keep up with the demands of your body.

Your physiotherapist will guide you to return to normal activities but will also challenge you past your normal boundaries to determine how your body reacts to different forces. Ultimately we prepare you to return to participating in your sport.

Whatever must be done – we’ll get you there. Push ups, pull ups, presses or handstands.

9th Phase of shoulder labrum tear: Sport specific training

This is the final stage of rehabilitation. Depending on your sport, your physiotherapist will tailor specific exercises to further improve your strength and endurance. A successful outcome is when you understand your condition, know how to prevent flare-ups and can participate at full power and speed, not to mention the benefits of minimizing your chance of future injury.

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Healing time for SLAP tear of the shoulder

The type of SLAP lesion will determine your treatment options. Non-surgical treatment can take 6 weeks to 3 months. Surgery may take even longer or up to 4 months to get back to your sport. There is no quick fix with a SLAP lesion, unfortunately you need patience, perseverance and the right care.

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Other medical treatments for shoulder SLAP lesion

Your GP may prescribe analgesic and anti-inflammatory medication, this will aid in symptom control but cannot repair the SLAP tear. Long term use of oral medication may cause side effects, like stomach ulcers, gastritis, and dependency.

Intraarticular cortisone injection will give symptomatic relief. Cortisone influences the integrity of the tissue and repetitive injections may predispose you to ligament laxity and rotator cuff muscle tears. This leads to a whole different type of challenge.

Biokinetic rehabilitation starts once you have reached pain-free, full range of motion with conservative or post-surgery treatment.

Manipulation and forceful joint adjustments will not aid the healing of a shoulder labrum tear. It may do more harm than good.

Surgery for torn shoulder labrum

There are different surgical interventions available for SLAP lesions. The type of shoulder SLAP lesion will determine the surgical procedure. Type 1 SLAP tears are debrided arthroscopically, the frayed edges of the shoulder labrum are removed and cleaned. Type 2 SLAP tears are fixated to provide stability for the bicep insertion anchor. The free fragment is removed with a type 3 SLAP tear by means of an arthroscopic shaver, while a type 4 SLAP tear can be repaired with multiple sutures.

Unfortunately, the chance of failure for surgical torn labrum repairs increase the older you are. Post surgical care and rehabilitation are therefore extremely important. You will need to wear a sling 4-6 weeks after your surgery and you won’t be able to drive or sleep on the operated side. Your rehabilitation starts immediately after the surgery to maintain muscle tone, progressions will be added as you are allowed to remove the brace. It can take up to 8 weeks to get you back to everyday activities after your surgery.

SLAP lesion also known as:

  • Shoulder SLAP lesion
  • Torn labrum of the shoulder
  • SLAP tear of the shoulder
  • Shoulder labrum tear
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What else could my SLAP lesion be?

The shoulder labrum is often involved in a wide range of shoulder pathology or found in combination with other shoulder problems.

  • Bicep pathology

Shoulder SLAP lesion is most commonly combined with a tear , tendonitis or bursitis of the proximal head of the biceps, because of the attachment site on the shoulder labrum. Bicep pathology will cause pain localized to the front of the shoulder only.

A tear or tendonitis of one or more of the rotator cuff muscles will cause pain on movement, a feeling of instability, but no grinding or clicking sensations.

Adhesive capsulitis causes pain and restriction of movement in all directions. A neglected torn shoulder labrum can develop into a frozen shoulder.

  • Supra scapular neuropathy

Compression or irritation of the supra scapular nerve may cause pain and weakness of the arm with a burning sensation or  pins and needles.