In the care of physicians who are not clinically experienced in addressing upper-limb joint disorders, SLAP tears can result in overtreatment, missed diagnoses, or failure to correct other shoulder disorders that may be the true cause of a patient’s symptoms.
January 13, 2021
Shoulder SLAP tears: they are more common than once thought, can be challenging to diagnose, and the most effective approaches to their treatment remain somewhat controversial, according to noted orthopedic surgeon and upper limbs specialist Alejandro Badia MD, founder and chief medical officer of the Florida-based Badia Hand to Shoulder Center and OrthoNOW®, a network of immediate care orthopedic clinics.
SLAP refers to Superior Labrum Anterior-Posterior. The labrum is the cartilage rimming the shoulder joint’s shallow glenoid, the shoulder-blade socket into which the upper arm’s humerus bone fits. This cartilage is what helps deepen the socket to keep the ball of the humerus in place. The labrum also facilitates attachment of other joint structures. Types of labral tears vary, but the SLAP tear involves damage to the superior, or upper, part of the labrum where the bicep muscle tendon attaches. Repair of a SLAP tear also may require reattachment of the bicep tendon.
“In the care of physicians who are not clinically experienced in addressing upper-limb joint disorders, SLAP tears can result in overtreatment, missed diagnoses, or failure to correct other shoulder disorders that may be the true cause of a patient’s symptoms,” says Dr. Badia, author of the book Healthcare From the Trenches. The book explores “flaws” in the United States health system, including inefficient, ineffective, and costly delivery of care services.
Dr. Badia cites authors of a study published in the Orthopaedic Journal of Sports Medicine who found a “high prevalence” of superior labral tears in the asymptomatic shoulders of middle-aged patients and concluded such tears are not necessarily the direct cause of shoulder pain reported by older patients. “In fact, presence of labral tears in the elderly is quite common due to a lifetime of normal shoulder use. A SLAP tear does not necessarily require surgery or other expensive therapy in this older population group,” Dr. Badia says.
And researchers, writing in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), indicate a large percentage of patients with confirmed SLAP tears also have co-existing shoulder joint disorders. In one study, described in the journal article, 88 percent of patients diagnosed as having SLAP tears had additional shoulder pathologies.
“That’s not surprising since an aging joint not only contributes to the fraying – and tearing – of the labrum but to development of a variety of other joint disorders, including rotator cuff damage, bursitis, and tendonitis. A skilled orthopedic specialist will understand this and look beyond a suspected SLAP tear for other causes of an older patient’s shoulder pain, stiffness, or instability,” says Dr. Badia.
Even in the age 30-50 population, incidence of SLAP tears is estimated at 30 percent, experts say, with the majority of patients able to tolerate – and live with – the injury.
Of course, joint degeneration due to advanced age is not the sole reason why the shoulder’s labrum may fail. A fall onto an outstretched arm, a direct blow to the shoulder, the lifting – or catching – of a heavy object, and repetitive, rapid overhead movements and throwing activities, such as those required in various occupations and sports, like serving in tennis or pitching in baseball, also can lead to SLAP tears.
Chronic deep shoulder pain or pain felt in the back of the joint during shoulder movements, shoulder weakness, inhibited range of motion, a clicking or popping in the joint, and a sensation that the joint is catching, or locking are all symptoms of a SLAP tear.
However, Dr. Badia concurs with JAAOS study authors who contend that “no single examination finding is accurate for diagnosis of SLAP tears.” In fact, the latest research, published in a 2020 edition of the International Journal of Orthopaedics Sciences, concludes that even magnetic resonance imaging scans “are not sensitive in diagnosing SLAP tears” and that physicians “need to understand the pitfalls of MRI while evaluating the…shoulder.”
For most patients with a symptomatic SLAP tear, first-line treatment is a nonsurgical one and includes anti-inflammatory medications to reduce pain and swelling in the joint and exercises to strengthen the shoulder and restore joint function. Next steps can be injection to the shoulder of an orthobiologic adjunct to stimulate healing such as PRP (platelet rich plasma) or newer “off the shelf” substances that promote healing.
If conservative therapy fails, the orthopedic specialist may advise a more aggressive approach, especially in younger patients and athletes, to remove damaged tissue and repair the labrum using debridement procedures and arthroscopic surgery. If necessary, the bicep tendon is also reattached – a procedure known as tenodesis — if the tendon was torn away as part of the labral tear, Dr. Badia says.
But even surgery has proven controversial. In the October 2020 edition of the International Journal of Sports Physical Therapy, investigators, who reviewed results of 22 studies of 617 athletes, say “limited evidence” suggests “fewer than three in four athletes return to their previous level of sports participation after SLAP injury intervention.”
Some studies suggest surgical management may not be desirable – or necessary – for correcting SLAP tears in middle-aged and elderly patients. Yet, scientists, writing in a September 2020 issue of Clinics in Orthopedic Surgery, report that SLAP tear repair and bicep tenodesis can be effective for certain types of tears in patients over age 45 when combined with needed rotator cuff surgery.
“Apparent in all the research is that an informed patient and a highly experienced orthopedic specialist are the primary determinants of the most successful approach for treating symptomatic SLAP lesions of the shoulder,” Dr. Badia says.
Meanwhile, Dr. Badia offers these tips to reduce risk of SLAP tears:
- Learn proper techniques for playing your specific sport.
- Warm up muscles and joints adequately before and after intense activity and exercise.
- Engage in exercises designed to stretch, strengthen, and stabilize shoulder joint capsules and shoulder blade muscles.
- Use correct methods for lifting heavy objects. Avoid undue stress on shoulders.
- “And take a break when performing repetitive overhead activities. Don’t spend an hour doing nothing but practicing your tennis serve,” Dr. Badia says.
Alejandro Badia, MD, FACS, internationally renowned hand and upper-limb surgeon and founder of Badia Hand to Shoulder Center and OrthoNOW®, a walk-in orthopedic care clinic. He is a member of the American Society for Surgery of the Hand, American Association for Hand Surgery and the American Academy of Orthopedic Surgeons and an honorary member of many international professional hand societies. Dr. Badia specializes in treating all problems related to the hand and upper extremities, including trauma, sports injury, joint reconstruction, nerve injuries and arthroscopic surgeries. http://www.OrthoNOWcare.com and http://www.drbadia.com.