what exactly is a slap tear

What Exactly Is a SLAP Tear? Top 5 Things You Need to Know About a Superior Labral Lesion

Superior Labral SLAP Tear**Updated in 2017**

A very common diagnosis for shoulder injuries is a superior labral tear, or SLAP tear.  SLAP stands for Superior Labral tear Anterior to Posterior.  There many different variations of SLAP tears, which have different levels of severity and treatment strategies.  Back in the day, surgeons would want to operate on all SLAP tears but we learned that some do well without surgery.  In fact, some SLAP tears aren’t even worrisome .

Understanding how a SLAP lesion occurs and what exactly is happening pathologically is extremely important to diagnose and treat these shoulder injuries appropriately.

This article is part of a 4-part series on SLAP Lesions

 

Classification of SLAP Lesions

As you can see in the figure, the long head of the biceps tendon inserts directly into the superior labrum.  There are several variations of injuries that can occur to the superior labrum where the biceps anchor attaches.

Following a retrospective review of 700 shoulder arthroscopies, Snyder et al: Arthroscopy 1990, identified 4 types of superior labrum lesions involving the biceps anchor. Collectively they termed these SLAP lesions, in reference to their anatomic location: Superior Labrum extending from Anterior to Posterior. This was the original definition but as we continue to learn more about SLAP tears, they certainly do not always extend from anterior to posterior. But, the most important concept to know is that a SLAP lesion is an injury to the superior labrum near the attachment of the biceps anchor.

SLAP Tear Classification

Type I SLAP Lesions

Type I SLAP lesions were described as being indicative of isolated fraying of the superior labrum with a firm attachment of the labrum to the glenoid. These lesions are typically degenerative in nature. At this time, it is currently believed that the majority of the active population may have a Type I SLAP lesion and this is often not even considered pathological by many surgeons.

 

Type II SLAP Lesions

Type II SLAP lesions are characterized by a detachment of the superior labrum and the origin of the tendon of the long head of the biceps brachii from the glenoid resulting in instability of the biceps-labral anchor. These is the most common type of SLAP tear. When we receive a script from a surgeon to treat a “SLAP repair” he or she is more than likely talking about a Type II SLAP and surgery to re-attach the labrum and biceps anchor.

Three distinct sub-categories of type II SLAP lesions have been further identified by Morgan et al: Arthroscopy ’90. They reported that in a series of 102 patients undergoing arthroscopic evaluation 37% presented with an anterosuperior lesion, 31% with a posterosuperior lesion, and 31% exhibited a combined anterior and superior lesion.

These findings are consistent with my clinical observations of patients. Different types of patients and mechanisms of injuries will result in slightly different Type II lesions. For example, the majority of overhead athletes present with posterosuperior lesions while individuals who have traumatic SLAP lesions typically present with anterosuperior lesions. These variations are important when selecting which special tests to perform based on the patient’s history and mechanism of injury.

 

Type III SLAP Lesions

Type III SLAP lesions are characterized by a bucket-handle tear of the labrum with an intact biceps insertion. The labrum tears and flips into the joint similar to a meniscus. The important concept here is that the biceps anchor is attached, unlike a Type II.

 

Type IV SLAP Lesions

Type IV SLAP lesions have a bucket-handle tear of the labrum that extends into the biceps tendon. In this lesion, instability of the biceps-labrum anchor is also present, similar to that seen in the type II SLAP lesion. This is basically a combination of a Type II and III lesion.

What is complicated about this classification system is the fact that the Type I-IV scale is not progressively more severe. For example a Type III SLAP lesion is not bigger, or more severe, or indicative to more pathology than a Type II SLAP lesion.
To further complicate things, Maffet et al: AJSM ’95 noted that 38% of the SLAP lesions identified in their retrospective review of 712 arthroscopies were not classifiable using the I-IV terminology previously defined by Snyder. They suggested expanding the classification scale for SLAP lesions to a total of 7 categories, adding descriptions for types V-VII.
  • Type V SLAP lesions are characterized by the presence of a Bankart lesion of the anterior capsule that extends into the anterior superior labrum.
  • Type VI SLAP lesion involve a disruption of the biceps tendon anchor with an anterior or posterior superior labral flap tear.
  • Type VII SLAP lesions are described as the extension of a SLAP lesion anteriorly to involve the area inferior to the middle glenohumeral ligament.

These 3 types typically involve a concomitant pathology in conjunction with a SLAP lesion. Although they provided further classification, this terminology has not caught on and is not frequently used. For example, most people will refer to a Type V SLAP as a Type II SLAP with a concomitant Bankart lesion.

Since then there have been even more classification types described in the literature, up to at least 10 that I know of, but don’t worry, nobody really uses them.

 

Top 5 things you need to know about classifying SLAP lesions

Here’s all you need to know about classifying SLAP tears:

  1. Just worry about Type I-IV SLAP lesions and realize that any classification system above Type IV just means that there was a concomitant injury in addition to the SLAP tear.
  2. You can break down and group Type I and Type III lesions together. Both involved degeneration of the labrum but the biceps anchor is attached. Thus, these are not unstable SLAP lesions and are not surgically repaired. This makes surgery (just a simple debridement) and physical therapy easier.
  3. You can also break down and group Type II and Type IV lesions together. Both involve a detached biceps anchor and require surgery to stabilize the biceps anchor. Type IV SLAP tears are much more uncommon and will involve the repair and a debridement of the bucket handle tear.
  4. Type II lesions are by far the most common that you will see in the clinic and are almost always what a surgeon is referring to when speaking of a “SLAP repair.”  That being said, we are seeing trends towards NOT repairing SLAP II lesions, as they may be more common than once expected.  This is especially true in overhead athletes.
  5. We all may have a Type I lesion, it is basically just fraying and degeneration of the labrum.

 

 

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If you want to learn even more about the shoulder, my online course at ShoulderSeminar.com will teach you exactly how I evaluate and treat the shoulder.  It is packed with tons of educational content that will help you master the shoulder, including detailed information on the clinical examination and treatment of SLAP tears.

 

 

 

  • Anonymous

    Good information on the SLAP Tear.

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  • Dorothy Scherr

    Hi, I had a fall in November 2010, which we believe to be the source of the bilateral tears on my shoulders. One of the reports stats a possible SLAP lesion *R shoulder) but not on the left. I do not want surgery as I am an attorney and our livelihood requires me to be at the computer a lot. My question however is about pain levels. I have not only severe pain not only in my shoulders, but also knees, ankles, cramps in feet and legs. My osteopath says there is nothing structurally to account for the level of pain. Bloodwork for infection appears normal, inflammation levels being tested now. Do you see this sometimes? I have been put on large dose of ciproflaxin with no effect. Any suggestions welcomed.

    • Priscilla

      Dorothy,
      This may or may not help, but if you are on the computer a lot you are likely sitting a large amount of your day. Our bodies were designed to move all day and if we don’t, we are likely hurt. Maybe a number of short walks a day will provide you relief. It will hurt at first but as your body gets use to it your joints should thank you. Consider checking out the web site http://www.juststand.org to discover more pressing reasons to get up a move more even if you actually regularly exercise. Hope this is of some help to you Dorothy. Sincerely, Priscilla

  • eric

    I am no doctor, but you guys have no idea what you are talking about. I seen about twenty different doctors, and some of the best doctor’s in the region, none of them were able to pick it up, one did pick up the injury, thank fully. You said that a SLAP 1 does not need surgery, I just had surgery for that, and I had it for 3 years, let me tell you, it is painful as hell, and I am still in pain till now/ Maybe you guys should listen to the patients a bit more, because ultimately they would know more about their bodies than the doctors in most cases.

    • L

      Eric,
      In regards to your comment I will say I understand your frustration but at the same time there are a lot of people walking around with disorders that do not require surgery. Meniscus tears, rotator cuff tears and yes labral tears. It all depends on the severity of the tear and how much it affects your personal daily life. If your an active person or manual laborer yes you might require surgery. If you have a sedentary job and can alleviate a majority of your symptoms with basic exercises and education, surgery can be avoided. Every patient is different and its not “classifying patients” its just classifying tears, EVERY patient is different 🙂 Hope this helps 🙂

      • DuelingDowntheStretch

        I agree with Eric. Doctors don’t listen to their patient, and take the route of what will bring us back for more money, rather than doing a test that will confirm or rule out just about everything, and could provide a definitive diagnosis, and a permanent fix.

        I’ve had shoulder issues since I was 17. I used to be very active as I rode horses and worked on farms. Stacking hay bales, went to lift and toss one up overhead, hear something pop and I couldn’t lift my arm more than a couple inches. The Dr.’s refused to do X-rays, had me do PT, and said I’d be back to full strength in 6mo. Nearly a decade later, after several rounds of PT, this arm has never been back to full strength and Dr.’s act like I’m crazy, saying it’s just a strain, and that it keeps getting injured because the muscle is weak….well it wasn’t weak when I was working around horses, yet it got re-injured twice more.

        After about the 5th time re-injuring it, I have a Doctor who doesn’t think I’m nuts. He wants to give me an MRI with contrast to see what is going on. Considering the thing bothers me while I’m just sitting down typing, and gets worse doing just about anything else, I’m guessing there is a lot going on in it.

    • I agree with you my friend about having different doctor’s and pain associated with slap tear it took a year to discover my slap tear UNBELIEVABLE

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  • SLAP tear extending posterior and anterior to the bicipital anchor, as well as possible extension into the bicipital anchor. There is normal variant cleft versus anterior extension of tear into anterior superior labrum. This is my diagnosis. I am a CNA. Can you tell me what classification this is and if it requires surgery?

  • Ben

    I had a MRI Arthrogram on my left shoulder due to a work accident and in the findings they said. “Extensive slap tear of the superior labrum. The tear extends both anteriorly and posteriorly beneath the biceps Labral anchor. Anteriorly, the tear extends to the equator. Posteriorly, the tear ends at the posterior superior Labral margin.”

    Does this require surgery to fix?

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  • Allan Licht

    I have a SLAP tear and it’s driving me crazy. I’ve had 3 cortisone shots, and one shot in the channels of the long head of the bicep muscle. I’m 60 years old, very athletic, and healthy and this daily pain is affecting my daily life. I may try PRP therapy in a couple weeks and if that doesn’t work I just may need surgery.