SLAP Lesions

What is it?

Superior labrum anterior posterior (SLAP) lesions are a group of injuries to the upper part of the labrum. The labrum is the cartilage rim that surrounds the glenoid (socket) of the shoulder joint; the upper (superior) part of the labrum is also where the long head of the biceps tendon originates (biceps anchor). From here, the biceps tendon runs over the humeral head and then takes a sharp downward turn into the upper arm.

long head of biceps attachment at the top of the glenoid

The course that the tendon takes means that in certain positions of the arm, the humeral head acts a lever and pulls (or tears) the tendon and the labrum in a front to back (anterior to posterior) direction.

The illustration below depicts the direction of pull and the displacement of the biceps anchor (right shoulder, viewed looking into the glenoid), as an expected response for each of the activities shown below.

Three types of SLAP tear

SLAP lesions are often seen in the context of sporting or athletic activity and frequently cause pain and clicking with overhead activities. The pain may be felt in the shoulder or it may radiate into the upper arm. There are different types of SLAP lesions and they vary in severity.

Who should have a SLAP repair?

Anti-inflammatories help control the pain, but if continued participation in sports or athletic activity is precluded because of persistent symptoms, then repair is indicated.

Some SLAP lesions can simply be debrided (scuffed tissue tidied up) but the majority require formal repair i.e. the biceps anchor reattached to the upper glenoid

Will I need any tests/scans?

X-rays and an MRI are usually requested to investigate SLAP lesions. Please see the section Surgery FAQs to see if you will need any other tests e.g. blood tests before your surgery.

How is it done?

SLAP lesion repair can be done using shoulder arthroscopy. The procedure is carried out under general and/or regional anaesthesia.

Three portals (incisions <1cm) are made around the shoulder. The torn labrum may be debrided using a shaver or reattached to the upper aspect of the glenoid using biodegradeable bone anchors (special devices inserted into bone with very strong sutures attached).

Concomitant pathology can be treated simultaneously.

At the end of the operation, steri-strips or one stitch is used to close each portal. Waterproof dressings and then a bulky dressing pad are applied to absorb the natural ooze from the joint. The arm is always placed into a polysling for comfort and to immobilise the shoulder to allow tissues to heal.

Can I go home the same day?

More often than not, as with most arthroscopic surgery, this is a day case procedure. Occasionally an overnight stay is advised depending on post-operative comfort levels, medical co-morbidity and time of day of the surgery.

What about after the operation?

You will see a physiotherapist before discharge to be instructed on simple exercises to carry out in the short term. This usually involves simple pendulum exercises out of the polysling and light stretches, often with assistance (e.g. your other arm or your physiotherapist) and you will be instructed on axillary hygeine. You should aim to exercise the shoulder 3-4 times a day; although the shoulder will be sore to start, there should be no lasting pain or pain that is not alleviated by the analgesia prescribed to take home. Sleeping with a pillow under the shoulder is recommended. It will be painful to sleep on the side of the operated arm for several weeks.

Restrictions of movement: for 6 weeks Mr Patel recommends no combined abduction and external rotation and restriction of forward flexion to shoulder height.

You will be prescribed analgesia to take home and Mr Patel strongly advocates its use to keep pain to a minimum; it should be noted that pain is more difficult to control if allowed to establish itself. Mr Patel recommends the regular application of ice as an adjunct to relieve pain and swelling in the acute post-operative period.

You will see Mr Patel two weeks after surgery for a wound check (and stitch removal) and a physiotherapy program will ensue thereafter which is paramount to the success of the operation. You are likely to have been seeing a physiotherapist before the operation and Mr Patel will liaise with him/her in detail to advise on the post-operative exercise program. For this procedure, Mr Patel recommends return to work (sedentary) when you feel able; for manual work this may be 3-6 months. Driving can resume after 6-8 weeks, as can swimming breastroke. Return to freestyle swimming, overhead athletic activity and contact sport is recommended at 3-4 months but is often guided by the strength of the individual.

What are the potential complications?

All surgery carries a risk. Specific risks to arthroscopic rotator cuff repair are:

Infection this can be either superficial (portals) or within the joint. You will be given antibiotics to reduce this risk.

Stiffness It is very important that some mobility of the shoulder is maintained after surgery. The physiotherapist will advise on simple exercises that can be carried out at home. Mr Patel also recommends that you take regular analgesia and use ice (see Surgery FAQs) to help minimise post-operative discomfort and facilitate early movements.

Bleeding this may require a return to the operating room for removal of blood clots and to stop the bleeding.

Neurological patients often describe a patch of numbness or a heavy feeling around the shoulder in the early post-operative phase. This is commonly swelling related and resolves as swelling reduces and full shoulder mobility is recovered.

Non-union despite a good repair, the labral tissue may not heal to the bone successfully. This usually manifests as peristent pain, continued poor function and commonly a re-tear of the tendon. This risk is greater with increasing age and poor quality tendon.

Device failure rarely, the bone anchors used for reapir can migrate (move out of position). They will need to be retrieved if this happens as if they are not flush with the bone surface or left to float around the joint, they can cause damage and inflammation in the sub-acromial space.

Recurrence re-tear can occur. Good compliance with post-operative rehabilitation will reduce your risk greatly. Contact sports and increasing age carry a higher risk for re-tear.