Slap Lesion


Glenoid Labrum – consists of dense fibrocartilaginous tissues and some elastic fibers. On the articular side, the labrum is continuous with the hyaline cartilage of the glenoid, and on the outer side, it is continuous with the fibrous tissue of the capsule.

For localizing the site of labral injury, the glenoid labrum has been divided into six areas:

(1) The superior labrum,

(2) The anterior labrum above the 3-o’clock position,

(3) The anterior labrum below the 3-o’clock position,

(4) The inferior labrum,

(5) The posteroinferior labrum, and

(6) The posterosuperior labrum

SLAP Lesions (tear) are the injuries of the labrum located above the equator of the glenoid (a line drawn between the 3-o’clockand 9-o’clock positions on the glenoid), classically involving labrum anterior and posterior to the biceps tendon attachment with or without detachment of biceps tendon.

My Shoulder Superior Labrum is Torn: Do I Need Surgery? - Shoulder & Elbow

Pathophysiology and mechanisms of injury:

  1. Most commonly repetitive overhead activities (often seen in throwing athletes) – in throwers may be due to tightness of the posterior-IGHL which shifts the glenohumeral contact point postero superiorly and increases the shear force on the superior labrum.

Dead arm syndrome causes, symptoms, diagnosis & treatment

  1. Fall on outstretched arm with tensed biceps
  2. Extrinsic secondary traction on the arm.

SLAP lesion increases the strain on the anterior band of the IGHL and thus compromises stability of shoulder

How does contracture of the posteroinferior capsule result in a type II SLAP lesion?

When a tight posteroinferior capsular contracture occurs, a posterosuperior shift of the glenohumeral contact point occurs as the arm is brought into abduction and external rotation.

With a posterosuperior shift of the glenohumeral contact point, further external rotation of the shoulder is gained

This allows greater tuberosity to clear the glenoid rim through a greater arc of external rotation before internal impingement occurs.

This allows throwers to externally rotate beyond their normal set point in the late cocking position.

Because of shoulder abduction and excessive external rotation, both shear and torsional forces at the biceps anchor and the posterosuperior labral attachment increases.

The biceps anchor and posterosuperior labrum then begin to fail via the peel-back mechanism producing a type II SLAP lesion.

Snyder Classification: Original classification which includes Types I-IV

Type I– described as fraying of the superior labrum with a solid biceps tendon anchor attachment.

Type II– lesions involve pathological detachments of the labrum and biceps anchor from the superior part of the glenoid without bucket handle. Most common type

These lesions most commonly progress posterior to the biceps but may progress anterior or both anterior and posterior to the biceps attachment.

Biceps-labral instability is evidenced by labral displacement of 3 mm or more with traction on the biceps tendon.

Type III – Bucket handle tear, intact biceps tendon anchor – Biceps is not a part of bucket handle

Type IV– lesions are bucket-handle type, with detached biceps tendon anchor. (Biceps remains attached to bucket handle tear)

Added subclassification

Type V – Type II + anteroinferior labral extension (Bankart lesion)

Type VI -Type II + unstable flap

Type VII – Type II + MGHL injury

Type VIII -Type II + posterior extension

Type IX – Circumferential

Type X – Type II + posteroinferior extension (reverse Bankart


Patient may give history of feeling “pop” sensation in shoulder during overhead activity or traumatic event.


Deep shoulder pain particularly, during overhead activities and maximum at late cocking phase. Some may have mechanical symptoms of popping, catching and clicking. This can result in weakness, easy fatigue, and decreased athletic performance

Slowing of the speed of throw or athletic activity and inability to reach preinjury levels often describing it as “dead arm syndrome.” This is because of a combination of pain and subjective unease in the shoulder, is extremely disabling and potentially career-ending to the overhead athlete. The dead arm syndrome is seen most commonly in young athletes (21-30 years) or individuals whose arms have been powerful hyperextended in elevation and external rotation of the shoulder. For years, physicians have been frustrated by poor results with conventional treatment in this group of athletes. In fact, as recently as the 1970s, pitchers with dead arm syndrome were often referred to psychologists and psychiatrists to discover why they “didn’t want to throw”.

Physical examination

A pop sound may be reproduced during overhead range of motion. Most important feature observed is internal rotation of the shoulder is less than external rotation.

Biceps provocation tests

Speed’s test – The examiner places the patient’s arm in shoulder flexion, external rotation, full elbow extension, and forearm supination, manual resistance is then applied by the examiner in a downward direction. The test is considered to be positive if pain in the bicipital tendon or bicipital groove is reproduced.

During this test biceps tendon acts as suspensory cable from its insertion on superior labrum to arm. Increased tension on this cable produces pain

Yergason’s test – elbow is flexed to 90 degrees with the forearm pronated. The examiner holds the hand/wrist to maintain pronated position while the patient attempts to actively supinate against this resistance. If there is pain located along the bicipital groove the test is positive for biceps tendon pathology. Examiner palpates biceps tendon in bicipital groove.

Yergason test and Speed test

This test actually tests transverse humeral ligament which holds biceps tendon, If it is torn, biceps sub luxates during test and causes pain.

Kim biceps load test – patient supine, arm abducted 90 degrees, elbow flexed 90 degrees, forearm supinated – shoulder slowly external rotated, when patient becomes apprehensive ER stopped, at this position patient is asked to flex further against resistance. Test is positive if shoulder becomes further painful.

SLAP lesion tests

Active compression test (O’Brien’s test) – performed in 2 steps

Patient forward flexes the affected arm to 90 degrees while keeping the elbow fully extended. The arm is then adducted 10-15 degrees across the body.

STEP 1-The patient then pronates the forearm so the thumb is pointing down. The examiner applies downward force to the wrist while the arm is in this position while the patient resists.

STEP 2-The patient then supinates the forearm so the palm is up and the examiner once again applies force to the wrist while the patient resists.

positive for SLAP tear if pain during step 1

References in An anatomic evaluation of the active compression test -  Journal of Shoulder and Elbow Surgery

crank test –hold the patient’s arm in an abducted to 160-degreeposition, axial load applied and apply passive IR and ER rotation

Apprehension test positive in 85% of patients

Treatment :

Practically treatment is based on the classification

TYPE 1 SLAP tear –

Nonoperative treatment-

Rest from sports followed by physical therapy and NSAIDs.

If Glenohumeral internal rotation deficit (GIRD) present, it should be treated with sleeper stretch exercises and may require posteroinferior capsular release.

Rehab focusing on scapular dyskinesia and rotator cuff strengthening for all patients

Surgical treatment-

Arthroscopic debridement with or without posteroinferior capsular release.

TYPE 2 SLAP tear –

Type II lesions should be repaired Arthroscopically to prevent further destabilization of the shoulder.

They have potency to progress posterior to the biceps but may progress anterior or both anterior and posterior to the biceps attachment at the supraglenoid tubercle.

Arthroscopic repair should be done using suture anchors.

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Patients older than age 50 years have less potential for healing and greater potential for stiffness and persistent pain. These patients generally do better with a biceps tenodesis/tenotomy procedure.

TYPE 3 SLAP tear –

Treatment options include

  • Arthroscopic repair of bucket handle tear of labrum
  • Excision and debridement of bucket handle tear of labrum

Treatment is customized individually to the patient considering various factors like age, activity level, healing potential.

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Usually, biceps procedures not required in this type

TYPE 4 SLAP tear –

Treatment options include

  • Arthroscopic debridement with repair of the labrum and biceps
  • Arthroscopic debridement with repair of the labrum with or without biceps tenotomy/tenodesis
  • Arthroscopic Excision and debridement of bucket handle tear of labrum with or without biceps tenotomy/tenodesis

Treatment is customized individually to the patient considering various factors like age, activity level, healing potential.

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