What is the treatment for a Superior Labrum Anterior to Posterior (SLAP) tear?

Treatment for a SLAP Tear

The treatment for a Superior Labrum Anterior to Posterior (SLAP) tear should begin with conservative management, including physical therapy, activity modification, and anti-inflammatory medications, with surgical intervention reserved for cases that fail to respond to non-operative treatment. 1

Diagnostic Approach

• Initial evaluation should include standard radiographs with at least three views: anteroposterior (AP) views in internal and external rotation and an axillary or scapula-Y view 2
• MR arthrography is considered the gold standard for imaging labral tears, particularly in patients under 35 years of age 2, 1
• MRI without contrast is appropriate for suspected labral tears with negative or indeterminate radiographs 1
• CT arthrography may be appropriate if MRI is contraindicated 2, 1

Non-Surgical Management

• Conservative treatment should be the first-line approach for most SLAP tears 3
• Physical therapy should focus on:
  • Strengthening of the rotator cuff and periscapular muscles 2
  • Core musculature strengthening 2
  • Capsule flexibility exercises 2
• For throwing athletes, rehabilitation should emphasize hip, core, and scapular exercise in addition to restoration of shoulder motion and rotator cuff balance 3
• Non-surgical treatment has shown a 53.7% return-to-play rate in athletes overall, which increases to 78% in those who complete their rehabilitation program 4
• Patients who successfully complete non-operative treatment typically attend around 20 physical therapy sessions 4

Surgical Management

Surgical options should be considered when non-operative management fails after an appropriate trial (typically 3-6 months). The choice of surgical procedure depends on patient factors:

Age-Based Approach:

• Patients under 40 years: SLAP repair without biceps tenotomy/tenodesis 5
• Patients over 40 years: Biceps tenodesis or tenotomy with more reliable pain relief and functional improvement 5

Activity-Based Approach:

• Throwing athletes: Primary SLAP repair with possible posterior inferior glenohumeral ligament release if conservative management fails 3
• Non-throwing athletes: SLAP repair for younger patients; biceps tenodesis for older patients 3, 6
• Low-demand individuals: Biceps tenotomy is a viable option, especially in elderly patients 5

Type-Specific Treatment

Treatment varies based on SLAP tear classification:

• Type I: Conservative treatment or arthroscopic debridement 6
• Type II: SLAP repair or biceps tenotomy/tenodesis based on age and activity level 6
• Type III: Resection of the unstable bucket-handle tear 6
• Type IV: SLAP repair (biceps tenotomy/tenodesis if >50% of biceps tendon is affected) 6

Post-Treatment Rehabilitation

• For non-surgical treatment, return to play generally occurs within 6 months 4
• After SLAP repair, throwing athletes should avoid throwing for a minimum of 6 weeks 2
• A strengthening phase of rehabilitation should follow for an additional 6 weeks (total of at least 3 months rest from throwing) 2
• Return to sports should be based on functional testing rather than arbitrary time points 7

Factors Associated with Poor Outcomes from Conservative Management

• Older age 4
• Participation in overhead sports (especially baseball pitchers) 4
• Traumatic injury mechanism 4
• Positive compression rotation test 4
• Concomitant rotator cuff injury 4
• Longer symptomatic period before treatment 4