What is the treatment for a superior labral (SLAP) tear?

Treatment for Superior Labral (SLAP) Tears

Begin with conservative management including physical therapy focused on rotator cuff, periscapular, and core strengthening plus capsular flexibility exercises, reserving surgery for patients who fail non-operative treatment after at least 3-6 months. 1, 2

Initial Diagnostic Workup

• Obtain standard radiographs with three views: anteroposterior in internal and external rotation plus axillary or scapula-Y view 1, 2
• MR arthrography is the gold standard for confirming labral tears, particularly in patients under 35 years 1, 2, 3
• Use MRI without contrast if radiographs are negative or indeterminate 1, 2
• Consider CT arthrography only if MRI is contraindicated 1, 2

Non-Operative Management (First-Line Treatment)

Physical therapy should be attempted for at least 3-6 months before considering surgery, as approximately 53-78% of athletes can return to play with conservative treatment alone. 4

Specific Rehabilitation Components:

• Rotator cuff strengthening exercises 1
• Periscapular muscle strengthening 1
• Core musculature strengthening 1
• Capsular flexibility exercises 1
• Correction of scapular dyskinesis 5
• Restoration of full range of motion 5

Success Rates and Predictors:

• Overall return-to-play rate is 53.7% in all athletes, increasing to 78% in those who complete the full rehabilitation program 4
• Return to prior performance level occurs in 72% of athletes who complete rehabilitation 4
• Patients who successfully complete non-operative treatment average 20 physical therapy sessions versus only 8 sessions in those who fail 4
• Conservative treatment provides symptom relief in approximately two-thirds of all patients 6

Factors Associated with Conservative Treatment Failure:

• Older age 4
• Overhead sports participation, especially baseball pitchers 4
• Traumatic injury mechanism 4
• Positive compression rotation test 4
• Concomitant rotator cuff injury 4
• Longer symptomatic period 4
• Presence of Bennett spur 4

Surgical Management (After Failed Conservative Treatment)

The choice between SLAP repair versus biceps tenodesis/tenotomy depends primarily on age, sport type, and injury mechanism—not arbitrary preferences.

Age-Based Algorithm:

For patients under 30-40 years old:

• SLAP repair is preferred for traumatic injuries with instability symptoms 6, 5
• Use knotless suture anchor techniques for repair 5
• Consider biceps tenodesis for overuse injuries without instability 6

For patients over 30-40 years old:

• Biceps tenodesis is first-line surgical treatment due to higher SLAP repair failure rates in this population 7, 5
• Tenodesis shows better outcomes and lower revision rates compared to SLAP repair in middle-aged patients 7

Sport-Specific Considerations:

Throwing Athletes (Baseball, Softball):

• This population requires special consideration due to unpredictable return-to-play rates 8
• Prioritize rigorous physical therapy centered on hip, core, and scapular exercises plus restoration of shoulder motion and rotator cuff balance 6
• Reserve peel-back SLAP repair with posterior inferior glenohumeral ligament release for those who fail rehabilitation 6
• Only 40% of professional baseball players successfully return to play after SLAP repair 5
• Biceps tenodesis is gaining popularity even in younger throwing athletes due to high SLAP repair failure rates 5

Non-Throwing Athletes:

• SLAP repair for traumatic injuries with clear instability in younger patients 6
• Biceps tenodesis for overuse injuries or patients over 30 years 6, 5

Type-Specific Surgical Approach:

• Type I: Conservative treatment or arthroscopic debridement 7
• Type II: SLAP repair in young patients (<30-40 years) with traumatic injury; biceps tenodesis/tenotomy in older patients or overuse injuries 7, 5
• Type III: Resection of unstable bucket-handle tear 7
• Type IV: SLAP repair if <50% biceps involvement; biceps tenodesis/tenotomy if >50% involvement 7
• Type V: Combined Bankart repair and SLAP repair 7
• Type VI: Flap resection and SLAP repair 7
• Type VII: Refixation of anterosuperior labrum and SLAP repair 7

Post-Operative Rehabilitation for Throwing Athletes

• Avoid throwing for minimum 6 weeks after SLAP repair 1
• Complete strengthening phase for additional 6 weeks (total 3 months minimum rest from throwing) 1
• Base return to sport on functional testing rather than arbitrary time points 1

Critical Pitfalls to Avoid

• Do not delay surgery in young, active patients with recurrent instability after failed conservative treatment 3
• Do not perform SLAP repair in middle-aged or older patients without considering biceps tenodesis as first-line option 7, 5
• Do not rush surgical intervention before completing adequate conservative treatment trial (minimum 3-6 months with 20+ therapy sessions) 4
• Do not overlook concomitant pathology, particularly rotator cuff tears and posterior inferior glenohumeral ligament tightness in throwing athletes 6, 4
• Do not confuse normal anatomic variations and degenerative changes with true SLAP lesions to avoid overtreatment 7