Marc Darrow, MD.
I get many inquiries from people asking if they should have a SLAP tear surgery or if there are options to avoid the surgery. The decision to proceed with surgery or other treatments should be made after a physical examination. A SLAP tear, or Superior Labrum Anterior and Posterior tear occurs when the superior portion (the top) of the labrum of the shoulder is damaged. The labrum is the lining of the shoulder socket. It holds the upper arm bone within the joint as well as attaches the upper bicep to the shoulder joint. When it is injured, the shoulder joint becomes unstable and this instability leads to pain and loss of function.
SLAP tears are commonly caused by degenerative wear and tear or acute injury. It is frequently seen in athletes who play sports that involve excessive overhead movement or force. Baseball, volleyball, tennis and swimmers are at a higher risk.
Suspected SLAP Tear symptoms:
- Shoulder pain and instability.
- Reduced range of motion including catching or locking of the shoulder.
- Popping, clicking, and grinding noises in the shoulder.
SLAP Tear treatment options
Above I wrote that I get many inquiries from people asking if they should have a SLAP tear surgery or if there are options to avoid the surgery. These people are now into a surgical recommendation because conservative care treatments including anti-inflammatory medication, pain killers, physical therapy, shoulder braces and other remedies did not help them. Nether problem is that people are looking for options because their surgeon does not have confidence that the outcome of surgery will be as successful as the patient hopes. Who are people that fall into this category? People with multi-directional shoulder instability, or, people who already had the surgery and despite it being a successful surgery, the person still had pain and range of motion issues.
Below I will provide some updated research in regard to SLAP tears and the remedies that can be employed to help this problem. Included will be a discussion on platelet rich plasma injections. However, before we get into the research, I would like to share with you my story.
I had a labral tear in my right shoulder. I had a supraspinatus and subscapularis tear as well. I did not have chronic or acute pain for the most part. A nag here and there. How did I know I had the tears? Because I looked at my shoulder under ultrasound when I was having shoulder pain, one day especially, when I had a frozen shoulder from hitting too many golf balls. I am a very repetitive motion type athlete.
I did have a shoulder surgery while I was in medical school. I had the orthopedic surgeon who happened to be one of my surgical professors perform it. The surgery was not successful. In fact, for me, it was terrible and failed. It was in part because of this failed shoulder surgery that I got into non-surgical medicine. I have treated and healed my shoulder using Platelet Rich Plasma Therapy and Stem Cell Therapy. I’ve injected both my shoulders, both my knees, both my elbows, and wrist. This is not to say that this will work for everyone, but it worked for me.
SLAP Tear treatment research from 2017 to 2023
- A SLAP Tear is an injury to the labrum of the shoulder. The labrum is the ring of cartilage that holds the upper arm bone or “ball” in the shoulder socket. A SLAP tear is then a Superior Labrum Anterior to Posterior tear. A labrum tear from front to back.
A recent paper outlined the treatment paths of a SLAP injury. It was published in The open orthopaedics journal (1) for orthopedic surgeons.
Here are the recommendations:
The management of SLAP lesions can be divided into 4 broad categories:
- Nonoperative management that includes scapular exercise, restoration of balanced musculature, and that would be expected to provide symptom relief in 2/3 of all patients;
- Patients with a clear traumatic episode and symptoms of instability that should undergo SLAP repair without (age < 40) or with (age > 40) biceps tenotomy or tenodesis;
- Patients with etiology of overuse without instability symptoms should be managed by biceps tenotomy or tenodesis; and
- Throwing athletes that should be in their own category and preferentially managed with rigorous physical therapy centered on hip, core, and scapular exercise in addition to restoration of shoulder motion and rotator cuff balance through treaments of the rotator cuff tendons. Peel-back SLAP repair, Posterior Inferior Glenohumeral Ligament (PIGHL) release, and treatment of the partial infraspinatus tear with debridement, PRP (this is use during surgery), or (rarely) repair should be reserved for those who fail this rehabilitation program.
Two surgical options are discussed above, the standard labral repair and biceps tenodesis. Let’s explore these options further.
- In the biceps tenodesis procedure, your surgeon cuts the attachment of the biceps tendon to the labrum and then reattaches it to the humerus bone.
“Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied.”
In May 2017, Norwegian researchers lead by Dr Cecilie Piene Schrøder, an Orthopedic surgeon, examined the effectiveness of the routine surgical procedures for SLAP lesions or tears of the shoulder. Here is what the research team noted:(2)
- Evidence for the effectiveness of the routine and standard labral repair and biceps tenodesis is lacking.
- To find this evidence, the researchers evaluated the effect of labral repair surgery, biceps tenodesis surgery and sham (placebo) surgery on SLAP lesions.
- The researchers then performed a double-blind, sham(placebo)-controlled trial with 118 surgical candidates (average age 40 years), with patient history, clinical symptoms and MRI arthrography indicating an isolated type II SLAP lesion.
- Forty patients were randomly assigned to get a labral repair surgery.
- Thirty-nine patients received a biceps tenodesis surgery.
- Thirty-nine patients received a sham surgery.
- Results There were no significant between-group differences at any follow-up in any outcome.
- Conclusion Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied.
“Most SLAP lesion patients, however, are ultimately treated non-operatively.”
A number of editorials were written by surgeons that rebuked Dr. Schrøder’s findings and observations. In July 2018, Dr. Schrøder followed up his paper with a short piece published in The open orthopaedics journal. (3) Here he addressed this criticism about his findings. When questioned on the usefulness of SLAP tear surgery, Dr. Schrøder responded: “Based on (our) results we have narrowed our indications for SLAP lesion surgery. We still treat some SLAP lesions surgically and individualize our treatment in each such cases. Most SLAP lesion patients, however, are ultimately treated non-operatively.”
The management of Type-II superior labral tears (SLAP) of the shoulder remains a controversial topic.
Another 2018 study, this time from Department of Orthopaedic Surgery, Stanford University (4) found that “The management of Type-II superior labral tears (SLAP) of the shoulder remains a controversial topic. Treatment ranges from non-operative management to surgical management including SLAP repair, biceps tenotomy, and biceps tenodesis. An optimal treatment algorithm has yet to reach universal acceptance.”
Management of Type-II SLAP tears remains a diagnostic and therapeutic challenge, especially in the context of lack of consensus in the literature
These researchers suggested: “Management of Type-II SLAP tears remains a diagnostic and therapeutic challenge, especially in the context of lack of consensus in the literature. Surgical management includes labral repair, biceps tenodesis, biceps tenotomy, or a combination. Clinical decision making should be based on patient age, desired activity levels, the degree of participation in overhead sports, and the presence or absence of other associated pathology. These variables should be considered carefully as the surgeon and patient develop the ideal surgical treatment plan after conservative measures have failed.”
In November 2019, researchers also noted a lack of consensus (5) : “In patients that do not improve with conservative treatment, there is a great deal of variability in the surgical management of these injuries that includes arthroscopic SLAP repair, arthroscopic SLAP repair with biceps tenodesis, biceps tenodesis alone and biceps tenotomy. Each surgical technique has specific effects on a patient’s postoperative course and functional recovery. Despite an increased incidence in treatment, there is currently no consensus on the optimal surgical procedure or treatment algorithm for Type II SLAP injuries.”
Returning to sport and work following surgery – “the most appropriate surgical option in elite throwers is controversial.”
There are many studies that assess the patient’s ability to return to sport and work following an arthroscopic shoulder procedure. A July 2021 study (6) provides this summary assessment of returning to sports and work after the procedures.
- Superior labrum, anterior and posterior (SLAP) lesions are common and identified in up to 26% of shoulder arthroscopies, with the greatest risk factor appearing to be overhead sporting activities.
- Symptomatic patients are treated with physical therapy and activity modification. However, after the failure of non-operative measures or when activity modification is precluded by athletic demands, SLAP tears have been managed with debridement, repair, biceps tenodesis or biceps tenotomy. Recently, there have been noticeable trends in the operative management of SLAP lesions with older patients receiving biceps tenodesis and younger patients undergoing SLAP repair, largely with suture anchors.
- For overhead athletes, particularly baseball players, SLAP lesions remain a difficult pathology to manage secondary to concomitant pathologies (other shoulder damage) and unpredictable rates of return to play.
- As a consequence, the most appropriate surgical option in elite throwers is controversial.
It takes nine months to recover from surgery to return to sport – unless you are a throwing athlete or pitcher
A December 2019 paper (7) offered these timetables for a return to sport in evaluating individuals undergoing arthroscopic SLAP repair. This research encompasses 22 previously published articles involving a total of 944 patients undergoing arthroscopic SLAP repair.
- Of the total included patients, 270 were identified as overhead athletes, with 146 pitchers.
- Across all patients, 69.6% (657/944 patients) of individuals undergoing arthroscopic SLAP repair returned to sport.
- There was a 69.0% (562/815 patients) return to previous level of play, with a mean time to return to sport of about nine months.
- The return-to-sport rate for pitchers compared with the return-to-activity rate for nonpitchers, encompassing return to work and return to sport, was 57.5% (84/146 patients) and 87.1% (572/657 patients), respectively, after arthroscopic SLAP repair.
Conclusion: “Arthroscopic SLAP repair is associated with a fair return to sport, with 69.6% of individuals undergoing arthroscopic SLAP repair returning to sport. SLAP repair in pitchers has significantly decreased return to sport in comparison with nonpitching athletes. Athletes on average return to sport within 9 months postoperatively.”
The Hospital of Special Surgery and the Mayo Clinic findings say mixed results
A January 2018 study from the Hospital of Special Surgery and the Mayo Clinic discussed the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex.
“Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion.”(8)
A bicep tenodesis is a surgery to repair a damaged bicep tendon. A biceps tenodesis may be performed as an isolated procedure but more often is part of a larger shoulder surgery, including rotator cuff repair.A recent study from Rush University Medical Center warns of including this procedure during the bigger shoulder surgery:
“High-demand patients with biceps tendonitis in the setting of a SLAP lesion with labral instability who undergo combined tenodesis and SLAP repair have significantly worse outcomes than patients who undergo either isolated labral repair for type II SLAP tears or isolated biceps tenodesis for a SLAP tear and biceps tendonitis.”(9)
SLAP tear surgery does cause a lot of damage, this is why revision surgery is generally not successful.
Similar findings were observed by surgeons at New York University Hospital for Joint Diseases. They found that on average 10% of patients would need a second shoulder surgery at average two years after the initial SLAP lesion procedure and those procedures were expanded to include subacromial decompression (35%), debridement (26.7%). repeat SLAP repair (19.7%), and biceps tenodesis or tenotomy (13.0%). After isolated SLAP repair, patients aged 20 years or younger were more likely to undergo arthroscopic Bankart repair.
The doctors concluded: “We identified a 10.1% incidence of subsequent surgery after isolated SLAP repair, often related to an additional diagnosis, suggesting that clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions. In addition, the number of isolated SLAP repairs performed has decreased over time, and management of failed SLAP repair has shifted toward biceps tenodesis or tenotomy over revision SLAP repair in more recent years.(10)
Also in the July 2018 edition of The open orthopaedics journal, (11) is another study that suggests that for many patients, SLAP tear surgery is not ideal. Risk factors for failure of SLAP repair include age, smoking, obesity, being female and concomitant bicep pathology(weakened, injured biceps). The researchers of this study cited a previous study that found that once a patient has failed first time repair, 71% will fail conservative therapy and 32% will continue to have suboptimal outcomes after a second surgical intervention.
The more surgery, the worse the outcome.
The surgical treatment of SLAP tears continues to be challenging for both the physician and the patient. Of course it becomes much more challenging to the patient if the surgery does not work to the patient’s expectations. Here is a recent paper discussing these problems from doctors at the University of Minnesota and Saarland University in Germany.
- Tears of the superior labrum involving the biceps anchor are a common entity, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature particularly for young athletes.
- However, the results in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance (see below for further documentation).
- The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates as compared to younger patients. In this population, tenotomy or tenodesis of the biceps tendon (doctors will move the bicep tendon attachment to a different place on the bone – usually part of a more major surgery) is a viable alternative to SLAP repairs in order to improve clinical outcomes. (12)
Revision surgery for the failed SLAP tear surgery
A study from in The open orthopaedics journal (13) throws a lot of questions at the effectiveness of SLAP tear surgery.
- “Optimal treatment of type II superior labrum anterior and posterior (SLAP) tears is controversial. There has been a recent trend towards biceps tenodesis over SLAP repair in older patients. Few surgeons have performed combined biceps tenodesis and SLAP repair with inferior results.”
- “Failed SLAP repair is often multifactorial and a thorough workup is needed. Combined biceps tenodesis and SLAP repair can cause pain, stiffness, and dysfunction which can be successfully treated with arthroscopic superior capsular release.”
The results of biceps tenodesis, compared with SLAP repair
In the three years since the debate of the effectiveness for SLAP tear surgery, more research started to appear in regard to the biceps tenodesis procedure as being an option. A September 2021 study in The American journal of sports medicine (14) compared the outcome of a biceps tenodesis compared to traditional SLAP tear repair. The quick points of this research is:
- The rate of return to sport and the return to preinjury level of sport were slightly higher in the biceps tenodesis group than in the SLAP repair group; however, in meta-analysis these factors did not reach statistical significance.
- The biceps tenodesis group showed a lower complication rate compared with the SLAP repair group without statistical significance.
Conclusion: “The results of biceps tenodesis, compared with SLAP repair, were not inferior in the surgical treatment of overhead athletes with SLAP lesions with regard to the ASES score, rate of return to sport, rate of return to preinjury level of sport, and complication rate. Further high-level, randomized controlled studies are needed to confirm this result.”
Younger patients may do better with arthroscopic biceps tenodesis
A January 2021 study (15) found: “in a young active population, primary arthroscopic biceps tenodesis is a viable surgical alternative to labral repair for type II SLAP lesions. The results of this study suggest that indications for arthroscopic tenodesis can safely be expanded to a younger patient group than has previously been demonstrated in the literature.”
Active patients and military personnel
An April 2022 study (16) investigated clinical outcomes in overhead athletes undergoing biceps tenodesis for the treatment of symptomatic, isolated SLAP tears involving the biceps-labral complex. The study included 44 overhead athletes. The average age was 34.9 years (range, 16-46 years), 79.5% were male, and the mean follow-up was 49.0 months (range, 18-107 months).
- Overall, 81.8% of patients returned to play their overhead sport after biceps tenodesis, and 59.1% of patients returned to the same or higher level of play.
- It took patients, on average, 8.7 months to return to play after biceps tenodesis.
A March 2022 (17) paper reported on short-term outcomes following biceps tenodesis combined with arthroscopic posterior labral repair of type VIII superior labrum anterior posterior (SLAP) lesions in active-duty military patients. They found that among thirty-two patients, thirty (93.75%) patients remained on active-duty military service and were able to return to preinjury levels of activity.
A November 2022 study (18) suggests “The surgical management of type II superior labrum anterior and posterior (SLAP) tears in patients younger than 40 years is controversial, but growing evidence suggests comparable outcomes between primary SLAP repair and primary biceps tenodesis, with lower rates of reoperations after primary biceps tenodesis.”
Research does not give clear evidence that athletes return to their previous level of sport or athletic performance following surgery
An October 2020 study (19) says: “Limited evidence suggests that less than three in four athletes return to their previous level of sport participation after SLAP injury intervention. Treatment success for an athlete with SLAP injury remains relatively unknown as only 59% of included studies clearly delineate RTS (return to sport) from RTSP (return to sport at previous level) and neither athletic performance nor career longevity were reported in any included studies.”
SLAP (labral) lesions may actually be rare injuries
Recently when Stephen C. Weber, MD presented the findings of his study that American Board of Orthopaedic Surgery (ABOS) Part II candidates (young surgeons) may be performing superior labral tear anterior to posterior (SLAP) repairs at greater rates than they should, he noted that the increase in surgeries were leading to poor outcomes and increased complication rates.
One of the reasons too many surgeries were being performed was because MRI suggested a SLAP tear when Slap tears were not there. Dr. Weber noted that magnetic resonance imaging (MRI) scans often produce false positives and that SLAP lesions are difficult to diagnose clinically. Numerous studies suggest that even experts disagree on how to define a type II SLAP tear.
“Furthermore, repairing SLAPs is not a benign process, and caring for failed SLAPs can be very difficult,” said Dr. Weber. “Complications include stiffness, persistent rotator cuff tears next to the portals, and damage to the articular cartilage.”
This was later supported in a 2019 paper (20) which said: “SLAP tear of the shoulder is considered relatively rare pathology. Only 6% of shoulder arthroscopies are related to this pathology. The most common SLAP tear is type II tear, which is 55% of all SLAP tears. This type of tear is prevalent in overuse shoulder injuries that occurs mostly in athletes whose sports require repeated external rotation and abduction of the shoulder followed by rapid overhead movement such as throwing and serving.”
To treat a SLAP tear, you must treat the whole shoulder
SLAP lesions do not happen overnight unless you take a fall with your arm extended. Then you can have an acute tear. More typically SLAP lesions occur as the result of repetitive motion or wear and tear injury. SLAP lesions, therefore, do not happen in isolation, they happen as part of a degenerative shoulder disease problem. People who email me typically describe that they have a SLAP tear as well as a torn tendon, torn rotator cuff muscles, and chronic shoulder instability, sometimes with dislocation. The have all the symptoms of a shoulder that is in a downward spiral: Pain and a lot of noise, clicking, grinding, and popping. They have limited range of motion and a significant decrease in strength. It is for these reasons that shoulder surgery for SLAP tears and lesions is not effective. The surgery does not address the whole shoulder problem.
This may be pointed out by a study from February 2021 (21) that looked at the reoperation rate in an isolated SLAP II type tear. In this paper sixty-six of 539 patients (12%) had unplanned reoperation (a revision surgery) after SLAP repair. The researchers found that if you only treated the SLAP tear without addressing other shoulder structures that may be damaged, you may put the patient at greater risk for the need for more surgery.
Platelet Rich Plasma Therapy
Platelet Rich Plasma Therapy is an injection technique that can accelerate the body’s own inflammatory response to repair the labral damage. But treating the whole shoulder capsule, with platelet rich plasma injections, we can not only repair the labrum, but we can also protect it from damage and shoulder instability caused by compromised shoulder structures, such as ligaments and tendons. By treating the whole shoulder, we can strengthen these weakened elements and stabilize the entire joint.
In examination PRP injection therapy can be assessed for treatments for shoulder problems that could include rotator cuff pathology, full thickness tear in any soft tissues including full thickness rotator tear injuries, failed shoulder separation repair or partial tears.
There is not much research currently on the use of PRP for SLAP tears beyond empirically evidence and clinical observation. A December 2018 study (22) suggested that PRP seemed to work in non-surgical and surgical settings but the definitive medical research is not there yet. This is what that study said:
“The use of PRP in orthopedic surgery is becoming more common, with increasing use in the shoulder in both operative and non-operative settings. . .PRP is thought to promote healing and stimulate growth by the release of growth factors from a high concentration of activated platelets. Yet despite this exciting promise, human subject research with PRP has not produced consistent results in favor of its use in either operative or non-operative conditions of the shoulder, and thus, no consensus exists regarding its therapeutic guidelines or application.
There are some limitations in the study of the efficacy of PRP for the treatment of shoulder pathology. One limitation includes the lack of standardized dosing, formulation, and concentration of the platelets and growth factors that comprise PRP. . . The application of PRP can also differ between administering clinicians, as there is no standardized technique. These variations make cross-study comparisons difficult to interpret.
Based on our review of the current literature, evidence in favor of PRP use for operative and non-operative management of shoulder conditions is inconsistent and cannot be absolutely supported or refuted. The potential benefits of PRP, perhaps not yet (understood), could outweigh the risks, which are minimal.”
More generally in regard to PRP helping patients with shoulder pain is a November 2021 study (23) which stated “PRP injections could provide better pain relief and functional outcomes than other treatments for persons presenting with common shoulder diseases. PRP injections have a greater capacity to improve shoulder-related Quality-of-life than other interventions.”
A case review study published in the journal F1000 Research (24) reported on two patients who had treatments. Here is the report:
“Labral tears commonly occur in both the general and sporting population, often leading to significant pain and dysfunction. Patients often engage in progressive rehabilitative programs, and surgical intervention may be required in severe cases. Autologous platelet rich plasma (PRP) injections have been growing in popularity in musculoskeletal medicine as an alternative to corticosteroid injections. This paper looks at the effectiveness of PRP injections in glenoid labral lesions.
Methods: The clinical and radiological findings are presented for two patients who have been treated with autologous PRP into the glenohumeral joint adjacent to the labral tear, in conjunction with a progressive rehabilitative program. Follow up occurred at 18 months and 13 months, respectively.
Results: Both subjects tolerated the PRP injection well with no adverse effects, and were compliant with their rehabilitative programs. On initial presentation, pain on the visual analogue scale (VAS) was 7/10 and 6/10 and at follow up it was reported as 0/10. Both subjects have now returned to normal sporting and work activities.”
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