Shoulder SLAP Arthroscopic Repair

What Is the Shoulder Labrum and a SLAP Tear?

Glenoid Labrum: A sturdy, flexible, cartilage-like (fibrocartilaginous) ring of tissue that surrounds the rim of the shoulder joint socket (glenoid). Its functions are as follows:

• Deepening the shoulder socket to increase joint stability.
• Distributing pressure within the shoulder joint.
• Serving as the attachment site for the shoulder ligaments and the tendon of the long head of the biceps muscle.

SLAP Tear: A tear that occurs in the upper part of the labrum, extending from the front to the back of the area where the biceps tendon attaches. These tears can be of different types (e.g., Type I: fraying only, Type II: separation of the labrum and biceps tendon from their attachment site – the most common type, Type III: a bucket-handle-shaped tear, Type IV: extension of the labral tear into the biceps tendon). Tears such as Type II and Type IV, which particularly disrupt the stability of the biceps tendon attachment site, produce more symptoms and often require surgical treatment.

Why Do SLAP Tears Occur? Risk Factors

SLAP tears can occur through various mechanisms:

• Acute Trauma:
  
  • Falling onto an outstretched arm.
  • A direct blow to the shoulder.
  • A sudden, forceful pulling of the arm (such as while lifting something heavy).
  • Forceful overhead movements (e.g., gripping the steering wheel during a car accident).
• Repetitive Overhead Activities (Overuse): This is one of the most common causes of SLAP tears. Repetitive strain on the shoulder, particularly in throwing sports (baseball, volleyball, handball), swimming, tennis, and weightlifting, can place excessive load on the biceps tendon attachment site and lead to a tear in the labrum (the “peel-back” mechanism).
• Degenerative Changes: SLAP tears can also occur as a result of wear and weakening of the labral tissue with advancing age. Such tears usually produce fewer symptoms or occur together with other shoulder problems, such as rotator cuff tears.

What Are the Symptoms of a SLAP Tear?

The symptoms of SLAP tears are usually non-specific, meaning they can be confused with the symptoms of other shoulder problems (such as shoulder impingement, rotator cuff tear, or biceps tendinitis). This can make diagnosis difficult. Possible symptoms include:

• Deep Shoulder Pain: Usually a dull, aching type of pain.
• Pain That Increases with Activity: Pain increases especially with movements such as raising the arm overhead (throwing, reaching), pushing, and pulling.
• Mechanical Symptoms: A sensation of clicking, popping, catching, or locking during shoulder movements.
• A Feeling of Instability: A sense of insecurity, giving way, or feeling like the shoulder is “about to slip out of place” (especially the “dead arm” sensation in athletes).
• Loss of Strength: Decreased shoulder strength, especially reduced performance in overhead activities or sports requiring throwing (e.g., decreased throwing speed).
• Difficulty with Tasks Requiring Strength: Difficulty lifting or carrying heavy objects.
• Biceps Tenderness: Pain may sometimes radiate to the front of the shoulder or the biceps muscle.

How Is a SLAP Tear Diagnosed?

Diagnosing a SLAP tear requires careful evaluation. Prof. Dr. Murat Bozkurt follows these steps:

• Detailed History: How the symptoms began, the mechanism of injury (if any), which movements trigger pain or mechanical symptoms, and the patient’s occupation, sports history, and activity level are noted.
• Physical Examination: The shoulder’s range of motion, muscle strength, and tender points (particularly the bicipital groove) are assessed. Special provocative tests suggestive of a SLAP tear are performed (such as the O’Brien test, Crank test, Biceps Load test, and Speed test). However, the diagnostic accuracy of these tests is not 100%, and they are usually interpreted together with other shoulder tests (impingement, rotator cuff).
• Imaging Methods:
  
  • X-ray: Usually does not show a SLAP tear but is taken to rule out bony problems, fractures, or osteoarthritis.
  • Magnetic Resonance (MR) Imaging: Standard MRI may not always be sufficient to detect SLAP tears.
  • MR Arthrography (MRA): This is the gold-standard imaging method for diagnosing a SLAP tear. In this method, an MRI is taken after contrast material (dye) is injected into the shoulder joint. The contrast material seeps into the tears in the labrum, allowing the tear to be seen more clearly. It is particularly valuable for a detailed evaluation of the upper part of the labrum and the biceps tendon attachment site.
• Diagnostic Arthroscopy: In some cases, particularly when imaging methods do not give a clear result or when arthroscopy is planned for another reason, a definitive diagnosis can only be made by directly viewing the shoulder joint with a camera during surgery.

Treatment Options: Is Surgery Always Necessary?

Treatment of a SLAP tear varies depending on the type of tear, the patient’s age, activity level, symptom severity, and whether there are other accompanying shoulder problems.

Non-surgical (Conservative) Treatment:

Non-surgical treatment is tried first, particularly for degenerative tears, stable tears such as Type I, or patients with mild symptoms.

• Rest and Activity Modification: Avoiding movements and overhead activities that increase pain.
• Medication: NSAIDs for pain and inflammation.
• Physical Therapy: An important part of treatment. The goals are to:
  
  • Strengthen the rotator cuff and shoulder blade muscles (to increase shoulder stability).
  • Correct shoulder mechanics and posture.
  • Increase flexibility.
  • Important: Exercises that place excessive strain on the biceps tendon may need to be avoided.
• Injections: Intra-articular corticosteroid injections can sometimes temporarily reduce pain, but they do not heal the tear and generally have little effect on mechanical symptoms.

Some patients (particularly older, less active patients or those with degenerative tears) can find relief with conservative treatment. However, it is often insufficient in active individuals or those with mechanical symptoms (catching, locking).

Surgical Treatment: Arthroscopic SLAP Repair (or Alternatives):

Surgical treatment is recommended for patients who do not respond to conservative treatment (usually 3-6 months) and continue to have pain, mechanical symptoms, or functional limitations, particularly young, active patients and athletes, or in certain tear types (e.g., unstable Type II). Surgery is usually performed using an arthroscopic (closed) technique.

Arthroscopic SLAP Surgery: Techniques and Considerations

During arthroscopic surgery, the shoulder joint is entered through small incisions using a camera and specialized instruments to assess the type and condition of the tear. The surgical technique used is determined based on the patient’s age, activity expectations, the type of tear, and the condition of the biceps tendon:

• Arthroscopic SLAP Repair:
  
  • Purpose: To anatomically reattach the torn upper labrum and the separated biceps tendon attachment site to the glenoid rim.
  • How Is It Performed? After the torn edges are prepared, small suture anchors (screws or hooks) are placed into the glenoid bone. Sutures attached to these anchors are passed through the labrum and tied, firmly fixing the labrum to the bone.
  • Who Is It For? This is usually the preferred method for young, active patients and athletes under 40-45 years of age, particularly for unstable Type II SLAP tears.
• Biceps Tenodesis:
  
  • Purpose: To eliminate the tension on the labrum caused by the biceps tendon, which is either the cause of the SLAP tear or problematic alongside it.
  • How Is It Performed? The long head of the biceps tendon is cut at the point where it separates from the labrum, and it is then reattached with special screws or sutures further down the shoulder, either in its groove on the humerus or at a different site.
  • Who Is It For? This is generally used in patients over 40-45 years of age, in cases where SLAP repair has failed or has a low potential for healing, when there is significant accompanying biceps tendinitis or a biceps tear, or it may be preferred as a primary treatment for certain SLAP types by some surgeons. It provides good pain control and functional outcomes.
• Biceps Tenotomy:
  
  • Principle: The long head of the biceps tendon is cut from the labrum but is not reattached elsewhere (this is the difference from tenodesis).
  • Who Is It For? This can be performed in older patients with lower activity expectations, when tenodesis is not possible, or when a simpler procedure is preferred.
  • Disadvantage: Some patients may develop a cosmetic bulge in the biceps muscle, known as the “Popeye” appearance, or cramp-like pain.
• SLAP Debridement:
  
  • Principle: Arthroscopic shaving and cleaning of worn labral edges in cases where the tear is stable (the labrum has not separated from the bone) and shows only fraying or degeneration (e.g., Type I, stable Type III).
  • Who Is It For? This can be performed as an additional procedure in degenerative tears that do not cause mechanical symptoms, or in patients undergoing arthroscopy for another reason.

The decision on which surgical method to choose is made by Prof. Dr. Murat Bozkurt after evaluating the patient’s individual condition.

Risks, Benefits, and the Long Rehabilitation Process

• Benefits: With successful surgery, pain relief, elimination of mechanical symptoms such as catching and locking, improved shoulder stability and function, and the possibility of returning to activity and sport (with appropriate rehabilitation).
• Risks:
  
  • General surgical risks: Infection, shoulder stiffness (adhesive capsulitis), nerve damage (rare), anesthesia risks.
  • Risks specific to SLAP surgery: Failure of the repair (the labrum failing to heal to the bone), loosening or dislodging of the anchors, ongoing pain or mechanical symptoms, pain/cramping/cosmetic problems in the biceps muscle after biceps tenodesis/tenotomy, restricted motion (especially in external rotation), and the need for repeat surgery.
• Recovery Process: Rehabilitation after SLAP repair or biceps tenodesis is long, gradual, and very important.
  
  • Use of an Arm Sling: To protect the repaired labrum or the tenodesed biceps, an arm sling is usually needed for 4 to 6 weeks after surgery.
  • Movement Restrictions: Active shoulder movements are restricted in the first weeks. In particular, movements that strain the biceps muscle (heavy lifting, pulling) must be avoided for a long period (3-4 months).
  • Gradual Physical Therapy: Treatment begins with passive movements, progressing over time to active movements and then to strengthening exercises for the rotator cuff, shoulder blade area, and shoulder muscles. The rehabilitation program is planned individually for each patient.
  • Return to Sport: While return to normal daily activities takes a few months, return to contact sports or overhead sports (such as throwing) can generally take 6 to 9 months or longer. Returning to previous performance levels is not always guaranteed, especially for elite-level overhead athletes. Full adherence to rehabilitation is critical.

SLAP Tear Surgery in Ankara and Prof. Dr. Murat Bozkurt’s Approach

SLAP tears are a significant cause of shoulder pain and loss of function, particularly among the active population and athletes in Ankara. Diagnosing and treating them requires experience. Prof. Dr. Murat Bozkurt follows these steps in his approach to patients with suspected SLAP tears:

• Rigor for an Accurate Diagnosis: He establishes the correct diagnosis and determines the type of tear by carefully evaluating the patient’s history, examination findings, and particularly the MR Arthrography results.
• Evaluation of Treatment Options: He first evaluates conservative treatment options. If non-surgical treatment fails or is not appropriate, he discusses surgical options with the patient in detail.
• Personalized Surgical Approach: He determines the most appropriate surgical technique (SLAP repair, biceps tenodesis, tenotomy, or debridement) based on the patient’s age, activity level, type of tear, and condition of the biceps tendon.
• Advanced Arthroscopic Techniques: He performs surgery using minimally invasive arthroscopic methods, employing current and reliable techniques.
• Guidance Through Rehabilitation: He guides patients through the long and important post-surgical rehabilitation process and coordinates with physiotherapists.