SLAP = Superior Labrum Anterior to Posterior tear at the biceps anchor; pain is deep, activity‑related, with mechanical clicking. Snyder classification I–IV (and extensions V–VII); Type II detachment is most common clinically; Type IV extends into biceps. Provocative tests: O’Brien/Active Compression, Crank, Biceps Load II—helpful but not definitive. MRI arthrogram is investigation of choice; arthroscopy is the diagnostic gold standard and allows treatment. Treatment is age- and demand‑based: debridement (Type I/III), labral repair (young/athletes Type II), and biceps tenodesis/tenotomy (older/degenerative or revision).
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Overview & Anatomy
The superior labrum anterior to posterior (SLAP) tear is a lesion of the superior glenoid labrum, including the anchor of the long head of biceps tendon (LHB) at the supraglenoid tubercle. SLAP tears range from fraying of the superior labrum to complete detachment of the biceps anchor, with or without extension into the glenohumeral ligaments. Understanding the classification, clinical diagnosis, and evolving management — including the shift toward biceps tenodesis over SLAP repair in many patient groups — is essential.
Incidence: approximately 6% of all shoulder arthroscopies; most common in overhead athletes (throwers, swimmers, tennis players) and labourers performing repetitive overhead activity
Mechanism: two main mechanisms — acute superior traction (fall on outstretched hand, sudden overhead pull) and repetitive overhead compression/traction (throwing athletes — peel-back mechanism)
Peel-back mechanism (throwing): during late cocking phase (maximum ABER), the biceps anchor is twisted and peeled posteriorly off the glenoid — produces Type II SLAP tears in overhead athletes; the biceps tendon twists and exerts a posterosuperior peel-back force on the labrum
Associated injuries: rotator cuff tears (frequently co-existing, especially in patients over 40), internal impingement, anterior instability (Type II + Bankart = combined SLAP-Bankart = Type V)
SLAP Classification (Snyder, 1990)
Type
Description
Management
I
Fraying of the superior labrum; biceps anchor intact
Débridement; no repair needed; often incidental
II
Detachment of superior labrum AND biceps anchor from supraglenoid tubercle; most common and most clinically significant
Bucket-handle tear of superior labrum; biceps anchor intact; displaced fragment into joint
Excise bucket handle; preserve biceps anchor
IV
Bucket-handle tear extending into biceps tendon; tendon split longitudinally
Excise fragment; tenodesis if >30% tendon involved; repair if young with <30% involvement
V
Type II + anterior Bankart labral tear (combined)
Combined SLAP repair + Bankart repair or stabilisation
Type II is by far the most clinically significant and most commonly treated SLAP tear — it is the peel-back lesion of the throwing athlete; all other types are less common and less controversial in management
Clinical Diagnosis
Symptoms: deep posterior shoulder pain worse with overhead activity; painful clicking or catching; reduced velocity or pain in late cocking phase in throwers; vague poorly localised pain difficult to distinguish from other shoulder pathology
Clinical tests for SLAP (all have limited sensitivity and specificity; no single test is diagnostic):
Test
Technique
Sensitivity / Specificity
O-Brien active compression test
Arm at 90° flexion, 15° adduction; maximally pronated then supinated; pain in pronation relieved in supination = positive for SLAP or ACJ
Sensitivity 47–63%; specificity 37–69%; modest
Speed test
Resist shoulder flexion with elbow extended and forearm supinated; pain in bicipital groove = positive
Also positive in biceps tendinitis; non-specific
Biceps load test II
ABER position, elbow at 90°; resist elbow flexion; pain increases = positive
Specificity 96.9%; better than most SLAP tests
Dynamic labral shear (O-Driscoll)
Shoulder in 90–120° abduction, ER; apply posterior force while moving from 90° to 120° abduction; pain or click = positive
Sensitivity 72%; specificity 98% for Type II SLAP in some studies
No single clinical test reliably diagnoses SLAP tear — combination of history, clinical tests, and MRI arthrography is required; diagnosis confirmed at arthroscopy; SLAP tears are frequently over-diagnosed and over-treated based on imaging alone
MRI arthrography (MRA): best imaging modality for SLAP tears; gadolinium contrast distends the joint allowing labral detachment to be visualised; sensitivity approximately 82–84%, specificity approximately 90%; superior to standard MRI for SLAP detection
Management Algorithm
Management of SLAP tears has evolved significantly over the past decade. There is increasing recognition that SLAP repair in patients over 35–40 years of age and in non-overhead athletes carries high failure rates and poor outcomes, leading to a paradigm shift toward biceps tenodesis in these groups.
Patient Group
Preferred Management
Rationale
Young (<35) competitive overhead athlete (pitcher, swimmer)
SLAP repair (Type II)
Biceps anchor function critical for overhead sport; repair restores native mechanics; return to sport approximately 70–74%
Age >35–40; non-overhead athlete; manual worker
Biceps tenodesis
SLAP repair has high failure rate (>50%) in older patients; tenodesis reliably relieves pain; better outcomes than repair in this group
Type II SLAP + significant rotator cuff tear
Biceps tenodesis + cuff repair
SLAP repair biologically unreliable in presence of cuff tear; tenodesis avoids over-constraining the shoulder
Type III (bucket handle); biceps intact
Excise displaced fragment; preserve biceps anchor
Remove mechanical block; no need to repair if anchor stable
Type IV; >30% tendon involved
Biceps tenodesis
Tendon too compromised to repair; tenodesis addresses both labral and tendon problem
SLAP Repair — Technique
Arthroscopic repair: standard approach; suture anchors placed at the superior glenoid rim; labrum and biceps anchor secured back to supraglenoid tubercle
Anchor number: 1–3 anchors depending on tear extent; posterior anchor placement critical for Type II tears to address peel-back; anchor at 12 o clock position (supraglenoid) addresses anterior component
Portal positioning: anterosuperior portal (Neviaser portal) provides best access for posterior SLAP anchor placement; standard posterior portal for viewing; mid-glenoid portal for anterior anchors
Return to throwing: typically 9–12 months; rehabilitation through interval throwing programme; full return to competitive pitching approximately 70–74% in most series — significantly less than after minor shoulder procedures
Stiffness after SLAP repair: a recognised complication particularly when capsule is over-tightened; avoid over-tensioning the repair
Biceps Tenodesis
Principle: detach the LHB from the supraglenoid tubercle and reattach (tenodesed) at the proximal humerus, eliminating the biceps anchor pain and SLAP pathology while maintaining biceps function
Tenodesis locations:
Location
Technique
Notes
Subpectoral (distal)
Small incision below inferior border of pectoralis major; interference screw into humeral tunnel
Removes entire intra-articular and intertubercular portion; most reliable for pain relief; preferred by many surgeons
Proximal (bicipital groove)
Arthroscopic or mini-open; anchor or interference screw at groove level
Preserves more LHB length; residual intertubercular tendinitis possible if groove pathology persists
Biceps tenotomy vs tenodesis: tenotomy (simple transection) is faster and appropriate for elderly low-demand patients; risk of "Popeye deformity" (distal biceps displacement) in approximately 30–40% and cramping; tenodesis prevents this; tenodesis preferred in younger patients and those concerned about cosmesis
Results of tenodesis for SLAP: excellent pain relief in approximately 85–90% of patients; superior to SLAP repair in patients over 35 years
Consultant-Level Considerations
The SLAP epidemic and overdiagnosis: MRI reports of "SLAP tears" frequently do not correlate with functionally significant pathology — the normal anatomy of the superior labrum includes a sublabral foramen, Buford complex, and meniscoid superior labrum, all of which can be mistaken for SLAP on imaging; clinical correlation is mandatory; do not operate on MRI findings alone
Return to throwing after SLAP repair: 70–74% in most series — significantly lower than expected; pitchers in particular have poor return to previous level; biceps tenodesis gives better return in older players but is not indicated in young competitive throwers who need biceps anchor integrity; counsel patients thoroughly before surgery
Internal impingement: posterior shoulder pain in throwing athletes from contact between the undersurface of the supraspinatus/infraspinatus and the posterosuperior glenoid labrum during ABER — produces "kissing lesions"; often associated with GIRD (glenohumeral internal rotation deficit) and posterior capsular tightness; manage with posterior capsular stretching (sleeper stretch), scapular stabilisation, and thrower rehabilitation; surgery rarely required; debriding the labrum without addressing GIRD leads to failure
SLAP repair failure: most common cause is biologically poor healing of the repair anchor to the glenoid in older patients; if revision is required after failed SLAP repair, biceps tenodesis is the preferred salvage — repeat SLAP repair has a very high re-failure rate
Exam Pearls
Type II SLAP most common and clinically significant — biceps anchor detached; peel-back mechanism in throwers
Peel-back: late cocking phase ABER twists biceps anchor posteriorly off glenoid — Type II SLAP in overhead athletes
SLAP repair: young (<35) competitive overhead athlete; biceps tenodesis: age >35, non-overhead athlete, rotator cuff tear co-existing
No single clinical test diagnoses SLAP reliably — Biceps Load II has best specificity (96.9%); MR arthrography best imaging
Return to throwing after SLAP repair: only 70–74% — lower than expected; counsel patients pre-operatively
Subpectoral tenodesis: most reliable pain relief — removes entire intra-articular and intertubercular LHB portion
Biceps tenotomy: fast; appropriate in elderly; Popeye deformity 30–40%; tenodesis prevents this
Type III: excise bucket handle; preserve biceps anchor if stable
SLAP overdiagnosis: sublabral foramen, Buford complex, meniscoid superior labrum mimic SLAP on MRI; do not operate on imaging alone
Internal impingement: ABER posterior shoulder pain in throwers; manage GIRD first (sleeper stretch); rarely needs surgery
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References
Snyder SJ et al. SLAP lesions of the shoulder. Arthroscopy. 1990;6(4):274–279.
Andrews JR, Carson WG, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med. 1985;13(5):337–341.
Boileau P et al. Arthroscopic biceps tenodesis: a new technique using bioabsorbable interference screw fixation. Arthroscopy. 2002;18(9):937–941.
Neri BR, ElAttrache NS, Owsley KC, Mohr K, Yocum LA. Outcomes of type II superior labral anterior posterior repairs in elite overhead athletes. Am J Sports Med. 2011.
Provencher MT et al. A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs. Am J Sports Med. 2008.
O-Brien SJ et al. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998.
Kim SH et al. Biceps load test II: a clinical test for SLAP lesions of the shoulder. Arthroscopy. 2001.
Rockwood and Matsen. The Shoulder. 5th Edition. Elsevier.
Campbells Operative Orthopaedics. 14th Edition. Elsevier.
Orthobullets — SLAP Tear, Biceps Tenodesis.
