SLAP Repair Surgery in Indore

Treatment for Upper Shoulder Labrum Tears – From Targeted Rehab to Arthroscopic Repair with Dr. Murtuza Rassiwala

A SLAP tear may manifest as deep, difficult-to-pinpoint shoulder pain that worsens during throwing, serving, bowling or lifting something over your head; a clicking or catching feeling; a sense that the arm loses strength at the top of a movement. SLAP stands for Superior Labrum Anterior to Posterior. This is a tear of the top part of the labrum that goes from front to back where the long head of the biceps tendon attaches.

SLAP tears are common in throwing athletes, weightlifters, and people who fall on an outstretched arm. They are also increasingly recognized as a normal change of aging in older adults. That means not all SLAP tears seen on MRI require surgery. Dr. Murtuza Rassiwala explains whether a SLAP tear is really causing your symptoms and which treatment – rehabilitation, repair or biceps procedure – is most likely to help.

Short answer: A SLAP tear is a tear of the upper labrum where the biceps tendon attaches in the shoulder. Physiotherapy is used to treat many. Arthroscopic SLAP repair is used to reattach the labrum to the socket with suture anchors. This is offered primarily to younger, active patients with persistent symptoms. Biceps tenodesis is often preferred in older patients.

SLAP Tears at a Glance

Anatomy of the Superior Labrum

The labrum is a ring of fibrous tissue around the socket of the shoulder. The long head of the biceps tendon attaches to the bone and labrum at the top of the socket in an area called the biceps anchor. This is the anchor that the bicep tendon pulls on when you throw and do overhead activities. Repetitive or sudden forces can rip the labrum and biceps off the top of the socket and this is a SLAP tear.

SLAP Tear Types

SLAP tears are divided into types, at first four and later increased:

• Type I – fraying of the upper labrum with biceps anchor still attached.
• Type II – the labrum and biceps anchor are torn away from the socket; the most common clinically significant type.
• Type III – a bucket-handle tear of the superior labrum with intact biceps anchor.
• Type IV – a bucket handle tear extending into the biceps tendon.

Other types refer to tears that extend into other parts of the labrum. Type determines if debridement, repair or biceps procedure is appropriate.

Causes

• Repetitive overhead throwing – The “Peel-back” mechanism during the late cocking phase of throwing.
• Go down on an outstretched arm.
• Sudden pulling injury – e.g. catching a heavy falling object.
• Weight training with heavy lifting and overhead.
• A shoulder dislocation, where the tear may extend into the upper labrum.
• Degeneration of the subjects >40 years of age.
  Symptoms
• A deep ache in the shoulder, usually at the back or top.
• Pain with throwing, lifting or using the arm overhead.
• Clicking, popping or locking.
• A feeling of weakness or a “dead arm” sensation when throwing.
• Athletes: Decreased throwing speed or performance.
• Occasional feelings of being off balance.

Diagnosis

SLAP tears are difficult to diagnose with a physical exam alone because there is a lot of overlap with a number of clinical tests for other conditions, such as rotator cuff and biceps problems. Dr Rassiwala correlates the history, special tests of examination and imaging. An MR arthrogram (MRI with contrast injected into the joint) increases the ability to see labral tears. Because SLAP-like findings are common on MRI in the older adult without symptoms, imaging is always interpreted according to the clinical picture. Final confirmation is usually by arthroscopy.

When is Surgery Considered?

• Prolonged pain and dysfunction despite a structured rehabilitation program.
• A type II or IV SLAP tear in a young active patient.
• SLAP lesions in the setting of shoulder instability.
• Mechanical symptoms of a bucket-handle fragment.

Surgical Treatments

Arthroscopic SLAP Lesion Repair

The labrum and biceps anchor are reattached to the top of the socket with suture anchors through small portals. This is usually reserved for younger patients, especially overhead athletes, with good quality tissue.

Debridement

In type I and some type III tears, fraying or a loose flap is debrided without repair.

Tenodesis of the Biceps

The long head of the biceps tendon is released from the labrum and reattached lower on the humerus. This removes the pull on the damaged area. Research has shown that tenodesis often has good results in patients older than around 35-40 years and in some revision cases and is increasingly favored over SLAP repair in these groups.

Tenotomy of biceps

The biceps tendon is just released from its attachment. It is a quicker operation and is often used for older, less active patients, although it can sometimes cause a bulge in the upper arm (Popeye sign) and cramping.
Decision between repair, tenodesis and tenotomy is based on age, activity level, tissue quality and patient preference.

The Procedure

The procedure is performed under general anesthesia with a nerve block. The shoulder is examined arthroscopically, the tear classified and associated problems identified. The planned repair or biceps operation is performed. Arm is placed in a sling. 

Recovery After SLAP Repair

After biceps tenodesis, heavy biceps use is typically restricted for about six to eight weeks, with overall recovery often somewhat quicker than after SLAP repair.

SLAP Tears in Different Patients

Throwing Athletes

SLAP tears are prone to repeated high-speed overhead motion such as in cricket fast bowlers, fielders with strong throws, volleyball players, handball players and javelin throwers. The goal of treatment is to correct mechanics and shoulder range, with surgery reserved for persistent problems.

Weight Lifter & Gym-Goers

Heavy bench pressing, overhead pressing and dips can strain the biceps anchor. Often the first step involves modifying technique and load.

Adults 40 and older

SLAP changes are common on MRI in this group and may not be the cause of the pain. Often the main issue is rotator cuff and biceps problems. If surgery is needed, biceps tenodesis is often preferred over repair.

After Dislocation

If the labral tear extends into the superior labrum secondary to dislocation, the SLAP component can be addressed in conjunction with a Bankart repair.

Interval Throwing Programme

Throwing athletes return to sport via a staged interval program. It starts with short gentle throws, over short distances, increasing distance, number of throws and intensity over the course of several weeks. Pain or loss of control at any point is a step back. Coaches and physiotherapists work together to monitor mechanics and workload and full effort bowling or throwing is only re-introduced when strength, range and control are satisfactory.

Life During Recovery

During sling period don’t lift, carry heavy bags or reach behind with the operated arm. Sleep on your side or propped up. Put sleeves on operated arm first. Desk work can usually be completed in one to two weeks; overhead and manual work require several months.

Costs and Insurance

The cost depends on the procedure (repair, tenodesis or tenotomy), the anchors used, hospital stay and physiotherapy. Surgery is usually covered by health insurance, if it is medically necessary, but this depends on the policy you have.  

Long Term Perspective

Many patients with SLAP tears return to recreational sport and comfortable daily function, whether they have repair, rehabilitation, or biceps procedure. Elite overhead athletes may have difficulty returning to the previous level following SLAP repair and some athletes require modification to training or position. Long-term protection of the shoulder depends on maintaining shoulder range of motion, especially internal rotation, and rotator cuff strength post-recovery.

Signs to Report Following Surgery

Contact the clinic promptly if you develop fever, redness or discharge from the wounds, persistent numbness in the arm after the nerve block has worn off or increasing pain not controlled with medicines.

Questions to Ask Your Surgeon

• Is the SLAP tear the main reason for my symptoms?
• Would it be fair for me to go to rehab alone?
• If surgery is advised, will it be a repair or a biceps procedure and why?
• When can I get back to throwing, lifting or my job?

How to Prevent SLAP Injuries in Overhead Athletes

Throwers and overhead athletes can reduce their risk by keeping their shoulders flexible (especially stretching the back of the shoulder), strengthening the rotator cuff and shoulder blade muscles, following sensible workload limits and working on efficient throwing mechanics that use the legs and trunk to generate power. Enough rest between high volume sessions and during the off-season allows the tissues to recover. Pain with throwing should be viewed as a warning sign, not something to be thrown through.

Why You Should Visit Dr. Murtuza Rassiwala

Dr. Rassiwala – MBBS (Baroda University, 2013), DNB in Orthopedics (NBE, 2018), MNAMS, F.I.A.S.M., F.I.A.J.R. – does arthroscopic shoulder surgery, evaluates SLAP tears in the setting of the entire shoulder and does not treat an incidental MRI finding. He takes into account age, sport and tissue quality in his recommendations as he decides between rehabilitation, repair and biceps procedures.

Schedule a Consultation

Deep shoulder pain with overhead activity or throwing should be accurately assessed. Book Online with Dr. Murtuza Rassiwala at Hakimi Ortho Care, Indore or Call +91-7224888071, 0731-4981538 or 0731-3695285.