SLAP Lesions

  • John M. TokishEmail author
  • Richard K. N. Ryu


Lesions of the superior labrum remain a diagnostic and therapeutic challenge for the arthroscopic surgeon. Given the variability of the anatomy in this region, its controversial role in shoulder biomechanics, and the natural history of fraying of the aging glenoid labrum, few diagnoses generate as much controversy in terms of the decision and method of treatment as the “SLAP” tear. Andrews et al. (Arthroscopy 1:117–122, 1985) were the first to describe these tears in conjunction with partial-thickness rotator cuff tears in a population of pitchers in 1985. Later that year, the same authors reported specifically on tears of the superior labrum in 73 pitchers. In 1990, Snyder et al. (Arthroscopy 6:274–279, 1990) described a series of superior labral anterior to posterior lesions, as a subset of arthroscopic shoulder surgeries, and coined the term “SLAP tear.” Since these publications, lesions of the superior labrum have become increasingly recognized as a source of shoulder pain, and treatment of these lesions has become a common, and some might suggest overtreated, surgical intervention.


Rotator Cuff Bicipital Groove Slap Lesion Overhead Athlete Rotator Cuff Pathology 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Andrews JR, Broussard TS, Carson WG. Arthroscopy of the shoulder in the management of partial tears of the rotator cuff: a preliminary report. Arthroscopy. 1985;1:117–22.PubMedCrossRefGoogle Scholar
  2. 2.
    Andrews JR, Carson Jr WG, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med. 1985;13:337–41.PubMedCrossRefGoogle Scholar
  3. 3.
    Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6:274–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Onyekwelu I, Khatib O, Zuckerman JD, Rokito AS, Kwon YW. The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs. J Shoulder Elbow Surg. 2012;21:728–31.PubMedCrossRefGoogle Scholar
  5. 5.
    Tokish J. Incidence of orthopaedic non-battle injury 2004–2008. Department of Defense Medical Surveillance System; Presented at 2012 Society of Military Orthopaedic Surgeons Meeting, Naples, Fl, 2012.Google Scholar
  6. 6.
    Weber SC, Martin DF, Seiler 3rd JG, Harrast JJ. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates. Am J Sports Med. 2012;40:1538–43.PubMedCrossRefGoogle Scholar
  7. 7.
    Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction. Am J Sports Med. 2011;39:1883–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Neri BR, ElAttrache NS, Owsley KC, Mohr K, Yocum LA. Outcome of type II superior labral anterior posterior repairs in elite overhead athletes: effect of concomitant partial-thickness rotator cuff tears. Am J Sports Med. 2011;39:114–20.PubMedCrossRefGoogle Scholar
  9. 9.
    Kim SH, Ha KI, Ahn JH, Choi HJ. Biceps load test II: a clinical test for SLAP lesions of the shoulder. Arthroscopy. 2001;17:160–4.PubMedCrossRefGoogle Scholar
  10. 10.
    O’Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998;26:610–3.PubMedGoogle Scholar
  11. 11.
    Coleman SH, Cohen DB, Drakos MC, Allen AA, Williams RJ, O’brien SJ, et al. Arthroscopic repair of type II superior labral anterior posterior lesions with and without acromioplasty: a clinical analysis of 50 patients. Am J Sports Med. 2007;35:749–53.PubMedCrossRefGoogle Scholar
  12. 12.
    Wilk KE, Reinold MM, Dugas JR, Arrigo CA, Moser MW, Andrews JR. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. J Orthop Sports Phys Ther. 2005;35:273–91.PubMedCrossRefGoogle Scholar
  13. 13.
    Snyder S. Superior labral anterior to posterior lesions. 2nd ed. Philadelphia: Williams and Wilkins; 2002.Google Scholar
  14. 14.
    Vangsness Jr CT, Jorgenson SS, Watson T, Johnson DL. The origin of the long head of the biceps from the scapula and glenoid labrum. An anatomical study of 100 shoulders. J Bone Joint Surg. 1994;76B:951–4.Google Scholar
  15. 15.
    Oh JH, Kim JY, Kim WS, Gong HS, Lee JH. The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion. Am J Sports Med. 2008;36:353–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Connell DA, Potter HG, Wickiewicz TL, Altchek DW, Warren RF. Noncontrast magnetic resonance imaging of superior labral lesions. 102 cases confirmed at arthroscopic surgery. Am J Sports Med. 1999;27:208–13.PubMedGoogle Scholar
  17. 17.
    Bencardino JT, Beltran J, Rosenberg ZS, Rokito A, Schmahmann S, Mota J, et al. Superior labrum anterior-posterior lesions: diagnosis with MR arthrography of the shoulder. Radiology. 2000;214:267–71.PubMedCrossRefGoogle Scholar
  18. 18.
    Tung GA, Entzian D, Green A, Brody JM. High-field and low-field MR imaging of superior glenoid labral tears and associated tendon injuries. AJR Am J Roentgenol. 2000;174:1107–14.PubMedCrossRefGoogle Scholar
  19. 19.
    Jee WH, McCauley TR, Katz LD, Matheny JM, Ruwe PA, Daigneault JP. Superior labral anterior posterior (SLAP) lesions of the glenoid labrum: reliability and accuracy of MR arthrography for diagnosis. Radiology. 2001;218:127–32.PubMedCrossRefGoogle Scholar
  20. 20.
    Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009;17:627–37.PubMedGoogle Scholar
  21. 21.
    Gobezie R, Zurakowski D, Lavery K, Millett PJ, Cole BJ, Warner JJ. Analysis of interobserver and intraobserver variability in the diagnosis and treatment of SLAP tears using the Snyder classification. Am J Sports Med. 2008;36:1373–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Eakin CL, Faber KJ, Hawkins RJ, Hovis WD. Biceps tendon disorders in athletes. J Am Acad Orthop Surg. 1999;7:300–10.PubMedGoogle Scholar
  23. 23.
    Habermeyer P, Kaiser E, Knappe M, Kreusser T, Wiedemann E. Functional anatomy and biomechanics of the long biceps tendon. Unfallchirurg. 1987;90:319–29.PubMedGoogle Scholar
  24. 24.
    Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg. 1998;6:121–31.PubMedGoogle Scholar
  25. 25.
    Rhee YG, Lee DH, Lim CT. Unstable isolated SLAP lesion: clinical presentation and outcome of arthroscopic fixation. Arthroscopy. 2005;21:1099.PubMedGoogle Scholar
  26. 26.
    Phillips JC, Cook C, Beaty S, Kissenberth MJ, Siffri P, Hawkins RJ. Validity of noncontrast magnetic resonance imaging in diagnosing superior labrum anterior-posterior tears. J Shoulder Elbow Surg. 2013;22:3–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Seroyer S, Tejwani SG, Bradley JP. Arthroscopic capsulolabral reconstruction of the type VIII superior labrum anterior posterior lesion: mean 2-year follow-up on 13 shoulders. Am J Sports Med. 2007;35:1477–83.PubMedCrossRefGoogle Scholar
  28. 28.
    Maffet MW, Gartsman GM, Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med. 1995;23:93–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Beltran J, Bencardino J, Mellado J, Rosenberg ZS, Irish RD. MR arthrography of the shoulder: variants and pitfalls. Radiographics. 1997;17:1403–12.PubMedCrossRefGoogle Scholar
  30. 30.
    Mohana-Borges AV, Chung CB, Resnick D. Superior labral anteroposterior tear: classification and diagnosis on MRI and MR arthrography. AJR Am J Roentgenol. 2003;181:1449–62.PubMedCrossRefGoogle Scholar
  31. 31.
    Nord KD, Ryu KN. Further refinement of SLAP classification. In: 24th Arthroscopy Association of North America annual meeting, E-poster, Orlando, 2004.Google Scholar
  32. 32.
    Powell SE, Nord KD, Ryu RKN. The diagnosis, classification and treatment of SLAP lesions. Oper Tech Sports Med. 2004;12:99–110.CrossRefGoogle Scholar
  33. 33.
    Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy. 2003;19:404–20.PubMedCrossRefGoogle Scholar
  34. 34.
    Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy. 1998;14:553–65.PubMedCrossRefGoogle Scholar
  35. 35.
    Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. J Bone Joint Surg. 2003;85A:66–71.Google Scholar
  36. 36.
    Nam EK, Snyder SJ. The diagnosis and treatment of superior labrum, anterior and posterior (SLAP) lesions. Am J Sports Med. 2003;31:798–810.PubMedGoogle Scholar
  37. 37.
    Voos JE, Pearle AD, Mattern CJ, Cordasco FA, Allen AA, Warren RF. Outcomes of combined arthroscopic rotator cuff and labral repair. Am J Sports Med. 2007;35:1174–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III: the SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003;19:641–61.PubMedCrossRefGoogle Scholar
  39. 39.
    Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM. Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med. 2006;34:385–91.PubMedCrossRefGoogle Scholar
  40. 40.
    Nakagawa S, Yoneda M, Hayashida K, Obata M, Fukushima S, Miyazaki Y. Forced shoulder abduction and elbow flexion test: a new simple clinical test to detect superior labral injury in the throwing shoulder. Arthroscopy. 2005;21:1290–5.PubMedCrossRefGoogle Scholar
  41. 41.
    Kibler WB. Specificity and sensitivity of the anterior slide test in throwing athletes with superior glenoid labral tears. Arthroscopy. 1995;11:296–300.PubMedCrossRefGoogle Scholar
  42. 42.
    Berg EE, Ciullo JV. A clinical test for superior glenoid labral or ‘SLAP’ lesions. Clin J Sport Med. 1998;8:121–3.PubMedCrossRefGoogle Scholar
  43. 43.
    Kim SH, Ha KI, Han KY. Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations. Am J Sports Med. 1999;27:300–3.PubMedGoogle Scholar
  44. 44.
    Zaslav KR. Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. J Shoulder Elbow Surg. 2001;10:23–7.PubMedCrossRefGoogle Scholar
  45. 45.
    Stetson WB, Templin K. The crank test, the O’Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. Am J Sports Med. 2002;30:806–9.PubMedGoogle Scholar
  46. 46.
    Myers TH, Zemanovic JR, Andrews JR. The resisted supination external rotation test: a new test for the diagnosis of superior labral anterior posterior lesions. Am J Sports Med. 2005;33:1315–20.PubMedCrossRefGoogle Scholar
  47. 47.
    Kim YS, Kim JM, Ha KY, Choy S, Joo MW, Chung YG. The passive compression test: a new clinical test for superior labral tears of the shoulder. Am J Sports Med. 2007;35:1489–94.PubMedCrossRefGoogle Scholar
  48. 48.
    Michener LA, Doukas WC, Murphy KP, Walsworth MK. Diagnostic accuracy of history and physical examination of superior labrum anterior- posterior lesions. J Athl Train. 2011;46:343–8.PubMedCentralPubMedGoogle Scholar
  49. 49.
    Cook C, Beaty S, Kissenberth MJ, Siffri P, Pill SG, Hawkins RJ. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elbow Surg. 2012;21:13–22.PubMedCrossRefGoogle Scholar
  50. 50.
    McFarland EG, Kim TK, Savino RM. Clinical assessment of three common tests for superior labral anterior-posterior lesions. Am J Sports Med. 2002;30:810–5.PubMedGoogle Scholar
  51. 51.
    Parentis MA, Mohr KJ, ElAttrache NS. Disorders of the superior labrum: review and treatment guidelines. Clin Orthop Relat Res. 2002;400:77–87.PubMedCrossRefGoogle Scholar
  52. 52.
    Hitchcock HH, Bechtol CO. Painful shoulder; observations on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg. 1948;30A:263–73.PubMedGoogle Scholar
  53. 53.
    Franceschi F, Longo UG, Ruzzini L, Rizzello G, Maffulli N, Denaro V. No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50: a randomized controlled trial. Am J Sports Med. 2008;36:247–53.PubMedCrossRefGoogle Scholar
  54. 54.
    Parentis MA, Glousman RE, Mohr KS, Yocum LA. An evaluation of the provocative tests for superior labral anterior posterior lesions. Am J Sports Med. 2006;34:265–8.PubMedCrossRefGoogle Scholar
  55. 55.
    Guanche CA, Jones DC. Clinical testing for tears of the glenoid labrum. Arthroscopy. 2003;19:517–23.PubMedCrossRefGoogle Scholar
  56. 56.
    Applegate GR, Hewitt M, Snyder SJ, Watson E, Kwak S, Resnick D. Chronic labral tears: value of magnetic resonance arthrography in evaluating the glenoid labrum and labral-bicipital complex. Arthroscopy. 2004;20:959–63.PubMedGoogle Scholar
  57. 57.
    Waldt S, Burkart A, Lange P, Imhoff AB, Rummeny EJ, Woertler K. Diagnostic performance of MR arthrography in the assessment of superior labral anteroposterior lesions of the shoulder. AJR Am J Roentgenol. 2004;182:1271–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Amin MF, Youssef AO. The diagnostic value of magnetic resonance arthrography of the shoulder in detection and grading of SLAP lesions: comparison with arthroscopic findings. Eur J Radiol. 2012;81:2343–7.PubMedCrossRefGoogle Scholar
  59. 59.
    Enad JG, Kurtz CA. Isolated and combined Type II SLAP repairs in a military population. Knee Surg Sports Traumatol Arthrosc. 2007;15:1382–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Boileau P, Baque F, Valerio L, Ahrens P, Chuinard C, Trojani C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg. 2007;89A:747–57.CrossRefGoogle Scholar
  61. 61.
    Zhang AL, Kreulen C, Ngo SS, Hame SL, Wang JC, Gamradt SC. Demographic trends in arthroscopic SLAP repair in the United States. Am J Sports Med. 2012;40:1144–7.PubMedCrossRefGoogle Scholar
  62. 62.
    Pfahler M, Haraida S, Schulz C, Anetzberger H, Refior HJ, Bauer GS, et al. Age-related changes of the glenoid labrum in normal shoulders. J Shoulder Elbow Surg. 2003;12:40–52.PubMedCrossRefGoogle Scholar
  63. 63.
    Warner JJ, Kann S, Marks P. Arthroscopic repair of combined Bankart and superior labral detachment anterior and posterior lesions: technique and preliminary results. Arthroscopy. 1994;10:383–91.PubMedCrossRefGoogle Scholar
  64. 64.
    Tokish JM, McBratney CM, Solomon DJ, Leclere L, Dewing CB, Provencher MT. Arthroscopic repair of circumferential lesions of the glenoid labrum. J Bone Joint Surg. 2009;91A:2795–802.CrossRefGoogle Scholar
  65. 65.
    Samani JE, Marston SB, Buss DD. Arthroscopic stabilization of type II SLAP lesions using an absorbable tack. Arthroscopy. 2001;17:19–24.PubMedCrossRefGoogle Scholar
  66. 66.
    Kim SH, Ha KI, Choi HJ. Results of arthroscopic treatment of superior labral lesions. J Bone Joint Surg. 2002;84A:981–5.Google Scholar
  67. 67.
    Ide J, Maeda S, Takagi K. Sports activity after arthroscopic superior labral repair using suture anchors in overhead-throwing athletes. Am J Sports Med. 2005;33:507–14.PubMedCrossRefGoogle Scholar
  68. 68.
    Brockmeier SF, Voos JE, Williams 3rd RJ, Altchek DW, Cordasco FA, Allen AA. Outcomes after arthroscopic repair of type-II SLAP lesions. J Bone Joint Surg. 2009;91A:1595–603.CrossRefGoogle Scholar
  69. 69.
    Gorantla K, Gill C, Wright RW. The outcome of type II SLAP repair: a systematic review. Arthroscopy. 2010;26:537–45.PubMedCrossRefGoogle Scholar
  70. 70.
    Sayde WM, Cohen SB, Ciccotti MG, Dodson CC. Return to play after Type II superior labral anterior-posterior lesion repairs in athletes: a systematic review. Clin Orthop Relat Res. 2012;470:1595–600.PubMedCentralPubMedCrossRefGoogle Scholar
  71. 71.
    Radkowski CA, Chhabra A, Baker 3rd CL, Tejwani SG, Bradley JP. Arthroscopic capsulolabral repair for posterior shoulder instability in throwing athletes compared with nonthrowing athletes. Am J Sports Med. 2008;36:693–9.PubMedCrossRefGoogle Scholar
  72. 72.
    Itoi E, Kuechle DK, Newman SR, Morrey BF, An KN. Stabilising function of the biceps in stable and unstable shoulders. J Bone Joint Surg. 1993;75B:546–50.Google Scholar
  73. 73.
    Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med. 1994;22:121–30.PubMedCrossRefGoogle Scholar
  74. 74.
    Pagnani MJ, Deng XH, Warren RF, Torzilli PA, O’Brien SJ. Role of the long head of the biceps brachii in glenohumeral stability: a biomechanical study in cadavera. J Shoulder Elbow Surg. 1996;5:255–62.PubMedCrossRefGoogle Scholar
  75. 75.
    Fedoriw W, Ramkumar B, Litner D. Nonsurgical and surgical treatment of superior labral tears in professional baseball pitchers. In: Abstracts American Orthopaedic Society for Sports Medicine 2012 annual meeting, paper #6, Baltimore, 2012.Google Scholar
  76. 76.
    Katz LM, Hsu S, Miller SL, Richmond JC, Khetia E, Kohli N, et al. Poor outcomes after SLAP repair: descriptive analysis and prognosis. Arthroscopy. 2009;25:849–55.PubMedCrossRefGoogle Scholar
  77. 77.
    Park S, Glousman RE. Outcomes of revision arthroscopic type II superior labral anterior posterior repairs. Am J Sports Med. 2011;39:1290–4.PubMedCrossRefGoogle Scholar
  78. 78.
    Nord KD, Masterson JP, Mauck BM. Superior labrum anterior posterior (SLAP) repair using the Neviaser portal. Arthroscopy. 2004;20:129–33.PubMedCrossRefGoogle Scholar
  79. 79.
    Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg. 1995;4:243–8.PubMedCrossRefGoogle Scholar
  80. 80.
    Reinold MM, Wilk KE, Hooks TR, Dugas JR, Andrews JR. Thermal-assisted capsular shrinkage of the glenohumeral joint in overhead athletes: a 15- to 47-month follow-up. J Orthop Sports Phys Ther. 2003;33:455–67.PubMedCrossRefGoogle Scholar
  81. 81.
    Cohen SB, Sheridan S, Ciccotti MG. Return to sports for professional baseball players after surgery of the shoulder or elbow. Sports Health. 2011;3(1):105–111.Google Scholar

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© Springer-Verlag London 2014

Authors and Affiliations

  1. 1.Department of SurgeryTripler Army Medical CenterHonoluluUSA
  2. 2.The Ryu Hurvitz Orthopedic ClinicSanta BarbaraUSA

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