Superior labrum tear: SLAP lesion
Some painful shoulder conditions are caused by a superior labrum tear or avulsion. The labrum is a ring-shaped cartilaginous structure that resembles the meniscus in the knee and attaches to the glenoid (scapula). The tendon of the long head of the biceps inserts onto the top of the labrum. Note that the biceps has two insertion sites on the shoulder: one on the labrum (long head of the biceps) and another a little further inward on the coracoid process of the scapula (short head of the biceps).
Superior labrum tears can be caused by repetitive forceful movements (as seen in baseball pitchers) or by excessive traction by the long head of the biceps (traumatic avulsion). People with abnormally high flexibility (ligament hyperlaxity) are also at increased risk.
How is a labral tear diagnosed?
A distinction must be made here between a SLAP lesion and the presence of an anatomical abnormality of the labrum. Labral tears are very common and are often discovered by chance during arthroscopy or an MRI scan. In other words, a labral tear is most often asymptomatic (some people call it a variation of normal), whereas a painful SLAP lesion is quite rare (beware of overdiagnosis!). The patient generally reports symptoms during large movements accompanied by a clicking or catching sensation. The physical examination may reveal a near-normal condition and the clinician will then try to reproduce the click (O’Brien’s test) or rule out any other shoulder pathology (bursitis, impingement, etc.). Radiologic imaging, even by magnetic resonance, may very well not show the superior labrum tear. The injection of a contrast medium into the shoulder (gadolinium arthrogram) prior to magnetic resonance imaging increases the accuracy of this test. In short, this condition is difficult to diagnose and a mere suspicion will sometimes lead the surgeon to perform arthroscopy to reveal the tear.
What is the treatment?
Superior labrum tears are classified into five types (there is no need to describe them here). Many cases respond well to nonsurgical treatment (rest, physiotherapy, etc.). When chronic pain is related to the superior labrum and does not respond to nonsurgical treatment, arthroscopy may be performed to re-anchor the labrum to the glenoid or remove the loose fragment.
In recent years, during the same intervention, I have sometimes performed a release of the long biceps tendon (tenolysis) with or without reattachment to the humerus (tenodesis) if I think that the biceps is the deforming force causing the labral avulsion or if it is abnormal (e.g., partial tear). These surgical procedures are usually performed arthroscopically and an additional small incision is sometimes required for the biceps tenodesis (attachment to the humerus). A rehabilitation program with physiotherapy is usually prescribed in the weeks and months following surgery.
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