SLAP lesion

DefinitionMRI SLAP Tear


Superior labrum anterior & posterior


Injury to superior part of glenoid labrum involving region of biceps tendon insertion




2 groups


1.  Young patients

- most common in young males

- fall / trauma

- also associated with glenohumeral instability


2.  Older patients 

- have rotator cuff tear or other pathology

- don't repair in this group

- tenotomy / tenodesis




Three mechanisms


1.  Compression force applied to GHJ


- commonest

- arm in abduction & forward flexion

- head subluxes superiorly over glenoid edge & detaches labrum by shear & compression


2.  Traction on Arm

- sudden pull on arm

- grab while falling


3.  Overhead motion

- throwing thlete

- repetitive microtrauma due to eccentric loading




Pain with overhead activities


Catching or popping with overhead activities


Acute trauma


Mimics impingement




Speed's Test 

Yergason's Test


O'Brien's test


Causes impingement of biceps on anterosuperior labrum


1.  Shoulder flexed 90o in plane of scapula

- adducted 30-45o / max IR

- i.e. thumb down

- resisted elevation produces pain


2.  Relieved when same again but with ER

- i.e. no pain with thumbs up


McMurray's Shoulder test


Compression-Rotation test

- patient supine 

- shoulder abducted 90°, elbow flexed 90°

- compression force to humerus and humerus rotated

- attempt to trap torn labrum

- positive if pain & click




See fluid up under biceps insertion

- note: difficult to distinguish pathological v normal variant


MRI Slap with SS tearMRI Anterior Bankart


Supralabral ganglion cyst

- associated with posterior SLAP tears


Normal Arthroscopy


Normal Biceps Insertion


Arthroscopic Classification Snyder


Type 1 (10%)

- fraying & degeneration of the edge of superior labrum

- firmly attached labrum and biceps anchor 


Arthroscopy Meniscoid Biceps Insertion


Type 2 (40%)

- Superior labrum + Biceps tendon stripped off glenoid   



- anterior

- posterior

- anterior and posterior


SLAP arthroscopyShoulder Scope SLAP Type 2


Type 3 (30%)

- bucket handle tear of superior labrum

- displacement of labrum into joint

- biceps tendon attached to glenoid


Shoulder Scope Type 3 SLAP


Type 4

- bucket handle tear of superior labrum with part of biceps

- extension into biceps tendon which remains attached but with partial tear


Type 4 SLAP Tear extends partially into bicepsSLAP Type 4


Type 5 - 7 added by Gartsman


Type 5
- SLAP 2 with anterior bankart extension


Type 6

- SLAP 2 with free flap of meniscal tissue


Type 7

- Slap 2 with anterior bankart extension and into MGHL


Normal Variations of the Superior Labrum


The superior labrum can be mobile

- normal cartilage extending over the tubercle

- no evidence of trauma

- the labrum and biceps is firmly attached to the tubercle

- this is not pathological

- do not repair


Arthroscopy Normal Cartilage under Biceps LabrumArthroscopy Stable Biceps Insertion


Davidson et al Am J Sports Medicine 2004

- described normal variations


1.  Triangular


2.  Bumper

- lump of fibrous tissue


3.  Meniscoid

- labrum extends down over glenoid face




Non Operative



- physio





Arthroscopic diagnosis

- high level of pre-operative suspicion

- must establish is pathological

- treated at time of arthroscopy




1. Debridement of frayed labrum / Type 1 & 3

2. Repair superior labrum and biceps / Type 2

3. Biceps tenodesis

4. Tenotomy




1.  Older patient with RC tear and SLAP


Francheschi Am J Sports Med April 2008

- RCT patients with SLAP and RC > 50

- tenotomy v SLAP repair in setting RC tear

- improved ROM and functional scores in tenotomy group


2.  Repair v Tenodesis Type II SLAP


Boileau et al Am J Sports Med May 2009

- compared cohort arthroscopic repair v arthroscopic tenodesis in overhead athletes (Level 3 evidence)

- repair group 40% satisified, 20% returned to previous level of sport

- tenodesis patients 93% satisified, 87% return to previous level of sport


Altcheck et al JBJS Am 2009

- case series of 37 athletes with SLAP 2 repair

- 87% rated outcome as good or excellent

- 75% able to return to previous level of sport

- this was higher (92%) if athlete described a discrete traumatic event


3.  SLAP and instability in young patient

- SLAP lesions can cause instability

- a SLAP lesion can contribute to inferior instability

- a SLAP and a Bankart can co-exist


MRI SLAPMRI Anterior Bankart


Management Algorithm


Type 1


Debride labrum


Type 2


A.  Arthroscopic repair


B.  Tenotomy / tenodesis


Type 3


Debride bucket handle labrum


Type 4


Remove labral flap


Repair / debride / tenodesis biceps

- may be evidence that do better with tenodesis


Types 5 - 7

- associated with instability

- repair as per treatment of instability