SLAP terminology is the abbreviation of the lesion occurring in the Superior Labral Antero Posterior area of the shoulder joint. This can be a cause of pain in the shoulder joint.
Labrum is the cartilage structure surrounding the glenoid rim of the shoulder joint. The glenoid is the dish like cup in the shoulder blade and the head of the arm bone articulates with the glenoid to form the shoulder joint. The glenoid is normally shallow and the fibrocartilagenous structure called labrum is attached around the glenoid to increase its concavity. This confers stability for the shoulder joint. Hence the labrum is located all around the glenoid like a ring. The top part of this ring is called superior labrum. One of the tendon of the biceps muscle gets attached in a broad fashion over the superior labrum. Any lesion occurring from the front of the attachment to the back of the attachment of this biceps tendon on the superior labrum is called Superior Labrum Antero Posterior (SLAP) lesion.
This occurs as a result of injury. A forceful pull of the arm, dislocation of the shoulder joint, falling on an outstretched arm, throwing injury, tackling in spots, weightlifting all can predispose to this. A small lesion occurs initially and if it does not heal, this itself can predispose to further injuries. Extent of tear depends on the severity of the injury. The lesion can vary from simple fraying of the labrum to complete avulsion of the superior labrum with also extension into the front or back of the glenoid.
The features include pain usually with overhead activities, catching, locking or a grinding feel in the shoulder joint, a sense of instability of the shoulder joint, reduced or a painful range of motion and loss of strength of the shoulder joint.
A thorough history, physical examination with special focus in relation to the SLAP lesion is useful. Some of the special tests whereby putting the biceps in forceful eccentric contraction can reproduce the pain. It is also essential to exclude other conditions that can present in similar way and also to confirm this diagnosis by certain investigations. An X ray of the shoulder joint and a MR Arthrography of the shoulder joint may be useful in confirming the diagnosis. Another better option is by performing arthroscopy of the shoulder joint. In arthroscopy the lesion can be directly visualized and also can be treated at the same time.
When the injury occurs, supportive treatment in the form of pain relieving medications, resting in sling should be done. When the acute pain improves to some extent mobilization as pain allows will help to regain some confidence in the shoulder joint. After the acute phase has settled, often there is possibility of recurrent pain and clicking as mentioned above. An arthroscopic surgery may be needed to treat the problem.
Superior labral antero posterior lesion with significant symptoms such as pain, clicking, catching, grinding will necessitate arthroscopic surgery to treat the lesion.
Arthroscopic surgery gives a chance to visualise the shoulder joint thoroughly. The labrum can be seen for obvious tears and can also be probed to identify if there are subtle tears. A dynamic assessment is possible so that the shoulder joint movements are reproduced passively and the hidden presence of any unstable tears can be detected. Some tears can be just fraying then they need debridement. But if the tear is full and if the labrum has avulsed from the glenoid then it needs to be fixed back by stitching the labrum with strong fibrewires and anchoring it to glenoid rim. This gives sound possibility for the lesion to heal.
The procedure is done under anaesthesia. Two or three tiny incisions are made around the shoulder joint. A tube like arthroscopic camera is introduced into the shoulder joint. Thorough assessment of the labrum all around the ring is performed. The diagnosis of the SLAP lesion will be confirmed. Then the tear is mobilized so that it can be attached back into the glenoid. A miniature drill is introduced to reach the glenoid margin and an absorbable screw with strong fibrewire is anchored to the glenoid margin. The fibrewire is then passed through the labrum and arthroscopic knots are applied to hold the labrum tight to the glenoid margin. Depending on the length of the labral tear there may be a necessity of two or three stitches. The arthrosocopy incisions in the skin will be closed with one or two stitches. There will not be any pain during the procedure as it is done with anaesthesia. Because the arthrosocpic surgery itself is done through tiny incisions the pain after the surgery is minimal.
A sling will be given to rest the arm for 4 weeks. A systematic physiotherapy programme will be implemented with the help of a trained physiotherapist. This will help you to get the pain free range of movements back. To get back to sports level activities it could sometimes take up to 3 to 4 months. The labrum that is reattached takes about 3 – 4 months to heal.
The procedure is safe and the success rate is high.
The complications are minimal. Infection, stiffness, chondral damage are rare possibilities.
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