SLAP tear of the shoulder: symptoms, treatment and recovery after repair

Gateshead Health NHS Foundation Trust explains that the shoulder is the most mobile joint in the body because the ball-and-socket joint has a very shallow socket (the glenoid). To compensate, the socket has a thick rim of cartilage, the labrum, which surrounds and deepens it. The labrum works with the rotator cuff muscles and the ligaments to keep the shoulder stable.

A SLAP lesion refers to a specific area of change or tear in the labrum, at the top, running from front to back. The long head of the biceps tendon attaches at this point, which is why SLAP tears are sometimes described together with biceps problems.

The trust says a SLAP tear usually occurs through trauma or repetitive overuse. Examples listed are a fall on to the outstretched hand, shoulder dislocation, a road traffic accident, catching a heavy object or a forceful pull on the arm, rapid or forceful movement of the arm when it is above shoulder height, and repetitive overhead sports or occupations such as throwing or weight lifting.

Over time, changes to the labrum can occur slowly and are seen as part of the normal ageing process. The leaflet says this is usually in those over the ages of 35 to 40 years and differs from an acute injury in a younger person. It means that a scan finding of a labral tear in an older adult does not by itself prove that the tear is the cause of pain.

The trust lists the symptoms of a SLAP tear:

• pain, the most common complaint, often associated with overhead movement

• a sensation of locking, catching, grinding or popping in the shoulder

• inability to lie on the affected side

• reduced shoulder strength

• loss of movement in the shoulder

Diagnosis starts with your history and an examination of the shoulder by a GP, physiotherapist or orthopaedic clinician. Versus Arthritis explains the scans used for shoulder problems in general: X-rays show bones and changes in the joints but not injuries to soft tissue; ultrasound can show swelling and damage to tendons, muscles and other soft tissues; and an MRI scan may be arranged if a more complex problem with the soft tissue is suspected, sometimes with dye injected into the shoulder first to give a clearer picture.

Scan findings need interpreting carefully. Versus Arthritis notes that small changes in the shoulder are quite common and may not be the cause of your trouble, and Gateshead Health explains that labral changes can be part of normal ageing, usually in people over 35 to 40, so a labral tear on a scan in an older adult does not by itself prove it is causing the pain.

The NHS shoulder pain page advises seeing a GP if shoulder pain is getting worse or does not improve after 2 weeks, or if it is very difficult to move the arm or shoulder. In many areas you may be able to get physiotherapy from NHS community musculoskeletal services without a GP referral.

It advises an urgent GP appointment or NHS 111 if you have sudden or very bad shoulder pain, cannot move your arm, your arm or shoulder has changed shape or is badly swollen, you have pins and needles that do not go away or no feeling in the arm, the pain started after an injury such as a fall, or you feel feverish or unwell. These can be signs of something serious such as a broken or dislocated bone or a torn tendon or ligament.

The trust says that for the vast majority of SLAP lesions the initial management is non-operative. A combination of rest, activity modification, painkillers and physiotherapy may help the symptoms, and often SLAP tears are part of the ageing process and do not need any treatment.

The NHS shoulder pain page gives practical advice that fits this stage: stay active and gently move your shoulder, try shoulder exercises for 6 to 8 weeks to stop pain returning, keep a good posture, use painkillers such as paracetamol and ibuprofen so that you can keep moving, and use heat or cold packs. It warns against stopping using the shoulder completely, doing things that make it worse, or making up your own strenuous exercises. It says it can take 6 months or longer to recover from shoulder pain. A pharmacist can advise on painkillers.

If the shoulder continues to be painful despite conservative measures, surgery may be considered, according to the trust. A SLAP repair reattaches the torn labrum to the shoulder socket, usually with small anchors and sutures. It is usually done arthroscopically, as keyhole surgery with a camera and instruments, leaving 2 to 4 small scars of 5 to 7 mm, but if it cannot be done that way an open procedure is used, which leaves a scar of about 7 cm and is likely to be more painful afterwards.

The leaflet lists the possible risks. Common ones are pain levels that vary, the possibility of not getting full pain relief, stiffness (almost all resolved by 1 year), bleeding (less than 1%), further dislocation or instability with a lifetime dislocation risk of 10 to 15%, and scarring. Less common ones include wound infection (less than 1% with arthroscopic surgery) and failure to resolve symptoms. Rare risks include failure of the repair needing revision surgery, persistent stiffness, deep infection, nerve injury, complex regional pain syndrome and blood clots.

Your surgeon explains what is right for you. The aim is to reduce symptoms and restore stability, and the intended benefits are improved pain, movement and function.

After surgery the shoulder is placed in a sling to protect the repair, and the physiotherapy team advises how long it is worn. The leaflet says significant pain and discomfort is common, especially in the first 6 weeks. You should not lie on the operated shoulder for the first 6 weeks, will need to use the other arm for eating, dressing and cooking for 3 to 6 weeks, and should avoid lifting anything heavy for at least 3 months.

Outpatient physiotherapy progresses your exercises and may continue for many months. The leaflet says functional range of movement is usually achieved by 8 to 10 weeks, improvement continues for up to 3 months, and slower improvement continues up to 1 year. It advises not driving for at least 6 weeks, returning to sedentary work usually after about 3 to 4 weeks, heavy manual work after at least 3 months, and no contact sport for at least 3 months. The majority of patients return to sport and full activity by 6 months.

Intense and lasting pain, for example for 30 minutes, means you should reduce that particular activity or exercise, according to the leaflet. Contact the surgical team if you develop a temperature, wound discharge, feel unwell or the wound becomes red, sore or painful.

NHS care generally starts with a GP or community musculoskeletal service, then physiotherapy, with referral to an orthopaedic shoulder surgeon if non-operative treatment fails. The NHS says physiotherapy is available but waiting times can be long, and that you can also pay for it privately. Private shoulder clinics can offer scans and surgery; whichever route you choose, ask about the evidence that surgery will help in your situation.