SLAP Tear Repair: Surgical Procedure, Recovery, and Rehabilitation

How is a SLAP tear repair?

SLAP tear repair typically involves an arthroscopic surgical procedure to reattach the torn superior labrum to the glenoid, often followed by a meticulously structured rehabilitation program to restore strength, mobility, and function.

Understanding SLAP Tears: A Brief Overview

A SLAP (Superior Labrum Anterior to Posterior) tear is an injury to the labrum, the ring of cartilage that surrounds the glenoid (shoulder socket) and helps deepen it, providing stability to the shoulder joint. Specifically, a SLAP tear involves the upper part of the labrum where the long head of the biceps tendon attaches. These tears can occur due to acute trauma, such as a fall on an outstretched arm, or from repetitive overhead movements common in athletes (e.g., throwing sports). Symptoms often include deep shoulder pain, popping, clicking, a sensation of grinding, and decreased range of motion or strength.

When is Surgical Repair Indicated?

While conservative management (rest, anti-inflammatory medication, physical therapy) is often the initial approach for SLAP tears, surgical repair is typically considered when:

• Conservative treatments fail to alleviate symptoms after several weeks or months.
• The tear is significant or unstable, compromising shoulder stability.
• The patient is an overhead athlete or has high functional demands, where a stable biceps anchor is crucial.
• There are associated injuries, such as rotator cuff tears, that also require surgical intervention.
• The patient experiences persistent pain, weakness, or mechanical symptoms (catching, popping).

The decision for surgery is made collaboratively between the patient and an orthopedic surgeon, taking into account the tear's characteristics, the patient's age, activity level, and functional goals.

Surgical Approaches to SLAP Tear Repair

The repair of a SLAP tear is almost exclusively performed using arthroscopy, a minimally invasive technique. This involves inserting a small camera (arthroscope) and specialized instruments through tiny incisions (portals) around the shoulder joint. This allows the surgeon to visualize the tear and perform the repair without making a large incision.

Specific Repair Techniques:

• Labral Repair: For most reparable SLAP tears, the primary goal is to reattach the torn labrum to the bone of the glenoid. This is achieved using small, bioabsorbable or permanent suture anchors. These anchors are inserted into the bone, and sutures are passed through the torn labral tissue, then tied down to secure the labrum back in its anatomical position. The number and placement of anchors depend on the tear's size and configuration.
• Biceps Tenodesis or Tenotomy: In some cases, particularly in older patients or those with significant degeneration of the biceps tendon at its attachment, or when the SLAP tear involves a substantial portion of the biceps anchor, the surgeon may opt for a biceps tenodesis or tenotomy instead of directly repairing the labrum.
  • Biceps Tenodesis: The long head of the biceps tendon is detached from its origin at the superior labrum and reattached (tenodesed) to a new location, usually on the humerus bone. This removes the tension from the SLAP repair site and can alleviate pain associated with biceps pathology.
  • Biceps Tenotomy: The biceps tendon is simply cut and released from its attachment. This is typically reserved for less active individuals as it can lead to a cosmetic deformity ("Popeye" muscle) and mild strength loss in supination (turning the palm up).

The choice between labral repair and biceps management depends on the tear type, patient age, activity level, and the surgeon's preference.

The Surgical Procedure: What to Expect

The arthroscopic SLAP tear repair procedure typically follows these steps:

1. Anesthesia: The patient receives general anesthesia, often combined with a regional nerve block (interscalene block) for post-operative pain control.
2. Positioning: The patient is positioned on their side or in a beach-chair position, allowing optimal access to the shoulder.
3. Incision and Arthroscopy: Small incisions (typically 2-4, about 1 cm each) are made around the shoulder. The arthroscope is inserted into one incision, and saline solution is pumped into the joint to expand it and improve visualization.
4. Assessment and Debridement: The surgeon thoroughly inspects the joint to confirm the SLAP tear and identify any other co-existing injuries. Unstable or frayed edges of the labrum may be debrided (cleaned up).
5. Preparation of Bone Bed: If the labrum is to be reattached, the bone surface where it was torn away is gently roughened (abraded) to promote healing.
6. Anchor Placement and Suture Passing: Suture anchors are drilled into the glenoid bone adjacent to the tear. Sutures are then passed through the torn labral tissue using specialized instruments.
7. Tying the Sutures: The sutures are tied down, pulling the labrum firmly back against the bone.
8. Closure: Once the repair is complete, the instruments are removed, and the small incisions are closed with stitches or sterile strips. A sterile dressing is applied.

The procedure typically takes 60-90 minutes, depending on the complexity of the tear and any associated procedures.

Post-Surgical Rehabilitation: The Crucial Phase

Rehabilitation is paramount for a successful outcome after SLAP tear repair. It is a structured, multi-phase process designed to protect the repair while gradually restoring range of motion, strength, and function. Adherence to the physical therapy protocol is critical to prevent re-injury and achieve optimal recovery.

Phases of Rehabilitation:

1. Phase I: Immobilization and Protection (Weeks 0-4/6)
   • Goal: Protect the healing repair, minimize pain and swelling.
   • Activities: The arm is kept in a sling, often with an abduction pillow, to prevent unwanted movements. Gentle passive range of motion (PROM) exercises may begin, primarily focusing on elbow, wrist, and hand movements. No active shoulder movement or lifting is permitted.
2. Phase II: Early Motion (Weeks 4/6 - 8/12)
   • Goal: Gradually restore passive and active-assisted range of motion (AAROM).
   • Activities: The sling is gradually weaned off. PROM and AAROM exercises are progressed, focusing on regaining shoulder flexion, abduction, and rotation. Gentle isometric exercises for the rotator cuff and scapular stabilizers may be introduced. Light daily activities are allowed, but no lifting or pushing.
3. Phase III: Strengthening (Weeks 12 - 20/24)
   • Goal: Progress to active range of motion (AROM) and initiate strengthening.
   • Activities: Active range of motion exercises are emphasized. Progressive resistance exercises for the rotator cuff, scapular stabilizers, and deltoid are introduced, starting with light resistance bands and progressing to light weights. Proprioception and neuromuscular control exercises begin.
4. Phase IV: Advanced Strengthening and Return to Activity (Weeks 20/24 +)
   • Goal: Optimize strength, power, and endurance; prepare for return to sport or demanding activities.
   • Activities: Advanced strengthening exercises, plyometrics, and sport-specific drills are incorporated. A gradual return to overhead activities is initiated, with careful monitoring and progression. Full return to sport may take 6-12 months, or even longer for overhead athletes.

Key Principles of Rehabilitation:

• Gradual Progression: Exercise intensity and range of motion are increased incrementally to avoid stressing the healing tissue.
• Pain-Free Movement: Exercises should be performed within a pain-free range.
• Consistency: Regular adherence to the prescribed exercise program is vital.
• Scapular Stability: A strong emphasis is placed on strengthening the muscles that stabilize the scapula, as this provides a stable base for arm movement.
• Rotator Cuff Strengthening: Essential for dynamic shoulder stability and power.

Potential Risks and Complications

While SLAP tear repair is generally safe and effective, potential risks and complications include:

• Infection: Though rare with arthroscopic surgery.
• Stiffness (Frozen Shoulder): Can occur if rehabilitation is not followed diligently.
• Nerve Damage: Temporary or, rarely, permanent damage to nerves around the shoulder.
• Re-tear or Failure of Repair: The labrum may re-tear, or the repair may fail to heal, especially with early or excessive stress.
• Continued Pain: Some patients may experience persistent pain despite a successful repair.
• Hardware Complications: Irritation or migration of suture anchors (rare).
• Biceps Pain: If the biceps tendon was involved in the original injury or repair.

Expected Outcomes and Recovery Timeline

The outcomes of SLAP tear repair are generally good, with many patients experiencing significant improvement in pain and function. However, the exact recovery timeline and final outcome can vary based on:

• Severity and Type of Tear: More complex tears may have longer recovery times.
• Patient Age: Younger, healthier individuals often recover more quickly.
• Adherence to Rehabilitation: Strict adherence to the physical therapy protocol is the most significant factor influencing success.
• Activity Level: Overhead athletes may have a longer and more challenging return to sport.

Full recovery, including a return to demanding activities or sports, typically takes 6 to 12 months or even longer. While most individuals regain excellent function, some overhead athletes may not fully return to their pre-injury performance level.

Conclusion: A Path to Recovery

SLAP tear repair is a well-established surgical procedure that can effectively alleviate pain and restore function in individuals suffering from this type of shoulder injury. The "how" of repair extends beyond the operating room, encompassing a critical and extensive post-surgical rehabilitation phase. By understanding the surgical techniques and committing to a diligent and progressive physical therapy program, patients can significantly improve their chances of a successful recovery and a return to their desired activities. Consulting with an orthopedic surgeon and a qualified physical therapist is essential for personalized guidance throughout this journey.