What are SLAP tears?
SLAP, as used in regards to shoulder problems, is an acronym that means Superior Labrum Anterior Posterior. The labrum is a fibrocartilage structure that attaches to the rim of the shoulder socket. The labrum can tear away from its attachment point. Sometimes that generates pain. Labral tears in young people usually result from injury. Labral tears are extremely common in older patients and are thought to represent a natural aging process of the shoulder.
A Tricky Diagnosis
It is difficult to diagnose a labral tear as a cause for shoulder pain. There is no telltale sign on physical examination that yields a clear cut diagnosis of labral tear. There is also not a classic pattern of pain or dysfunction associated with labral tear. To make matters even more difficult for the shoulder practitioner, an MRI scan of the shoulder will commonly suggest a labral tear when there is no labral tear. When a test suggests that there is pathology and there is no pathology present, that is referred to as a “false positive”. False positives are very common when it comes to diagnosing labral tears. Internal observer reproducibility is poor when different specialists are asked to review the same MRI scan of a shoulder. If orthopedic radiologists are given the same images to look at but are blind to the information that others have interpreted, there’s not a high correlation between different radiologists concerning the diagnosis of labral tear.
So, what is the gold standard for diagnosing a labral tear? It might seem logical that looking at the labrum, as is done with arthroscopic surgery, would yield an accurate answer. That is not the case. When shoulder specialists are shown the same video or still photography of the labrum in question, they typically do not agree about the diagnosis.
Some generalizations about labral pathology can be made. In younger patients, labral tears are usually associated with a notable injury to the shoulder. Most patients that are candidates for surgery for a labral tear will show suggestion of a labral tear on an MRI study. Most of those same patients will show distinctive findings at surgery that suggest a labral tear.
In older patients, labral tears are very common as a variation of normal. It seems that as shoulders age, the labrum becomes susceptible to tearing with everyday activities. Most labral tears in older patients will not require surgical treatment.
In either case, SLAP tears often happen in the area that the biceps tendon attaches to the labrum.
What are disorders related to the biceps tendon?
The long head of the biceps tendon can cause quite a bit of discomfort about the shoulder. The biceps muscle has one connection in the elbow area. It has 2 connections around the shoulder area. The connection to the part of the shoulder blade known as the coracoid process is tough, durable and rarely causes problems. This connection is called the short head of the biceps. The connection called the long head is a notorious troublemaker. The long head biceps tendon is a tendon that goes from the belly of the biceps muscle to the top of the shoulder socket. It passes along the anterior aspect of the humerus. It moves in a special groove in the proximal humerus and then enters the shoulder joint. It travels across the top of the ball of the shoulder to connect at the top of the shoulder socket (the glenoid). Looking at the socket like the face of a clock one will usually find the biceps tendon somewhere between 11:00 and 1:00. The exact position of attachment varies from individual to individual.
Most biceps tendon problems seem to be a result of degeneration caused by aging. As the tendon degenerates, some of the individual tendon fibers break. The tendon has a structure that has some similarity to a rope. It is composed of thousands of individual tendon strands like the individual strands of a rope. As individual fibers break the tendon will tend to flatten out. A normal tendon is rounded and slightly smaller than a #2 pencil. I have seen some flattened out tendons at surgery that are almost an inch wide.
Almost everybody’s biceps tendon will begin to degenerate eventually. It seems that most biceps tendons don’t cause pain when they begin to degenerate. Some biceps cause a tremendous amount of pain. The pain is generally well localized in the vicinity of the bicipital groove.
The treatment of the biceps tendon problem has a lot in common with the treatment of a rotator cuff tendon problem. Treatment may include rest, supervised physical therapy, home exercises, activity modification, medication taken by mouth, medication administered by injection, and surgery.
One need not stop using the arm to rest the biceps tendon. It works hard when one is twisting the wrist repeatedly with a load in the wrist. It works hard when one is flexing the elbow repeatedly. One can rest the biceps tendon by simply diminishing those tasks that involve a lot of twisting of the forearm or flexing the elbow.
Supervised physical therapy
A regimen of strengthening the shoulder girdle musculature will often lessen biceps tendon pain. Often this is best undertaken with the advice of the physical therapist to coach on the proper way to do a home exercise regimen.
Exercises that strengthen the deltoid muscle, exercises that strengthen the biceps and triceps muscles, and a general upper body workout will sometimes lessen the pain of biceps tendon inflammation.
Medication taken by mouth
Anti-inflammatory medicine will sometimes diminish the pain caused by inflammation of the biceps tendon. Nonprescription medications such as ibuprofen or naproxen sodium are worth a try if one does not have a contraindication to these drugs. Prescription drugs for inflammation are usually no more effective than over-the-counter drugs for inflammation. Their main advantage is that they have fewer undesirable side effects.
Medication by injection
Injection of a small amount of cortisone around the biceps tendon is very effective in decreasing biceps tendon pain.
There are many different surgeries appropriate for a biceps tendon problem that has failed to respond to nonoperative treatment. Most of these are arthroscopic. Some of them involve a minimal skin incision in addition to arthroscopy.