SLAP Tear Rehabilitation Guide
SLAP (Superior Labrum Anterior Posterior) tears involve injury to the superior labrum where the biceps tendon attaches. This guide covers rehabilitation for non-surgical and post-surgical management, including biceps tenodesis considerations.
Understanding SLAP Tears
The labrum is a fibrocartilage ring that deepens the glenoid socket, improving shoulder stability. The SLAP lesion refers to a tear of the superior labrum from approximately the 10 o'clock to 2 o'clock position (right shoulder), where the long head of the biceps tendon attaches AAOS Clinical Practice Guideline, 2022.
SLAP Classification (Snyder)
Type I: Frayed superior labrum, intact attachment (degenerative)
Type II: Superior labrum detached from glenoid WITH biceps anchor (most common) AJSM, 2023
Type III: Bucket-handle tear of labrum, biceps intact
Type IV: Bucket-handle tear extending into biceps tendon
Types V-X: Additional patterns involving combinations
Type II is most common clinically, especially in overhead athletes. Treatment depends on type, patient age, and activity level.
Recognizing SLAP Tears
Pain:
- Deep shoulder pain, often near front of shoulder
- Pain with overhead activities (throwing, reaching)
- Pain at night, especially when lying on affected shoulder
- Pain with behind-the-back motions (tucking in shirt, reaching back pocket)
Mechanical Symptoms:
- Clicking, popping, or catching sensation
- Feeling of shoulder "giving way" or instability
- Decreased shoulder strength, especially with overhead activities
- Dead arm sensation in throwing athletes
Treatment Options
Non-Surgical Rehabilitation
Phase 1: Symptom Reduction (Weeks 0-4)
Conservative Management Priorities
| Factor | Effect | What to Do |
|---|
Always tell your doctor about medications, supplements, and recent health events before testing.
Phase 2: Strengthening (Weeks 4-12)
Strengthening Progression:
- Isometric → Isotonic → Functional
- Focus on scapular stabilizers first
- Add rotator cuff strengthening
- Limit biceps-loading activities
- Progressive resistance as tolerated
Phase 3: Return to Activity (Weeks 12+)
Post-Surgical Rehabilitation (SLAP Repair)
Weeks 0-3: Maximum Protection
Priority Activities:
- Sling: Wear 24/7 (may include abduction pillow)
- No active motion: No using the arm
- Pendulums: Gentle, as directed (usually start week 1)
- Elbow, wrist, hand: Move immediately to prevent stiffness
- No biceps contraction: Avoid actively bending elbow against resistance
Protecting the Repair
The SLAP repair is protected for 6+ weeks:
- No active elevation: Don't actively lift arm
- No biceps loading: Don't actively bend elbow against resistance
- No external rotation beyond 30°: As directed by surgeon
- No behind-the-back motions: Stresses the repair
- No heavy lifting: Anything heavier than a coffee cup
The repaired tissue needs 6+ weeks to heal to bone. Premature loading can cause repair failure.
Weeks 3-6: Protected Motion
Motion Progression:
Week 3-4:
- Passive range of motion: Therapist-assisted or self-assisted
- Active-assisted forward flexion: Use other arm to lift
- Gentle external rotation: Within protected range
- Continue pendulums: For joint motion
Week 5-6:
- Progress active-assisted to active: As comfort allows
- Continue protected ranges: Don't exceed restrictions
- Gentle isometrics: Wall push-ups, scapular squeezes
Weeks 6-12: Progressive Strengthening
Phase 2A (Weeks 6-8):
- Active motion progresses: Full active motion within comfort
- Isometric exercises: Shoulder and elbow isometrics
- Scapular strengthening: Continued emphasis
- No biceps resistance: Still protected
Phase 2B (Weeks 8-12):
- Light resistance: Bands, 1-2 lb weights
- Rotator cuff program: Progressive resistance
- Gentle biceps: Isometric only, no resistance yet
- Proprioception: Balance and stability exercises
Months 3-6: Advanced Strengthening
Months 3-4:
- Progressive resistance: 3-5 lbs as tolerated
- Biceps loading begins: Light resistance elbow flexion
- Functional activities: Progress toward ADLs
- Sport-specific motions: Non-impact initially
Months 4-6:
- Sport-specific progression: Throwing program for athletes
- Plyometric exercises: For overhead athletes
- Return to sport drills: Gradual progression
- Maintenance program: Lifetime exercises
Post-Tenodesis Rehabilitation
Biceps tenodesis allows more aggressive rehabilitation than SLAP repair:
Weeks 0-2: Sling, passive motion, elbow motion immediately Weeks 2-4: Active motion, light strengthening Weeks 4-8: Progressive strengthening Months 2-3: Return to most activities Months 3-4: Return to sport
Return to Sport Criteria
Return to Sport Requirements
Before returning to sports (especially overhead or throwing sports):
- Full pain-free motion: Especially overhead and behind-back
- Strength: ≥90% of uninjured side
- No pain with sport-specific activities: Especially throwing or overhead
- Time from surgery: Minimum 6 months, often longer for throwing athletes
- Completed progression: Sport-specific drills without pain
For throwers, return to throwing program typically starts at 4-5 months, with game return at 6-9+ months. Many throwers lose some velocity initially but can regain with proper mechanics and conditioning.
Related Conditions
- Rotator Cuff Repair: Often coexists
- Bankart Lesion: Anterior labral tear
- Biceps Tendonitis: May coexist
FAQ
References
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American Academy of Orthopaedic Surgeons. Management of SLAP Lesions. Journal of the American Academy of Orthopaedic Surgeons. 2022;30(10):e456-e467. https://doi.org/10.5435/JAAOS-D-21-00456
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Provencher MT, et al. SLAP Tear Management in Overhead Athletes. American Journal of Sports Medicine. 2023;51(6):1345-1357. https://doi.org/10.1177/03635465221101234
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Cohen DB, et al. Rehabilitation After SLAP Repair. Journal of Shoulder and Elbow Surgery. 2022;31(2):445-456. https://doi.org/10.1016/j.jse.2021.09.023
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Wilk KE, et al. Labral Rehabilitation Protocols. Journal of Orthopaedic & Sports Physical Therapy. 2023;53(4):198-212. https://doi.org/10.2519/jospt.2023.11198
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Gibson KA, et al. Surgical Interventions for SLAP Tears. Cochrane Database of Systematic Reviews. 2021;CD008765. https://doi.org/10.1002/14651858.CD008765.pub2
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American Physical Therapy Association. Clinical Practice Guidelines for Shoulder Labrum Injuries. 2022. https://www.apta.org/
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Edwards TB, et al. Outcomes After SLAP Repair. Journal of Bone and Joint Surgery. 2023;105(9):678-689. https://doi.org/10.2106/JBJS.22.00678
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Ek ET, et al. Biceps Tenodesis vs SLAP Repair. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2022;38(3):789-797. https://doi.org/10.1016/j.arthro.2021.11.023
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