SLAP Tear Simplified One-stop resource: from Pain to performance

A SLAP tear (superior labrum anterior-posterior lesion) is an injury to the labrum, the ring of cartilage that stabilises the shoulder socket. For pitchers, swimmers, volleyball players, or lifters, even a small tear can mean the difference between peak performance and sitting on the bench. The tricky part? SLAP tears often hide behind vague symptoms, such as shoulder pain, instability, or loss of throwing velocity, making it a challenge to spot them early.

 

In this blog, we will explore what a SLAP tear is, why overhead athletes are especially vulnerable, how to diagnose, the most effective treatment strategies, and the Return to Sport (RTS) guidelines.

What exactly is a SLAP Tear?

Let’s think of your shoulder socket (the glenoid cavity) like the face of a clock. It is deepened by the glenoid labrum, a cartilaginous rim that enhances stability and increases the contact area between the bones. Let’s consider the superior rim is at 12 o’clock, and the inferior rim is at 6 o’clock. A SLAP tear usually extends from around 10 o’clock to 2 o’clock positions.

 

At the top of the glenoid cavity, the long head of the biceps tendon attaches to the labrum. Together, they form the biceps-labral complex, which helps stabilise your shoulder during explosive movements.

 

When this complex is damaged, athletes may feel pain deep inside the shoulder, experience popping or catching, or notice a sudden drop in performance.

 

There are a number of classifications available for SLAP tears. However, the original classification by Snyder, who described 4 types of SLAP tears: Type I-IV, continues to be the most recognised and referenced in research and practice.

what is slap tear

How Do SLAP Tears Happen?

The underlying cause is often multifactorial – shoulder anatomy, mechanics, workload, and fatigue all play a role. But the injury may be due to

Acute Traumatic Injuries

Trauma can tear the labrum in one of three ways:

 

  1. Compression-type injuries: Falling on an outstretched arm (FOOSH) with your arm in various positions of abduction.

compression type injury

2. Traction-type injuries: A sudden jerking pull, such as water skiing, losing grip on a heavy object, or grabbing something overhead to stop a fall.

traction type injury

3. Combined-type injuries: A mix of compression and traction forces.

Other causes include direct blows to the shoulder (as in contact sports such as Rugby ) or accidents (e.g., car crashes).

Chronic Overuse Injuries

Usually, in overhead athletes, SLAP tears develop slowly from repetitive overhead activities:

 

  • Throwing (baseball, javelin)
  • Serving (tennis, volleyball)
  • Swimming strokes
  • Repeated heavy lifting 

 

Also, SLAP tears become increasingly prevalent with ageing (Lansdown et al., 2018) 

What are all the symptoms experienced by the patient?

  • Deep shoulder pain (often hard to localise)
  • Mechanical symptoms: popping, locking, catching 
  • Loss of velocity or power in throwing/serving
  • Shoulder instability or weakness
  • Sudden onset of pain after a jerking force or trauma

Diagnosing SLAP Tears:

SLAP tears are often difficult to diagnose. So it requires detailed history collection and appropriate physical examination to diagnose a SLAP tear. 

 

History collection:

During history taking, it is important to ask about

 

  • Mode of injury: Any contact injury, traction injury, or fall on an outstretched hand. 
  • Enquire whether the athlete experiences any clicking or popping sounds during overhead activities. 
  • Ask how long they have been experiencing the problem
  • Aggravating and relieving factors
  • What treatments have they already undergone before consulting you?
  • Review their training diary or periodisation chart to understand how often they train, compete, and manage workload, since poor workload management can lead to chronic stress on the shoulder structures, resulting in repetitive overload and a potential SLAP tear. 

Physical examination:

Range of motion 

  • On examination, the shoulder range of motion should be assessed, particularly the total arc (internal rotation + external rotation). 
  • In overhead athletes, it is normal to see higher external rotation and reduced internal rotation on the dominant side compared to the non-dominant side, as this is a natural adaptation.
  • However, A side-to-side difference in glenohumeral internal rotation (IR) of ≥20° is often considered pathological and is referred to as GIRD (Glenohumeral Internal Rotation Deficit), which is considered a risk factor for SLAP tear.
  • Measure Total Rotational Motion, TRM = IR + ER, to see if the overall range is preserved.

 

Example: 

  • Loss of 25° IR but gain of 25° ER → TRM is equal, likely adaptation.
  • Loss of IR + no gain in ER → true deficit, higher injury risk.

 Strength testing

  • Muscle strength should also be assessed, ideally with a handheld dynamometer. 
  • An isometric break test is practical and cost-effective in a clinical setting. Athletes with a SLAP tear may demonstrate reduced strength in the rotator cuff and biceps, while other shoulder muscles may be slightly affected.
  • Sometimes, however, muscle strength may not show significant deficits. In such cases, performance-based testing becomes important.

Performance-based testing

Assess throwing velocity and power-based tests such as the CKCUES test (Closed Kinetic Chain Upper Extremity Stability Test) and single-arm medicine ball throws. If possible, compare current performance with previous testing records taken before the injury to evaluate changes and symmetry.

  • History taking and physical examination provide valuable insights into the athlete’s condition. However, a SLAP tear cannot be confirmed solely based on clinical assessment.

Do we need Imaging to diagnose a SLAP tear?

  • You may think that an MRI is required to confirm a SLAP tear, but it has limitations. MRI can detect abnormalities even in pain-free individuals.  Normal anatomical adaptations in an overhead athlete’s shoulder may resemble a SLAP tear. (LeVasseur, Matthew R et al.)
 
  • In many cases, MRI diagnosis of a SLAP tear is incidental, which can cause unnecessary concern and often leads to harmful surgical procedures (Mathew et al., 2018).)
 
  • MRI is not definitive, but MRI arthrography (MRA) may provide greater accuracy. 

Is a special test valuable to diagnose SLAP tear?

  • A 2019 IJSPT paper (Clark et al.) suggested that using a combination of at least 3 positive special tests may be more clinically useful than MRI/MRA. 
  • The combination of Biceps Load I, Biceps Load II, and O’Brien’s tests demonstrated the best diagnostic value.
O’Brien’s test.

obriens test

Biceps load test I 

biceps load test

Biceps Load Test II

biceps load test 2

Then, how to diagnose?

A comprehensive approach consists of history, physical examination, a cluster of special tests, and MRA imaging for greater accuracy in diagnosing SLAP tears.

Differential diagnosis

Differential diagnosis analysis is crucial.  

 

Other conditions that mimic SLAP tear symptoms include:

 

  • Rotator cuff tendinopathy 
  • Biceps strain
  • Subscapularis strain
  • Pectoralis major strain
  • Internal impingement
  • Even referred pain from the cervical spine

 

Does it really matter, and will it change the treatment plan? I think it may be a little, but overall, it will remain a pretty similar treatment approach to other similar pathologies. 

 

What are the clinical features of the above conditions?

1. Biceps Strain 

  • pain and tenderness over the bicipital groove/arm
  • pain with supination/flexion
  • Speed’s test +ve 

 

2. Pec Major Strain

  • Pain in Anterior chest/axilla
  • Weakness in adduction & IR 
  • Pain in resisted horizontal adduction
  • History of Bench press injury

 

3. Subscapularis Strain

  • Pain over Anterior shoulder
  • Weakness in internal rotation
  • Lift-off test +ve 
  • Pain reaching behind the back

 

4. Rotator Cuff Tendinopathy

  • Pain over the Lateral shoulder/deltoid
  • Night pain
  • Hawkins-Kennedy test +ve 

 

5. Internal Impingement

  • Pain in the Posterior shoulder
  • Pain in late cocking
  • 90/90 ER test +ve 
  • Overhead athletes are more common (especially those who have GIRD)

What is the best treatment approach?

Nonoperative treatment of SLAP tears in athletes can be successful, especially in the subset of patients who can complete their rehabilitation program before attempting a return to play.

Non-Surgical Management

  • What conservative treatments are available? Options include rest, physical therapy, injections (such as lidocaine or PRP), and non-steroidal anti-inflammatory drugs (NSAIDs). But do these conservative treatments really work? What does the research say about their effectiveness?
  • Most clinicians recommend 3-6 months of rehabilitation before considering surgery. Why? Because even if imaging confirms a tear, surgery doesn’t always guarantee a successful return to play, especially for high-level overhead athletes.
  • Research shows that some athletes who fail their first rehab attempt may succeed with a second, if the program is well-structured and progressive.
  • Research shows that the average time to return to play after non-surgical management varies from 5.2 months to 5.7 months, with an average session required for successful rehabilitation is 20 sessions (8-18)

Surgical management

  • A study by Frantz et al., 2020 and Recker et al 2022 shows that Biceps tenodesis offers encouraging functional outcomes and RTS rates, particularly in recreational athletes, than Labral repair. 
  • But another study by Schrøder CP et al., 2017 shows that neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions. 
  • Thus, Surgery is considered when:
  • Non-operative care fails
  • Symptoms persist and significantly limit performance
  • Imaging + clinical exam strongly suggest an unstable tear
  • Procedures vary based on age, sport, and surgeon preference (labral repair, biceps tenodesis, debridement, etc.).
  • But surgery is not the end. A 9-12 month rehab program is still needed for full recovery.

Rehabilitation 

Rehabilitation isn’t just about regaining function. For some individuals, it makes them do their daily activities. For some individuals, it helps them get back to their work. For athletes, it’s about preparing them to return stronger and more resilient to the sport.

 

Phase 1: Restore Full, Pain-Free ROM and Strength

  • Use the uninjured shoulder as a reference (ROM, Strength), but remember that Overhead athletes often have natural side-to-side differences.
  • Focus not only on the shoulder, but also periscapular muscles, trunk, pelvis, and lower body conditioning. 

 

Components of resistance training (11,12,13) 

  • Isometric and ROM exercise – Activates RC muscles and scapular stabilisers without stressing the biceps anchor or labrum. 
  • Closed kinetic chain (CKC) concentric exercise – provides co-contraction and joint compression, introduces low shear forces to the shoulder.
  • Open kinetic chain (OKC) concentric exercise – Introduces high shear force. Allows us to strengthen the shoulder muscles in a more functional range
  • Eccentric exercise – Builds tendon/ labral tolerance and prepares for overhead and throwing demands.

eccentric exercise slap tear

  • Focus on cardiovascular fitness as well. 
  • At the end of this phase, ensure that adequate progress is made in terms of strength, ROM, and that it is measured objectively throughout the rehabilitation, preferably with a hand-held dynamometer ( can also use maximum RM strength testing )  and an inclinometer/ goniometer.

 

Phase 2: Introduce Plyometrics and Power Strength (Build on strength with explosive exercises)

  • 2–3 sessions per week, with 48 hours rest in between.
  • Mix plyometric and resistance training.

 

Components of Plyometric Exercise

plyometrics exercise

  • Force absorption (e.g Med ball catch, catching a ball in an open chain)

force absorption

  • Force creation (e.g Pendlay rows, Bench throws, Ball throws for distance)

force creation

  • Stretch shortening cycle phase (e.g Plyometric push up, Push press, Med ball catch and throws)

stretch shortening cycle phase

  • Maximal demand phase (e.g Shoulder hops, Push jerks, Reactive ball catches, Return to sport-specific throwing)

 

Phase 3: Throwing Programme

  • Gradual, stepwise return to throwing/serving/spiking.
  • The programme should be performed every other day to allow one day of recovery and evaluation.

 

Phase 4:  Return to Sport Testing

  • There’s no gold-standard RTS test yet, but clinicians simulate worst-case demands of the sport (e.g., clinching, blocking, throwing under fatigue).
  • We can utilise RTS tests for the shoulder recommended in a paper by Schwank, Ariane et al., 2022.

 

Sport-Specific Tests Recommended by the Delphi Group for Overhead (With or Without Throwing) Athletes and Collision-Sport Athletes

Performance TestROM/Strength TestKinetic ChainSport-Specific Test Example
CKCUEST90°/90° concentric/eccentric rotator cuff testingPush-up test: assessing for ability, quality of movement, control, and enduranceNumber of pain-free throws/serves at or above previous speed
PSETIsometric rotation strength ER/IR at 90°/0°Side plank enduranceThrowing at full speed
Shoulder Endurance Test (SET) (endurance test for ER in ABD/ER, 90°/90°)Total rotational ROM within 10% of the contralateral sidePlyometric push-upVisual assessment of the “smoothness” of the throwing technique
The Athletic Shoulder Test (ASH-Test)ER force measured with HHD in prone at 90°/90° and 90°/0°Single-leg squat testWrestling drills
Y Balance Test for the upper and lower extremitiesER/IR ratio: sport-specific numbers applyThoracic spine rotationTackle replication (eg, for American football or rugby)
Seated medicine-ball throwIR/ER ratio at 90°/90° in sitting (break test, HHD)Bench press 
Ball abduction-ER test   
IR/ER ratio in sitting at 90° of abduction and neutral rotation Upper-limb rotation test 
Ball taps on the wall test………
Prone ball-drop test………
  • Shared decision-making between the athlete, the medical team, and coaches is essential while sending the athlete back to the sport. 
  • Also, assess the player’s psychological readiness and confidence along with RTS, as it plays an important role in RTS. 

 

Phase 5: Return to Performance

Getting back to competition ≠ , regaining peak performance. True return to form is often achieved only after full competition exposure.

 

Research shows that the return-to-play rate was 53.7% in all athletes and 52.5% in elite or higher-level athletes. In athletes who were able to complete their nonoperative rehabilitation program, the return-to-play rate was 78% in all athletes and 76.6% in elite or higher-level athletes. The overall rate of return to prior performance was 42.6%, which increased to 72% for those athletes who were able to complete their rehabilitation. 

Take-home message 

  1. SLAP tears are common in overhead athletes and often present with vague symptoms like deep shoulder pain, popping, or loss of throwing velocity.
  1. Diagnosis is challenging- a combination of history, physical exam, special test clusters, and selective imaging gives the best accuracy.
  1. Non-surgical rehab is the first-line treatment, with structured programs showing higher return-to-play rates than surgery.
  1. Rehabilitation must be progressive, moving from ROM and strength to plyometrics, throwing, RTS testing, and finally returning to performance.
  1. Successful return to sport depends not only on physical healing but also on workload management and psychological readiness

Reference 

  1. Steinmetz, Raymond G et al. “Return to play following nonsurgical management of superior labrum anterior-posterior tears: a systematic review.” Journal of shoulder and elbow surgery vol. 31,6 (2022): 1323-1333. doi:10.1016/j.jse.2021.12.022
  2. Freijomil, Nicholas et al. “THE SUCCESS OF RETURN TO SPORT AFTER SUPERIOR LABRUM ANTERIOR TO POSTERIOR (SLAP) TEARS: A SYSTEMATIC REVIEW AND META-ANALYSIS.” International journal of sports physical therapy vol. 15,5 (2020): 659-670. doi:10.26603/ijspt20200659
  3. Clark, Richard C et al. “USE of CLINICAL TEST CLUSTERS VERSUS ADVANCED IMAGING STUDIES in the MANAGEMENT of PATIENTS with a SUSPECTED SLAP TEAR.” International journal of sports physical therapy vol. 14,3 (2019): 345-352. doi:10.26603/ijspt20190345
  4. Michener, Lori A et al. “National Athletic Trainers’ Association Position Statement: Evaluation, Management, and Outcomes of and Return-to-Play Criteria for Overhead Athletes With Superior Labral Anterior-Posterior Injuries.” Journal of athletic training vol. 53,3 (2018): 209-229. doi:10.4085/1062-6050-59-16
  5. Schrøder CP, Skare Ø, Reikerås O, et alSham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial. British Journal of Sports Medicine 2017;51:1759-1766.
  6. Borkar, Tejas. “Recent Trends in Rehabilitation and Return to Sports Criteria Post SLAP Lesion in Overhead Athletes – A Systematic Review.” International Journal of Health Sciences and Research, 2024.
  7. Schwank, Ariane et al. “2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels.” The Journal of Orthopaedic and Sports Physical Therapy, vol. 52,1 (2022): 11-28. doi:10.2519/jospt.2022.10952
  8. LeVasseur, Matthew R et al. “SLAP tears and return to sport and work: current concepts.” Journal of ISAKOS: joint disorders & orthopaedic sports medicine vol. 6,4 (2021): 204-211. doi:10.1136/jisakos-2020-000537
  9. Mathew, Cristin John, and David Mark Lintner. “Superior Labral Anterior to Posterior Tear Management in Athletes.” The Open Orthopaedics Journal, vol. 12, no. 1, 31 July 2018, pp. 303–13, https://doi.org/10.2174/1874325001812010303. 
  10. Dodson, Christopher C, and David W Altchek. “SLAP lesions: an update on recognition and treatment.” The Journal of Orthopaedic and Sports Physical Therapy, vol. 39,2 (2009): 71-80. doi:10.2519/jospt.2009.2850
  11. Gaunt, Bryce W et al. “The American Society of Shoulder and Elbow Therapists’ consensus rehabilitation guideline for arthroscopic anterior capsulolabral repair of the shoulder.” The Journal of Orthopaedic and Sports Physical Therapy vol. 40,3 (2010): 155-68. doi:10.2519/jospt.2010.3186
  12. Wilk, Kevin E et al. “Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability.” North American journal of sports physical therapy: NAJSPT vol. 1,1 (2006): 16-31.
  13. Popchak, A., Patterson-Lynch, B., Christain, H., & Irrgang, J. (2017). Rehabilitation and return to sports after anterior shoulder stabilisation. Annals Of Joint, 2(10). doi:10.21037/aoj.2017.10.06
  14. Lansdown, Drew A et al. “Imaging-Based Prevalence of Superior Labral Anterior-Posterior Tears Significantly Increases in the Ageing Shoulder.” Orthopaedic journal of sports medicine vol. 6,9 2325967118797065. 17 Sep. 2018, doi:10.1177/2325967118797065
  15. Frantz, Travis L et al. “Biceps Tenodesis for Superior Labrum Anterior-Posterior Tear in the Overhead Athlete: A Systematic Review.” The American journal of sports medicine vol. 49,2 (2021): 522-528. doi:10.1177/0363546520921177
  16. Recker, Andrew J et al. “Biceps Tenodesis Has Greater Expected Value Than Repair for Isolated Type II SLAP Tears: A Meta-analysis and Expected-Value Decision Analysis.” Arthroscopy: the journal of arthroscopic & related surgery: official publication of the Arthroscopy Association of North America and the International Arthroscopy Association vol. 38,10 (2022): 2887-2896.e4. doi:10.1016/j.arthro.2022.05.005