Overview
The shoulder socket is shallow, and the labrum is the ring of fibrocartilage around its rim that deepens it, anchors the capsule and ligaments, and anchors the long head of the biceps at the top. Tears at the top, where the biceps attaches, are SLAP tears (superior labrum, anterior to posterior). Tears at the front accompany dislocations and are covered under shoulder instability. Tears at the back occur mainly in linemen and weightlifters.
Labral tears are common on MRI and many do not need to be fixed. Deciding which ones do rests on age, whether the shoulder is unstable or merely painful, and what the arm is asked to do. For a SLAP tear, age matters more than almost anything else: the same tear is repaired in a 22-year-old pitcher and treated by tenodesis in a 45-year-old.
Common Symptoms
- Deep, poorly localized pain, often described as “inside” the joint rather than on the surface
- Catching, clicking or popping with rotation and overhead movement
- Pain in the late cocking phase of throwing or serving, and loss of velocity or control
- Pain with bench press, push-ups and other loaded pushing in posterior tears
Deep pain with catching in an overhead athlete points to the labrum. Pain on the outside of the arm with weakness lifting sideways is more typical of a rotator cuff tear. Front-of-shoulder pain with palm-up lifting alone may be biceps tendinitis, and a painful arc with overhead reaching in a stable shoulder is often impingement.
Causes & Risk Factors
SLAP tears in young athletes come from repetitive peel-back of the biceps anchor at the top of the throwing or serving motion, made worse by a tight posterior capsule; pitchers, tennis players, volleyball hitters and swimmers are the typical patients. A single event can also tear the labrum: a fall on an outstretched arm, a sudden pull, or a dislocation. Posterior tears follow repetitive loading with the arm forward, as in blocking and bench press. After about 35 the labrum frays at the top as a matter of wear, and a SLAP tear on the MRI of a middle-aged shoulder is often incidental.
How It Is Diagnosed
No single exam test settles a labral tear, so Dr. O'Donnell combines several. O'Brien's active compression test (resisting the arm forward with the thumb down, then palm up) and the dynamic labral shear test load the superior labrum; the crank test compresses and rotates the labrum against the socket; Speed's test loads the biceps anchor. For posterior tears the jerk and Kim tests push the ball backward against the labrum. He measures internal rotation deficit in throwers, because a tight posterior capsule is usually part of the mechanism, and checks for anterior instability with the apprehension and relocation tests.
X-rays are taken to look at the bone: a bony Bankart fragment, a Hill-Sachs dent from a dislocation, or arthritis. Plain MRI shows large tears but misses small ones; an MR arthrogram, with contrast injected into the joint before the scan, outlines the labrum clearly and is the test of choice when the result will decide treatment. Out-of-town athletes can upload existing scans through mymedicalimages.com for review before traveling.
Treatment Options
Non-operative care
Most labral tears without instability are treated non-operatively first, and many overhead athletes return without surgery. The program rests the shoulder from throwing for a few weeks, stretches the posterior capsule with sleeper and cross-body stretches until internal rotation matches the other side, strengthens the rotator cuff and shoulder-blade stabilizers, and then rebuilds throwing or hitting through an interval program. An ultrasound-guided injection can reduce pain in a shoulder too irritable to train. Patients over 35 with a degenerative SLAP tear are treated as if the labrum were not torn, and most improve over six to twelve weeks.
Labral repair
Dr. O'Donnell performs arthroscopic labral repair, reattaching the labrum to the socket rim with small suture anchors, when the tear is detached, the patient is young, and rehabilitation has failed or the shoulder is unstable. For SLAP tears the best candidates are athletes under about 30 to 35 with a clearly detached biceps anchor; for posterior tears, contact athletes and lifters with a confirmed posterior tear and posterior apprehension. Surgery is performed under a nerve block and general anesthesia as an outpatient at Bayside Surgery Center.
Biceps tenodesis
For SLAP tears in patients over about 35, in anyone whose SLAP repair has failed, and in overhead athletes whose biceps anchor is degenerate rather than cleanly detached, biceps tenodesis gives more reliable pain relief than repair. The biceps is released from the labrum and fixed to the humerus lower down, removing the pull on the top of the socket, and the frayed labrum is trimmed. Recovery is faster and the risk of stiffness is lower.
Recovery & What to Expect
The two operations protect different things, so their timelines differ: a labral repair protects healing tissue at the socket rim, a tenodesis protects a tendon fixed to bone.
| Milestone | Labral repair (SLAP / posterior) | Biceps tenodesis |
|---|---|---|
| Sling | 4–6 weeks; posterior repairs often in a neutral-rotation brace | 2–4 weeks |
| Early restrictions | No weight through the arm for 6 weeks; anterior repairs limit external rotation to 30° for 4 weeks, posterior repairs avoid internal rotation, cross-body reach and pushing for 6 weeks | No resisted elbow flexion or forearm supination for 6–8 weeks; no biceps stretch |
| Full motion | Weeks 8–12 | Weeks 4–8 |
| Strengthening | Weeks 8–16; advance at 80% strength | Weeks 8–12; biceps loading from week 8 |
| Interval throwing program | From about month 4 | From about month 3 |
| Return to sport | Months 4–6; contact sport typically 5–6 months | Months 3–4 |
Desk work is possible within a week of either procedure, driving once the sling is off (4 to 6 weeks after repair, 2 to 4 after tenodesis), and competitive throwing or serving at 4 to 6 months after repair and 3 to 4 months after tenodesis. The protocols are available as PDFs: anterior labral repair, posterior labral repair and biceps tenodesis.
Frequently Asked Questions
Can a SLAP tear heal on its own?
The torn labrum does not reattach itself, but that is not the deciding question. Many SLAP tears stop causing symptoms once the tight posterior capsule is stretched out and the cuff and shoulder blade are strengthened, and most overhead athletes are given 3 months of that program before surgery is considered. Over 35, a SLAP tear on MRI is usually incidental and is not treated at all.
Do I need surgery for a labral tear?
Only if the tear is causing instability, or pain and catching that have not responded to a proper course of rehabilitation. A detached labrum in a young athlete, a posterior tear in a lifter with posterior apprehension, and any labral tear that accompanies recurrent dislocation are the usual surgical cases. A frayed labrum in a stable shoulder is rarely operated on for its own sake.
What is the difference between SLAP repair and biceps tenodesis?
SLAP repair reattaches the labrum and biceps anchor to the socket with suture anchors and is used in athletes under about 35 with a cleanly detached anchor. Tenodesis moves the biceps off the labrum altogether and fixes it to the humerus; it recovers faster, has a lower risk of stiffness, and is preferred over 35, after a failed repair, or when the anchor tissue is degenerate.
How long until I can throw again after labral surgery?
An interval throwing program begins at about 4 months after a labral repair and about 3 months after tenodesis, once motion is full and cuff strength is at least 80% of the other side. Competitive pitching or serving typically returns at 4 to 6 months after repair and 3 to 4 months after tenodesis.
Do I need an MRI or an MR arthrogram?
If a labral tear is suspected and the result will change treatment, an MR arthrogram is ordered because standard MRI misses smaller tears. Dr. O'Donnell examines the shoulder and takes X-rays first, and does not order the arthrogram in patients who will be treated non-operatively regardless. If you already have imaging, upload it through mymedicalimages.com.
This page is for general education and is not a substitute for a medical evaluation. Treatment recommendations depend on your individual diagnosis and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.