The glenoid labrum is a circumferential ring of fibrocartilaginous tissue surrounding the glenoid fossa. A superior labrum anterior to posterior (SLAP) tear is an injury to the superior aspect of this labrum.^1-3 SLAP tears are commonly associated with biceps tendon pathology, as the long head of the biceps tendon attaches to the superior labrum.⁴ These injuries are most commonly seen in overhead throwing athletes due to repetitive microtrauma.⁵ Studies have shown that the presence of SLAP tears ranges from 6 to 26 percent on arthroscopy but can be present in up to 83 percent of throwing athletes.^6,7 In terms of the demographics of SLAP lesions, the highest incidence of SLAP tears was seen in males and in patients between twenty and twenty-nine and between forty and forty-nine years of age.⁸

Anatomy

Anatomically, the labrum serves as the attachment site of the glenohumeral ligaments and the long head of the biceps tendon. Half of the long head of the biceps tendon originates from the superior labrum, while the other half of the tendon originates from the supraglenoid tubercle of the scapula.⁹ The blood supply to the labrum arises from the suprascapular, circumflex scapular, and posterior humeral circumflex arteries.¹⁰ Functionally, the labrum deepens the glenoid by 50 percent and provides static stability to the glenohumeral joint by preventing humeral head subluxation.¹¹ Neer et al. and Andrews et al. suggested that the long head of the biceps plays a role in shoulder stability through depression and compression of the humeral head.^12,13 Later studies have clarified that the long head of the biceps plays a minor role in shoulder stability but can be a source of pain.¹⁴ Snyder et al. developed a classification system for SLAP tears, categorizing these lesions into four types, which are outlined in table 4.1.

Pathophysiology

There are several proposed theories, which are based upon the mechanism of injury, that explain the development of SLAP tears and biceps tendon pathology.³ For overhead throwing athletes, Andrews et al. postulated that tension on the long head of the biceps during the deceleration and follow-through phases of throwing effectively causes the tendon to pull off of the superior labrum.¹² Burkhart et al. further theorized that the position of the arm in maximal abduction and external rotation during throwing causes excessive torsional stress on the biceps tendon attachment, leading to the detachment of the posterosuperior labrum.¹⁵ For more acute injuries caused by trauma, excessive traction on the biceps tendon is capable of causing type II SLAP tears.¹⁶ They can also be degenerative in nature and are a common finding in patients over forty-five.

History

The evaluation of SLAP tears and biceps tendon pathology begins with taking a history.^1-3,7 Patients typically present with deep anterior shoulder pain that may be accompanied by mechanical symptoms such as clicking, catching, and popping. The pain is often exacerbated by overhead activities. Patients may also report a subjective sense of gross instability with these injuries. Furthermore, in throwers and overhead athletes, complaints about a decline in athletic performance, such as a loss in throwing velocity or distance, should raise clinical suspicion of a SLAP tear. Additionally, it is important to note any acute injuries, such as a fall on an outstretched arm or traction injury. Key additional elements of history to be gathered include a previous history of shoulder dislocation or other shoulder trauma, occupation, and level of sport participation.

Physical Examination

The physical examination in SLAP tears and biceps tendon pathologies involves inspection, palpation, range of motion, and diagnostic maneuvers.^1-3,7 Inspection of both shoulders should be performed with attention to scapular position, muscle atrophy, and skin changes, such as previous surgical scars. Next, palpation of the bicipital groove to assess tenderness in the long head of the biceps tendon should be performed. A proximal biceps tendon rupture is signified by the presence of the classic Popeye’s sign, where the biceps loses its normal elliptical contour, balls up, and sags distally. Both active and passive range of motion should be assessed in the affected and unaffected shoulders. Overhead athletes may present with a glenohumeral internal rotation deficit (GIRD), which is a deficit of greater than 20 degrees in internal rotation in the throwing shoulder compared to the non-throwing shoulder.¹⁷ Lastly, assessment of scapular motion at rest and during range of motion should be performed due to the association between scapular dyskinesis and shoulder pathology in overhead athletes.¹⁸

Special Tests for SLAP Tears

There are several tests that have been developed for the assessment of superior labral pathology, including O’Brien’s active compression test and the anterior slide test. As no one single physical examination maneuver used alone can definitively diagnose a SLAP tear, these tests should be used in conjunction with history and advanced imaging.¹⁹ The first maneuver, the O’Brien’s active compression test, requires the patient’s shoulder to be placed in 90 degrees of forward elevation with the elbows fully extended and the arm adducted 10 to 15 degrees (video 4.1; figure 4.1).²⁰ In this first position, the patient’s thumb is directed to the floor. The examiner applies an inferiorly directed force to the patient’s arm, while the patient resists. In the second position, the patient’s thumb is now directed toward the ceiling. Again, the examiner applies an inferiorly directed force to the patient’s arm, while the patient resists. The patient is asked to report pain or the absence of pain with each maneuver. A positive test occurs if there is pain in the glenohumeral joint (“deep”) in the first position with the thumb directed downward that is improved or alleviated with the second position. A positive O’Brien’s test is suggestive of a SLAP tear. If the patient describes the pain from this maneuver as “superficial,” it may suggest acromioclavicular joint (ACJ) pain.

Next, the anterior slide test can also be performed in the assessment of a SLAP tear (figure 4.2).²¹ The patient is standing upright or sitting on the examination table with their hands on their hips. The examiner places one hand under the patient’s elbow and the other on the patient’s shoulder and applies an axial compressive force to the patient’s elbow simultaneously with an anterior directed force to the humerus. A test is positive if the patient experiences pain in the anterior shoulder with this maneuver. A positive test is suggestive of a SLAP tear.

Special Tests for Biceps Tendon Pathology

Several tests have been developed for the assessment of proximal biceps tendon pathology as well, but notably they have variable predictive values that are dependent on the examiner and patient population.²² First, the Speed’s test is performed with the patient’s shoulder in 90 degrees of forward elevation, the elbow in full extension, and the forearm in full supination (figure 4.3).^22-24 The examiner palpates the patient’s bicipital groove and asks the patient to forward elevate their arm against resistance. A test is considered positive if there is pain along the bicipital groove with this maneuver and is suggestive of proximal biceps tendon pathology. Notably, in a comparison with the diagnostic standard of arthroscopy, Holtby et al. noted that the Speed’s test had a sensitivity of 32 percent and a specificity of 75 percent for biceps tendon pathology and SLAP tears.²²

In addition, Yergason’s test is also useful in the assessment of proximal long head of the biceps tendon pathology (video 4.3; figure 4.4).^22,24 The patient’s elbow is placed in 90 degrees of flexion with the arm at the side. The examiner palpates the patient’s bicipital groove with one hand and places the other hand on the patient’s forearm, holding it in pronation. Then, the examiner asks the patient to supinate against resistance. Pain along the bicipital groove indicates a positive test result, which is suggestive of biceps tendon pathology. Similarly, Holtby et al. noted that, in comparison with the diagnostic standard of arthroscopy, the sensitivity and specificity of Yergason’s test in detecting biceps tendon pathology and SLAP tears was 43 percent and 79 percent, respectively.²²

Sensitivities and specificities for all examinations described in Chapter 4 are outlined in table 4.2.^21-23,25

Key Terminology

Anterior Slide Test 

Physical examination maneuver performed in the assessment of a SLAP tear. The patient is standing upright or sitting on the examination table with their hands on their hips. The examiner places one hand under the patient’s elbow and the other on the patient’s shoulder and applies an axial compressive force to the patient’s elbow simultaneously with an anterior directed force to the humerus. A test is positive if the patient experiences pain in the anterior shoulder with this maneuver. ↵

Glenohumeral Internal Rotation Deficit (GIRD)

Deficit of greater than 20 degrees in internal rotation in the throwing shoulder compared to the non-throwing shoulder, commonly seen in the dominant arm of throwing athletes. ↵

Labrum

Circumferential ring of fibrocartilaginous tissue surrounding the glenoid fossa that deepens the glenoid articulation by 50 percent and provides static stability to the glenohumeral joint by preventing humeral head subluxation. ↵

O’Brien’s Active Compression Test 

Physical examination maneuver used in detecting SLAP tears and acromioclavicular joint pathology. The patient’s arm should be placed in 90 degrees of forward elevation with the elbow fully extended, and the arm adducted 10 to 15 degrees. In the first position, the patient’s thumb is directed to the floor, and the examiner applies an inferiorly directed force to the patient’s arm. In the second position, the patient’s thumb is now directed toward the ceiling and the examiner again applies an inferiorly directed force to the patient’s arm. A positive test occurs if there is pain in the glenohumeral joint in the first position with the thumb directed downward that is improved or alleviated with the second position. A “deep” location of pain is suggestive of a SLAP tear, while a “superficial” location of pain is suggestive of acromioclavicular joint (ACJ) pathology. ↵

Popeye’s Sign 

Physical examination finding that indicates a biceps tendon rupture. The biceps loses its normal elliptical contour and in a proximal rupture, the muscle belly is seen more distally and appears rounded on physical examination with the patient’s arm flexed to 90 degrees. ↵

Speed’s Test 

Physical examination maneuver for the assessment of long head of the biceps tendon pathology. The patient’s arm is placed in 90 degrees of forward elevation, the elbow in full extension, and the forearm in full supination. The examiner palpates the patient’s bicipital groove and asks the patient to forward elevate their arm against resistance. A positive test is indicated by pain along the bicipital groove with this maneuver. ↵

Superior Labrum Anterior to Posterior (SLAP) Tear 

Injury to the superior aspect of the labrum, which is the attachment site of the long head of the biceps tendon. ↵

Yergason’s Test 

Physical examination maneuver for the assessment of long head of the biceps tendon pathology. The patient’s elbow is placed in 90 degrees of flexion with the arm at the side. The examiner palpates the patient’s bicipital groove with one hand and places the other hand on the patient’s forearm, holding it in pronation. The examiner asks the patient to supinate against resistance. A positive test result is indicated by pain along the bicipital groove. ↵

References

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5. Boesmueller S, Nogradi A, Heimel P, et al. Neurofilament distribution in the superior labrum and the long head of the biceps tendon. J Orthop Surg Res. 2017;12(1):181. ↵

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13. Neer CS, 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54(1):41-50. ↵

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15. Burkhart SS, Morgan CD. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy. 1998;14(6):637-640. ↵

16. Bey MJ, Elders GJ, Huston LJ, Kuhn JE, Blasier RB, Soslowsky LJ. The mechanism of creation of superior labrum, anterior, and posterior lesions in a dynamic biomechanical model of the shoulder: the role of inferior subluxation. J Shoulder Elbow Surg. 1998;7(4):397-401. ↵

17. Rose MB, Noonan T. Glenohumeral internal rotation deficit in throwing athletes: current perspectives. Open Access J Sports Med. 2018;9:69-78. ↵

18. Saini SS, Shah SS, Curtis AS. Scapular dyskinesis and the kinetic chain: recognizing dysfunction and treating injury in the tennis athlete. Curr Rev Musculoskelet Med. 2020;13(6):748-756. ↵

19. Calvert E, Chambers GK, Regan W, Hawkins RH, Leith JM. Special physical examination tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnostic systematic review. J Clin Epidemiol. 2009;62(5):558-563. ↵

20. O’Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998;26(5):610-613. ↵

21. Kibler WB. Specificity and sensitivity of the anterior slide test in throwing athletes with superior glenoid labral tears. Arthroscopy. 1995;11(3):296-300. ↵

22. Holtby R, Razmjou H. Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. 2004;20(3):231-236. ↵

23. Bennett WF. Specificity of the Speed’s test: arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy. 1998;14(8):789-796. ↵

24. Varacallo M, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. Treasure Island, FL: StatPearls; 2021. ↵

25. Buijze GA, Mariaux S, van Spanning SH, et al. The O’Brien test demonstrates a higher diagnostic value in identifying posteroinferior labral tears than superior labral anterior to posterior (SLAP) tears. JSES Int. 2023;7(1):67-71. ↵