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SLAP Tears & Sleeper Stretches

By Dr. Jeffrey Gutmann MD FAAOS, 09/04/11, 7:00AM EDT

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A tear of the shoulder labrum can be a season,  or even career, career-ending. Labral tears are  being diagnosed at a rapid rate, with throwing athletes serving as the most common victims. This is both a function of increased participation in throwing sports such as baseball and softball. In addition, it is important to note that the awareness of this particular injury has significantly improved. It has also become easier to diagnose, in large part, due to tests such as an MRI.

The labrum is an important part of the anatomy of the shoulder. The shoulder is a ball and socket type joint. However, the socket is very shallow which makes it inherently unstable.  The labrum is a rim of cartilage that deepens the shoulder socket and forms an attachment site for the ligaments that help stabilize the shoulder. The uppermost, or superior portion of the labrum also serves as an anchor for the tendon of the biceps and is prone to tearing from the repetitive stresses of throwing.

This particular subset of labral injuries, termed “SLAP tears” (Superior Labrum from Anterior to Posterior) were first described by renowned sports medicine specialist Dr. James Andrews in 1985 and can be particularly problematic in the throwing athlete. SLAP tears can cause pain, loss of strength, loss of velocity and/or control, and a “dead-arm” sensation. Any one of these symptoms can lead to decreased performance or inability to throw.

Unfortunately, these symptoms are not unique to SLAP tears and can be seen in other shoulder injuries, such as injuries to the rotator cuff, making the diagnosis difficult at times even for the most experienced sports medicine specialist.  Special studies, such as MRI or MRI after injection of contrast into the shoulder (MR arthrogram), may be needed to confirm the diagnosis of a SLAP tear.

Since a SLAP tear can be such a disabling injury to a pitcher or other throwing athlete, preventing these injuries is paramount. Before we can understand how to prevent an injury, we must first understand how it is caused. Some SLAP tears are caused by a single trauma, usually a fall on the shoulder or outstretched arm, and may not be possible to prevent. Others are caused by the repetitive stress of overhand throwing. The exact etiology of these repetitive stress SLAP tears remains somewhat controversial. It is theorized that tight ligaments in the back of the shoulder (posterior capsule) force the shoulder ball upward when the arm is fully cocked. This upward movement of the ball creates a shearing effect on the superior labrum, which can cause it to tear. When the arm is fully cocked, there may also be a “peeling back” of the superior labrum off of the rim of the shoulder socket, which can also lead to tearing.

Tightness of the posterior capsule is extremely common amongst throwing athletes and is likely an important precursor to developing a SLAP tear. Preventing such tears starts with stretching of the posterior capsule. This is best accomplished with a very simple exercise called a “sleeper stretch.” This is performed by lying directly on the affected shoulder with the arm at 90 degrees to the plane of the body and the elbow bent to 90 degrees. The hand of the unaffected side is then placed on the wrist of the affected side and used to slowly push the forearm down towards the bed/floor. There is generally a feeling of mild discomfort from stretching the tight tissues in the back of the shoulder.

Although it is overly simplistic to think that by doing sleeper stretches one can prevent all SLAP tears, stretching of the posterior capsule should be an important part of the training regimen of the throwing athlete. We have all of our throwers incorporate posterior capsular stretching into their shoulder workout routine, which also includes exercises to strengthen the rotator cuff and scapular stabilizing muscles. Proper training should also include stretching and strengthening of the legs and core muscles, and attention to good throwing mechanics to get more power with less demand on the shoulder.

SLAP tears in the throwing athlete pose a great challenge to the orthopaedic surgeon. Our treatment plan often starts with a period of rest, anti-inflammatory medication, and a rehabilitation program supervised by a physical therapist.  Unfortunately, many of these tears cannot be successfully managed non-operatively and require surgical repair. The good news is that we have advanced surgical techniques that allow us to fix almost all SLAP tears arthroscopically (using a small camera that can be placed inside the shoulder to perform the surgery while looking at a video screen). The bad news is that recovery from this procedure is generally 6-9 months which usually means missing a full season. Therefore, with SLAP tears, as with all sports injuries, the goal remains prevention.

SLEEPER STRETCH
(See Diagram)
Lie on your side on a firm, flat surface with the affected shoulder under you and the arm positioned as shown, keeping your back perpendicular to the surface. With
the unaffected arm, push the other wrist down, toward the surface. Stop when you feel a stretching sensation in the back of the affected shoulder. Hold this position
for 30 seconds, then relax the arm for 30 seconds. Perform 2 to 3 sets of 4 repetitions daily. Continue for a total of 2 to 3 weeks.