The Labral Labyrinth: SLAP injuries – Part 2

Cleveland Guardians relief pitcher Tim Herrin delivers a pitch in the ninth inning against the Colorado Rockies at Progressive Field. Mandatory Credit: David Richard-Imagn Images.

Effective management of SLAP (Superior Labrum Anterior to Posterior) injuries, frequently seen in athletes involved in repetitive overhead activities or following acute trauma, can be difficult to diagnose and treat definitively. Their subtle presentation, coupled with the limitations of standard imaging and assessment techniques, can result in ongoing shoulder dysfunction and frustration for patients and clinicians. A thorough clinical evaluation, anchored in a detailed patient history and a targeted physical examination, is essential for an accurate diagnosis. 

Management of SLAP injuries is more nuanced than a simple step-by-step protocol, as treatment may involve either a structured rehabilitation-based approach or surgical intervention, depending on the individual case. Clinicians should take care when identifying causative factors related to the injury to address them as part of the rehabilitation, if possible.

“…clinicians prefer an initial trial of conservative management…” 

SLAP tears can result from a combination of intrinsic and extrinsic risk factors that compromise the stability and integrity of the superior labrum and its biceps anchor (see table 1). Overhead athletes, especially baseball pitchers, are at elevated risk due to the cumulative microtrauma imposed by the throwing motion, particularly during the late cocking and acceleration phases. The interplay between these intrinsic and extrinsic elements significantly contributes to both the onset and recurrence risk of SLAP pathology, and clinicians should consider them when planning and conducting each phase of rehabilitation.

Table 1: Intrinsic and extrinsic risk factors that compromise the stability and integrity of the superior labrum

Conservative Management

Surgery carries inherent risks and does not guarantee long-term success. Therefore, clinicians prefer an initial trial of conservative management, lasting three to six months, as the first-line approach. However, this depends on patient factors such as age, activity level, and symptom severity.

Researchers from Washington University in the United States conducted a systematic review examining the return to play (RTP) in patients who underwent non-operative management of SLAP tears. Type II SLAP tears were the most frequently reported, with baseball, softball, and weightlifting identified as the primary sports associated with these injuries. The overall RTP rate following nonoperative management was 53.7%, with a similar rate of 52.5% observed in elite and high-level athletes. However, among those who completed their full rehabilitation program, the RTP rate rose significantly to 78% across all athletes and 76.6% in the elite groups⁽¹⁾. 

Effective rehabilitation should follow clear guiding principles while allowing flexibility to meet individual needs, especially for these overhead throwing athletes (see figure 1). Initially, the focus should be on reducing inflammation and addressing impairments such as glenohumeral internal rotation deficit (GIRD) and scapular dyskinesis through activity modification, temporary rest from overhead activities, anti-inflammatory medications, and cryotherapy as needed.

As rehabilitation progresses, the priority shifts to restoring neuromuscular control and gradually building strength and endurance in the rotator cuff and periscapular muscles. Clinicians must restore ROM, with particular attention to shoulder flexion, external rotation, and internal rotation, to ensure mobility without compromising healing. Strengthening should include targeted exercises for the rotator cuff, posterior shoulder, elbow flexors, and weight-bearing activities, alongside compound pulling and pushing movements to build integrated upper limb and scapular stability.

In later stages, clinicians must incorporate power and dynamic control exercises using medicine ball drills, such as dribbles, catches, and throws, to replicate the functional demands of overhead sports. Return to sport should be guided by clear criteria, including the absence of symptoms, full pain-free range of motion, and the successful completion of sport-specific functional goals. While these categories provide a structured foundation, exercise selection and progression should be tailored to the athlete’s sport, goals, and presentation to optimize outcomes throughout the rehabilitation process.