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Mr Apurv Sinha
Consultant Trauma and orthopaedics
What is a SLAP lesion?
The shoulder joint is a ball and socket joint, which is held together by a combination of ligaments and muscles. There is also a rim of cartilage around the socket called the labrum. The labrum acts to deepen the socket to make the shoulder even more stable.
The biceps tendon which sits at the front of the shoulder joint also acts to provide stability. It inserts onto the top (’superior’ part) of the shoulder into the labrum. Superior Labrum Anterior to Posterior (SLAP) lesions are an abnormality of the top part (superior) aspect of the labrum.
They can be a cause of significant pain and instability in the shoulder. Damage to this area can be caused by a number of reasons including subtle instability in the shoulder, repetitive trauma (such as in overhead athletes or manual work above shoulder height), or following more significant trauma (such as a fall onto an outstretched arm).
Other injuries associated with SLAP lesions
Rotator Cuff Tears: Your surgeon will assess you rotator cuff muscles at the time of surgery. Sometimes, there will be a small tear which if found, will need repairing. This will be discussed with you prior to your operation and will change the instructions that you will need to follow after your operation.
‘Bankart’ Lesion: This is where the ring of cartilage (labrum) at the bottom of the socket is damaged. If this is found a ‘Bankart Repair’ to mend this damage is performed at the same time as your SLAP repair.
Long head of Biceps damage Sometimes, there is extensive damage to the biceps tendon itself in addition to its attachment, and it is not repairable. Your surgeon may perform a biceps tenodesis or a biceps tenotomy in this case.
Biceps tenodesis involves cutting the tendon at its attachment and reattaching it into the top of the humerus (arm bone). It can sometimes create pain in the top of the arm bone.
Biceps tenotomy involves cutting the tendon at its attachment and leaving it. The tendon tends to slide down the arm resulting in a ‘popeye deformity’.
Rarely, it can cause cramping sensation and can be cosmetically unappealing. These operations can reduce strength in the arm by around 10% but this is usually not noticeable , especially in the older population.
How are these operations carried out?
SLAP repair surgery is carried out under a general anaesthetic, with a nerve block in your neck. Repair work to the detached biceps tendon is usually carried out as key-hole (arthroscopic) surgery. An arthroscopy is an operation using a specially designed small telescope linked to a TV camera which allows your surgeon to look inside your shoulder joint. This allows the surgeon to examine the shoulder joint and then use very small instruments to repair the damaged labrum. SLAP Repair.
Arthroscopic surgery will leave you with 2 - 4 small scars on the back, side and front of your shoulder. Arthroscopic surgery is usually performed as a day case procedure. This means you will go home on the day of your operation. Some patients who have other medical conditions may require an overnight stay in hospital.
What are the benefits of having a SLAP repair?
The aim of shoulder surgery is to restore the stability and normal joint biomechanics of the shoulder joint, and therefore reduce the symptoms associated with the damage such as pain, clicking and reduced strength in the shoulder. It is normal to feel discomfort following the operation but this will usually settle as your wounds heal. It can take up to three months for the repair to fully heal, and you may still be seeing improvements in your shoulder up to 12 months post-surgery.
Are there any complications of having shoulder stabilisation surgery?
As with most types of surgery there are risks involved and complications can occur unrelated to the shoulder surgery.
Anaesthetic risks (such as sickness, nausea or rarely cardiac, respiratory or neurological - less than 1%)
Blood clots in the legs (deep vein thrombosis)
Blood clots in the lungs (pulmonary embolus)
Some other complications, which can occur specifically following this type of shoulder surgery, are:
Infection (less than 1%)
Ongoing pain and stiffness in the shoulder (around 10%)
The need to re-do surgery
These risks are very small but if any occur, further treatment or an operation may be necessary.
Infection can be a serious complication. Some infections show up immediately whilst you are still in hospital, others are not apparent until you have gone home. If you are at particular risk your surgeon may recommend that you take antibiotics.
Ongoing pain and stiffness of your shoulder are possible especially if you do not continue with your individual home exercise plan.
Nerve damage can occur as many of the large nerves and blood vessels that enter the arm pass close to the site of the operation; but it is very rare for any permanent damage to occur.
A need to re-do surgery. The repair may fail and the shoulder becomes unable again. This occurs in 3-20% of cases. Rarely, one of the anchors used to repair the tissues can back out, resulting in shoulder damage. This is an extremely rare occurrence.
What will happen if I decide not to have surgery?
f you decide not to have this surgery, other treatment options are:
Physiotherapy: exercises can strengthen up your shoulder muscles to help improve the muscle control of your shoulder - you may have already tried this if you have reached the stage of discussing surgery.
Activity modification: changing the way you do activities or stopping activities which involve stretching your arm into the end of range positions may reduce the number of times you dislocate.
What happens if I agree to have shoulder stabilisation surgery?
If you and your surgeon agree that this type of shoulder surgery is necessary, you will be asked to attend a Pre-Assessment Clinic a few weeks before your surgery to ensure you are fit for the operation and to record some baseline information. During your clinic appointment, the pre-operative assessment nurse will discuss your stay in hospital and organise any other necessary tests. These may include a blood test, urine test, an ECG (heart tracing) and x-rays. Your surgeon or one of his team will check you are still happy to go ahead with surgery and to sign a consent form. We must seek your consent for any procedure or treatment beforehand. Staff will explain the risks, benefits and alternatives where relevant before they ask for your consent. If you are unsure about any aspect of the procedure or treatment proposed, please do not hesitate to ask for more information. Another purpose of this clinic visit is for you to ask any further questions about the forthcoming surgery.
How long will I be in the hospital for?
If your surgery is to be carried out arthroscopically (key-hole surgery), it will generally be carried out as a day case procedure unless you have any other medical conditions which may require you to stay overnight. If you are having your operation as day surgery, you will need to ensure someone can collect you from the hospital and stay with you overnight to check that you are okay. If your surgery is to be carried out as an open procedure, you will generally be kept in hospital overnight.
What will I need to do before coming in for surgery?
You will receive a letter which will confirm your admission date and it will include specific instructions you need to follow before coming into hospital. Please remove any body piercings and nail varnish before coming into hospital. If you take regular medication you will be told at pre-assessment clinic whether you should continue taking it as normal.
Will I have any pain after the operation?
Your anaesthetist may decide to perform a nerve block during the surgery. This involves an injection of a local anaesthetic, guided by an ultrasound scan, into your neck to numb the nerves going into your arm. The purpose of this is to provide immediate pain relief to your shoulder. The injection usually lasts for 12 - 24 hours, during which time your shoulder and arm will feel numb and heavy. It is important to take regular painkillers on your discharge from the hospital to avoid any unpleasant pain as the nerve block wears off. If you require further medication, please see your GP.
Will I have any stitches?
Your shoulder wounds will have dressings on them and if you have had stitches they can be removed at your GP's surgery, usually 10-14 days after the operation. It is normal for your shoulder to appear swollen after surgery and you may also find that your shoulder leaks a watery blood-stained fluid, this usually settles after 24 - 48 hours. Keep all wounds dry until well healed. Avoid using spray deodorants, talcum powder or perfumes near the scar. If your wound changes in appearance, weeps fluid or pus or you feel unwell with a high temperature, contact your GP.
Will I have to wear a sling?
Your arm will be supported in a sling straight after your operation. This is to protect the repair to your shoulder. Your shoulder will be in a sling for three weeks after the operation the therapist can suggest ways to help you. A physiotherapist will see you on the ward to advise you what exercises you can do and an outpatient appointment will be made for you within one week from leaving the ward to progress your exercises.
What clothes should I wear with the sling?
Most people find it difficult to manage ordinary clothes immediately after surgery, due to limitation of shoulder movements; therefore you are advised to wear a loose-fitting button through shirt. A bra may be uncomfortable in the early days so it would be advisable to bring an underslip or loose-fitting underwear to put on after surgery. You may find your armpit uncomfortable whilst wearing a sling. Try using a dry pad or cloth to absorb the moisture.
How will I sleep?
You must sleep in your sling for the first 3-4 weeks. Sleeping can be a little uncomfortable. We recommend that you lie on your back or on the opposite side. Ordinary pillows can be used to give you comfort and support. (Feather pillows are easier to mould than foam ones). If lying on your side, a pillow tucked along your back helps to prevent you from rolling onto your operated shoulder in the night.
Will I have to come to physiotherapy?
Physiotherapy is very important following a SLAP repair if you are to get the most out of your shoulder following your operation. The main aim of physiotherapy during the initial sling wearing stage is to prevent your shoulder joint stiffening up. These exercises will be supported so to limit the tension on your shoulder repair. Whilst waiting for your physiotherapy appointment. It is important to keep your elbow and hand moving, and also to make sure your neck muscles don't stiffen up. Try doing the following exercises: With your sling on, gently practise shrugging your shoulders up and down. Repeat 10 times With your sling on, tilt your head from side to side to gently stretch the top of your shoulder. With your sling on, practise making a fist and stretching your fingers out straight to prevent your hand stiffening up. Take your arm out of your sling and gently bend and straighten your elbow to prevent your elbow getting stiff. Repeat 10 times. Place your arm back in the sling after this exercise.
A rough guide for returning to activities: Your physiotherapist or surgeon will advise you when to remove the sling. Following this, there will be a gradual emphasis on strengthening the muscles in your shoulder and increasing your movement further.
How often will I need to have physiotherapy?
Initially, you should expect to have physiotherapy once a week. As you improve this may reduce to once a fortnight. Is that the end of my treatment? You will be seen in the orthopaedic clinic at approximately six weeks following your operation. This maybe your surgeon's specialist physiotherapist to check that your rehabilitation is going to plan. Your surgeon may see you at about 3 months after your operation.
When can I drive?
Driving is a potentially hazardous activity and people will vary as to how soon they are able to perform this task safely. We would advise you not to drive until you have enough movement and strength in your arm to control the car safely (at least 4 weeks following surgery). Check your insurance policy. You may need to inform the insurance company of your operation.
When can I return to normal activities?
This depends upon your symptoms. Most people feel comfortable enough to perform light day to day activities between three to six weeks after surgery. Soon after surgery your physiotherapist will discuss with you the type of activity you wish to return to in order to tailor your rehabilitation exercises appropriately.
As a general guide, non-contact sports can be commenced at around 3 months following surgery and contact sports at around 4-6 months. Please ensure you check with your physiotherapist or surgeon before recommencing any activities.
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