SLAP Lesion

Upper Limb

Overview

A SLAP lesion is a tear of the superior glenoid labrum that extends from the anterior to posterior aspect, often involving the biceps tendon anchor. These injuries commonly occur in overhead athletes and from falls on an outstretched arm, causing significant shoulder dysfunction and instability.

Pathophysiology

The superior labrum acts as an anchor for the long head of biceps and contributes to glenohumeral stability. SLAP lesions typically result from repetitive microtrauma in overhead activities or acute trauma, causing the labrum to detach from the glenoid rim. This compromises the superior glenohumeral ligament and destabilizes the humeral head, leading to altered scapulohumeral rhythm, compensatory muscle tension, and progressive degenerative changes.

Patient Education

SLAP lesions often require activity modification and structured rehabilitation to restore scapular stability and neuromuscular control; surgical intervention may be necessary if conservative management fails after 3-6 months.

Typical Presentation

Site

Anterior and superior shoulder, often with deep intracapsular pain; may refer to posterior shoulder

Quality

Deep ache, instability sensation, clicking or clunking, sharp pain with specific movements

Intensity

Moderate to severe (5-8/10), worse with overhead activities and may improve with rest

Aggravating

Overhead throwing or reaching, carrying heavy objects, sleeping on affected shoulder, aggressive stretching, rapid acceleration movements

Relieving

Rest, arm support with sling, ice application, gentle range of motion exercises, scapular stabilization

Associated

Scapular dyskinesis, weakness in external rotators, positive O'Brien's test, dead arm sensation, possible apprehension or instability, clicking with movement, reduced overhead reach

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade A
A+ABCDStrong clinical value: substantially changes the diagnosis (LR ≥10 or ≤0.1)
useful both to rule in and rule out.

Crank Test

Procedure

Patient supine or seated. Elevate the arm to about 160° in the scapular plane with the elbow bent to 90°. Push along the length of the humerus into the glenoid while rotating the shoulder in and out.

Positive Finding

Pain, with or without a click or catch, during the rotation, reproducing the familiar symptoms.

Sensitivity / Specificity

91%/93%

Reference: Liu SH et al., Am J Sports Med 1996; PMID 8947391

Interpretation

Supports a labral tear. Results for labral tests vary widely between studies, so combine it with the history (catching, pain with overhead activity) and other labral tests. MR arthrography or arthroscopy confirms the diagnosis. Liu (1996) reported the crank test at 91% sensitivity / 93% specificity; the previously shown 72%/97% did not match the source.

Sources

Grade B
A+ABCDGood clinical value: meaningfully changes the diagnosis in one direction (LR 5–10 or 0.1–0.2)
best for ruling IN (confirmation).

Anterior Slide Test

Procedure

Patient standing with hands on hips, thumbs pointing backwards. Stabilise the top of the shoulder with one hand and push forwards and upwards through the elbow with the other, while the patient pushes back gently.

Positive Finding

Pain at the front or top of the shoulder, or a click, reproducing the familiar symptoms.

Sensitivity / Specificity

78%/92%

Reference: Kibler WB, Arthroscopy 1995; PMID 7632305

Interpretation

Loads the superior labrum and biceps anchor. A positive test supports a SLAP lesion; use it with the history and other labral tests. Kibler (1995, Arthroscopy — not "Jobe, Clinics in Sports Medicine" as previously cited) reported the anterior slide test at 78.4% sensitivity / 91.5% specificity.

Sources

Grade D
A+ABCDLimited value: little effect on the diagnosis on its own
limited standalone value.

O'Brien's Test (Active Compression Test)

Procedure

Patient standing. Arm raised to 90° of flexion and 10–15° across the body, elbow straight, thumb pointing down. Apply a downward force while the patient resists. Repeat with the palm facing up.

Positive Finding

Deep pain inside the shoulder in the thumb-down position that is reduced with the palm up.

Sensitivity / Specificity

72% (pooled, 18 studies, 3,091 patients)/52% (pooled)

Reference: Davis C, Immormino J, Higgins BM, Clark K, Engebose S, Garcia AN, et al. Diagnostic utility of the Active Compression Test for the superior labrum anterior posterior tear: A systematic review. Shoulder Elbow. 2019;11(5):321-331.

Interpretation

Deep pain points to the biceps anchor and superior labrum; pain on top of the shoulder points to the acromioclavicular joint. It is often positive in other shoulder problems, so do not use it alone. Pooled in a 2019 systematic review (Davis et al.) of 18 studies, most with high or unclear risk of bias. The test is somewhat more sensitive than specific and changes the probability of a SLAP tear only a little either way; the authors do not recommend relying on it. The very high figures in the original 1998 description have not been reproduced.

Sources

Grade D
A+ABCDLimited value: little effect on the diagnosis on its own
limited standalone value.

Biceps Load Test II

Procedure

Patient supine. Shoulder abducted to 120° and fully externally rotated, elbow bent to 90°, forearm supinated. Ask the patient to bend the elbow against your resistance.

Positive Finding

Reproduction of deep shoulder pain during resisted elbow flexion.

Sensitivity / Specificity

27.6%/77.8%

Reference: Somerville L et al., Surg J (N Y) 2017; PMID 29018839

Interpretation

Loads the biceps anchor. Results vary between studies; a positive test adds some support for a SLAP lesion but does not confirm one. Kim 2001 originally reported the Biceps Load II test at 90%/97%, but that single cohort had spectrum bias and was excluded as an outlier by the Gismervik 2017 meta-analysis. In an independent replication, Somerville 2017 found only 27.6% sensitivity / 77.8% specificity (LR+ 1.24, LR- 0.93) — essentially non-discriminative for SLAP lesions, so it should not be used as a stand-alone rule-in.

Sources

No accuracy study

Speed's Test

Procedure

Patient standing, shoulder flexed to 90°, elbow straight, forearm supinated. Apply a downward force at the forearm while the patient resists.

Positive Finding

Pain in the bicipital groove or deep in the front of the shoulder.

Interpretation

A general biceps loading test; it does not separate a SLAP lesion from other biceps problems. (The biceps load test II is a separate test, listed above.) Speed's test accuracy is inconsistent across studies (e.g. Bennett 1998: 90% sensitivity, 14% specificity); no reliable pair is shown.

Sources

No accuracy study

Compression-Rotation Test

Procedure

Patient supine. Abduct the shoulder to 90° with the elbow bent to 90°. Push along the humerus into the glenoid while rotating the shoulder in and out, as if grinding a mortar and pestle.

Positive Finding

Pain with catching or clicking, reproducing the familiar symptoms.

Interpretation

Designed to trap a torn labrum between the humeral head and the glenoid. Not well validated; use it with other labral tests.

Sources

⚠ Red Flags

  • •Severe acute trauma with immediate loss of function suggesting complete labral detachment
  • •Neurovascular compromise (numbness, tingling, color changes)
  • •Signs of infection (fever, expanding swelling, warmth)
  • •Complete loss of active range of motion unresponsive to 2 weeks conservative care
  • •Progressive neurological deficit or persistent paraesthesia in radial nerve distribution

⚡ Yellow Flags

  • •Worker's compensation claim affecting motivation for rehabilitation
  • •Fear-avoidance behavior limiting normal activity participation
  • •Catastrophizing about shoulder function and return to sport
  • •Dependence on passive modalities without active participation
  • •Poor compliance with home exercise program
  • •Psychological distress related to loss of athletic identity
  • •Overtraining behaviors in athletes prior to injury

Osteopathic Techniques

Non-surgical rehab is the usual first step: in a 2022 review about half of athletes returned to play, and about three-quarters of those who completed rehab. No trials of osteopathic or manual techniques in SLAP tears were found.

Region

Glenohumeral joint (Spencer sequence)

Technique

Articulation, shoulder (Spencer technique)No trials found

Rationale

Gentle mobilisation within a rehab program. No trials in SLAP tears.

How it's done, cautions & evidence

How it's done

Patient side-lying, affected shoulder up. Stabilise the shoulder girdle with one hand and support the arm at the forearm and wrist with the other. Work through seven stages: extension, flexion, circumduction with compression, circumduction with traction, abduction (then adduction with external rotation), internal rotation, and traction in abduction. At each barrier use slow rhythmic oscillations, then a gentle isometric contraction to reach the new barrier.

Cautions

Its isometric step is a muscle energy technique, so do not use it with a fracture, a ruptured ligament, tendon or muscle, or a joint infection.

Evidence in SLAP Lesion

Searched 24 Oct 2026: no trials of shoulder articulation in SLAP tears.

Region

Posterior shoulder (horizontal abductors and external rotators)

Technique

Muscle energy, glenohumeral (posterior shoulder)
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials in SLAP tears. In baseball players, posterior shoulder MET improved range straight away.

Rationale

Patient-powered stretch for posterior shoulder tightness. Improved range in baseball players; untested in SLAP tears.

How it's done, cautions & evidence

How it's done

Take the arm to the barrier in horizontal adduction or internal rotation. The patient gently pushes back (horizontal abduction or external rotation) against equal resistance at 10–20% effort for 5–10 seconds, then relaxes for 3–5 seconds, and the arm is taken to the new barrier. Repeat 3–5 times, then re-check range.

Cautions

Very safe, but not used with a fracture, a ruptured ligament, tendon or muscle, or a joint infection.

Evidence in SLAP Lesion

Searched 24 Oct 2026: no trials of glenohumeral MET in SLAP tears. A 2011 trial in baseball players found MET for the horizontal abductors increased horizontal adduction range straight after treatment.

Region

Rotator cuff, deltoid and periscapular muscles

Technique

Soft tissue, shoulder and periscapular musclesNo trials found

Rationale

Eases tension in the rotator cuff and shoulder blade muscles. No trials in SLAP tears.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the muscles around the shoulder: the rotator cuff, deltoid and the muscles around the shoulder blade. In trials it was given alongside shoulder exercise.

Evidence in SLAP Lesion

Searched 24 Oct 2026: no trials of shoulder soft tissue technique in SLAP tears.

Region

Upper and mid thoracic spine

Technique

Muscle energy, thoracicNo trials found

Rationale

Low-force, patient-powered upper-back technique. No trials in SLAP tears.

How it's done, cautions & evidence

How it's done

Seated or supine. The restricted segment is localised (using the head and neck as a lever for T1–T4, the trunk for T5–T12) and taken to its barrier while the transverse process is monitored. The patient gently pushes back toward neutral for a few seconds against equal resistance, relaxes, and the new barrier is taken up. Repeat, then re-check.

Cautions

Do not use with an acute fracture or dislocation. Recent ligament, tendon or muscle injury may make it unsuitable, and spasm driven by the central nervous system responds poorly. The patient must be able to follow instructions.

Evidence in SLAP Lesion

Searched 24 Oct 2026: no trials of thoracic MET in SLAP tears.

Rehabilitation Exercises

Pendulum Circles (Codman's Pendulum)

Range of MotionBeginner

Posterior Shoulder Capsule Stretch (Cross-Body)

StretchingBeginner

Prone Scapular Squeeze (Rhomboid Activation)

StrengtheningBeginner

Prone Horizontal Abduction at 90°

StrengtheningIntermediate

External Rotation with Arm at Side (Lateral Rotation)

StrengtheningBeginner

Prone External Rotation (90/90 Position)

StrengtheningIntermediate

Scapular Retraction Against Wall

PosturalBeginner

Lower Trapezius Activation (Prone Y Position)

StrengtheningIntermediate

Serratus Anterior Punch (Modified Push-Up Plus)

StrengtheningIntermediate

Single-Arm Stability Ball Wall Holds

BalanceAdvanced

Eccentric External Rotation (Advanced Overhead)

StrengtheningAdvanced

Sleeper Stretch with Soft Tissue Release

Range of MotionBeginner

Referral Criteria

  • •Positive MRI or ultrasound confirming SLAP lesion with structural instability requiring imaging correlation
  • •No improvement after 6-8 weeks of conservative osteopathic and physiotherapy management
  • •Persistent instability or dead arm sensation affecting function or sport participation
  • •Consultation with orthopedic surgeon if considering surgical intervention (SLAP repair or biceps tenodesis)
  • •Positive or worsening neurological signs suggesting brachial plexus involvement
  • •Return-to-sport decision for athletes requires sports medicine or orthopedic clearance
  • •Chronic pain with significant disability warranting pain management specialist consultation