SLAP Repair

SLAP tears are one of the most over-diagnosed and over-treated conditions in shoulder surgery. The consequences of that over-treatment — particularly post-operative stiffness that can be severe and difficult to reverse — are serious enough that the diagnosis deserves far more scrutiny than it typically receives.

A positive MRI or MR arthrogram is not sufficient to diagnose a SLAP tear. It never has been. The labrum has a well-known normal anatomic variant in which it is not fully attached to the glenoid — and when contrast dye is injected during an arthrogram, it can leak under the labrum and appear on imaging as a tear when the labrum is completely normal. Radiologists, reading imaging without the benefit of a clinical history or physical examination, frequently call this a SLAP tear. Many of those readings are wrong.

Dr. Raffy Mirzayan has spent 25 years treating overhead athletes and has diagnosed true SLAP tears on a handful of occasions across that entire career. In a busy shoulder practice, a genuine SLAP tear is an extremely rare finding — and it is almost exclusively seen in overhead throwing athletes, not in the general population. Before any treatment is recommended, the diagnosis must be established through a careful history and a targeted physical examination. MRI is supporting evidence. It is not the diagnosis.

If you have been told you have a SLAP tear based on an MRI, call (310) 746-5918 before making any surgical decisions. A thorough clinical evaluation may change the picture entirely.

What Is a SLAP Tear?

SLAP stands for Superior Labrum Anterior to Posterior. The labrum is the ring of fibrocartilage that deepens the glenoid socket and serves as the attachment point for several important structures — including the long head of the biceps tendon, which anchors to the top of the glenoid at the labrum. A SLAP tear involves detachment or tearing of the superior labrum at this biceps anchor point.

True SLAP tears occur in overhead throwing athletes — baseball pitchers, quarterbacks, volleyball players, tennis players — as a result of the extreme torsional and tensile forces placed on the biceps anchor during the throwing motion. They can also occur from a single traumatic event such as a fall onto an outstretched arm or a sudden traction injury to the arm. They are not a common finding in recreational athletes, non-throwing athletes, or the general population — despite how frequently the diagnosis appears on MRI reports.

Why SLAP Tears Are Over-Diagnosed

The shoulder labrum has a normal anatomic variant — present in a significant portion of the population — in which the superior labrum is loosely attached to the glenoid rather than firmly adherent. This is called a sublabral recess or sublabral foramen, and it is a normal finding. On MR arthrogram, contrast dye injected into the joint can seep beneath this loosely attached labrum and create the appearance of a tear on imaging. Without clinical correlation, this normal variant is frequently misread as a SLAP tear.

This is not a failure of radiology in isolation — it is a failure of the diagnostic process when imaging is used as a substitute for clinical evaluation rather than a complement to it. A radiologist reading an MRI does not have access to your history, your symptoms, your sport, or your physical examination findings. That context is everything when it comes to SLAP tears.

Dr. Mirzayan does not diagnose SLAP tears from imaging alone. The diagnosis is made — or excluded — based on a detailed history of symptoms and mechanism, combined with a targeted physical examination that includes specific provocative tests designed to reproduce the patient's pain in a way that is consistent with superior labral pathology. The MRI is reviewed in the context of that clinical picture. If the history and examination do not support the diagnosis, the MRI finding is treated as the normal variant it most likely is.

Who Actually Has a True SLAP Tear?

In Dr. Mirzayan's 25 years of practice — including a career dedicated to the care of overhead athletes — true SLAP tears requiring surgical treatment are among the rarest diagnoses he makes. When they do occur, the patient profile is almost always the same: a competitive overhead throwing athlete with a history of pain specifically related to the throwing motion, physical examination findings consistent with superior labral pathology, and imaging that corroborates rather than drives the diagnosis.

The typical history includes posterior shoulder pain during the late cocking or early acceleration phase of throwing, a sense of catching or popping in the shoulder, and often a gradual decline in velocity or command rather than a single traumatic event. Physical examination findings — including the active compression test, the O'Brien test, the Speed test, and dynamic labral shear testing — provide far more diagnostic information than any imaging study.

If your history does not fit this pattern — if you are not an overhead throwing athlete, if your symptoms are vague or diffuse, if the diagnosis came primarily from an MRI report — the likelihood that you have a true SLAP tear requiring surgery is very low.

Treatment: Starting with the Right Foundation

Non-Operative Treatment — The First and Most Important Step

The vast majority of overhead athletes with true superior labral pathology can be successfully treated without surgery. Dr. Mirzayan's non-operative approach focuses on three components that address the underlying biomechanical contributors to SLAP pathology in the throwing athlete: posterior capsular stretching to address the posterior capsular tightness that is almost universally present in throwers and that alters the mechanics of the glenohumeral joint, rotator cuff strengthening to restore the dynamic stabilizing function of the cuff and reduce stress on the superior labrum during throwing, and scapular stabilization exercises to address the scapular dyskinesis that frequently accompanies labral pathology in overhead athletes.

This rehabilitation program, when performed consistently and correctly, resolves symptoms in the majority of patients who have been diagnosed with a SLAP tear — including many who were told they needed surgery.

PRP Injection

For patients who have completed a structured physical therapy program without adequate improvement, Dr. Mirzayan recommends an intra-articular platelet-rich plasma injection before considering any surgical intervention. PRP delivers a concentrated dose of the patient's own growth factors directly to the labral tissue, supporting the biological healing response in a structure that has limited intrinsic blood supply. This step alone resolves symptoms in a meaningful subset of patients who have failed physical therapy.

Surgery — Reserved for True Failures of Non-Operative Management

For the rare patient who has completed physical therapy, received a PRP injection, and still has symptoms consistent with a true SLAP tear, arthroscopy is indicated. At the time of arthroscopy, Dr. Mirzayan directly visualizes the superior labrum and assesses whether a true tear is present — because even at this stage, the arthroscopic findings may not confirm what the MRI suggested. If a true SLAP tear is confirmed, the treatment depends on the patient's specific anatomy, age, activity level, and the nature of the tear.

SLAP repair — reattachment of the torn labrum to the glenoid using suture anchors — is appropriate in a carefully selected subset of overhead athletes with a true Type II SLAP tear, healthy labral tissue, and a compelling clinical indication. Dr. Mirzayan has performed SLAP repairs exclusively in overhead athletes, in highly selected cases, with good outcomes in that specific population. The key to avoiding the post-operative stiffness that has given SLAP repair a complicated reputation in the literature is precise surgical technique, limited anchor placement, and a rehabilitation protocol that prioritizes early motion.

Biceps tenodesis — detaching the biceps anchor from the glenoid and reattaching it lower on the humerus — eliminates the pathologic pull of the biceps on the superior labrum and resolves pain in many patients with SLAP pathology. It is technically straightforward, reliably effective, and associated with lower rates of post-operative stiffness than labral repair. However, it is a controversial choice in high-level overhead athletes because the role of the biceps in throwing mechanics is not fully defined. Some surgeons believe the biceps serves as a humeral head depressor and contributes meaningfully to shoulder performance in the throwing athlete — and that detaching it from its native anchor point, even with tenodesis, may affect performance at elite levels. There is limited data in the literature specifically addressing biceps tenodesis outcomes in high-level throwers, and the decision requires careful discussion between surgeon and athlete about the specific risks and goals.

Dr. Mirzayan approaches this decision individually for each patient — considering the level of competition, the athlete's specific role, their age, the nature of the tear, and the available evidence — rather than applying a single algorithmic answer to every case.

Coming from Las Vegas, Phoenix, or Out of State?

If you are an overhead athlete who has been told you have a SLAP tear and are considering surgery, a second opinion from a surgeon who has spent 25 years caring for throwing athletes — and who understands how rarely this diagnosis truly requires surgical intervention — is worth pursuing before committing to an operation.

Dr. Mirzayan regularly treats patients from Las Vegas, Henderson, Phoenix, Scottsdale, and across the country. Virtual consultations are available. You can submit your MRI and clinical history in advance, meet Dr. Mirzayan on video, and get an honest assessment of whether your diagnosis is accurate and whether surgery is truly indicated — before making any decisions.

If you carry a commercial insurance plan — Blue Cross Blue Shield PPO, Aetna, Cigna, United Healthcare, or a self-funded employer plan — you likely have out-of-network benefits that cover a substantial portion of the cost of evaluation and treatment. His office will verify your coverage before your visit.

Call (310) 746-5918 or contact us online to schedule your consultation.

Frequently Asked Questions

Can a SLAP tear be diagnosed from an MRI alone?

No — and this is one of the most important points Dr. Mirzayan makes to every patient who comes to him with an MRI report showing a SLAP tear. The labrum has a normal anatomic variant in which it is loosely attached to the glenoid, and MR arthrogram contrast can leak beneath this normal labrum and create the appearance of a tear on imaging. Radiologists reading without clinical context frequently call this a SLAP tear. The diagnosis must be established through a careful history and physical examination. MRI is supporting evidence — not the diagnosis.

I am not an overhead athlete. Can I still have a SLAP tear?

True SLAP tears requiring surgical treatment are almost exclusively seen in overhead throwing athletes. They can occasionally result from a single traumatic event such as a fall onto an outstretched arm or a sudden traction injury, but they are not a common finding in recreational athletes or the general population. If you are not an overhead athlete and your diagnosis came primarily from an MRI, the likelihood that you have a true SLAP tear requiring surgery is very low. A thorough clinical evaluation is essential before proceeding.

Do most SLAP tears need surgery?

No. The majority of overhead athletes with superior labral pathology can be successfully managed without surgery through a structured program of posterior capsular stretching, rotator cuff strengthening, and scapular stabilization. For those who fail physical therapy, a PRP injection is the next step before any consideration of surgery. Surgery is reserved for the rare patient who has truly exhausted non-operative options and has a confirmed tear at arthroscopy.

What is the risk of SLAP repair surgery?

The most significant and well-documented risk of SLAP repair is post-operative stiffness — a complication that can be severe, difficult to reverse, and career-ending for an overhead athlete. This is one of the reasons SLAP repair has a complicated reputation in the surgical literature and why many experienced shoulder surgeons are reluctant to perform it except in highly selected cases. In Dr. Mirzayan's experience, careful patient selection, precise technique, limited anchor placement, and an aggressive early motion rehabilitation protocol are the critical factors in avoiding this outcome.

What is a biceps tenodesis and is it appropriate for an overhead athlete?

Biceps tenodesis involves detaching the long head of the biceps from its anchor at the superior labrum and reattaching it lower on the humerus. It effectively eliminates the pathologic pull of the biceps on the superior labrum and is associated with reliable pain relief and lower rates of stiffness than labral repair. However, it is controversial in high-level overhead athletes because the full role of the biceps in throwing mechanics is not completely understood, and some surgeons believe detaching it from its native anchor may affect shoulder performance at elite levels. The decision requires individualized discussion between surgeon and athlete. Dr. Mirzayan does not apply a single answer to every case.

How do I know if my symptoms are truly from a SLAP tear?

The history and physical examination are far more informative than imaging. True SLAP tear symptoms in a throwing athlete typically include posterior shoulder pain during the late cocking or early acceleration phase of throwing, a catching or popping sensation, and often a gradual decline in velocity or command. Specific physical examination tests — including the active compression test, O'Brien test, and dynamic labral shear testing — help confirm or exclude the diagnosis. If your symptoms do not fit this pattern, the diagnosis should be questioned.

Do you offer virtual consultations for out-of-state patients?

Yes. Dr. Mirzayan offers virtual consultations for patients and families traveling from out of state. You can submit your MRI and clinical history in advance and get an honest second opinion on whether your diagnosis is accurate and whether surgery is truly indicated — before committing to any treatment. Call (310) 746-5918 to schedule.

About Dr. Raffy Mirzayan

Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon with 25 years of experience caring for overhead athletes and throwing athletes at every level of competition. In that time — across a busy shoulder practice that includes some of the most complex instability, cartilage, and rotator cuff cases in the country — true SLAP tears requiring surgical treatment have been among the rarest diagnoses he has made. That is not a reflection of limited experience. It is a reflection of diagnostic rigor: a commitment to making the diagnosis through history and physical examination rather than defaulting to an MRI report, and a willingness to pursue every non-operative option before recommending surgery for a condition whose surgical treatment carries real and well-documented risks. For overhead athletes who have been told they need SLAP surgery — or who want to make sure their diagnosis is accurate before proceeding — Dr. Mirzayan offers the clinical experience and the intellectual honesty to give them the right answer, not the convenient one. He practices at DOCS Health in Los Angeles, serves as a Clinical Professor of Orthopaedic Surgery at USC, and welcomes patients from across the United States, including Las Vegas, Phoenix, and Scottsdale, for virtual consultations and in-person care.

DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com