SLAP’d with a Shoulder Injury?
Karen Hsu Physical Therapy
Karen Hsu, PT, DPT
In recent years, rock climbing as a sport has experienced a large increase in popularity. As more people have started climbing, so have injury rates grown. Today, the nature of these injuries are mostly due to overuse and mostly affect the upper limbs. With increased safety awareness and the advent of technologies that keep us safer, overuse injuries now account for 65% of climbing injuries versus acute trauma due to a fall. 90% of these injuries affect the upper limb—namely the hand/wrist, followed by the elbow, and then the shoulder 10, 2. Shoulder injuries make up about 17% of all rock climbing injuries, and chronic pain has been reported in 33% of elite climbers 4.
Sport climbing is often associated with more overuse injuries because of: a) reduced fear of falling, b) willingness to try harder moves as a result, and c) often using one shoulder to ‘lock off’ while pivoting the rest of the body around that shoulder 10,2,26.
In particular, if you are male, like climbing at higher grades of difficulty, climb frequently, have been climbing for more than 10 years, or enjoy lead climbing or bouldering, then you are at higher risk for injury 1,32,23,13.
There are a myriad of upper extremity injuries that we can discuss, but we are going to focus on one shoulder injury here—the SLAP tear. A SLAP tear is an injury in which the top of the cartilaginous ring surrounding your shoulder joint is torn (see below for further details). SLAP tears have not been discussed a whole lot, even though it’s often associated with commonly occurring climbing injuries to the shoulder.
In order to understand how to help protect your shoulder, first, let’s talk about what the shoulder is and what is it designed to do.
The Evolution of the Human Shoulder
If we step way back in time to follow our ancestral tree, we now know that the African ape has a shoulder blade that points straight up and was designed for hanging, climbing, and swinging among trees (see image a). And this is very different from the morphology of the human shoulder today (see image d). When our ancestors, Homo erectus, started walking on 2 legs, our shoulders began to change—the shoulder joint descended and allowed us to work with tools in front of us. The shoulder blade moved onto our backs rather than sitting at the sides of our rib cages, as our range of motion increased. The collarbone lengthened and became horizontal, allowing us to throw and therefore to hunt as efficient predators. And all this happened over the span of millions of years14,25,24.
Image from: www.sciencedirect.com
But why does our history matter? Because it helps to explain why repeatedly hanging from rocks, crimps, and tiny pocket holds with all of our body weight on 2 fingers through one arm can lead to an upper extremity injury. This is not to discourage you from climbing, but to emphasize the importance of employing and practicing strategies that will allow you to keep doing what you love doing—despite what our evolutionary history may dictate.
Why is the Shoulder Joint at risk?
The shoulder evolved to have a large degree of freedom through its ball-and-socket design and movable attachment to the torso, meaning it could move in any direction and fast. That gave us the advantage to throw with power and accuracy for hunting. And in many daily tasks, it is extremely useful. In climbing, this range of motion allows us to use a drop knee and hold on as we pivot our hips and torso around our shoulder joint; it allows us to reach up overhead as we flag, or to thrust ourselves up to the next hold from an undercling. Conversely, for our modern day uses, the complexity, mobility, and freedom of motion that the shoulder joint allows us is also what predisposes the shoulder to injury.
Image from: www.pivoltalphysio.com
Rotator cuff tendinitis or tear, biceps tendinitis or tear, and shoulder impingement are common shoulder injuries among climbers. SLAP tears, though, are more commonly misdiagnosed and often accompany the latter injuries 11,12. A SLAP tear is a tear of the top of the labrum from the front to back of the shoulder joint. (Hence, the acronym SLAP which stands for superior labral tear from anterior to posterior). The labrum is a ring of fibrocartilage that surrounds the ‘socket’ of your shoulder joint. In comparison to the ball, the ‘socket’ is only 1/3 the size of the ball. Therefore, the labrum forms a rim that helps to increase the shoulder joint’s depth, stability and shock absorption capacity15.
Image (left): Healthy labrum, from www.huangortho.com
Image (right): SLAP tear, from www.houstonmethodist.org
It is also important to note that about half of your biceps tendon attaches to the top part of your labrum31. For this reason, 95% of patients with some form of biceps tendinitis usually have an accompanying rotator cuff tear or SLAP tear5. Other commonly associated pathologies include shoulder instability, acromioclavicular (aka AC joint) and/or glenohumeral (shoulder) joint arthritis21,12.
Image: Biceps tendonitis, from McKesson Corporation
What can cause a SLAP tear?
SLAP lesions can be caused by trauma, such as a fall onto an outstretched arm or through traction during climbing. Imagine you are climbing up an overhang. You suddenly lose your footing and all of a sudden all of your body weight is loaded through your right arm. You quickly try to recover by using your right arm to pull you towards the rock. Then, you hear a loud click in your shoulder followed by sudden pain. That position where your arm is raised to the side of your body and your hand is cocked back, almost like a pitching position, is the most common position in which SLAP tears can occur. It can also occur from repetitive overuse of the shoulder in the chicken wing position as seen in the photo below secondary to the stress the position puts on the biceps tendon in the front of the shoulder.
Image of cocking phase during throwing, from www.breakingmuscle.com
Image of vulnerable arm position (chicken wing) during climbing
On the other hand, somewhere around 1/3 of people will develop a SLAP tear through gradual overuse and without a clear trauma30. Both bouldering and sport climbing, for example, require high loads on the shoulder, are repetitive, and involve short rest periods between routes. It has been reported that inadequate rest periods between episodes of tendon loading may not allow a tendon time to adapt and could lead to rotator cuff or biceps tendinopathy in climbers—both of which are commonly concurrent injuries with a SLAP tear6.
Repetitive overhead activity, particularly when the shoulder is in an abducted and externally rotated position (as shown above), has been identified as a common cause for grade 2 SLAP tears3. As described above, climbers will commonly assume this same position while pulling themselves into the rock. This stress will cause the biceps tendon to detach and ‘peel back’ along with the labrum, constituting a grade 2 SLAP tear3.
Image from: www.clinicalgate.com
What are the symptoms?
Common symptoms include:
- Deep pain at the back of the shoulder (can also be felt at the front if biceps tendon is involved)
- Pain increased with lifting or overhead activity (usually in mid to end range of motion)
- Painful clicking, popping, stiffness or locking sensations
- Shoulder instability and/or weakness
- Reduced range of motion
How then, as a climber, can you reduce your risk of incurring a SLAP tear? Here are some suggestions to keep your shoulder safer, healthier, and less prone to a SLAP injury.
1. Posture – Get the tracks straight so the train can run
Ever head the saying, ‘You are what you practice’? The same is true with movement. If you keep practicing the same movements over and over again—pulling, rounding the shoulder forward, and repetitive movements that work the front of your chest—that is how you develop “climber’s back” or hunchback. Your body will adapt to the movements you do over and over again, so it is important to vary the movements you regularly do. A rounded forward posture or hunchback is problematic to the shoulder because your shoulder blade sits on your back, which consists of your thoracic spine and rib cage. Think of your thoracic spine and rib cage as the tracks that your shoulder blade has to move along in order to move your shoulder. If your shoulder blade is sitting on a track that is curved forward or hunchback, your shoulder blade and shoulder are no longer moving as optimally anymore. The range of motion that your shoulder blade is able to move is limited, putting your shoulder at a biomechanical disadvantage and predisposing you to shoulder injury7,9,18,16.
These are some exercises to re-set your posture and to create better ‘tracks’ for your shoulder and shoulder blade to travel along as you move your arm.
A. Thoracic mobility: Extension
Lie on your back with a foam roller or medicine ball in between your shoulder blades. Support your head with your hands. Use your legs to help you roll up and down along your spine from the top of your shoulder blades to your nipple line. Keep your neck in a neutral position. Open your chest as the ball or foam roller rolls down your back toward your feet. Do this for 2-3 minutes.
You can also see a video here:
B. Segmental thoracic mobility
C. Thoracic mobility: Rotation
Kneeling on your knees, place your right hand behind your head. Rotate your torso to the right. You may need a towel roll or your left hand under your forehead to support your head. Do 15 times on each side.
2. Centering the joint — Get the train running on the tracks
Once you have improved the mobility of the thoracic spine, you have set the tracks for the shoulder blade and shoulder to move better. You then want to make sure that they are following those tracks. As mentioned earlier, altered movement of your shoulder blade can derail your shoulder, as the shoulder has so many degrees of freedom. That’s why precision of movement in so important. Often times, it is not just overuse that leads to injury but, more precisely, motions that practice poor quality movement over and over again—or misuse.
Ideally, when you move your arm, your humerus or arm bone will start moving first. After the first 30-60 degrees of motion, your shoulder blade will then start moving as well. You humerus and shoulder blade should then continue moving at about a 2:1 ratio for the rest of your full range of arm motion. However, studies have shown that in rock climbers, that ratio is much higher, around 3.6:127. Meaning, in rock climbers, this study found that the humerus was moving a lot more than the shoulder blade, predisposing the climbers to a much higher rate of shoulder impingement. As mentioned above, if one part of your shoulder complex is moving well but the other part is not, this could also lead to aberrant movement, and eventually, pain or injury. While it is important to have strong scapular muscles that stabilize your scapula, it is also important that your scapula moves when you arm moves. So train that movement too to prevent your scapula from getting in the habit of always sticking to your torso.
You can test this concept out on yourself by squeezing your shoulder blades together and then trying to lift your arm. Then try again, this time focusing on getting your shoulder blade moving as you lift your arm. You will notice it is a lot easier to move your arm and that your arm has a greater excursion when you let your shoulder blade move. You need that motion when your arm is reaching overhead or winding back as far as possible. And you need it to maintain that ratio of motion that is healthiest for your shoulder joint.
So how do you train your movement quality?
It all breaks down into shoulder blade and shoulder joint movement quality. See below exercises A-D for the shoulder blade and exercises E-H for the shoulder joint.
A. Shoulder Blade: Flexion with Scap Assist
Begin to raise your arm in front of you. When your hand reaches belly button level, reach your other hand around to cup the bottom of your shoulder blade. As you continue to raise your arm in front of you, use the hand on your shoulder blade to guide your shoulder blade all the way up so that the tip of your shoulder blade reaches almost in line with the middle of your armpit. As you lower your arm, you can release your grip on your shoulder blade.
B. Shoulder Blade: Abduction with self-scapular assist
Begin to raise your arm out to your side. When your hand reaches waist level, reach your other hand around to cup the bottom of your shoulder blade. As you continue to raise your arm out to the side, use the hand on your shoulder blade to guide your shoulder blade all the way up so that the tip of your shoulder blade reaches almost in line with the middle of your armpit. As you lower your arm, you can release your grip on your shoulder blade.
C. Shoulder Blade: Scapular circles (drawing circles)
Lay on your stomach. Bend your elbows and let your hands hover off of the floor. Start to make circles with your shoulder blades. Your hands will also move in circles, but you should focus on the movement of you shoulder blades in smooth circles. Do 15x in each direction.
D. Shoulder Blade: Reaching in Climbing Specific Positions
Once you have gotten your shoulder blade warmed up and moving, practice reaching your arm in all directions while keeping your shoulder blade moving. You can practice reaching in a flag or reverse flag position, for example, while maintaining your focus on keeping your shoulder blade moving as you reach. See the images below from Dr. Jared Vagy’s Book “Climb Injury-Free” to see how to perform a flag and reverse flag on the ground.
For the shoulder joint:
E. Shoulder Joint: Centration
First, lay down on your back and bring your arm out a little bit away from your side. Rest a blanket or towel roll under your elbow. Take note of the position of your shoulder. Is it rounding forward, like in the picture on the left? See if you can relax and get your shoulder to drop down so that it is on a flat plane with your chest. You want to try to maintain this shoulder position as best you can during the following exercises. You should also take note if your shoulder starts to creep forward during the day and try your best to correct this, just as you would do in this exercise.
F. Shoulder Joint: Centration with Movement
Lay on your back and from the same starting position, start to rotate your arm forward and backward. This video shows you what you should avoid, but what commonly occurs. You will notice that the shoulder position is moving around a lot.
This video shows you what you want to achieve as you rotate your arm forward and backward. The shoulder here is rotating about an axis that is not moving around a lot, but rather staying centered around an optimal alignment for the shoulder. This is helping to re-educate your brain and body to keep the ball moving in its socket with the best congruency possible. Imagine a wheel that stays centered about its axis as it turns. If it started bouncing around its axis, it would move less efficiently and may even fall off its axis. The shoulder operates in much the same way.
G. Shoulder Joint: Centration with Resistance
Once you’ve mastered the exercises above, you can progress to adding resistance to the same movement to make it more challenging. As mentioned, once you start climbing, the demand on your shoulder goes up. That’s why it is important to practice the same controlled motion with increasing levels of demand.
Dr. Jared Vagy, DPT, also known as “The Climbing Doctor”, developed a way to do this by using Therabands to add resistance.
For internal rotation:
Point the band so that it is pulling your arm back and away from your body. You will have to anchor it in the door or to the leg of a table. Rotate your arm towards your body against the resistance of the band. Focus on keeping your shoulder joint centered as practiced in the last two exercises as you move.
For external rotation:
Point the band so that it is pulling down towards your navel. Rotate your arm away from your body against the resistance of the band. Focus on keeping your shoulder joint centered as practiced in the last two exercises as you move.
H. Sucking the ball into the socket
In this exercise, start with your arm in that pitcher’s cocking position that is often a vulnerable one for climbers. Tie a band around your forearm and stabilize it in a doorway. The band pulls your arm away from your body. You will resist this pull by ‘sucking the ball back into its socket’.
You can also perform this exercise by placing the band in front of you, stabilized in a doorway. The band will pull your shoulder forward, and you try to resist this pull by pulling your arm back in line with the plane of your chest. This is very similar to the motion in exercise A, but now you have added resistance and you are assuming that vulnerable arm position for climbers.
These exercises are particularly good for those with shoulder instability or past dislocations. Please note: If you have had a recent dislocation, consult your Physical Therapist before performing this exercise.
Once you are able to demonstrate good control with these exercises, exercises F & G can also be progressed into a standing position or on the wall. These are demonstrated in the Cuff Clock exercise and the Cuff on the wall exercise in the ‘Balanced Shoulder’ article by Tanya Anne Mackenzie on The Climbing Doctor blog that can be found below:
3. Remember to use the lower body whenever possible.
This may seem obvious but it’s worth mentioning. Your legs have larger muscle groups, are used for weightbearing, and locomotion. The more weight you can put into your legs and work you can do with your legs and feet, the less your arms (with smaller muscle groups) have to work. So when you’re on an overhang and you’re assuming positions which put your shoulder at risk, remember to use your legs, keep your feet on the wall, and look for resting points.
Keep in mind that sports that traditionally use a lot of upper extremity strength and motion, like pitching, rowing, and surfing, also require lower extremity strength and power in order to prevent arm injuries and to improve performance in their sport. Likewise, in climbing, using your larger muscle groups puts less demand on your smaller muscle groups and makes your movement more efficient. Therefore, don’t forego your leg strength and mobility workouts, and make them a part of your upper extremity workouts so that you get into the habit of pushing through your legs rather than just pulling through your arms.
Some examples of how to do this are below. The focus here is pushing with your legs more than pulling with your arms.
-Pull up on a rope using your legs to assist to push you up as you climb.
-Climb up a rope using your legs to assist to push you up the rope.
4. Fatigue factor: Intensity is more important than volume
Studies have found mixed results on the tipping point for climbing volume and frequency and its correlation to rates of injury. However, studies have shown that as climbing intensity increases, so do injury rates19,23. So take note of how your body is feeling as you climb and when it is time to take the intensity down a notch. In other words, don’t climb your hardest level climbs 100% of the time.
5. Hanging Right
When hanging, protect your shoulders by hanging this way:
For more details, visit ‘Hang Right for Shoulder Health’
6. Get a Movement Screen
Lastly, get a movement screening test done by a Physical Therapist. It has been found that climbers with a history of shoulder injury have altered mechanics and poor movement control. Both of these factors can lead to injury and your PT can help you identify faulty movement patterns and adopt new strategies.
Or, video tape yourself climbing so you can see how you climb, how you might be hanging, how well your shoulder blades are moving when you arm is moving, or which positions are giving you pain, if any, when you climb.
What if I already have a SLAP tear or think I might have one?
- See your PT to get recommendations on training modifications, exercises that are safe, and if you need further referral to another healthcare professional.
- It it’s necessary, imaging may be recommended. X-rays are often used to rule out fracture or arthritis. MRI (arthrography) is generally recommended to best view a SLAP tear.
- In general, if you are not an elite overhead athlete, conservative management is recommended first. If you are a candidate for surgery or have undergone at least 3 months of conservative treatment without relief, the overall good to excellent results for SLAP type II repair varies from 40% to 94%8. The return to pre injury level of sporting activity varies and depends on your age and activity level. But, results are better in the non-throwing, non-overhead athlete. These results are similar whether you are an elite athlete or someone who participates in sporting activities for leisure28,20.
Dr. Karen Hsu owns and operates Karen Hsu Physical Therapy in Los Angeles, CA. She earned her Doctorate of Physical Therapy from USC. She works one-on-one with all of her patients for a full hour to get you back to the activities and lifestyle you love without pain or limitations. She combines her knowledge of physical therapy with the teachings of yoga and pilates to provide integrative care.
Dr. Hsu has been fortunate enough to travel and rock climb in West Railway Beach, Thailand, Guilin, China, and in the Patagonia. She loves the camaraderie of rock climbing and spending time among big rocks with her friends. She also loves all things adventure related, including surfing, trail running, and camping.
For more info, visit www.karenhsupt.com
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