Shoulder Pain in a National-Team Butterfly Swimmer With a 'SLAP Tear' on MRI
A 21-year-old right-hand-dominant national-team butterfly swimmer presents with 5 months of right shoulder pain that began insidiously during a taper block. She trains 2.5 hours daily, six days per week, and pain now occurs in the catch phase and wakes her at night. She completed eight weeks of physical therapy elsewhere with generic rotator cuff strengthening and stretching, without improvement. Examination: painful arc 90–120°, positive Neer and Hawkins-Kennedy, no weakness, external rotation 100° on the right and 95° on the left, internal rotation 45° right and 65° left, total arc 145° right and 160° left. Scapular dyskinesis with forward head posture. MRI report states 'SLAP tear, type II, and mild tendinopathy.'
1. The MRI labels a type II SLAP tear. How do the examination findings change your interpretation of that report, and what is your next step?
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The MRI label should not drive the decision. Two examination numbers matter more: glenohumeral internal rotation deficit is 20° (45° right versus 65° left), and the total arc is 15° smaller on the symptomatic side. In a high-volume overhead athlete, that pattern points to posterior capsular contracture with resulting anterosuperior shear and adaptive labral change, not necessarily a traumatic labral detachment. External rotation of 100° versus 95° argues against global laxity. Type II SLAP signal is reported in a substantial fraction of asymptomatic overhead athletes, so imaging alone has poor specificity here; the painful arc and Neer/Hawkins signs could equally reflect subacromial pain or subtle instability rather than a labral pain generator. My next step is therefore not surgery but a targeted 12-week program: sleeper and cross-body posterior capsule stretching, serratus anterior and lower trapezius activation, thoracic extension work, stroke-volume adjustment, and a diagnostic intra-articular or subacromial local anesthetic injection if the pain generator remains ambiguous. Reassess at 6 and 12 weeks using the same measurements so change can be judged rather than impressions compared.
2. What findings would push you toward surgery, and how would you counsel her about outcome and risk?
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My thresholds are: failure of at least 3–6 months of well-supervised, diagnosis-specific rehabilitation; mechanical symptoms such as catching, locking, or reproducible painful clicking rather than pain alone; and arthroscopic confirmation of an unstable peel-back superior labral lesion, ideally with no more than grade 2 chondral change. At her age and level, labral repair is reasonable, with biceps tenodesis reserved for a degenerative or non-repairable biceps anchor. Counseling should be candid. Return to the same butterfly volume takes 4–6 months and is not guaranteed; series of overhead athletes show roughly 20–30% do not return to their prior level after SLAP repair, and outcomes are worse when the labrum is an adaptive secondary finding rather than the primary pain generator. Continuing modified training and competing with symptoms is a legitimate alternative if she tolerates it. She should understand that a failed repair complicates revision and may force tenodesis, and that posterior capsule work continues either way.