How are Labral Tears of the Shoulder Repaired?
The two most common types of labral tears we see in sportsmedicine are the superior labral tear (SLAP) and the anterior labral (Bankart) tear.
The shoulder is at risk for injury in many sports. The rotator cuff can be injured through overuse or through trauma. Rotator cuff tendinitis is common in overhead sports such as baseball, tennis, volleyball, and swimming. Rotator cuff tears can occur if the tendons are overloaded in weight lifting or football. In young athletes rotator cuff tears are seldom complete and therefore usually treated without surgery. There are ligaments which hold the shoulder bone in its socket. These ligaments (labrum) get torn when there is a dislocation or when they fatigue from repetitive overhead or extreme activities. The shoulder has a very large range of motion, and needs some flexibility of the ligaments to allow for that range. But if the ligaments become stretched or torn, this can lead to instability. A mild amount of instability will allow the shoulder to slip out of the socket partially, called a subluxation. When the shoulder comes completely out of its socket this is called a dislocation. A dislocation is a severe forcefull injury which causes extensive damage to the joint, labrum, bone, cartilage, and the surrounding tissues. Subluxation can occur through stretching of the capsule and ligaments following hundreds of overhead throws, spikes, serves, or pitches. The ligaments of the shoulder are attached to the socket at the labrum. Tearing of the labrum (SLAP tear) sometimes occurs with a dislocation (see further discussion below). Another part of the shoulder commonly injured is the acromioclavicular or AC joint on top of the shoulder. The clavicle or collarbone meets the shoulder at the acromion where a small joint is found. This joint can be injured to varying degrees in a fall onto the outside part of the shoulder. Injury to the AC joint is called an AC separation. AC separations occur in contact sports and are frequently seen in skiing and biking falls. Usually a mild grade AC joint separation cause only a deformity. Clavicle fractures are common injuries seen frequently in sports where speed or contact are involved.
SLAP (Superior Labral, Anterior Posterior) Tears
SLAP stands for superior labrum-anterior and posterior to the biceps tendon anchor. The biceps attaches to the labrum on the upper (“superior”) glenoid. the labrum acts as a speed bump which “checks” the humeral head back into place if it starts to move away from the center. If the labrum is detached in this region, the biceps tendon is no longer firmly attached to the socket. This will often cause pain with throwing, reaching to the front or side, or trying to lift objects to or above shoulder level. The most common causes of this injury are repeated strain on the biceps tendon (for example, throwing, and repetitive overhead usage of the arm) or a sudden trauma such as falling on an outstretched hand and jamming the shoulder. Pain and popping is frequently noted. The pain is often in the back of the shoulder. Those that throw or use their arms overhead are often unable to continue doing so.
Diagnosis of a SLAP tear is achieved by a careful history and a thorough physical examination. However, other injuries can imitate a SLAP tear; therefore an MRI scan is often necessary to confirm the diagnosis. This scan should be done with some dye injected into the shoulder and often with the arm positioned into the overhead or cocked position. Injecting the dye and scanning the shoulder with the arm in this position are quite helpful in demonstrating these tears.
In general, SLAP tears in older patient are probably not the main cause of pain. Degenerative SLAP tears are frequently a concomitant finding on MRI along with a rotator cuff tear. These degenerative tears are usually not the cause of pain in older patients. In cases of SLAP tears following a sports injury in a young patient treatment is initially non operative. In cases of persistent pain and dysfunction the SLAP tear can be repaired. For successful treatment, the labrum must be reattached to the glenoid. This is done arthroscopically using suture anchors implanted into the bone, which are then used to suture the labrum back into place. The arm must be kept in a sling postoperatively to protect the sutures while the labrum heals. Some limited range of motion is possible but only within these limits! If the arm is moved too vigorously too soon, the sutures will fail and the repair will separate. Due to the fact that the repair is within the “ball and socket” joint, the main side effect of surgery is stiffness. It is also critical that the anchors be fully seated otherwise they can cause devastating damage to the humeral head.
Physical therapy will usually begin within the first week after the surgery. We will check you approximately one week postoperatively followed by checks every few weeks until your recovery is advanced. Typical return to desk work is within a few days after the surgery, reaching overhead approximately 6 weeks after the surgery, and return to throwing approximately 3 months after the surgery. A return to competition for throwers is usually between 4 and 6 months post-operatively. Supervised physical therapy is usually necessary for the first 2-3 months at least.
Bankart Tears of the Shoulder Following a Dislocation
A Bankart lesion is when the labrum becomes detached from the front of the glenoid socket. In this area, the labrum serves as the attachment point for the main ligaments that stabilize the shoulder, i.e. keeps the shoulder joint in place (the inferior glenohumeral ligament). The labrum is the “speed bump” of the shoulder which helps to maintain the round humeral head in the center of the joint. If the shoulder has dislocated, the labrum is often detached causing the inferior glenohumeral ligament to lose its attachment to the glenoid. This typically does not heal and recurrent dislocations can recur.
The Bankart tear is diagnosed by a careful history and thorough physical examination looking for signs and symptoms of persistent instability in the shoulder, i.e., looseness. A sensation of looseness, popping out, instability, or locking of the shoulder can be associated with this. The Bankart lesion typically does not heal on its own and therefore requires surgical repair. In fact, an active young male athlete who has had a dislocation of his dominant shoulder will have an approximately 70-90% chance of having repeat episodes if he does not have surgical treatment and continues his usual activities. Most athletes prefer to have this repaired. If the patient is not an athlete nor a hard physical laborer, surgery is not usually needed. When surgery is chose, it can usually be done arthroscopically (small incisions), but in collision athletes (such as football players or goal-keepers) open repair (4 inch incision) may be preferred. The repair technique involves reattachment of the labrum (speed bump) to the glenoid bone using special anchors embedded in the glenoid which are then used to tie the labrum back to its normal position. This serves to reattach the ligaments to the socket and restore stability to the shoulder. Rehabilitation takes approximately 3-4 months. Return to hard contact sports is usually 6-9 months. You will be able to begin moving your shoulder within the first few weeks after the surgery. A sling is worn for the first 6 weeks. The timing of this depends upon the exact nature of the repair. Supervised physical therapy is necessary to assure satisfactory progression of motion and strength without jeopardizing the repair.
About Steve A. Mora MD:
Dr. Mora is a native of Orange County. He graduated from Anaheim High School in Orange County CA. He completed his training at the UC Irvine where he earned top of his class honors with his induction into the Alpha Omega Alapha Medical Society honors. He completed his Orthopedic Surgery training USC. He then completed a Sports Medicine, Cartilage, Shoulder, and Knee Fellowship at Santa Monica Orthopaedic and Sports Medical Group. He is currently practicing Orthopedic Surgery in Orange County. Dr. Mora’s practice focus on sports related trauma, knee ligament and cartilage repair, shoulder rotator cuff and instability, hip arthroscopy and partial knee replacement and ACL reconsctruction. He sees athletes of all levels including professional soccer and UFC/MMA. He is team doctor for the Anaheim Bolts pro indoor soccer team and Foothill High School. Some of the procedures he performs include Cartilage transplantation (Genzyme), partial custom knee replacement, OATS, tibial osteotomies, meniscus transplant, knee ligament reconstruction, shoulder reconstruction, elbow arthroscopy, hip arthroscopy, platelet rich plasma and adult stem cell injections. Dr. Mora’s family heritage is Peruvian. He speaks fluent Spanish.
Steve A. Mora MD, Orange County ACL Surgeon. You can request an appointment with me by calling 714 639-3750 or going to my web page www.MyOrthoDoc.com[contact-form-7 404 "Not Found"]
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