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Shoulder Pain. Could You Have a Torn Labrum? E-mail
Written by Jeff Behar, MS, MBA   

Shoulder – Labrum Tear

The shoulder joint is a ball and socket joint, similar to the hip. The socket of the shoulder joint is extremely shallow, and inherently unstable. To compensate for the shallow socket, the shoulder joint has a cuff of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move within and hold the joint in place while allowing a very wide range of movements (more than any other joint in the body). A second function of the labrum is as an attachment of other structures or tissues around the joint such as the ligaments that help hold the joint together. Another structure that attaches to the labrum is the tendon of the biceps muscle. The tendon about the size of a pencil attaches inside the shoulder joint at one end and to a larger tendon, which attaches beyond the elbow in the forearm. The portion, which attaches in the shoulder goes through a small hole in the rotator cuff tendons and once inside the joint the tendon attached in part to the bone near the socket and in part to the labrum at the top of the joint.

What are the symptoms of a torn labrum?

Symptoms of a labral tear depend on where the tear is located, but may include:

  • Deep aching sensation in the shoulder joint
  • Catching of the shoulder with movement
  • Pain with specific activities

 

How can a labral tear occur?

The labrum can tear for a variety of reasons, such as:

  • Injury. The ligaments of the shoulder are attached to the socket at the labrum. When a patient sustains a shoulder injury, it is possible that the patientcan tear the lambrum.
  • Brittleness. The labrum becomes more brittle with age, and can fray and tear as part of the aging process, and also because of shoulder instability.

 The most common patterns of labral tears are:

  • Superior Labrum Anterior and Posterior (SLAP) Tear. The SLAP tear is a type of labral tear that occurs the top of the shoulder socket where the biceps tendon attaches to the shoulder. The area of the labrum where the SLAP tear occurs is susceptible to injury because it is an area of relatively poor vascularity. Other areas of the labrum often heal more easily because the blood supply delivers a healing capacity to the area of the tear. In the area of SLAP tears this is not the case, and chronic shoulder pain can result. Common mechanisms of a SLAP tear include fall onto an outstretched hand, repetitive overhead actions (throwing), and lifting a heavy object. Typical symptoms of a SLAP tear include a catching sensation and pain with overhead movement, most typically overhead activities such as throwing. Patients usually complain of pain deep within the shoulder or in the back of the shoulder joint. It is often hard to pinpoint symptoms, unless the biceps tendon is also involved. In cases of SLAP tears with associated biceps tendonitis, patients may complain of pain over the front of the shoulder. There have been several grading systems or classification systems of this injury. In a lesser injury the labrum is only partially detached in this area. In a more severe injury the whole labrum is pulled off of the bone along with the biceps tendon.
  • Posterior Labral Tear, seen in athletes in a condition called internal impingement (when the rotator cuff and labrum are pinched together in the back of the shoulder).
  • Bankart Lesion, a labral tear that occurs when a shoulder dislocates.

How is it diagnosed?

Because the labrum is located deep in the shoulder, it is very difficult to make the diagnosis of a torn labrum upon physical examination.

The relationship between labrum tears and symptoms has not been totally figured out, so it is not clearly known which ones should be repaired and which ones can be left alone.

There are several tests that the surgeon can perform which may indicate a torn labrum, but these tests are not always accurate, especially since labrum tears take different forms as described above. Certain tests may detect one kind of tear but not another.

The best tests available to make the diagnosis of a labral tear are magnetic resonance imaging (MRI) or a test called a CT-arthrogram (a CAT scan preceded by an arthrogram where a contrast dye Gadolinium) is injected into the shoulder to highlight tears of normal structures, including labrum tears. Both of these tests are relatively good at defining a labrum tear due to a subluxation or dislocation, but they are only around 80-85% accurate. Neither test is currently very good at making the diagnosis of a SLAP lesion because it is difficult to reliably get good pictures of this area with MRI.

The best way to make the diagnosis of labrum tearing is with arthroscopy of the shoulder. Arthroscopic surgery involves the use of a special camera attached to a long, narrow surgical telescope to visualize the inside of a joint. The camera transmits the signal to a video monitor for improved visualization, as well as allowing photographic and video graphic documentation of the surgical findings and the procedure performed. Working through small incisions about the size of dime Small (5mm) in the back, side, and front of the shoulder the surgeon can uses specially created instruments to repair damaged tendon, cartilage, capsule, and other tissues. The three incisions are made so that the arthroscope and instruments may be switched between each of these positions as necessary. Unfortunately this is an operative procedure and requires some form of anesthesia. Making the diagnosis also takes some experience on the part of the surgeon, since the anatomy of the inside of the shoulder can be quite complex.

Labrum tears often just part of the problem 

It is important to understand that labrum tears often occur in conjunction with other shoulder problems such as rotator cuff tears, and even shoulder arthritis.

How is a labral tear treated?

How is a labral tear treated?

The treatment of a torn labrum depends on the type of tear that has occurred (SLAP, Posterior, Bankart, etc.). Generally speaking treatment that are often used in cases of a labrum tear include:

  • Rest/Ice to control inflammation
  • Anti-inflammatory medications (steroidal and non-steroidal)
  • Cortisone injections
  • Physical therapy

Surgical Treatment

Labral tears do not require surgery; however, in patients who have persistent symptoms despite more conservative treatments, arthroscopic surgery of the shoulder may be necessary.

There are several specific surgical procedures that may be performed, depending on the type and extent of the tear. The surgeon will complete diagnostic arthroscopy and bursoscopy (inspection of bursa) with the specialized camera attached to a long, narrow surgical telescope to inspect the biceps tendon within the shoulder, the fibrous ring or “labrum” which surrounds the glenoid, the capsule and ligaments, the cartilage surfaces of the head and glenoid, and the rotator cuff tendons to determine the treatment approach. Treatment may include:

  • Debridement. When a tear is debrided, the torn portion of the labrum is shaved away to leave a smooth edge. This option is only suitable for minor tears that do not involve the biceps tendon. 
  • Repair. A labrum repair is an arthroscopic procedure that uses sutures with anchors attached to re-secure the torn labrum down to the shoulder socket. It is typically performed when the attachment of the labrum (the so-called biceps anchor) is unstable and when debridement would not be adequate to alleviate the symptoms of the SLAP tear.Because the arthroscope magnifies the structures seen, irregularities in the surface of less that 1 mm may be seen and removed, such as spurs. If required the under-surface of the acromion may also be smoothed to provide more room for the repair and to relieve pressure from the healing tendon. When repairing a rotator cuff tear any thin or fragmented portions are removed and the area where the tendon will be reattached to the bone is typically lightly debrided to encourage new blood vessel in growth for healing.
  • Biceps tenodesis. A biceps tenodesis is procedure that cuts the biceps tendon from where it attaches to the labrum, and reinserts it in another area to decrease forces that pull on the labrum. It can either be performed arthroscopically, or through a small incision over the top of the shoulder. Determining how to best perform a biceps tenodesis depends primarily on other conditions being treated within the shoulder joint.

After the completion of the surgical procedure, the shoulder is typically injected with a long acting local anesthetic to assist with postoperative pain management; the incisions are closed with a single nylon stitch and covered with steri-strip tapes, followed by a dry sterile dressing. Ice (or a Cryocuff ™) shoulder pad is applied to provide postoperative cold therapy to assist in postoperative pain and swelling management. In my case a Don Joy Ultrasling II™ was applied to immobilize and protect the procedure performed and remove stress and tension on the sutured tendon.

Recovery

Recovery depends upon many factors, such as where the tear was located, how severe the tear was, whether the ligaments were reconstructed (Bankart repair, anterior capsular shift), and how good the surgical repair was.

It typically takes at least four to six weeks for the labrum to re-attach itself to the rim of the bone, and probably another four to six weeks to get strong. Once the labrum has healed to the rim of the bone, caution should be taken regarding stressing the labrum (which includes stressing the bicep tendon) so that it can heal. If the ligaments are reconstructed (as in a Bankart repair, or a anterior capsular shift) the recovery will tends to be longer.

Regarding returning to work most people will need a week off from work (for most sedentary jobs). When you return to work your arm will be in a sling but you should be able to manage as long as you do no lifting, pushing, pulling or carrying. Most patients can start light duty work involving no lifting, pushing, pulling or carrying more than one to two pounds, 6 weeks after surgery. Work at waist level and 5-10 pounds of lifting is started 3 months after surgery. You will generally need 3-6 months of recovery before beginning occasional work at the shoulder level, but a return to heavy lifting or overhead use may require 6-12 months.

Although rehabilitation protocols differ depending on how conservative the surgeon is, and how the patient may respond, a typical recovery plan for a torn labrum might include:

  • Starting Day 1: (1) Hand Squeezes or Grip Strengthening.  This is typically done using a small soft rubber ball or soft sponge. 3-5 sets of 10-20 repetitions each day is typically what is prescribed. (2)Wrist Range of Motion: Roll your wrist in circles for 30 seconds after each round of grip exercises.
    • On Day 3 add: Elbow Range of Motion Exercise: Turning your palm inward, towards your stomach, flex and extend the elbow as comfort allows.  This will decrease pain and prevent elbow stiffness.
    • On Day 4 add: Pendulum Exercise: Holding the side of a table with your good arm, bend over at the waist, and let the affected arm hang down.  Swing the arm back and forth like a pendulum. Then swing in small circles and slowly make them larger. Do this for a minute or two at a time, rest, and then repeat for a total of 5 minutes, 3 times per day.
    • Week 2, add: (1)Wall Walking Exercise: facing a blank wall with your feet approximately12 inches away does this.  “Walk” the fingers of the affected hand up the wall as high as comfort allows. Do at least 10 repetitions, 3 times per day.  The goal is to slowly “walk” the hand higher to increase range of motion. When more comfortable and stronger (not before three weeks) your surgeon may allow you to do this exercise sideways, with the affected side facing the wall. Walk your finders down the wall as well as up. Important: Do not let the hand drop down from the wall—this will be painful and strain the repair. If you will have weakness on the way down, so use the other arm to help. (2) Biceps Curls: Curl the arm up and down 12 times; rest for one minute and repeat for a total of 3 sets of 12. This exercise should not be painful. If painful decrease or eliminate the weight.

How much motion and strengthening of the arm is allowed after surgery also depends upon many factors, and it is up to the surgeon to let you know your limitations and how fast to progress.

Because of the variability in the injury and the type of repair done, it is difficult to predict how soon someone can to return to activities and to sports such as bodybuilding after the repair. However, a majority of patients have full function of the shoulder after labrum repair. Typically your surgeon will allow walking, and stationary bicycle riding within one to two weeks after surgery. Returning to weight lifting is unpredictable. You may need one full year before performing activities such as the bench press and you may never recover enough to lift heavy weights.

 
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