Labral Tears of the Shoulder and Shoulder Dislocation
Common symptoms of labral tears include pain with end points of motion, popping or grinding sounds, and a sense of instability. Visible deformity and loss of function of the shoulder occurs after subluxation or sensation changes such as numbness or even partial paralysis can occur below the dislocation because of pressure on nerves and blood vessels.
The labrum or capsule can be injured with repetitive use or from a dislocation. A dislocation occurs when the end of the humerus (the ball portion) partially or completely dislocates from the glenoid (the socket portion) of the shoulder. A partial dislocation is referred to as a subluxation whereas a complete separation is referred to as a dislocation. The classic tear in a shoulder dislocation is an anterior labral tear referred to as a “Bankart” tear. In addition, the humeral head can impact the socket or glenoid resulting in what is called a “Hill-Sachs” lesion.
Common mechanisms of injury include:
- Falling on an outstretched hand
- Repetitive overhead sports such as baseball, swimming, volleyball, or weightlifting
Risk factors for recurrent instability include younger age, male sex, generalized laxity, and high demand sporting demand activities. In the case of anterior shoulder instability, the risk of recurrent instability, for instance, is about 75% under the age of 20, 50% under the age of 30, and drops to 5-10% after the age of 40.
With dislocations each injury also damages the bone. This damage can be progressive, with each dislocation increasing the risk of recurrent instability and long-term arthritis. Thus, it is important to prevent recurrent instability especially for young patients.
Conservative treatment is most common labral tears without dislocation (those from repetitive use) or for dislocations in people over the age of 35. Most dislocations under the age of 30 to 35 require surgical treatment because the risk of recurrence is so high and further damage occurs with each dislocation.
The goal of conservative treatment for shoulder instability is to restore stability, strength, and full range of motion. Conservative treatment measures focus on initial rest and ice, followed by physical therapy to strengthen the surrounding muscles. When the conservative treatment options fail to relieve shoulder instability, or for most patients with a shoulder dislocation under the age of 30, a surgical stabilization is recommended. While published outcomes are variable, in our patients we can lower the risk of recurrent dislocation down to 5 to 10%. Most of the procedures are performed arthroscopically. Arthroscopy is a surgical procedure in which an arthroscope, a small flexible tube with a light and video camera at the end, is inserted into a joint to evaluate and treat of the condition. The benefits of arthroscopy compared to the alternative, open shoulder surgery are smaller incisions, minimal soft tissue trauma, less pain leading to faster recovery.
With a labral repair, the labrum and ligaments are repaired back to the socket with several small anchors. Each anchor is about 2-3 mm in size. The anchor goes into the bone and sutures are used to tighten the labrum and capsule back to the socket. This procedure takes about 45 minutes to perform and afterwards people are in a sling for 4 to 6 weeks.
Remplissage can be added to a labral repair for anterior shoulder dislocation. Remplissage is a procedure in which the structures in the back of the shoulder are fixed into the Hill-Sachs defect. We have done several studies on this procedure and found that this procedure increases biomechanical strength and lowers the risk of dislocation. In one study we did the risk of recurrent instability after this procedure was only 2%!
When multiple dislocations occur, bone on the front of the socket is “knocked” off. When bone loss is substantial (more than 20-25% of the glenoid), a bone restoring procedure must be performed to maintain stability.
With Latarjet bone graft is taken from the coracoid bone and placed against the socket to restore the bone loss. This is often done with screws, although techniques continue to evolve. In some cases, the bone graft can be taken from other sources as well.
Rotator Cuff Tear Symptoms
The rotator cuff is made up of four muscles (subscapularis, supraspinatus, infraspinatus, and teres minor). The rotator cuff surrounds the ball and socket joint (glenohumeral joint) and provides stability to the joint as well as movement. Because the shoulder is a shallow joint and the most mobile joint in the body, it requires the rotator cuff for stability. If let untreated tears can lead to arthritis of the shoulder (rotator cuff arthropathy). This doesn’t mean that good function can’t be maintained with a tear. In fact, many people are able to maintain function despite a tear because the shoulder remains balanced with the remaining rotator cuff and other muscles that control shoulder movement.
Muscle inserts into bone via tendon. In the vast majority of cases, when a tear occurs the tendon pulls away from the bone. Broadly speaking, tears are classified as partial or full-thickness. Partial tears go part way through the tendon while full-thickness tears represent complete detachment. Frequently, an MRI will report “partial-tearing.” Since most people over the age of 40 to 50 have some changes within the rotator cuff, partial tears usually not a problem. The distinction with partial tears is when the tears are considered “high-grade,” meaning that they go almost all the way through the tendon.
Rotator cuff tears may occur after an injury or repetitive activity over time, but most cases occur without an injury. As we age the rotator cuff tendon degenerates and age and genetics are the greatest risk factors for a tear. Studies show that about 50% of people over the age of 65 have a full-thickness rotator cuff tears. Most of these people don’t even know they have a tear!
Treatment for rotator cuff tears is based on age, health, and response to conservative treatment. The rotator cuff tendon is not capable of repairing itself. Rather then tear will stay the same size or enlarge over time. In people under the age of 60, the risk of progression is about 50% in a two-year period. The ability to get healing with a surgical repair depends upon age, the tear size, muscle atrophy, associated arthritis, and health (smoking and diabetes for instance). One must also consider timing of repair. Traumatic tears have a better outcome if fixed within 6 months of injury. Additionally, after about six months of symptoms atrophy may occur. Unfortunately, atrophy of the rotator cuff is not considered reversible. Based on this, if someone desires repair, I typically recommend performing this within six months of beginning treatment.
Guidelines for surgery are general and must be individualized as noted above. But, as a general guideline, I recommend repair for all full-thickness tears in people under the age of 60 given the risk of increase in tear size. For people between the ages of 60 and 70, treatment is based on the above factors with health and activity expectations being the most important factors. For people over the age of 70, I nearly always recommend an attempt at conservative treatment. Surgery is then considered if one does not respond to conservative treatment.
For partial tears, conservative treatment should almost always be attempted first since these tears progress slowly or may not progress at all. Then surgery is considered if one does not respond to 4 to 6 months of conservative treatment.
Treatment options include:
Anti-inflammatories such as ibuprofen (Motrin or Advil) and naproxen (Aleve) are used to reduce pain and inflammation. The max does for ibuprofen is 800 mg three times per day. The max does for naproxen is 500 mg twice daily. Prolonged usage should be avoided and these should be taken with food since they can affect the stomach lining. If one experiences an upset stomach these should be stopped.
Injection of a steroid (cortisone) may be used to provide pain relief and facilitate physical therapy. I perform these injections with an ultrasound machine. This allows direct visualization of the joint and improved accuracy of the injection. Up to 3 injections over a 2 year period are allowed. Beyond this there are typically diminishing returns and excessive injections may be detrimental to the rotator cuff.
Alternative injections include Toradol (an anti-inflammatory agent similar to ibuprofen), prolotherapy, or platlet-rich plasma (PRP). ). I use Toradol in people who do not tolerate steroids. Prolotherapy involves injecting a substance such as sugar into tissue to “stimulate a healing response.” I do not perform prolotherapy as it has not been shown to improve symptoms in rotator cuff tears. PRP involves taking a small amount of blood from a patient, spinning in a centrifuge to separate the growth factors from the red blood cells, and then injecting the growth factors back into the shoulder to potentially decrease pain. While PRP has anti-inflammatory properties, it has not been shown to heal the rotator cuff. Therefore, it is not covered by insurance and is an out-of-pocket expense. Typically a series of 3 injections are performed at weekly intervals for 3 weeks.
Physical therapy with strengthening is one of the mainstays of treatment of rotator cuff tears. Long-term studies show that despite not healing the rotator cuff, therapy can lead to substantial improvements in function with good patient satisfaction. The core exercises in strengthening the rotator cuff are provided at the end of this handout. These exercises can be performed twice per day, 5 days a week.
Most tears, regardless of size can be repaired. I perform all my rotator cuff repairs arthroscopically. This is less invasive and therefore less painful than an open incision. It also allows a better view of the rotator cuff. This procedure requires general anesthesia, takes about 60 to 90 minutes to perform, and patients go home the same day. Small incisions are made in the shoulder, a scope is inserted, and the rotator cuff is repaired with anchors. Anchors are essentially headless screws which are placed flush with the bone. These anchors have sutures that are used to bring the tendon done to the bone so that the tendon can heal to the bone. The long-term outcome of this procedure is very good (>90% success in most cases) and the risk of complication is very low (1/5000 chance of infection). However, repair requires a long recovery period and the tendon takes about 12 weeks to heal into the bone. Therefore, a sling is worn for 6 weeks after surgery. Specific motion exercises afterwards are tailored to the tear pattern (patient-specific). The sling is removed at 6 weeks and motion is progressed. Strengthening is allowed at 12 weeks, followed by gym activities at 4 months. Full recovery takes 6 months for small tears and 12 months for large or massive tears.