FAQ Category: Shoulder

A SLAP injury of the shoulder refers to a tear of the labrum around the rim of the acetabulum (shoulder socket). The labrum is a ring of cartilage around the shoulder socket. It helps support and hold the round head of the humerus (upper arm bone) in the very shallow socket.

The superior labrum is located along the top of the socket. It is attached loosely by elastic connective tissue. A force or load through the shoulder that is greater than the tensile strength of the thick connective tissue can cause tearing of the structures.

There are four types of SLAP lesions. The groups are based on severity. Type 1 occurs most often in older adults. Fraying and thinning of the labrum is most common with this type of SLAP lesion. If surgery is called for, the surgeon will shave off any fragments and smooth the remaining edges of the labrum.

The other types describe the extent of injury. For example, in a type 2 SLAP injury, the biceps anchor where the labrum attached is detached. There may be some frayed edges of the labrum as well.

Type 3 is a bucket-handle shaped tear in the labrum but the biceps anchor is not disturbed. Type 4 has a similar bucket-handle shape that extends all the way into the biceps tendon. Sometimes people have more than one type of tear at a time. Surgery is often needed to repair the more severe injuries.

SLAP stands for superior labral anterior posterior and refers to an injury of the labrum in the shoulder. The labrum is a dense ring of fibrocartilaginous tissue attached to the outer rim of the shoulder socket. SLAP injuries of the labrum are most common with overhead athletes. But they can occur with age and degeneration.

There are over two dozen clinical tests possible for the examination of the shoulder. Not all of these test specifically for SLAP lesions but many do. Not all tests for SLAP lesions are positive even when there is a tear. That’s because there are four types of SLAP tears based on the severity of the damage. Some tests work better for mild lesions. Others are more accurate for severe tears.

A recent review of clinical tests for SLAP lesions looked at studies done over a 10-year period of time. Validity, reliability, and accuracy of each test were carefully studied. There was no single test accurate enough to identify the presence or absence of a SLAP injury.

Arthroscopic exam does seem to be the most accurate. The surgeon can insert a long, thin needle into the shoulder joint. There’s a tiny TV camera on the end that broadcasts on a viewing screen a picture of what’s going on inside the joint. This is really the most accurate diagnostic test possible.

While regular shoulder replacements can be very successful for the right patients, if the patients have torn rotator cuffs, this is not the ideal solution. The movement of the shoulder places a lot of strain on the rotator cuff.

The regular shoulder replacements include replacing the ball at the top of the humerus (the upper arm bone) with a metal ball. The socket in the scapula (shoulder blade) is replaced with a plastic socket. However, if the patient has a torn rotator cuff, this replacement can come loose. In the reverse replacement, the ball is at the top, where the scapula is, and the socket is part of the humerus. With this arrangement, the upper arm muscle, the deltoid takes on the responsibility of the movement rather than the rotator cuff.

You may be having what’s called the painful arc syndrome. The affected individual tries to raise his or her arm overhead. The motion is done with the hand down by the side. The arm is then raised out to the side as far as possible going up toward the ear.

For a positive painful arc sign, pain begins at about 60-degrees of motion and continues until the arm is at 120 degrees of elevation. At that point, the pain goes away and movement feels normal again.

A positive painful arc sign points to impingement (pinching) of one of the rotator cuff tendons of the shoulder. This is the usually the supraspinatus tendon. As the tendon moves under the arch of bone formed by the acromion, it gets pinched between the bone and the (deltoid) muscle underneath. The acromion comes from the shoulder blade and curves around over the top of the shoulder joint.

There are many possible causes of an impingement problem. The most common is postural. The position of the head, neck, and upper arms contribute to this pinching process. Sometimes arthritic changes such as bone spurs create this problem.

If your symptoms don’t go away on their own in seven to 10 days, then consider seeing an orthopedic physician. The doctor will assess this problem and plan an appropriate treatment program.

Steroid injections can be very helpful with some shoulder problems. But a corticosteroid drug is used and it has some potential negative side effects. To avoid injecting the wrong site, a careful examination is essential.

After the physician conducts a history and exam, she probably started in on a list of important tests. Some doctors use a 16-step shoulder exam. This helps them cover all the bases and avoid missing something important.

The physician starts with visually inspecting the area. Any deformities, skin changes, and loss of muscle definition or other changes are noted. The patient is asked to move the shoulder through a series of motions designed to identify areas of weakness, loss of motion, and impingement of the bursae or tendons.

X-rays are an important part of the examination process. X-rays show the joint space. The physician can look for narrowing from arthritis. The presence and severity of arthritic changes are also noted. The shape and position of the bones around the shoulder are examined. Areas where the bones may be pinching the soft tissues may be observed. Calcifications of the tendons may also be seen on X-rays.

All of this information will be used when planning the treatment. Injections are most effective when the affected tissue is accurately targeted and reached.

With early identification and intervention, many pro-athletes can return to their pre-injury level of play after surgery. Although labral tears can be difficult, high professional players can rehab and return even better than before.

This isn’t always the case, though. And some upper-level professional (major and minor league) players end up retired or playing at a lower level. Without more information, it isn’t possible to predict if you will see your brother back in action.

Based on the statistics available on other players with shoulder labral injuries, there’s a good chance that surgery and rehab may be enough to return him to the same or higher level of play. Shoulder injuries are harder to rehab and recover from compared with elbow injuries. But it can be done!

The rotator cuff is a group of four muscles and their tendons that surround the shoulder joint. They work together to move the arm and hold the shoulder in place. Tears of the rotator cuff are common in athletes, manual laborers, and older adults.

Trauma and overuse can lead to rotator cuff tears in younger adults. Degenerative changes linked with aging are a more common cause among older adults. The tear is usually classified as partial-thickness or full-thickness. A full-thickness rotator cuff tear is the same as a ruptured tendon.

Sometimes damage to the tendon is massive and is considered inoperable. This usually means there’s not enough tendon left to reattach. In other cases, the tendon retracts so far into the belly of the muscle, it can’t be retrieved and reattached.

The patient can often regain stability use of the arm. This is done by strengthening the other muscles around the shoulder. A physical therapist evaluates the patient and sets up an appropriate exercise program. If there is a loss of motion, range of motion exercises are included. The patient’s age, occupation, and activity level are all considered when establishing a rehab program.

When it comes to giving patients advice or direction today, doctors are in an equal dilemma. Many patients want to be considered consumers. Their attitude is: just give us the information and we will decide what’s best.

Physicians are trying to honor and respect that whenever possible. If a surgeon feels comfortable offering either choice, it’s likely that he or she is skilled and confident in performing either one. This is good since the surgeon’s experience and technical abilities are important to the final outcome.

There are advantages and disadvantages to both procedures. The mini-open doesn’t disrupt as much soft tissue as the open operation. In particular, the deltoid muscle along the upper arm isn’t cut during the mini-open approach. But the surgeon has better visibility with an open incision.

If the tear is small, the mini-open method works well. The hospital stay is shorter, so there may be lower costs, too. With the mini-open incision, the surgeon can always switch over to a full incision if needed.

You can always ask your surgeon for more specific direction in this decision. He or she may be trying to give you as much choice as possible without knowing your needs and wants for information and independence.

You may be noticing some early signs of joint degeneration. Arthritic changes aren’t uncommon after shoulder surgery for recurrent shoulder dislocations. In fact, some studies show up to 20 per cent of patients who have surgery for shoulder instability develop postoperative arthritis.

Sometimes early arthritic changes are already present in the shoulder before the surgery. This has been observed in about nine per cent of patients with chronic shoulder instability. Loss of shoulder motion and function seem to be linked with deficiencies leading to arthritis.

A follow-up visit with your orthopedic surgeon may be in order. At the very least, an X-ray of the joint will be done to rule out fracture or loose fragments in the joint. The X-ray can also confirm the presence of arthritic changes.

Early diagnosis of orthopedic problems is always recommended. Taking care of a minor problem can help prevent major problems later.

Shoulder replacement is the removal of the shoulder socket and head of the humerus (upper arm bone). These parts are replaced with an artificial implant.

On the shoulder socket side, a cup-shaped metal or ceraminc implant is pressed or cemented into the bone. On the humeral side, an implant shaped like the head of a humerus with a long stem is inserted down into the shaft of the humerus. New bone from the humerus grows into and around the implants.

With joint resurfacing, the surgeon removes any bone spurs and smooths the joint surface. Then the joint surface is covered with tissue from some other part of the body. This could be a piece of tendon, flap of muscle, or rim of meniscus. The tissue usually comes from a donor bank.

Biologic resurfacing is also known as interpositional arthroplasty. It has been around in one form or another since the mid-1800s. It is one alternative to a total joint replacement for young, active adults. Less bone is removed. This makes it possible to convert to a total shoulder replacement later, if needed.

The labrum is a dense fibrocartilage ring that is firmly attached around the acetabulum (shoulder socket). It provides both depth and stability to the normally shallow acetabulum.

A labral tear can result in a painful and unstable shoulder. A stiff, painful (frozen) shoulder is not uncommon after shoulder trauma. This may be the body’s protective response. It is usually self-limiting. This means it will eventually get better on its own.

If conservative care does not take care of the problem, then surgery may be needed. The surgeon may just manipulate the shoulder. This is a careful moving of the shoulder through its full motion while the patient is anesthetized. If that doesn’t help, then incision and release of the anterior shoulder capsule may be needed.

A stiff and painful shoulder with limited motion is known as a frozen shoulder. It can be the result of trauma, diabetes, or from unknown causes. The condition does tend to follow the rule of threes. It has three stages that each last about three months.

The first stage is the freezing phase. The arm starts to lose motion and become painful. The second stage is the frozen phase. The pain is less but stiffness prevents functional movement. This phase lasts at least three months (sometimes longer). In the final stage, the shoulder starts to thaw. Range of motion slowly returns to normal.

The wait-and-see approach is sometimes referred to as benign neglect or supervised neglect. This treatment method seems to work about as well as any other. Some patients prefer to seek the services of a physical therapist to help them regain motion and strength.

Other forms of conservative (nonoperative) treatment may include cortisone injections, oral steroids, or nerve block. Manipulation (movement) of the shoulder can be tried under anesthesia before surgical release of the capsule is considered.

Studies have not been done to show which approach works best — or if any treatment is really even needed. Until proven differently, the wait-and-see management style is considered acceptable at this time.

Improvements in both surgical procedures has narrowed the gap of advantages of one over the other. The arthroscopic approach uses two or three puncture wounds to insert a long, thin scope into the joint. It has been suggested that this approach has a more pleasing appearance and shorter operative and recovery time.

The incision approach uses a fairly small open incision to access the joint. The main difference is that the subscapularis muscle is split during the open surgery. Some surgeons feel this puts the patient at a strength disadvantage.

To check out this theory, a team of surgeons and sport medicine staff from Canada put it to the test. They compared before and after muscle strength of the shoulder for an equal number of patients treated arthroscopically versus with an open incision.

They were surprised to find out that patients in both groups had significant strength deficits. External rotation was affected more than internal rotation for both groups. But there wasn’t a discernible difference between the two groups. The reason for these two findings remains unknown but a point of interest for future research.

Rehab programs after a shoulder stabilization procedure may be the same whether it was an open versus closed procedure. Sometimes this depends on the surgeon’s preferences. Type of sutures used, amount of damage to the soft tissues, and condition of the joint capsule are only three of the important considerations.

Most often, the protocol used during the early phase of rehab is one that can be modified for each patient. Your therapist will advance you along as quickly as possible. The rehab protocol is really just a guideline.

Most likely you will be put in a shoulder immobilizer (sling) in the operating room. This is worn for two to four weeks. Exercises are started at two weeks. Passive and active-assisted partial range of motion is allowed. Full, active range of motion is permitted at six weeks.

The therapist will progress you to and through a series of strengthening exercises. The speed at which you will be able to advance may depend on your level of pain, degree of stiffness, and strength. You will be able to start training for tennis participation between eight and 12 weeks. If there are no complications or problems, you may expect to return to your sport about four months after surgery.

There are many factors to consider when evaluating a rotator cuff repair failure. The immediate repair strength is one concern. Surgeons are careful to use suturing techniques known to have high success rates. But the sutures can still saw through the tendon or the tendon can give way after cyclical loading (repetitive motions).

Patients are encouraged to follow post-op instructions carefully. The idea is to avoid having suture breakage, pullout, slippage, or tendon tears. Too much load, too soon can lead to repair failure.

For some patients, bone quality is an important factor as well. Brittle or soft bones in older adults may not hold the sutures in place during the healing phase.

Your surgeon may be able to answer this question more specifically once the tendon repair is examined. The surgeon will look at the location of the failure (e.g., at the suture to bone interface, suture to tendon interface, or tendon to bone attachment). Poor tendon quality can have a negative effect on a rotator cuff repair.

An orthopedic surgeon would be the best one to answer your question. Age is an important variable but there are many other factors to consider. The condition of the torn tendon is one. Excessive scar tissue, weak tendon fibers, and poor bone quality can reduce the changes of a successful repair.

The location and extent of your tear must be considered. The surgical technique used may depend on these factors. There are numerous types of sutures and anchors used to repair the tear. Placement of the fixation may affect the outcome.

Many surgeons use a double row of sutures. This can be done arthroscopically or through a mini-incision. A newer technique of suture anchor without knots has simplified the arthroscopic procedure. Fewer anchors are needed and they are easier to make. They also withstand greater loads than previously used corkscrew anchor repair.

Some methods of repair seem to work better for younger patients. Your surgeon will take into consideration both anchor and suture designs for your particular rotator cuff tear. Future improvements are needed to reduce the friction between the suture and anchor. Research is ongoing to find ways to increase the strength of the suture against rubbing.

Studies show that immobilizing the arm after a primary (first) shoulder dislocation doesn’t change what happens in the long-run. Even applying the sling several weeks after the dislocation first occurred doesn’t seem to change what will happen a year or even more than a year later.

Over half of all shoulder dislocations stabilize and recover well. In fact, according to a study over a period of 25 years, many patients with a shoulder dislocation couldn’t even remember which arm was dislocated.

Some experts have advised immediate surgery for anyone with a shoulder dislocation who is an athlete, especially throwing athletes. Results of the long-term study just mentioned did not agree with this counsel. According to their data, athletic activity was not linked with recurrent shoulder dislocation.

A trial period of immobilization followed by a rehab program is considered a good first step following shoulder dislocation. Even if surgery is eventually needed, the strengthening program will prepare the shoulder for a better result after surgical reconstruction takes place.

It’s best to check with the physician or other health care provider who examined you and gave you the sling. Several factors determine how much motion can be allowed during these early days of healing and recovery.

The first is the extent of the damage. A shoulder that has dislocated for the first time without a tear of the labrum or fracture of the bone may not need anything more than a period of immobilization. The labrum is the dense fibrocartilage ring that is firmly attached to the shoulder socket. It makes the shallow socket deeper to help further stabilize the shoulder.

But if surgery is anticipated, then strict immobilization may be required. This period of rest will help the soft tissues lay down scar tissue to start the healing process of torn ligaments and other inelastic fibers.

The sling usually holds the arm in a position of internal rotation across the body. But at least one study tried immobilizing patients in a position of external rotation (the opposite direction). The results were just as good as if the arm had been internally rotated. And another study compared immobilization with no immobilization. They found no difference between the groups in terms of recurrence of dislocation and final outcome.

There’s still much we don’t know about the best treatment for a first-time shoulder dislocation. More studies are needed to find out if activity level, age, or gender makes a difference in how the arm is treated. We don’t really know how long the sling must be worn for the best results (or if wearing one is even needed).

Until more details are known, it may be best to follow the standard treatment procedure advised by your health care provider.

Posterior instability as a cause of shoulder pain and/or clicking is an uncommon, but not unheard of, condition. Anterior shoulder problems are much more common. In fact, many pitchers or throwing athletes suffer from an anterior instability. Posterior refers to the back of the shoulder. Anterior refers to the front of the shoulder.

In either case, repetitive microtrauma from the action of overhead throwing is the cause of the problem. During the follow-through phase of pitching, the shoulder is close to the body, flexed, and rotated inwardly. This repetitive motion may put stress along the back of the shoulder.

The shoulder capsule and labrum (rim of cartilage around the shoulder socket) can also get pinched causing pain. This is more likely to occur during the late cocking phase of throwing when the arm is drawn back and externally rotated.

The problem is made worse if the athlete has any natural laxity (looseness) or contracture (tightness) of the soft tissues in this area. Repeated stresses from throwing 100s of pitches can lead to labral tears or a stretched capsule.

These types of injuries are not easy to diagnose. There can be different directions of instability at the same time causing confusion. Clinical signs and symptoms and results of testing aren’t always consistent for multidirectional injuries. Diagnosis is delayed when there is more than one lesion (and even a combination of problems).

The surgeon will have to sort out the site of damage and resulting structural and biomechanical problems. Even with history, physical exam, and imaging studies, arthroscopy may be the only way to make the final diagnosis.

It sounds like your surgeon is suggesting arthroscopic surgery. A long needle with a tiny TV camera on the end is inserted through the skin into the joint. The surgeon can see on a screen what is going on inside the joint.

The scope makes it possible to find and repair damage to the joint capsule, cartilage, and ligaments or tendons in the area. Studies show this type of surgery is very successful. There is no need for a large, open incision. Rehab and recovery is faster because major muscles haven’t been cut through.

The two or three puncture holes needed for placement of the scope usually present no problems. There is a small risk of infection at those sites. Usually, they just fill in with collagen fibers and scar tissue. They may only be visible on close inpsection.

The recovery process does take some time. Depending on what the surgeon has to do, you probably won’t be able to go back to work right away. Most patients are placed in a sling with a pillow under the arm.

You’ll probably see a physical therapist several weeks after the operation. The focus of rehab will be on restoring range of motion, strength, and function. Specific exercises may be prescribed to help you prepare to return to overhead work.