What is the labrum and how is it injured?
Your labrum is the cartilage that surrounds the glenoid (shoulder socket) and provides stability to your shoulder. It can become torn and/or frayed from dislocating your shoulder, pulling or pushing of the arm, repetitive overhead activity (i.e sports or repetitive labor work), or direct trauma (i.e sports, a fall, or motor vehicle accident). The labrum completely surrounds the glenoid and the tears are described by their location (i.e. SLAP tear- is a tear in the superior labrum extending anterior to posterior).
What are symptoms of a labral tear?
- Pain
- Feeling of instability- “my shoulder is loose”
- Locking
- Clicking
- Catching
If your doctor suspects a labral injury by history and physical exam, he will often order a MRI arthrogram which requires injecting dye into the joint and obtaining an MRI. This is the best test for evaluating the labrum; however, it is still not perfect.
How do we treat labral tears non-operatively?
- Anti-inflammatory medications- These decrease inflammation and, therefore, decrease pain.
- Cortisone shots- steroids are very potent anti-inflammatory medications and go directly to the source with little systemic absorption.
- Physical Therapy- strengthening the rotator cuff stabilizes the shoulder and may make the shoulder feel better.
- These options above are best for older patients with degenerative-type tears; shoulder arthroscopy with labral debridement or repair is preferred in younger patients.
What is shoulder arthroscopy?
Shoulder arthroscopy is a surgical procedure using a small camera to view the shoulder joint through small incisions. The camera is inserted into the shoulder joint and a complete inventory of the shoulder is performed. Your surgeon is able to see your shoulder joint in detail to repair or remove damaged tissue. This is the most predictable option for treatment of tears in younger, active patients. Small, frayed tears are best treated with arthroscopic debridement and large, unstable tears are best treated with arthroscopic repair.
How is shoulder arthroscopy performed?
First, the anesthesiologist administers a nerve block in pre-op that typically lasts between 12- 18 hours. You are then placed under general anesthesia and your shoulder is examined to test your shoulder without muscle resistance. The camera is then placed into your shoulder through a small incision. A complete inventory of your shoulder is performed looking at all the structures in your joint. Additional portals are made for the insertion of the working instruments. If the labrum is torn at the top of the socket, then the biceps can become unstable causing pain and popping. In older patients with this type of tear, we can treat this by releasing the biceps tendon. The labrum is sewn back down to the bone using implants called suture anchors (special screws with attached sutures). The anchor goes into the bone and the labrum is sewn down with the sutures. The suture holds the labrum to the socket until it heals.
When you wake up, you will be in a sling and your incisions are stitched together and white steri-strips are placed over your incisions. Your shoulder is also wrapped in a dressing. Keep your dressing clean, dry, and intact for 3 days post-op. You can shower post-op day 3, scrubbing your neck and letting the soapy water run over your incisions. Do not scrub your incisions. You will be sent home with pain medication and a medicine for nausea.
Complications of shoulder arthroscopy occur infrequently but can include and are not limited to bleeding, infection, persistent or increased pain, damage to nerves, blood vessels, or cartilage, worsening condition, instability, stiffness, or need for reoperation.
Post-Op Rehabilitation
In most cases, you can go home the same day. If the pre-op block worked, you will be comfortable but be sure to take your pain medication when you get home before your block wears off. You wake up in a sling which is to be worn at all times for the first 72 hours and then you may take it off only to shower then put it back on. Wearing a button-up shirt is easiest. Ice as much as possible for the first 72 hours. Follow up with your surgeon 3-5 days post-op.
Physical therapy is prescribed to restore your motion and strength. The amount of therapy that you will need depends on what type of surgery was performed. Physical therapy is very important in optimizing your outcome. It is hard to estimate when you can return back to work or sport, as each surgery is highly variable. It is important to anticipate the expected length of recovery; it often can be estimated before surgery.
For labral repair, range of motion exercises are started at 1 week post-op and strengthening begins at 8-12 weeks. Depending on your surgery, certain motion restrictions may be in place. Common restrictions for labral repair are 90 degrees of forward flexion and abduction and no internal or external rotation for 1 month. Continue to wear the sling for the first month and thereafter in uncontrolled environments. Active range of motion (moving your shoulder by yourself) without restrictions begins at 1 month. Full recovery may take 4-6 months. You can drive when you are off all narcotic pain medications and no longer require the sling. Ask your doctor before you drive and practice in a parking lot first.
For labral debridement, rehab is much faster with fewer restrictions than labral repair. Patients can begin to wean out of their sling at their first post-op visit. Physical therapy is recommended for 6-10 weeks for strengthening and range of motion exercises.
