The shoulder is the most mobile joint in the human body with a complex arrangement of structures working together to provide the necessary movement. The shoulder is a ball-and-socket joint made up by the humerus (the ball) and the glenoid (the socket). A strong network of soft tissues, muscles, and bones work cohesively to provide movement and stability to the shoulder. The head of the humerus fits into a shallow socket in the scapula, called the glenoid fossa, while the shoulder capsule, a strong connective tissue, surrounds the shoulder joint. Synovial fluid lubricates the joint and the shoulder capsule to ease the movement of the shoulder.
The glenoid is a shallow and flat part of the scapula and makes up the socket of the shoulder. The labrum is essentially a rim of soft tissue, much like a gasket, that turns the flat surface into a deeper socket that molds to fit the head of the humerus. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles originate from the scapula and insert onto the humerus and are responsible for both movement and dynamic stability of the shoulder joint. The rotator cuff helps raise and rotate the arm and as the arm is raised and keeps the humerus seated tightly in the glenoid fossa. The labrum may start to tear if there is excessive movement within the joint, causing the humerus to rub against the labrum, or with trauma. The labrum may also become damaged over time. Tears of the labrum are fairly common. While some tears are completely asymptomatic and cause no problems for the patient, others can cause pain, catching sensations, or a sense of shoulder instability. The bicep tendon actually inserts directly to the top of the labrum as well. There are some situations where the bicep tendon may be causing pain related to the labral tear.
Individuals who are have a labral tear typically experience the following symptoms:
- Sharp pop or catching sensation in the shoulder during certain shoulder movements
- Occasional pain that interferes with sleep or day-to-day activities
- Sense of instability of the shoulder
- Limited or restricted range of motion associated with weakness
If these symptoms persist, a visit to the physician is highly advised to avoid further damage and to identify the source of the pain.
If an individual is experiencing shoulder pain, a labral tear can be diagnosed with the help of physical examination and imaging studies. The physician will ask for a history of the injury to understand how it occurred and examine the shoulder to test the range of motion of the shoulder joint. The physician may perform a series of special tests to check for instability and to test specific structures within the shoulder, such as the labrum, rotator cuff, and bicep tendon, to determine which of those is causing the pain. The physician may order X-rays to rule out arthritis, fractures, and look for any changes in the bone to indicate injury or a predisposition to certain conditions. An MRI scan, usually with an injectable dye, may help confirm the presence of a labral tear if this is thought to be the source of pain. Additionally, an injection directly into the shoulder joint, under x-ray guidance, can be used as both a diagnostic test and for therapeutic effect.
Since the labrum has a rich supply of blood that helps with the healing process, there are a large number of labral tears that heal on their own without treatment. However, if conservative treatments don’t seem to reduce pain and other symptoms, the physician may recommend surgery to address the particular condition.
Medication - Over-the-counter anti-inflammatory medication such as ibuprofen and naproxen usually help reduce pain and swelling.
Physical Therapy - Physical Therapists will often prescribe specific strengthening and range of motion exercises that promote healing and help recover as much mobility in the shoulder joint as possible. It is crucial that these exercises be done accurately and routinely to optimize recovery of the mobility of the shoulder joint.
Steroid Injections - Injecting the shoulder joint with cortisone, a powerful anti-inflammatory medicine, and a temporary numbing agent, might aide in decreasing pain and may also serve as a diagnostic test.
Surgery - If more-conservative treatments have not helped reduce symptoms, the physician may recommend surgery to reduce pain and avoid further damage to the joint and surrounding tissues and muscles. The exact procedure will depend on the nature and location of the labral tear:
- Debridement - In most cases of labral tears, if the tear is small and is mostly getting caught as the shoulder moves, simply removing the frayed edges and any loose parts floating in the shoulder may get rid of the symptoms. This “cleaning out” process is called debridement and is typically done arthroscopically where small incisions are made around the joint. Surgical instruments and the arthroscope, which is essentially a small camera, will go into these incisions and the image will be sent to a video monitor allowing the physician to see inside the joint. Using special surgical instruments, the physician my remove the loose parts that are causing pain and inflammation. Sutures will be used to close the incisions and the arm will be placed inside a sling for five to seven days until the incisions have healed.
- Bankart Repair - When the shoulder capsule is stretched or torn or the labrum detaches itself from the glenoid, shoulder dislocation or instability can cause severe pain and discomfort. When this happens, a pocket forms at the front of the glenoid allowing the humeral head to move and dislocate into the pocket. When the shoulder dislocates, the front, or anterior, portion of the labrum is often torn; this is called a Bankart lesion or tear and is the most common form of labral injury to the shoulder. A Bankart repair is a minimally-invasive arthroscopic surgery where small incisions are made around the joint where surgical instruments and the arthroscope, which is essentially a small camera, will go into these incisions and the image will be sent to a video monitor allowing the physician to see inside the joint. Using surgical instruments inserted into the joint, the physician will reattach the labrum to the glenoid using sutures and anchor-like devices. Often, a Bankart lesion is associated with tears to the shoulder capsule surrounding the joint and is typically located in the same area as the detached labrum. Therefore, the physician will also make any necessary repairs to the capsule using sutures. Once the labrum is attached and all necessary repairs are made, the incisions are closed and the procedure is complete. The arm may be placed inside a sling for five to seven days until the incisions have healed. The surgery is followed by a period of immobilization and a course of physical therapy (usually 3 months) to restore function without causing recurrent instability or stretching out the repair.
SLAP Lesion Repair - Individuals who participate in overhead sports such as weightlifting can experience labral tears as a result of repeated shoulder motion. In individuals over the age of 40, however, tearing of the superior (top) labrum can be seen as part of the normal aging process. In a superior labrum anterior and posterior (SLAP) injury, the superior (top) part of the labrum where bicep tendon attaches to the labrum is injured. SLAP lesions or tears occur in the front as well as the back of this point of attachment; therefore it is possible for some damage to the bicep tendons to occur. There are several types of SLAP tears, therefore the physician will determine the best way to repair the injury once he or she enters the joint arthroscopically. Using surgical instruments inserted into the joint, the physician may elect to reattach the labrum to the glenoid using sutures and anchor-like devices. Alternatively, the bicep tendon may be detached from the superior labrum where it is pulling at torn tissue and causing pain. The bicep tendon may remain detached or may be reattached in an area that will not cause pain, depending on the patient. Once all necessary repairs are made, the incisions are closed and the procedure is complete. The arm may be placed inside a sling for five to seven days until the incisions have healed, followed by a period of immobilization and a course of physical therapy.
Regardless of the treatment approach taken, patients go through a rehabilitation program which includes physical therapy exercises that are crucial to restore range of motion. Each patient is unique, so the therapy program will vary based on his/her level of pain, extent of injury, and desired level of activity they would like to return to. Recovery after surgery can take anywhere from six weeks to six months depending on the complexity of the procedure, but the individual's commitment to following all the restrictions set forth by the surgeon and the exercises prescribed by the physical therapist is the most important factor in returning to all the desired activities.
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