by Vic Goradia, MD, Knee, Shoulder & Sports Medicine Specialist Basic Anatomy of Shoulder
The shoulder is a ball and socket joint. It consists of three bones: the upper arm bone (humerus), wing bone (scapula) and collarbone (clavicle). The ball (humeral head) fits into the small socket (glenoid). The glenoid is surrounded by a soft cartilage lip (labrum), which deepens the socket. The upper part of the wing bone (acromion) projects over the shoulder joint. One end of the collarbone is joined to the acromion by ligaments to form the acromioclavicular (AC) joint.
Labral Tears
The shoulder ligaments attach the humeral head to the glenoid. These ligaments attach to the labrum which is firmly attached to the glenoid. The labrum is the cartilage lip that lines the shoulder socket or glenoid. This lip helps to deepen the socket so the shoulder ball will stay in the socket. When the labrum tears away from the glenoid, patients experience pain, catching, clicking and/or locking. Depending on which part of the labrum tears, it has different names.
For example, tears on the top part are known as Superior Labral Anterior Posterior (SLAP) lesions. Since this is a mouthful it is much easier to refer to them simply as SLAP lesions. Tears in the front part of the labrum that extend to the bottom are known as Bankart Lesions.
SLAP Lesions
The term SLAP lesion was first developed by Dr. Steve Snyder from Los Angeles in the early 1990s. However the actual lesion was described in 1985 by Dr. James Andrews. Prior to this time many patients suffered from shoulder pain that could not be easily diagnosed or treated. Today most sports medicine and shoulder specialist are able to diagnose and treat SLAP lesions. Unfortunately, there are situations in which these tears are actually over-diagnosed. In other words, patients are sometimes treated for SLAP lesions that do not actually exist. It is therefore important to see a surgeon that treats a large number of SLAP lesions and other shoulder problems. SLAP tears can occur when falling on the arm/shoulder, having the arm suddenly pulled, a lifting injury or repetitive overhead activity with the arm. Most commonly they occur during work injuries in which the arm is suddenly yanked or in overhead athletes. In this latter situation, the tears are a result of repetitive overuse more often than a sudden injury. It is very common to hear of baseball pitchers having SLAP lesions. With repetitive throwing or other similar activities, the biceps can slowly pull the labrum away from the socket. As you will recall from above, the biceps tendon from the arm attaches onto the Superior Labrum. In other cases, the Superior Labrum repetitively pinches between the glenoid (socket) and rotator cuff causing the labrum to gradually tear. Regardless of the cause of a SLAP tear, the labrum will not heal back to the bone. In those individuals that have to use their arm repetitively, surgery is needed to treat the SLAP lesion. Fortunately, the condition can be treated with arthroscopic surgery.
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Bankart Lesions
Bankart lesions are another type of labral tear. They occur as a result of a shoulder dislocation or multiple dislocations. When the ball (humeral head) dislocates out of the socket (glenoid), the ligaments that normally hold these two structures together will either stretch or tear. When they tear it is called a Bankart Lesion. In this case the inferior (i.e. lower) glenohumeral ligament pulls the inferior labrum away from the glenoid. Less commonly the ligament will pull the labrum with a piece of bonethis is known as a bony Bankart lesion. Most shoulder dislocations have to be forcefully relocated (i.e., put back in place) by a doctor, sometimes with sedation. Next, the patient is placed in a sling for immobilization that allows some scarring and healing of the damaged ligament, labrum and /or bone. In many cases, however, these structures do not heal in the correctly. Studies have shown variable results with non-surgical treatment. Many published studies have noted re-dislocation rates of 75-90% in patients under the age of 25 with a first time dislocation. This risk is greatest for dominant arms of active individuals.
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>Bankart Lesions
If a patient has a first-time dislocation and is under the age of 25 years, I will discuss options of immediate surgery vs. trying a period of immobilization. The latest research shows that immobilization in external rotation (with the arm rotated out) is best if non-surgical treatment is attempted. I carefully counsel the patient about the 75-90% risk of recurrent dislocations. For individuals over 40 years of age that have a first-time dislocation, I base my recommendations on the patients activity level and work requirements. Many patients can be treated without surgery unless they have strenuous hobbies or work. The middle group of patients, from 25-40 years of age, fall in a gray area. Again, it is important to note their activity level, how loose their shoulder feels when I examine it and how large the tear appears on the MRA. Regardless of age, if patients have recurrent dislocations or are apprehensive about participating in activities because of their shoulder, I will recommend and discuss surgery.
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>After Surgery
After arthroscopic repair of SLAP and Bankart tears, patients are generally given a sling or immobilizer. Approximately one week after surgery, I send patients to physical therapy for protected range of motion exercises. As the tear begins to heal over a period of 6-8 weeks, the therapist begins a strengthening program. At 12 weeks most patients can begin heavier strengthening and light sports specific training. Most patients resume non-contact sports by 4-6 months and contact sports by 6-9 months.
Baseball pitchers and other similar overhead athletes require a slightly modified rehabilitation program that focuses strongly on throwing mechanics after the initial healing period. As with all surgeries, I work closely with the physical therapist to develop a specific rehabilitation program for every patient. For athletes we also include the athletic trainer(s) and coaches in our team approach to treatment.
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