• What should I know about the Shoulder Joint?

    The shoulder joint is a ball and socket joint.  Compared to other ball and socket joints in the body, like the hip joint, it has a very shallow socket.  That socket, called the glenoid, is rimmed by a firm cartilage ring called the labrum.  The labrum functions to deepen the socket and thereby contributes to shoulder joint stability.  The labrum is also the point of attachment for some of the shoulder’s ligaments and the biceps tendon.  This relatively shallow socket, coupled with relatively loose or lax ligaments, allows the shoulder to have a range of motion much greater than other joints.

  • Can labrum anatomy differ from patient to patient?

    The anatomy of the labrum is quite variable from patient to patient.  I explain to my patients that there can be several zones or segments around the socket (glenoid) where it can be very normal for the labrum to have no attachment at all.  This lack of attachment actually contributes to shoulder motion and surgical reattachment not only is not indicated but can cause loss of normal motion.  Not only can some zones have no attachment but in others the degree of attachment can be quite variable.  In some patients the attachment of the labrum to the glenoid is like molding around the base of a wall.   The attachment is tight and secure.  In other zones around the glenoid the labrum frequently can have a tight attachment like wall molding but in many patients the attachment is more like a bed skirt or “duvet cover” where it hangs loosely over the glenoid rim and one can easily lift it up and look under it.  This variability in normal labral anatomy can make the diagnosis of labral tears difficult on tests like an MRI as well as even at the time of direct inspection by arthroscopy.

  • How can the labrum become injured or damaged?

    The labrum can be injured or damaged in several different ways.   The best diagnostic test for evaluation of the shoulder labrum is an MRI scan with dye or “contrast” injected into the shoulder.  Certainly some age related or “degenerative” change of the labrum occurs in most patients.  This degenerative change is rarely the primary source of patient’s shoulder pain.  Since these degenerative changes are common in all of us as we age they are common findings on MRI scans as well as at the time of direct examination of the shoulder joint by arthroscopy.  I explain to my patients that these changes noted on MRI should not be a surprise anyone.   It is my job to determine though a detailed history of the patient’s symptoms, physical exam, and personal review of the MRI images whether these changes are important or incidental.  I frequently use the analogy that MRI scans are like pictures.  It should not be surprising or cause for concern that some “abnormalities” are detected as we age.  It is no different in my mind than the reality that a picture of any one of us taken when we were 20 years old does not look like one taken at age 40, 50, or beyond.  As we have aged we may have developed skin wrinkles or lost hair but that doesn’t mean that we are not healthy or don’t feel well.

    Besides degenerative changes, which as discussed above are common and frequently not the primary cause of symptoms, most other injuries are caused by one of several mechanisms.  Some labral tears are caused by shoulder dislocations.  More than 90% of patients less than 40 years old who dislocate their shoulder will have a labral tear at the time of dislocation.  These labral tears are rarely the cause of ongoing shoulder pain.  When the labrum is torn or detached from the socket (glenoid) with a dislocation of the shoulder, because some of the shoulder ligaments attach to the labrum, this type of labral tear can be associated with ongoing or recurrent instability or dislocation (slipping out of place).  In this situation repair of the labrum may be indicated to restore stability to the shoulder.

  • What is a SLAP tear and how is it treated?

    The biceps tendon attaches to the labrum at the top or “superior” zone of the shoulder socket.  Because labral tears in this area are unique, in that they are subjected to repeated pulling from the attached biceps, they may be associated with ongoing pain.  Orthopedists have called tears in this superior zone SLAP tears.  SLAP stands for Superior Labrum Anterior to Posterior.  These SLAP tears almost always occur either from some unexpected pull on the arm or by a fall onto an outstretched hand.  Because the biceps tendon attaches to the superior labrum the pull or “traction” can detach the labrum.  Falls onto an outstretched hand can cause the labrum to be sheared off by the ball passing forcefully over the edge of the superior socket.

    Ideal treatment of these SLAP tears remains controversial amongst shoulder experts.  Some experts contend that the diagnosis is either not a frequent source of pain or that the diagnosis is “over diagnosed” by treating surgeons.  That being said more than 20 years of clinical practice and hundreds of shoulder arthroscopy have convinced me that some patients can have pain from this diagnosis.  That being said successful treatment of SLAP tears requires selecting patients who have a mechanism of injury, physical exam, and diagnostic testing all consistent with that diagnosis.  As I reviewed earlier this diagnosis can be difficult to make on MRI and even arthroscopy because of normal variability in labral anatomy.  Ensuring that all these parts of the puzzle fit together greatly increases the probability of successful treatment if surgery is selected.

    Some patients will simply have decreasing pain with time and other conservative measures such as physical therapy and anti-inflammatory medications.  This diagnosis is not one that will become more difficult to treat or where surgical treatment will be less successful if surgical intervention is delayed in order to attempt conservative care.  Since the diagnosis itself is not thought to cause damage or degeneration of the shoulder, and delay in surgery does not cause more complicated or less successful surgery, virtually all patients will undergo an attempt at non-operative treatment.

    For those patients who have a mechanism of injury, physical exam, and MRI all consistent with the diagnosis of SLAP tear surgery becomes a reasonable option.  Exactly what gets done at the time of surgical arthroscopy depends upon the intra-operative findings as well as patient specific factors such as age and presence or absence of shoulder stiffness at the time of surgery.  The surgical options are essentially between repair of the SLAP tear or what is called “debridement” which is the medical term for cleaning up or trimming smooth.  In order to successful repair the SLAP tear the labrum and attached biceps tendon both must be of good quality.  If they have been damaged by the injury event then “debridement “becomes a better option.

  • What other surgery options are available?

    Debridement likely is also a better option in several other situations.   We know that healing potential of the labrum is somewhat limited and that healing potential probably declines with age and smoking.  In patients over the age of 40 and/or smokers the better option frequently is “debridement” of the torn labrum to smooth and secure margins with a “biceps tenodesis” or “biceps tenotomy”.  If the labrum is shaved smooth then something will need to be done with the biceps tendon that normally attaches in that area.  The options are tenodesis or tenotomy.  With tenodesis the biceps tendon is reattached to the humerus or upper arm.  This does require healing in this location but typically this has been more reliable than repair within the shoulder.  Because the repair is generally more secure than repair within the shoulder and because it is not stressed by movement of the shoulder rehabilitation is more rapid with this option.  Some restriction of forceful lifting or use of the biceps will still be necessary for several months.

    The final surgical option would be “debridement” with “tenotomy”.  In this scenario the labrum is trimmed smooth and the biceps is simply cut.  That seems radical or unwise to most patients at first impression but it is a reasonable and likely best choice in many cases.  With this option rehabilitation is very rapid as there has been no stitching or repair so there is no need to protect the shoulder and activities can progress without limitations other than those from the initial postoperative pain.  Tenotomy in most patients does not cause a meaningful or readily apparent change in their strength.  In patients with heavy laboring jobs there can be an increased probability of ache or fatigue weakness with repetitive forceful use of the arm and in this patient group this may not be best.  In very thin patients tenotomy will also cause a cosmetic change in the upper arm causing a “Popeye” appearance to the biceps.  Again this may be a situation where tenodesis or repair is better.

  • Where can I learn more?

    I hope that you have found this discussion education, informative, and helpful.   I look forward to answering any additional questions and helping you care of your shoulder problems.

    SLAP Tears

    Biceps Tendon Tears

  • SLAP Repair Video--Dr. Kassman

  • Post-operative Instructions

SLAP surgery options for shoulder pain

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