Shoulder Labral Tear and Shoulder Dislocation

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Cody Parsons
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1 Shoulder Labral Tear and Shoulder Dislocation The shoulder joint is a ball and socket joint with tremendous flexibility and range of motion. The ball is the humeral head while the socket is the glenoid. The labrum is a ring of cartilage that is attached to the glenoid. Labral tears often occur in younger active patients, particularly those involved in contact, overhead, or throwing sports and activities. What does it do? The labrum provides stability to the shoulder in several ways. The labrum increases the size of the socket, which helps keep the humeral head in place. The labrum also is attached to key stabilizing ligaments and to the biceps tendon. There are 2 common labral tears. The Bankart tear is a tear in the front lower portion of the labrum. This typically occurs after a shoulder dislocation. When the humeral head comes out of place, it puts tremendous pressure on the front of the labrum and often causes it to tear. This leads to loss of shoulder joint stability. In patients who dislocate their shoulder from a significant force or after multiple recurrent dislocations, the labral tear can extend towards the back of the glenoid as well. The other common labral tear is the SLAP tear. The SLAP tear is a tear in the upper portion of the labrum. This can happen after a fall or shoulder dislocation. This can also occur with repetitive overhead sports and throwing as an overuse type injury. Patients with shoulder dislocations and acute labral tears often have immediate pain and describe hearing or feeling a pop in their shoulder. Patients will oftentimes need help from a medical professional to reduce the shoulder, or put it back in place. There can be lasting aching and pain in the shoulder and limited motion due to the pain. Some patients may even have numbness or tingling in their arm from nerves being stretched by the injury. Patients with chronic labral tears usually have deep shoulder pain, especially after sports and activities which involve overhead motions or throwing. Some patients can feel like the shoulder is loose, unstable, and going to pop out of place. In patients with SLAP tears, the biceps tendon can be tender to touch and cause pain during activities and shoulder motion. For patients with Bankart tears or tears after shoulder dislocation, surgery is typically recommended, especially in younger athletic and active patients who wish to return to sports and activities. Non-surgical treatment can lead to chronic shoulder instability and multiple shoulder dislocations, which can worsen the labral tear and may lead to cartilage damage as well. The goals of shoulder labral surgery are to restore shoulder stability, prevent further damage, and allow for effective rehabilitation. The labrum is repaired and the stabilizing ligaments are tightened usually with an arthroscopic, minimally invasive technique. In some patients, especially those who are at high risk for repeat dislocation, an open repair may be necessary. Dr. Kumar will discuss surgical options with you prior to surgery and describe the expected recovery course. After surgery, a rehabilitation program specific for each patient is created with a physical therapy team in order to reduce post-surgical pain, restore motion, and regain strength. Sport-

2 specific training is a critical aspect of recovery in order to return patients to sports and activities as quickly and safely as possible. For patients with SLAP tears, non-surgical treatment is the initial treatment step. is focused on reducing pain, restoring motion, and regaining strength with a specific physical therapy program. Once the pain is improved with rest, a rehabilitation program focused on strengthening the upper back and shoulder muscles is implemented to recondition the shoulder. Once the shoulder has improved in strength and flexibility, sport-specific training is performed. For patients involved in overhead and throwing sports, a focus on improving mechanics and strengthening the core, hip, and legs are also included to prevent re-injury. For many patients, non-surgical treatment can provide the relief necessary to return to sports and activities. However, some patients may not improve as expected and surgery may be recommended in these cases. There are many surgical options in such cases and Dr. Kumar will discuss these with you prior to surgery. Age, sports, work, physical exam, and radiology findings all play a role in determining which procedure may best work for each patient. After surgery, a rehabilitation program specific for each patient is created with a physical therapy team in order to reduce postsurgical pain, restore motion, and regain strength. Sport-specific training is a critical aspect of recovery in order to return patients to sports and activities as quickly and safely as possible.

3 Shoulder Impingement The shoulder joint is a ball and socket joint with tremendous flexibility and range of motion. The ball is the humeral head while the socket is the glenoid. The rotator cuff attaches to the top of the humerus and sits below a part of the shoulder blade called the acromion. Shoulder impingement can occur in patients of all ages, especially those involved in sports and activities with repetitive overhead motion. During certain shoulder motions, the space for the rotator cuff becomes very narrow. The rotator cuff tendon can begin to scuff on the outside against the acromion or underneath against the glenoid and labrum. Impingement is commonly seen in patients of all ages with weak upper back, shoulder blade, and shoulder muscles. This imbalance leads to poor shoulder mechanics and reduces the space for the rotator cuff. Poor flexibility and range of motion can also cause this imbalance. Patients involved in sports and activities with repetitive overhead or throwing motions place significant stress on the shoulder and are at risk for developing impingement. Patients with impingement have deep aching shoulder pain which can be worse after sports and activities. Pain can also be worse at night and result in difficulty sleeping. Activities that involve overhead or throwing motions are also difficult to perform due to pain. Sometimes, attempting to elevate the arm above shoulder height can cause a sharp pain. Shoulder motion can also be limited because of the pain. Surgery is not usually necessary for patients with shoulder impingement. is focused on reducing pain, restoring motion, and regaining strength with a specific physical therapy program. Once the pain is improved with rest, a rehabilitation program focused on strengthening the upper back and shoulder muscles is implemented to recondition the shoulder and improve joint mechanics. Shoulder flexibility is also a focus, particularly with stretching of the internal rotators and pectoralis muscles. Once the shoulder has improved in strength and flexibility, sport-specific training is performed. For patients involved in overhead and throwing sports, a focus on strengthening the core, hip, and legs is included to prevent re-injury. For many patients, non-surgical treatment can provide the relief necessary to return to sports and activities. However, some patients may not improve as expected and further investigation may be warranted. Dr. Kumar will discuss all of your options with you with the goal of returning patients to sports and activities as quickly and safely as possible.

4 Rotator Cuff Tear The rotator cuff tendon attaches at the top of the humerus (arm bone) and is a major contributor to shoulder motion, function, and strength. Rotator cuff tears can occur in patients of all ages, especially those involved in sports and activities with repetitive overhead motion and heavy lifting. What does it do? The rotator cuff is actually made up of 4 different muscles and tendons. The subscapularis is located at the front of the shoulder. The supraspinatus, infraspinatus, and teres minor are located on the back of the scapula (shoulder blade). The rotator cuff has many functions. It is critical for forward elevation of the arm and for abduction, or bringing the arm out to the side. It also helps with internal and external rotation. The rotator cuff is especially important for motion above shoulder height. Rotator cuff tears can happen in multiple ways. Acute (sudden) tears can occur after shoulder trauma, such as a fall or dislocation. Sometimes, an already weak rotator cuff can tear after a mild injury. Trauma involving significant force on the shoulder can tear a normal healthy rotator cuff tendon. Usually, the rotator cuff tendon tears due to a chronic, degenerative process. Over time, repetitive stress on the tendon combined with poor shoulder mechanics and weak upper back muscles cause small tears to develop. This leads to irritation, inflammation, and pain, all of which can make the shoulder weaker and lead to greater stress on the rotator cuff. Eventually, these small tears can become bigger and more problematic. Patients with rotator cuff tears oftentimes have deep aching in the shoulder, which can be aggravated after sports and activities. Pain can be worse at night and result in difficulty sleeping. Activities that involve overhead or throwing motions are often difficult to perform due to pain. Carrying heavy objects away from your body and attempting to elevate the arm above shoulder height can cause a sharp pain. Shoulder motion, particularly raising the arm above shoulder height or reaching behind your back, can become more and more difficult over time. for rotator cuff tears is based on many factors, including age, severity of tear, shoulder motion and function, and other shoulder conditions. Non-surgical treatment is usually the initial step in treatment. A physical therapy program focused on reducing pain, restoring motion, and regaining strength is developed. Once the pain is improved, strengthening the upper back and shoulder muscles is performed to recondition the shoulder and improve joint mechanics. Shoulder flexibility is also a focus to maintain motion. Once the shoulder has improved in strength and flexibility, sport-specific training is performed to prepare the patient for return to sports and activities. For many patients, non-surgical treatment can provide the relief necessary to return to sports and activities. However, some patients may not improve with a proper physical therapy and rehabilitation program. In these cases, surgery may be recommended to repair the rotator cuff. The goals of rotator cuff surgery are to repair the torn tendon, prevent progression of tear size,

5 and allow for effective rehabilitation. The rotator cuff is repaired using an arthroscopic, minimally invasive technique. Some patients may have other conditions of the shoulder which may need to be addressed surgically at the same time as rotator cuff repair. Dr. Kumar will discuss all of the surgical options with you prior to surgery and describe the expected recovery course. After surgery, a rehabilitation program specific for each patient is created with a physical therapy team in order to reduce post-surgical pain, restore motion, and regain strength. Sportspecific training is a critical aspect of recovery in order to return patients to sports and activities as quickly and safely as possible.

6 Multi-Directional Instability of the Shoulder The shoulder joint is a ball and socket joint with tremendous flexibility and range of motion. The ball is the humeral head while the socket is the glenoid. The labrum is a ring of cartilage that is attached to the glenoid which helps increase shoulder joint stability. Multi-directional instability (MDI) of the shoulder is a condition where the shoulder is more flexible and looser than normal. It is typically seen in patients involved with overhead and throwing sports and activities, particularly in younger female patients. What is MDI? MDI of the shoulder is typically a condition where the stabilizing ligaments are looser and more flexible than normal. This allows the shoulder to have more flexibility and motion. However, the shoulder joint relies on these stabilizing ligaments to keep the joint in place. In patients with MDI, the ligaments do not work as efficiently to stabilize the joint. In patients with MDI, the scapular (upper back), rotator cuff, and other shoulder muscles have to work extra hard to keep the shoulder stable. If these muscles are poorly conditioned, imbalanced, or fatigued, the mechanics of the shoulder begin to change. This leads to injuries, pain, and decreased function. Patients with MDI can develop other shoulder conditions, such as shoulder impingement, labral tears, or rotator cuff tears. The decreased joint stability may also place patients at higher risk for injuries such as shoulder dislocation. There are many patients with MDI who have no symptoms. Patients with symptomatic MDI usually have deep shoulder pain, especially after sports and activities which involve repetitive overhead motions or throwing. Some patients can feel like the shoulder is loose, unstable, and going to pop out of place. The shoulder can tire and fatigue easily, which leads to poor function and loss of sports performance. In some patients, certain motions and shoulder positions can cause numbness and tingling down the arm and into the hand. MDI can be found in both shoulders, although only 1 shoulder can be problematic. For patients with MDI, surgery is oftentimes not necessary. is focused on reducing pain and regaining strength with a specific physical therapy program. Once the pain is improved with rest, a rehabilitation program focused on strengthening the upper back and shoulder muscles is implemented to recondition the shoulder. Sport-specific training is performed to prepare the patient for return to sports and activities. For patients involved in overhead and throwing sports, a focus on improving mechanics and strengthening the core, hip, and legs are also included to prevent re-injury. For many patients, non-surgical treatment can provide the relief necessary to return to sports and activities. However, some patients may continue to have pain, loss of function, and symptoms of instability. In these cases, surgery may be recommended. The goals of shoulder MDI surgery are to restore shoulder stability, prevent further damage, and allow for effective rehabilitation. The labrum and the stabilizing ligaments are tightened usually with an arthroscopic, minimally invasive technique. In some patients, especially those who are at high risk for recurrent instability, an open repair may be necessary. Dr. Kumar will discuss surgical options with you prior to surgery and describe the expected recovery course. After surgery, a rehabilitation

7 program specific for each patient is created with a physical therapy team in order to reduce postsurgical pain, restore motion, and regain strength. Sport-specific training is a critical aspect of recovery in order to return patients to sports and activities as quickly and safely as possible.

8 Acromioclavicular Joint Separation (AC separation) The acromioclavicular joint (AC joint) consists of the clavicle (collarbone) and the acromion (part of the shoulder blade). This joint is stabilized by several key ligaments. AC separation can occur in patients of all ages, particularly those involved in contact or collision sports. What does it do? The AC joint attaches the clavicle to the scapula. Multiple ligaments as well as the joint capsule keep the end of the clavicle in place. Ligament tears can lead to the clavicle becoming unstable in the up-down and front-back directions. AC separations usually occur after a fall or direct force onto the outside of the shoulder. This force causes the stabilizing ligaments to stretch and possibly tear. There are many types of AC separations. Mild injuries can sprain the ligaments. Major injuries can tear the ligaments completely, leading to an unstable clavicle. Signs and symptoms Patients with AC separations can have various symptoms, depending on the severity of the injury. Most will have acute, sharp shoulder pain located at the top of the shoulder. This pain can limit motion, particularly motion above shoulder height. Carrying heavier objects can also be difficult. Patients with mild sprains can have shoulder ache which improves slowly over time. Patients with AC joint instability can notice a bump at the topic of the shoulder and can sometimes feel popping with shoulder motion. Oftentimes, the shoulder can fatigue and tire easily. Many factors are considered when treating patients with AC separations. For many patients, especially with mild injuries, non-surgical treatment can provide pain relief in order to allow return to sports and activities. is focused on reducing pain, restoring motion, and regaining strength with a specific physical therapy program. Once the pain is improved and the ligaments are allowed to heal, a rehabilitation program focused on strengthening the upper back and shoulder muscles is implemented to recondition the shoulder and improve joint mechanics. Once the shoulder has improved in strength and flexibility, sport-specific training is performed to prepare the patient for return to sports and activities. For many patients, non-surgical treatment can provide the relief necessary to return to sports and activities. However, some patients may not improve as expected, especially those with severe injuries or patients who required significant demand of the shoulder for sports or work. In these cases, surgery may be recommended. Because the AC joint ligaments are not repairable, the ligaments must be reconstructed. There are multiple graft options which can be used to accomplish this goal, and Dr. Kumar will discuss these options with you prior to surgery. After surgery, a rehabilitation program specific for each patient is created with a physical therapy team in order to reduce post-surgical pain, restore motion, and regain strength. Sport-specific training is a critical aspect of recovery in order to return patients to sports and activities as quickly and safely as possible.

9 Proximal Humeral Epiphysiolysis (Little Leaguer s Shoulder) The rotator cuff tendon attaches at the top of the humerus and is a major contributor to shoulder motion, function, and strength. In young patients who are still growing, the rotator cuff attaches near a growth plate which can be irritated with repetitive stress. Little Leaguer s shoulder is an overuse injury seen in young patients with open growth plates who are involved in overhead and throwing sports and activities. The growth plate is typically the weakest part of the bone. The rotator cuff tendon, which attaches near a growth plate, is very strong. Patients involved in repetitive overhead and throwing sports require a strong rotator cuff, which puts a tremendous strain on the growth plate. Repetitive stresses of this growth plate lead to irritation, inflammation, and pain. Continued participation in sports with an injured growth plate leads to worsening symptoms and further injury. Patients with Little Leaguer s shoulder have deep aching shoulder pain which is worse after sports and activities. In particular, sharp pain at the outer shoulder can occur during certain motions while throwing. Sometimes, the outer shoulder can be tender to touch. Surgery is not usually necessary for patients with Little Leaguer s shoulder. is focused on reducing pain, restoring motion, and regaining strength with a specific physical therapy program. A critical aspect of treatment is an initial active rest period. During this time, activities and sports which aggravate the pain are avoided in order to give the growth plate time to heal. Once the rest period is complete, a rehabilitation program focused on strengthening the upper back and shoulder muscles is implemented to recondition the shoulder and improve joint mechanics. Shoulder flexibility is also a focus, particularly with stretching of the internal rotators and pectoralis muscles. Once the shoulder has improved in strength and flexibility, sport-specific training is performed to prepare the patient for return to sports and activities as quickly and safely as possible. For patients involved in overhead and throwing sports, a focus on strengthening the core, hip, and legs is included as well as a throwing program.

Shoulder Instability. Fig 1: Intact labrum and biceps tendon

Shoulder Instability. Fig 1: Intact labrum and biceps tendon Shoulder Instability What is it? The shoulder joint is a ball and socket joint, with the humeral head (upper arm bone) as the ball and the glenoid as the socket. The glenoid (socket) is a shallow bone