The shoulder joint is a “ball and socket” joint that enables the smooth gliding and thereby the movements of arms. However, it is inherently unstable because of the shallow socket.
A soft rim of cartilage, the labrum lines the socket and deepens it so that it accommodates the head of the upper arm bone better. This is a detachment or tear of the superior aspect (upper portion) of the cartilage rim that surrounds the socket bone of the shoulder called the glenoid labrum. This serves as the insertion point of the long head of the biceps tendon.
Shoulder labral tears are a common injury in throwing athletes but most commonly occur in patients with wear and tear, those who have fallen, or those who have received traumatic injury or a blow to the shoulder. In addition, aging may weaken the labrum leading to an injury. A shoulder labral tear injury may cause symptoms such as pain, a catching or locking sensation, decreased range of motion and joint instability.
Your doctor may start with conservative approaches, such as prescribing anti-inflammatory medications, and advise rest to relieve symptoms until diagnostic scans are done. Rehabilitation exercises may be recommended to strengthen rotator cuff muscles. If the symptoms do not resolve with these conservative measures, your doctor may recommend arthroscopic shoulder surgery.
During arthroscopic shoulder surgery, your surgeon examines the labrum and the biceps tendon. If the damage is confined to the labrum without involving the tendon, then the torn flap of the labrum will be removed.
In cases where the tendon is also involved or if there is detachment of the tendon, absorbable wires or sutures will be used to repair and reattach the tendon. After the surgery, you will be given a shoulder sling to wear for 3-4 weeks. You will also be advised of motion and flexibility exercises after the sling is removed. These exercises increase the range of motion and flexibility of shoulder joint.
The biceps tendon often attaches to superior glenoid bone, whereas in others the biceps predominantly attach to superior labrum. Slight detachment of the superior posterior (upper back portion) of the labrum may be normal in older adults.
A Buford Complex is an anatomical variant where a central ligament appears cord-like and will often be frayed; this is often associated with a physiologically normal anterior (front) -superior labral hole which is normal and not surgically repaired. Attempts to close down this sub-labral hole with an absorbable tack anchor may precipitate a frozen shoulder. In most cases, a SLAP lesion will show inflammatory changes around the biceps tendon origin.
CONFIRMATION OF TRUE TEAR (ARTHROSCOPIC FINDINGS):
- Glenoid chondromalacia (degeneration and wearing of cartilage lining the bone) in the area of the detachment, with corresponding fraying of the detached labrum and glenoid.
- Intra-operative Dynamic Testing.
- Instability of the labral tissue and/or biceps tendon upon probing with surgical instrument.
- Instability of the Shoulder.
- Rotator Cuff injury. This occurs approximately 40% of the time and is dependent upon the degree of severity of the labral tearing.
- Glenoid Cysts. This is often a gradual development and is dependent on the duration of the tearing.
- Patient history and Physical Exam.
- MRI Imaging: A closed MRI is ideal. Often an MRI with contrast is needed. X-rays are needed to complement the findings.
CLASSIFICATION AND TREATMENT:
The labrum is evaluated based on its individual stability, as well as the stability of the joined biceps/labral attachment. The individual biceps tendon attachment is also determined. SLAP tears will show more than 5 mm of exposed superior glenoid bone and often present positive during dynamic testing during Arthroscopy. Prior to an Arthroscopy, a quality MRI can classify the type of tear.
- TYPE I:
- Fraying and degeneration of the superior labrum, normal biceps tendon with no detachment.
- This is the most common type of SLAP tear. It accounts for more than half of the documented SLAP tears.
- This is often associated with rotator cuff tears.
- These tears may be treated initially with non-operative treatment (physical therapy) if no other significant problems exist. If other associated findings exist or the patient does not improve with physical therapy, then Arthroscopic debridement (careful removal of damaged tissue) is performed.
- TYPE II:
- Detachment of superior (upper) labrum and biceps tendon insertion from the supra-glenoid tubercle (top portion of the shoulder socket bone).
- During Arthroscopy, traction may be applied to the biceps tendon and the labrum will display arching away from the glenoid.
- Typically important ligament structures are unstable.
- Patients older than 40 years of age with these tears have been shown to be associated with a rotator cuff tear.
- Patients younger than 40 years were associated with participation in overhead sports and shoulder instability.
- Treatment involves anatomic arthroscopic repair.
- TYPE III:
- Bucket-handle type tear displaced large fragment into (and lodged in) the joint.
- Biceps anchor is intact.
- Treatment involves anatomic arthroscopic repair.
- TYPE IV
- This is a vertical tear (bucket-handle tear) of the superior labrum, which extends into biceps tendon tear itself.
- May be treated with anatomical arthroscopic repair with or without a biceps tenodesis. A tenodesis is the anchoring of a biceps tendon back on to the bone. Tenodesis is performed if more than 50% of the tendon is involved.
Shoulder Arthroscopy is a minimally invasive surgical procedure which avoids cutting muscles and tendons in order to repair the affected area. Click on the links in this sentence to learn more about Shoulder Arthroscopy and Leon E. Popovitz, MD, who is a top orthopedic surgeon that performs Arthroscopic Shoulder Surgery.
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