Brief introduction to shoulder labrum tear

The labrum refers to a ring of firm tissue around your shoulder socket that ensures your shoulder remains more stable. In short, the labrum is responsible for keeping your arm bone in the shoulder socket.

An injury to this part of the shoulder (shoulder labrum tear) is generally referred to as SLAP tear which stands for "superior labrum, anterior to posterior". 

But what causes this kind of a tear? There are a number of factors that can prove to be the cause.

• ·         A fall on your outstretched arm.
• ·         A fall on your shoulder.
• ·         Brace yourself with your outstretched arm in a car accident.
• ·         Lift heavy objects repeatedly or too suddenly.
• ·         Excessive overhead activities, such as throwing a ball etc.

Common symptoms seen in SLAP tears are:               

• ·         Popping, clicking or catching in the shoulder.
• ·         Severe pain when the arm is moved over the head or other similar actions.
• ·         A feeling of weakness or instability in the shoulder.
• ·         Aching pain. People often have a hard time describing or pointing to exactly where the pain is.

Identification of a SLAP tear can be tough owing to the fact that they are not so common and there are numerous factors causing shoulder pain. To ensure a right diagnosis of a SLAP tear, the following methods may be utilised by your physician:

• ·         Conduct tests by moving the joint to check which movement cause pain
• ·         Use MRI arthrogram method where a is injected into your shoulder before you have an MRI scan to pinpoint the affected area
• ·         The best way to confirm a SLAP tear would be a shoulder arthroscopic surgery. This method is a better choice as the shoulder surgeon can effectively repair the tear during the very same surgery.

The initial course of treatment in such cases would involve pain medicine and rehabilitation (rehab) which would include exercises to strengthen the rotator cuff muscles. Following which, NSAIDs, which are anti-inflammatory medicines, may be prescribed in the treatment for shoulder pain. Patients can also be suggested to try using heat or ice on the affected shoulder for about 15 to 20 minutes at a time. A sling would be generally advised if the shoulder pain becomes severe during this period.

Common factors preceding rotator cuff tear treatment

There are a number of reasons as to how a rotator cuff tear can occur. But what exactly is a rotator cuff is? A rotator cuff tear refers to a tear of one or more of the tendons of the four rotator cuff muscles of the shoulder. Known to be one of the most common conditions affecting the shoulder, injury to the rotator cuff can include any type of irritation or overuse of those muscles or tendons.

So now that we’ve shed some light on the condition, let’s delve deeper into circumstances where the option of rotator cuff tear treatment is one to consider.

- If you experience shoulder pain when at rest and it doesn’t show signs of improvement even after exercise over a period of six months or more.

- You have an active lifestyle which involves a lot of movement of the shoulder.

- You are experiencing weakness in the shoulder and it restricts your daily activities.

In most cases, a partial tear wouldn’t require surgery. Rather, the ideal course of action in such cases would a good amount of rest and relaxation to aid the healing process of the shoulder. This process works best for individuals who don’t apply excessive strain on their shoulder on a regular basis.

But there are times when this approach just doesn’t aid the treatment of shoulder pain. Mentioned below are some of the common scenarios where rotator cuff surgery is the only course of action left:

- The rotator cuff tear is a large or completely torn.

- A recent injury was the case of the tear.

- The tendons of the rotator cuff were not already torn from chronic rotator cuff problems.

So, when a diagnosis of rotator cuff tear is made, discuss these factors with your shoulder surgeon/physician in details to gain better insight into the treatment process.   

Shoulder fracture - Proximal Humerus fractures

Proximal Humerus fractures are the third most common fractures in the elderly population. Fortunately 80% of the fractures are non-displaced or minimally displaced and can be managed non-operatively. The remaining 20% of the fractures require some sort of operative management. The fractures that require surgery are the ones that are significantly displaced and will not yield a good outcome if left as such in the displaced position. 

Proximal humerus fractures are divided into 3 major types- two part, three part or four / five part fractures depending on weather the Greater tuberosity or lesser tuberosity is fractured from the shaft of the humerus bone. The two part fractures are simple to treat operatively if displaced. They can be fixed with a interlock nail of locking plate.  The three part and four part can be managed non-operatively if they not significantly displaced. The recent published data shows that the three part fractures that are significantly displaced in the older age group tend to have similar outcomes whether managed non-operatively or if fixed internally with a locking plate. However it will be wise to anatomically reduce and fix a significantly displaced fracture in the younger age group to restore active movements the shoulder.

Often in the elderly age group when the fracture is 4-5 part and the bone is very osteoporotic, internal fixation is not a good option and in this scenario, the head of humerus needs to be replaced. Hemi-replacement of the shoulder has been practiced since a long time with average to fair results. Off late reverse shoulder replacement for comminuted proximal humerus fractures has been increasingly used in the western countries.

Reverse shoulder replacement yields superior outcomes than hemi replacement in the elderly in very comminuted fractures, especially when the greater tuberosity is also broken into many pieces. Experience with reverse shoulder has grown in recent years and while there are reportedly more complications with this prosthesis, it also yields far superior results if properly done.

In short the recommendation is for non-operative management in both young and old for minimal displaced or non-displaced fractures. In the significantly displaced 3-4 part fractures, internal fixation by locking plate is best in the younger age group and some older people, though most elderly will require either they being left alone or replaced with hemi replacement or reverse shoulder replacement

Arthroscopic Repair

Shoulder arthroscopy involves a tiny camera called an arthroscope to examine or repair the tissues inside or around the shoulder joint. The arthroscope is inserted through a small incision (cut) in the skin.

The word arthroscopy is derived from two Greek words, “arthro” (joint) and skopein" (to look). Therefore, the term literally means "to look within the joint.“ During the procedure, the surgeon inserts a small camera, called an arthroscope, into the shoulder joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments. 

Due to the thin structure of the arthroscope and surgical instruments, the surgeon uses very small incisions, rather than the larger incision needed for standard, open surgery. This results in less pain for patients and shortens the recovery time.

Causes

Injury, overuse, and age-related wear and tear are common reasons behind most shoulder problems.

Arthroscopic shoulder surgery

may relieve painful symptoms of many problems that damage the rotator cuff tendons, labrum, articular cartilage, and other soft tissues surrounding the joint.

Common arthroscopic procedures include:

·         Rotator cuff surgery

·         Bone spur removal

·         Removal or repair of the labrum

·         Repair of ligaments

·         Removal of inflamed tissue or loose cartilage

·         Repair for recurrent shoulder dislocation

Less common procedures such as nerve release, fracture repair, and cyst excision can also be performed using an arthroscope. 

The procedure

Shoulder arthroscopy is most commonly performed using regional nerve blocks which numb the shoulder and arm. This numbing medicine is injected in the base of the neck or high on the shoulder. This is where the nerves that control feeling in the shoulder and arm are located. In addition to its use as an anesthetic during surgery, a nerve block will help control pain for a few hours after the surgery is completed. Many surgeons combine nerve blocks with sedation or a light general anesthetic because patients can become uncomfortable staying in one position for the length of time needed to complete the surgery.

Most arthroscopic procedures take less than an hour; however, the length of the surgery depends on what repairs are required.

During the surgery, the surgeon will first inject fluid into the shoulder to inflate the joint. This makes it easier to see all the structures of the shoulder through the arthroscope. The surgeon then proceeds to make a small puncture in the shoulder (about the size of a buttonhole) for the arthroscope. Fluid flows through the arthroscope to keep the view clear and control any bleeding. Images from the arthroscope are projected on the video screen showing the surgeon the inside of the shoulder and any damage.

The surgeon may close the incisions with stitches or steri-strips (small Band-Aids) and cover them with a large, soft bandage.

Recovery

Although recovery from arthroscopy is often faster than recovery from open surgery, it may still take weeks for the shoulder joint to completely recover.

Some pain and discomfort can be expected for at least a week after surgery. In cases involving extensive surgery, it may take several weeks before the pain subsides. Ice and painkillers aid in the treatment for shoulder pain that follows the surgery.

Also, rehabilitation plays an important role in the recovery process. An exercise program helps regain shoulder strength and motion.

Frozen shoulder or adhesive capsulitis

“Frozen Shoulder” term is a big misnomer.

There is nothing frozen inside or outside the shoulder. In fact it may just be the opposite. The tissues may be inflamed to some extent for some time period.

Codman coined the term “frozen shoulder” in 1934.  However, now it is loosely applied to any misunderstood painful condition of the shoulder.

Scientifically speaking, frozen shoulder, also known, as adhesive capsulitis is a global restriction of movements of the shoulder, which is diagnosed clinically and with a plain X Ray without the aid of any complex investigation like MRI or CT scan

The most important role in diagnosing this condition is that of the clinician, since this can only be diagnosed clinically.

The big question is, however, how to best treat it? Surgery? Rest? Exercise? Physiotherapy?

There are equal numbers of patients disappointed by each of the above treatment modalities.

The best way forward is very clear in my mind, after having treated several of frozen shoulders. Exercises done at home with a corticosteroid injection in the shoulder is the best way to treat it. The key point is to never opt for surgery and to remember that the patient has to work hard at the exercises by himself at home without relying on physiotherapy.

Injection of a corticosteroid is one of the key steps in the management of this condition, since the pain in shoulder does not let the patient do a whole lot of exercises. An injection in the shoulder eases the pain and in some cases the pain disappears entirely within 3-4 weeks. The site of injection, however, varies as per the preferences of the treating physician. The latest advancement in the field of pain management is to inject corticosteroid in the area of the Suprascapular Nerve, which eases the pain considerably.

This is followed by a set of stretching exercises done at home regularly, which slowly increases the range of motion of the patient’s shoulder.

The onlything to remember here is that these are stretching exercises and NOT theraband or strengthening exercises. 

Shoulder Replacement Surgery

Shoulder replacement surgery involves replacing the shoulder joint if it has been damaged or worn away, usually by arthritis or injury. The primary goal of shoulder replacement surgery is pain relief, with a secondary benefit of restoring motion, strength, function, and assisting with returning patients to an activity level as near to normal as possible. 

Causes

Shoulder replacement surgery is usually done when there is severe pain in the shoulder area, which limits the ability to move the arm. Common reasons behind shoulder pain are:

·         Osteoarthritis

·         Poor result from a previous shoulder surgery

·         Rheumatoid arthritis

·         Badly broken bone in the arm near the shoulder

·         Badly damaged or torn tissues in the shoulder

.         Tumor in or around the shoulder

Procedure

Before surgery

The patient is asked about any medications that they have been taking. This includes medicines, supplements, or herbs bought without a prescription. Medicines which make blood clotting harder to occur shall be refrained from consumption before surgery. Consumption of cigarettes or alcohol would be prohibited before the surgery as these factors slow down the recovery process. The patient will likely be asked not to drink or eat anything for 6 to 12 hours before the procedure.

During surgery

There are various types of shoulder replacement surgeries. For total shoulder replacement, the round end of the arm bone will be replaced with an artificial stem that has a rounded metal head. The socket part (glenoid) of the shoulder blade will be replaced with a smooth plastic shell (lining) that will be held in place with special cement. If only 1 of these 2 bones needs to be replaced, the surgery is called a partial shoulder replacement, or a hemiarthroplasty.

For shoulder joint replacement, the surgeon will make an incision (cut) over the shoulder joint to open up the area. Then the surgeon will:

·         Remove the head (top) of the upper arm bone (humerus)

·         Cement the new metal head and stem into place

·         Smooth the surface of the old socket and cement the new one in place

·         Close the incision with staples or sutures

·         Place a dressing (bandage) over the wound.

The surgeon may place a tube in this area to drain fluid that may build up in the joint. The drain will be removed when the patient no longer needs it. Usually, the surgery takes about 1 to 3 hours. The patient would be expected to stay in the hospital for 2 to 3 days post surgery. Painkiller may be prescribed as treatment for shoulder pain to lessen any discomfort when the anesthetic wears off.

Recovery

It usually takes at least three months to make a full recovery from a shoulder replacement surgery. However, this varies between individuals, so it’s important to follow the surgeon’s advice.

The amount of time the dissolvable stitches take to wane off depends on the type of stitches used. For this procedure, they should usually disappear in about six weeks. The patient may need to keep their arm in a sling for several weeks after the operation.

 They should be able to look after themselves and eat and dress within a few weeks after surgery. The patient should refrain from placing their arm in any extreme positions (such as straight out to their side or behind their back) for six weeks after the operation.

The surgeon may recommend avoiding any heavy lifting for up to six weeks after the operation. It’s best not to do any repetitive heavy lifting at all after the operation as this will help the new joint last longer.

What is a Bankart Repair?

The glenoid labrum is a fibrocartilage rim surrounding the edge of the glenoid fossa (shoulder socket). The shoulder labrum tear can occur in different ways. When a patient’s shoulder is dislocated, the anterior (front) portion of the labrum is often torn. This is called a Bankart tear or lesion, and it is the most common form of ligament injury to the shoulder.  Many of these patients will go on to experience recurring shoulder dislocation.  This will have a significant effect on the ability to participate in sport and sometimes also their work.

Recent technical advances combined with improvements in implant choice and suture material this arthroscopic shoulder surgery the procedure of choice. Current arthroscopic techniques are associated with failure rates of 5% to 10%, comparable to open procedures.

Advantages

The advantages of an arthroscopic shoulder surgery include less surgical morbidity, less postoperative pain, improved cosmesis and an easier, if not shorter, rehabilitation. Also, the anatomy can be better visualized at the time of surgery and if the tear is more extensive, particularly if it extends into the posterior part of the shoulder the arthroscopic procedure allows for this to be repaired at the same time.

Procedure
The goal of the procedure is to re-attach and tighten the torn labrum and ligaments of the shoulder. To do so, the surgeon inserts an arthroscope into a small incision and uses sutures and small bone anchors to secure the ligaments firmly in place. It is performed under a general anaesthetic and generally takes about an hour. The patient will be in the operating theatre complex for several hours as they need to be prepared for anaesthesia and then will need to wake up from the anaesthetic. Usually, an overnight stay is recommended post surgery.

Recovery

Following the procedure, the patient will be wearing a sling with a body belt. This may be a standard sling or an External Rotation sling, depending on the procedure performed.  The sling should be worn at night and when out and about for 3 weeks. The patient will then wean off the sling with the aid of a physiotherapist over the next 3 weeks. 

A nerve block is usually used during the surgery. This means that immediately after the operation the shoulder and arm often feel completely numb. This may last for a few hours. After this, the patient may experience soreness in their shoulder. Treatment for shoulder pain would include administration of painkillers during the hospital stay. These can be continued after they are discharged. Ice packs may also help reduce pain.

This operation is usually done through two or three 5mm puncture wounds. There will be no stitches, only small sticking plaster strips over the wounds. These should be kept dry until healed. This usually takes 5 to 7 days.

For the first three weeks most activities of daily living for example feeding, dressing, cooking etc must be carried out using the un-operated arm. The patient will not be able to drive for a minimum of 6 weeks. The surgeon will confirm when the patient may begin.