Shoulder Labrum/Rotator Cuff

a. Labrum/Rotator Cuff

What is a Labral Tear?
A labral tear is a tear of the cartilage in the shoulder that surrounds the socket and helps to make it deeper. The ligaments that hold the ball of the shoulder to the socket attach to the shoulder at the labrum. These structures are often injured together. The biceps tendon attaches to the top of the shoulder socket at the labrum. Injuries to this attachment are called SLAP lesions (Superior Labrum Anterior-Posterior).

What causes a Labral Tear?

There are many ways in which the labrum can be injured. The most common include: shoulder dislocations, falls onto the shoulder or outstretched arm, and heavy lifting.Traction injuries, in which the shoulder is pulled away from the body, frequently lead to labral tears. Athletes who compete in sports requiring use of the arm overhead are particularly at risk. Sports where labral injuries are commonly identified include: baseball, softball, tennis and volleyball. Age related labral tears are common findings in older patients.

What are the symptoms?
Patients with labral tears will have shoulder pain, and may experience a click with range of motion. There is generally a loss of strength, and for throwing athletes, a loss of velocity. Overhead movements of the shoulder are painful. Re-dislocation may also occur. Tears involving the biceps tendon, will cause pain in biceps muscle. Patients may develop pain in their rotator cuffs as a result of failure of the labrum to hold the humeral head centered in the socket.

How is a Labral Tear diagnosed?
Your surgeon will obtain a careful history of your shoulder pain, and the mechanism by which the shoulder was injured. Patients who have had shoulder dislocations have a labral tear by definition. Physical exam may suggest a labral tear, but these are generally confirmed on MRI. Your surgeon may obtain an MRI with dye placed in the shoulder to more accurately evaluate the labrum. If the dye is seen to have entered inside, or completely surround the labrum, it is torn or detached. Even with MRI, labral tears can be difficult to detect. In this instance, your surgeon may suggest a shoulder arthroscopy to evaluate the labrum.

How is it treated?

Non-operative
Labral tears in sedentary or older patients, or in the non-dominant extremity of an athlete may be successfully treated non-operatively. Physical therapy to strengthen the rotator cuff will help maintain the humeral head in the socket and reduce pressure on the labrum. Anti-inflammatory medications or a cortisone injection may be offered.

Operative
Symptomatic labral tears in the dominant extremity of athletes, and patients who have failed non-operative treatment, will require arthroscopic surgery. If the labrum is not repairable, it is trimmed away. Labral tears, which can be repaired, are reattached to the socket with small plastic devices containing suture. Young patients who have suffered shoulder dislocations should undergo operative repair, as the labrum and ligaments injured during a dislocation do not heal. This leaves the patient at risk for future dislocations and arthritis. SLAP tears are treated identically, except when they extend into the biceps tendon. If the biceps attachment is severely compromised, the biceps is released from the socket, and reattached outside the shoulder joint.

b. Rotator Cuff Tears

What is a Rotator Cuff Tear?
A Rotator Cuff tear is a detachment of the tendon from the humeral head. The rotator cuff is the group of tendons whose muscles act to center and stabilize the humeral head in the shoulder socket. They provide power to assist in rotation and elevation to the shoulder joint. Rotator cuff tears may be partial or complete.

What causes Rotator Cuff Tears?
Rotator cuff tears may result from trauma, such as motor vehicle accidents or falls onto the shoulder or outstretched hand. Patients with occupations that frequently require them to lift their arms over their heads, such as plumbers, painters, electricians and carpenters, are particularly at risk. Lifting a heavy object may lead to a tear. Athletes who play overhead sports, such as baseball, softball, volleyball and tennis may develop tears. Patients with curved acromions, or those with bone spurs, or arthritis in the shoulder are at risk.  Older patients who dislocate their shoulder will frequently tear their cuffs. In some patients, the rotator cuff will tear due to age-related wear without an identified incident.

What are the symptoms?
Patients will complain of pain in the outside portion of the shoulder, especially at night. They point to the anterolateral area of the deltoid muscle as the chief source of pain. Although the problem is deep inside the shoulder joint, the brain interprets the pain as coming from lower down in the arm. When the brain feels pain in a different location than the cause of the problem, it is called ‘referred pain’. Patients will have pain with overhead lifting, or with rotating the arm internally, such as reaching for a wallet, or unhooking a bra strap.  Patients with larger tears will have a loss of strength or be unable to lift the affected arm. Patients may also complain of clicking or popping when moving the shoulder.

How is a Rotator Cuff Tear diagnosed?
Your surgeon will take a history of your shoulder pain and perform a physical examination. On exam, patients typically demonstrate weakness with elevation and rotation of the arm. Placing the rotator cuff under stress reproduces pain. X-ray may show indirect signs of a tear, such as the shape of the acromion, changes in the attachment site of the cuff, the humeral head sitting too high in the socket or arthritis in the shoulder. MRI will confirm the tear. Some surgeons use ultrasound to detect rotator cuff tears.

How is it treated?

Non-operative
Non-operative treatment can be attempted in patients with partial tears of the rotator cuff, or small tears with minimal symptoms. Physical therapy, anti-inflammatory medication or cortisone injections into the space just above the cuff may alleviate pain. Patients whose pain does not resolve with non-operative treatment should undergo surgery.

Operative
Tears in which the tendon has detached from the bone should be surgically repaired, as they cannot heal on their own. Your surgeon may perform this operation arthroscopically or through an open incision. The cuff is sutured and pulled back to its original attachment sight. It is held in place using suture connected to anchors, or passed through tunnels created in the bone.

Partial tears that fail to improve with non-operative treatment should be evaluated arthroscopically. If a partial tear involves more than 50% of the tendon, a repair should be performed. If the tear is less than 50% of the tendon, than the injured tissue can be trimmed and more space for the cuff created by removing some bone over the top of the cuff. This is called ‘subacromial decompression’, because the bone is removed from the undersurface of the acromion.Following a procedure, your surgeon will recommend a sling to protect the repair while it heals, and start physical therapy to regain motion and strength in the shoulder.

c. Proximal Biceps Rupture

What is a Proximal Biceps Rupture?
The biceps tendon attaches in two places inside the shoulder and one in the forearm. Its function is to turn the palm of the hand face-up and assist in flexing the elbow. It exits the shoulder just in front of the rotator cuff and passes through a groove in the humerus called the bicipital groove. A proximal biceps rupture occurs when the tendon tears in or above the bicipital groove.

What causes Proximal Biceps Ruptures?
Biceps ruptures occur as a result of overuse of the shoulder or from an injury, such as a fall. Because the tendon is closely associated with the rotator cuff, injuries to the anterior cuff will place more stress on the biceps, leading to inflammation, deformity and eventual failure of the tendon.

What are the symptoms?
Patients with biceps ruptures will have pain, swelling and sometimes bruising in the front of the shoulder. The biceps is tender to the touch. A visible deformity will be present, in which a depression will form in the top of the biceps, and a bulge will form in the lower part of the arm as the sagging muscle slumps down. This is referred to as a ‘Popeye Deformity’, as the biceps will form a large ball when flexed by the patient. Patients will also have trouble turning doorknobs, using screwdrivers or lifting their arm over their heads.

How are Proximal Biceps Ruptures diagnosed?
Your surgeon will perform an examination that stresses the biceps muscle. Tenderness over the biceps and a ‘Popeye’ deformity are diagnostic. If obtained, an MRI of the shoulder will show an empty bicipital groove.

How is it treated?

Non-operative
Because there is no functional deficit from Proximal Biceps ruptures, strong consideration should be given to non-operative treatment. Physical therapy, anti-inflammatory medication (NSAIDS), and avoiding painful activities will usually resolve the symptoms.

Operative
In patients dissatisfied with the ‘Popeye Deformity’ or with persistent pain, a biceps tenodesis should be performed. Through an open incision, your surgeon locates the end of the torn biceps in the arm. The surgeon shortens the tendon and reattaches it under tension with a screw or anchors to the humerus. This provides relief of pain and corrects or improves the cosmetic deformity.

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