Shoulder Slap Lesion

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SLAP tear is an injury to a part of the shoulder joint called the labrum. The shoulder joint is a ball and socket joint, similar to the hip; however, the socket of the shoulder joint is extremely shallow, and thus inherently unstable. To compensate for the shallow socket, the shoulder joint has a cuff of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move within.

A specific type of labral tear is called a SLAP tear; this stands for Superior Labrum from Anterior to Posterior. The SLAP tear occurs at the point where the tendon of the biceps muscle inserts on the labrum.

How does a SLAP tear occur?
Common reasons for a SLAP tear include:

  • Fall onto an outstretched hand
  • Repetitive overhead actions (throwing)
  • Lifting a heavy object

The area of the labrum where the SLAP tear occurs is susceptible to injury because it is an area of relatively poor vascularity. Other parts of the labrum often heal more easily because the blood supply delivers a healing capacity to the area of the tear. In the area of SLAP tears this is not the case, and chronic shoulder pain can result.

What are the symptoms of a SLAP tear?
Typical symptoms of a SLAP tear include a catching sensation and pain with shoulder movements, most often overhead activities such as throwing. Patients usually complain of pain deep within the shoulder or in the back of the shoulder joint. It is often hard to pinpoint symptoms, unless the biceps tendon is also involved. In cases of SLAP tears with associated biceps tendonitis, patients may complain of pain over the front of the shoulder.

How is a SLAP tear diagnosed?
There are several tests a skilled examiner can perform to detect for SLAP tears. These tests are part of a shoulder physical examination. In addition, careful questioning of the patient can help the examiner identify symptoms consistent with a SLAP tear.

Diagnosis of a SLAP tear can be difficult, as these injuries may not show up well on MRI scans. SLAP tears tend to be seen best on MRI when the study is performed with an injection of contrast. A contrast MRI is performed by injecting a fluid called gadolinium into the shoulder; the gadolinium helps to highlight tears of normal structures, including SLAP tears. Sometimes the diagnosis of a SLAP tear is made at the time of surgery.

Most patients with SLAP tears will respond to conservative (meaning non-surgical) treatments. Any patient with a SLAP tear will be advised to rest after the injury to allow the injured tissue to cool down. A period of rest will allow inflammation to subside and may help to alleviate symptoms.

Other treatments that are often used in cases of a SLAP tear include:

  • Physical therapy
  • Anti-inflammatory medication
  • Injections

What if these treatments do not work?
In patients who have continued symptoms despite these treatments, arthroscopic surgery of the shoulder may be recommended. There are several specific surgical procedures that may be performed, and it is important to understand that SLAP tears often occur in conjunction with other shoulder problems such as rotator cuff tears, and even shoulder arthritis. In these cases, surgical treatment will have to take into account these factors.

The primary treatment options for the SLAP tear are:

  • Debridement of the SLAP tear
    When a SLAP tear is debrided, the torn portion of the labrum is shaved away to leave a smooth edge. This option is only suitable for minor tears that do not involve the biceps tendon.
  • SLAP repair
    A SLAP repair is an arthroscopic procedure that uses sutures with anchors attached to resecure the torn labrum down to the shoulder socket. A SLAP repair is best suited to patients with an otherwise healthy shoulder who want to remain athletically active.

A SLAP repair is a procedure performed for treatment of a SLAP tear. Surgical treatment of a SLAP tear is considered for patients who do not respond to more conservative treatments. In these patients who have a symptomatic SLAP tear, surgical treatment is an option.

As stated previously, several surgical options are available. These include SLAP debridement, SLAP repair, and biceps tenodesis. A SLAP debridement simply removed any excess or damaged tissue that causes symptoms of catching and pain in the shoulder.

When is a SLAP repair an appropriate treatment?
A SLAP repair is considered for treatment when the attachment of the labrum (the so-called biceps anchor) is unstable. In these cases, debridement would not be adequate to alleviate the symptoms of the SLAP tear.

How is a SLAP repair performed?
A SLAP repair is performed arthroscopically using sutures to reattach the torn labrum back to the bone. The steps of a SLAP repair are:

1. The SLAP tear is identified and excess tissue is removed.

2. A small hole is drilled into the bone where the labrum has torn off (the SLAP tear).

3. An anchor is placed into this hole; attached to the anchor is a strong suture.

4. The suture is used to tie the torn labrum snuggly against the bone.

What are the advantages of a SLAP repair?

  • A SLAP repair restores the normal anatomy of the shoulder by reattaching the labrum in its normal position.
  • Once healed, the SLAP repair allows normal function of the previously damaged labrum and biceps attachment.

What are the advantages of other treatments such as debridement or tenodesis?

  • The rehabilitation is often not as restrictive as is the case with a SLAP repair.
  • The results of surgery are usually more predictable, as healing of a SLAP repair is not as reliable.

What is the rehab after a SLAP repair?
Rehabilitation varies depending on factors such as the strength of the SLAP repair, and the preference of the surgeon. Most often, a period of time of restricted motion is maintained for about six weeks following a SLAP repair. During this first phase of rehabilitation, some passive motion is allowed to prevent shoulder stiffness. In the first phase, the torn labrum is healing into its proper position.

Once healed, patients enter the second phase of rehabilitation and can begin more motion at about six weeks. Physical therapy continues to help maintain motion and regain strength of the shoulder. The final phase of rehabilitation involves more active strengthening of the muscles that surround the shoulder joint, and full recovery is expected between 3 to 4 months.

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Shoulder Dislocation / Instability

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Shoulder instability is a problem that occurs when the structures that surround the glenohumeral (shoulder) joint do not work to maintain the ball within its socket. If the joint is too loose, is may slide partially out of place, a condition called shoulder subluxation. If the joint comes completely out of place, this is called a shoulder dislocation. Patients with shoulder instability often complain of an uncomfortable sensation that their shoulder may be about to slide out of place–this is what physicians call apprehension.
Shoulder instability tends to occur in three groups of people:

  • Prior Shoulder Dislocators. Patients who have sustained a prior shoulder dislocation often develop chronic instability. In these patients, the ligaments that support the shoulder are torn when the dislocation occurs. If these ligaments heal too loosely, then the shoulder will be prone to repeat dislocation and episodes of instability. When younger patients (less than about 35 years old) sustain a traumatic dislocation, shoulder instability will follow in about 80% of patients.
  • Young Athletes. Athletes who compete in sports that involve overhead activities may have a loose shoulder or multidirectional instability (MDI). These athletes, such as volleyball players, swimmers, and baseball pitchers, stretch out the shoulder capsule and ligaments, and may develop chronic shoulder instability. While they may not completely dislocate the joint, the apprehension, or feeling of being about to dislocate, may prevent their ability to play these sports.
  • “Double-Jointed” Patients. Patients with some connective tissue disorders may have loose shoulder joints. In patients who have a condition that causes joint laxity, or double-jointedness, their joints may be too loose throughout their body. This can lead to shoulder instability and even dislocations.

What is the treatment of shoulder instability?
Treatment of shoulder instability depends on several factors, and almost always begins with physical therapy and rehab. If patients complain of a feeling that their shoulder is loose or about to dislocate, physical therapy with specific strengthening exercises will often help maintain the shoulder in proper position. Shoulder strengthening is most likely to help the second group of patients athletes with multi-directional shoulder instability. Other treatments sometimes used to treat shoulder instability include injections and anti-inflammatory medications.

Will I need surgery for shoulder instability?
If therapy fails, there are surgical options that can be considered. Depending on the cause of the instability, the surgical treatments may be quite different.

If the cause of the shoulder instability is a loose shoulder joint capsule, then a procedure to tighten the capsule of the shoulder may be considered. This can be done with an arthroscope in a procedure called athermal capsular shrinkage. In this surgery, a heated probe shrinks the shoulder capsule to tighten the tissue. The more standard method of this procedure is called an open capsular shift. In this surgery, the shoulder joint is opened through a larger incision, and the capsule is tightened with sutures. The advantage of the open capsular shift is that the results are more predictable. The advantage of the arthroscopic procedure is that the recovery is faster and the incision is smaller. Sometimes a particular problem is better suited to one procedure or the other, discuss this with our surgeon.

If the problem is due to a tearing of the ligaments around the shoulder, called the labrum, then a procedure called a Bankart repair can be performed to fix this ligament. A Bankart repair can also be done either through an incision or an arthroscope. Again, the results of the open procedure are more predictable (more patients get better), but the arthroscopic procedure does not leave as large an incision.

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Shoulder Arthritis

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Osteoarthritis is the most common type of shoulder arthritis. Also called wear-and-tear arthritis or degenerative joint disease, osteoarthritis is characterized by progressive wearing away of the cartilage of the joint. As the protective cartilage surface of the joint is worn away by shoulder arthritis, bare bone is exposed within the shoulder.

The other common type of shoulder arthritis is rheumatoid arthritis. Rheumatoid arthritis is a systemic condition that causes inflammation of the lining of the joints. This inflammation can, over time, invade and destroy the cartilage and bone.

Who develops Shoulder Arthritis?

Shoulder arthritis typically affects patients over 50 years of age. It is more common in patients who have a history of prior shoulder injury. There is also a genetic predisposition of this condition, meaning shoulder arthritis tends to run in families.

What are the common symptoms of Shoulder Arthritis?

Shoulder arthritis symptoms tend to progress as the condition worsens. What is interesting about shoulder arthritis is that symptoms do not always progress steadily with time. Often patients report good months and bad months, or symptom changes associated with weather changes. This is important to understand because comparing the symptoms of arthritis on one particular day may not accurately represent the overall progression of the condition.

The most common symptoms of shoulder arthritis are:

  • Shoulder Pain with activities
  • Limited range of motion
  • Stiffness of the shoulder
  • Swelling of the joint
  • Tenderness around the joint
  • A feeling of grinding or catching within the joint

Evaluation of a patient with shoulder arthritis should begin with a physical examination and x-rays. These can serve as a baseline to evaluate later examinations and determine progression of the condition.

What is the treatment for Shoulder Arthritis?

Treatment of shoulder arthritis should begin with the most basic steps, and progress to the more involved, possibly including surgery. Not all treatments are appropriate in every patient, and you should have a discussion with your doctor to determine which treatments are appropriate for your shoulder arthritis.

  • Shoulder Exercises
  • Physical Therapy
  • Anti-Inflammatory Medicines
  • Anti-Inflammatory Injections
  • Joint Supplement (Glucosamine)
  • Shoulder Arthroscopy
  • Shoulder Replacement Surgery

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Rotator Cuff Tear

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The rotator cuff is made up of four muscles that help move and stabilize the shoulder joint. Damage to any one of the four muscles or their ligaments that attach the muscle to bone can occur because of acute injury, chronic overuse, or gradual aging. This can cause significant pain and disability with range of motion or use of the shoulder joint.

The shoulder is a ball-socket joint that allows the arm to move in many directions. It is made up of the humeral head (the upper end of the bone of the upper arm) fitting into the glenoid fossa of the scapula (shoulder blade). The humeral head is kept in place by the joint capsule and labrum, thick bands of cartilage that form an elongated cone where the humeral head fits. The rotator cuff muscles are the dynamic stabilizers and movers of the shoulder joint and adjust the position of the humeral head and scapula during shoulder movement.

When the rotator cuff is damaged, a variety of issues arise:

  • Shoulder Pain and spasm limit the range of motion of the shoulder.
  • The muscles do not make the small adjustments within the joint to allow the humeral head to move smoothly.
  • Fluid accumulation within the joint due to inflammation limits movement.
  • Arthritis and calcium deposits that form over time limit range of motion.

The severity of injury may range from a mild strain and inflammation of the muscle or tendon, that will lead to no permanent damage, to a partial or complete tear of the muscle that might require surgery for repair.

What are the causes of Rotator Cuff Injury?

Injuries to muscle-tendon units are called strains and are classified by the amount of damage to the muscle or tendon fibers. Grade I strains involve stretching of the fibers without any tears. Grade II injuries involve partial muscle or tendon tearing, and grade III injuries are defined as a complete tear of a muscle or tendon.

The muscles and tendons in the rotator cuff group may be damaged in a variety of ways. Damage can occur from an acute injury (for example from a fall or accident), from chronic overuse (like throwing a ball or lifting), or from gradual degeneration of the muscle and tendon that can occur with aging.

  • Acute rotator cuff tear
  • This injury can develop from sudden powerful raising of the arm against resistance or in an attempt to cushion a fall (for example, heavy lifting or a fall on the shoulder).
  • The injury requires a significant amount of force if person is younger than 30 years of age.
  • Chronic tear
  • Found among people in occupations or sports requiring excessive overhead activity (examples, painters, baseball pitchers)
  • The chronic injuries may be a result of a previous acute injury that has caused a structural problem within the shoulder and affected the rotator cuff anatomy or function (for example, bone spurs that impinge upon a muscle or tendon causing inflammation).
  • Repetitive trauma to the muscle by everyday movement of the shoulder
  • Tendinitis
  • Degeneration (wearing out) of the muscles with age.
  • This usually occurs where the tendon attaches to bone. The area has poor blood supply and a mild injury may take a long time to heal and potentially lead to a secondary tear.

What are the symptoms of Rotator Cuff Injury?

Symptoms of a rotator cuff injury are due to the inflammation that accompanies the strain. This inflammation causes swelling, leading to the clinical picture of pain and decreased range of motion. Because the muscles and tendons of the rotator cuff are hidden well below skin level, it may be hard to feel the swelling that accompanies the injury, but that swelling within the small space that makes up the shoulder joint prevents the normal range of motion of the shoulder joint.

  • Acute rotator cuff tear
  • Symptoms can be a sudden tearing sensation followed by severe pain shooting from the upper shoulder area (both in front and in back) down the arm toward the elbow. There is decreased range of motion of the shoulder because of pain and muscle spasm.
  • Acute pain from bleeding and muscle spasm: This may resolve in a few days.
  • Large tears may cause the inability abduct the arm (raise it out to the side) due to significant pain and loss of muscle power.
  • Chronic rotator cuff tear
  • Pain usually is worse at night and may interfere with sleep.
  • Gradual weakness and decreased shoulder motion develop as the pain worsens.
  • Decrease in the ability to abduct the arm or move it out to the side. This allows the arm to be used for most activities but the affected person is unable to use the injured arm for activities that entail lifting the arm as high as or higher than the shoulder to the front or side.
  • Rotator cuff tendinitis
  • More common in women 35-50 years of age
  • Deep ache in the shoulder also felt on the outside upper arm over the deltoid muscle
  • Point tenderness may be appreciated over the area that is injured
  • Pain comes on gradually and becomes worse with lifting the arm to the side (abduction) or turning it inward (internal rotation)
  • May lead to a chronic tear: When a rotator cuff tendon becomes inflamed (tend=tendon +itis=inflammation), it runs the risk of losing its blood supply, causing some tendon fibers to die. This increases the risk that the tendon can fray and partially or completely tear.

What are the treatment options available for rotator cuff injury?

  • Anti-inflammatory medications like ibuprofen and naproxen may help reduce pain and swelling.
  • A sling may help support the arm rest the rotator cuff muscles. Long-term use of a sling is not advised, since it may cause significant stiffening of the shoulder joint.
  • Usually, acute rotator cuff injuries require more than one visit to the care provider and may also require referral to an orthopedic specialist for advice and care. Surgery may be considered within a few weeks, especially in younger, active patients, to return the shoulder to full function.

Indications for surgical treatment include the following:

  • Usually for patients younger than 60 years of age
  • Complete rotator cuff tears
  • Failure of conservative therapy (physical therapy, rest and anti-inflammatory medications) after six to eight weeks
  • Employment or sporting activity that requires constant shoulder use.

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What is Rotator Cuff Tendonitis?

Labral Tear (Labrum Tear)

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The shoulder joint is a ball and socket joint, similar to the hip; however, the socket of the shoulder joint is extremely shallow, and thus inherently unstable. This means that the bones of the shoulder are not held in place adequately, and therefore extra support is needed.

To compensate for the shallow socket, the shoulder joint has a cuff of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move within. The labrum circles the shallow shoulder socket (the glenoid) to make the socket deeper. This cuff of cartilage makes the shoulder joint much more stable, and allows for a very wide range of movements (in fact, the range of movements your shoulder can make far exceeds any other joint in the body).

What is a labral tear?
The labrum is made of a thick tissue that is susceptible to injury with trauma to the shoulder joint. When a patient sustains a shoulder injury, it is possible that the patient has a labral tear. The labrum also becomes more brittle with age, and can fray and tear as part of the aging process.

What are the symptoms of a torn labrum?
Symptoms of a labral tear depend on where the tear is located, but may include:

  • An aching sensation in the shoulder joint
  • Catching of the shoulder with movement
  • Shoulder Pain with specific activities

In addition, some types of labral tears, specifically a Bankart lesion, can increase the potential for shoulder dislocations.

What are the common types of labral tears? 
The most common patterns of labral tears are:

  • SLAP Tears 
    A SLAP tear is a type of labral tear most commonly seen in overhead throwing athletes such as baseball players and tennis players. The torn labrum seen in a SLAP tear is at the top of the shoulder socket where the biceps tendon attaches to the shoulder.
  • Bankart Lesions 
    A Bankart lesion is a labral tear that occurs when a shoulder dislocates. When the shoulder comes out of joint, the labrum is torn, and makes the shoulder more susceptible to future dislocations.
  • Posterior Labral Tears 
    Posterior labral tears are less common, but sometimes seen in athletes in a condition called internal impingement. In this syndrome, the rotator cuff and labrum are pinched together in the back of the shoulder.

Symptoms of a labral tear depend on where the tear is located, but may include:

  • An aching sensation in the shoulder joint
  • Catching of the shoulder with movement
  • Pain with specific activities

What is the treatment for a torn labrum?
The treatment of a torn labrum depends on the type of tear that has occurred. Most labral tears do not require surgery; however, in patients who have persistent symptoms despite more conservative treatments, surgery may be necessary.

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Rotator Cuff Tendonitis (Bursitis)

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What is Rotator Cuff Tendonitis?

Rotator cuff tendonitis is an inflammation (irritation and swelling) of the tendons of the shoulder.

What are the causes of Rotator Cuff Tendonitis?

The shoulder joint is a ball and socket type joint where the top part of the arm bone (humerus) forms a joint with the shoulder blade (scapula). The rotator cuff holds the head of the humerus into the scapula.

Inflammation of the tendons of the shoulder muscles can occur in sports requiring the arm to be moved over the head repeatedly as in tennis, baseball (particularly pitching), swimming, and lifting weights over the head. Chronic inflammation or injury can cause the tendons of the rotator cuff to tear.

The risk factors are being over age 40 and participation in sports or exercise that involves repetitive arm motion over the head (such as baseball).

What are the symptoms of Rotator Cuff Tendonitis?

  • Shoulder Pain associated with arm movement
  • Pain in the shoulder at night, especially when lying on the affected shoulder
  • Weakness with raising the arm above the head, or pain with overhead activities.

How to diagnose Rotator Cuff Tendonitis?
A physical examination may reveal tenderness over the shoulder. Pain may occur when the shoulder is raised overhead. There is usually weakness of the shoulder when it is placed in certain positions.

X-rays may show a bone spur, while MRI may show inflammation in the rotator cuff. An MRI can show a tear in the rotator cuff.

What is the treatment for Rotator Cuff Tendonitis?
Treatment involves resting the shoulder and avoiding activities that cause pain. Ice packs applied to the shoulder and nonsteroidal anti-inflammatory drugs will help reduce inflammation and pain.

Physical therapy to strengthen the muscles of the rotator cuff should be started. If the pain persists or if therapy is not possible because of severe pain, a steroid injection may reduce pain and inflammation enough to allow effective therapy.

If the rotator cuff has had a complete tear, or if the symptoms persist despite conservative therapy, surgery may be necessary. Arthroscopic surgery can be used to repair some tears and remove bone spurs and inflamed tissue around the shoulder. Some large tears require open surgery to repair the torn tendon.

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