Overview

Rotator Cuff Tear

The combination of the muscles and ligaments in the shoulder is called the "rotator cuff." The rotator cuff is located under part of the shoulder blade and provides stability to the joint during movement. Rotator cuff injuries are fairly common. Causes of this injury may include falling, lifting and repetitive arm activities, especially those done overhead. A common tear in the rotator cuff is an acute tear. This tends to happen as a result of a sudden, powerful impact.

Symptoms may include pain and tenderness in the shoulder, especially when reaching overhead, behind the back or pulling and lifting items. The patient may also experience shoulder weakness and loss of shoulder range of motion. Symptoms may show up immediately or gradually, depending on the extent of the injury.

Labral Tear

The shoulder joint is very 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 ring of cartilage around the socket called a labrum that forms a deeper cup for the ball portion of the upper arm bone (humerus). This ring of cartilage increases stability of the shoulder joint, yet allows for a wide range of movements. The following describes two common labral tears.

    Bankart Lesion Tear

The Bankart lesion is one of the more common causes of instability in the shoulder. It is a tear of the labrum below the middle of the glenoid socket. This type of tear can occur from stresses placed on the front of the shoulder when performing overhead activities such as throwing or serving a tennis ball. Another common way to develop a Bankart lesion is when a shoulder dislocates. As the shoulder moves out of the joint, the labrum is often torn, especially in younger patients.

Symptoms of a Bankart lesion may include a sense of instability or aching in the shoulder. You may even experience repetition of the dislocation or a catching sensation in the shoulder. Patients will often complain that they cannot trust their shoulder, fearing it may dislocate again.

    SLAP Lesion Tear

SLAP is short for Superior Labrum from Anterior (front) to Posterior (back). It is a tear of the labrum above the middle of the glenoid socket. This type of labral tear is 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. An injury or tear to this part of the body typically results from overuse, trauma and accidents such as falling onto an outstretched hand.

Symptoms of a SLAP Lesion may include some pain and soreness in the front of the shoulder when bending the elbow or turning the wrist. You may also experience a click or snap with movement of the shoulder and it may feel like the shoulder is being dislocated.

Biceps Tendon Rupture

A biceps tendon rupture results when the tendon attachment separates from the bone. Following a biceps tendon rupture, the muscle cannot pull on the bone, and certain movements may be weakened and painful. There are two types of biceps tendon ruptures: proximal and distal biceps tendon ruptures. Proximal is an injury to the biceps tendon at the shoulder joint and distal is an injury toward the elbow joint.

A distal biceps tendon rupture is characterized by sudden pain over the front of the elbow. Swelling and bruising around the elbow are also common symptoms. A proximal biceps tendon rupture usually does not include a significant amount of pain; however, some patients may experience pain relief after the rupture.

Treatment

Non-surgical

Partial tears to these shoulder muscles and ligaments can typically be treated with rehabilitation and bracing. However, specific treatment for a shoulder ligament/tendon injury will be determined by your physician based on age, overall health, medical history, extent of the injury, the patient's tolerance for specific medications, procedures and therapies. Also, depending on the extent of the injury, treatment may include muscle-strengthening exercises, protective shoulder brace, RICE (rest, ice, compression and elevation), or potentially surgery.

Surgical

If the ligament is a complete tear or the patient is not healing from rehabilitation therapy, then the surgeon may suggest a complete reconstruction of the ligament in order to prevent further damage and stabilize the shoulder. Arthroscopic surgery may be performed. Arthroscopy is a technique that allows surgeons to visualize, diagnose and treat a variety of joint problems. Rotator cuff tears, labrum tears, biceps tendon rupture,  and many other conditions can all be treated arthroscopically. Arthroscopy is performed using an arthroscope, a small optic instrument that enables a close look at the inside of a joint through a small skin incision.

Arthroscopic surgery was developed as a way to avoid making long skin incisions. While the long incisions allowed surgeons to fully visualize the joint, the subsequent disruption of tissue created long healing times, increased risk of infection and resulted in long scars.

Arthroscopic surgery avoids long, invasive incisions by using an arthroscope, a small tube-like instrument that allows the surgeon to see inside the joint. The arthroscope is inserted into the joint through a short incision generally less than 1/4" - 1/2". Several small incisions may be made to see other parts of the joint or to insert instruments. The arthroscope uses a camera that projects the image of the joint onto a monitor. The surgeon is able to view the joint, and its structures, including cartilage, ligaments and surrounding tissue. Once the problem is identified, the surgeon may be able to use specially designed instruments and/or implantable fixation devices to repair conditions or remove any damaged bone or tissue.

Recovery

Arthroscopic surgery rarely takes more than an hour or two for isolated injuries. Most patients who have arthroscopic surgery are discharged within the same day. The small skin incision wounds take several days to heal. Several follow-up appointments may be necessary. The patient can usually resume daily activities within a few days, but the injury may require several weeks to months to fully recover. Surgery may involve the repair, reconstruction or removal of the damaged tissue. Suture anchors may be used to sew the damaged tissue back in place. A physical therapy program will usually follow the surgery in order to strengthen the muscles and restore full joint mobility.

    Rotator Cuff/Impingement

Post-surgical care for impingement and rotator cuff tears are similar. General care recommendations include:

1. *    Incisions must be kept dry for two or three days after surgery.
   

2. *    Stitches are usually removed 7 - 10 days after surgery.
   

Impingement rehabilitation begins almost immediately:

1. *    Exercises to regain shoulder motion usually begin with a therapist in the first week after surgery and continue for about 6 weeks.
   

2. *    At 6 weeks, most patients have regained full motion and will continue to regain strength with a home exercise program.
   

3. *    Full recovery time after surgery varies; most patients have greatly improved at 3 months and are close to normal by 6 months.
   

Rotator cuff recovery is generally slower and requires more supervision. In order to achieve a full and rapid recovery, surgery should be performed as soon as the patient has full range of motion and has gained good muscle strength from a physical therapy program started when the injury is first detected. After surgery, the patient follows a closely monitored program:

1. *    Therapy is carefully controlled in the first 6 - 12 weeks while the tendons heal back to the bone.
   

2. *    The first goal is to regain full motion within 3 months after surgery. A therapist will assist in the early stages with gradual recovery of motion.
   

3. *    During the first 6 weeks, there is no active use of the shoulder in order to protect the surgical repair.
   

4. *    Once initial healing is achieved, a progressive stretching and strengthening program should begin.
   

5. *    Full recovery can take more than 6 months. Some patients may require more time to regain muscle strength and complete the healing process.
   

    Labral Repair

In the early recovery period, physical therapy to regain hand and elbow range of motion can begin immediately. Labral tears that require only debridement are allowed early range of motion and physical therapy to prevent stiffness.

1. *    Sutures are inspected seven to ten days after surgery and showering can resume.
   

2. *    Shoulder range of motion exercises after a biceps repair begin approximately six weeks after surgery, when the healing process is complete.
   

Physical therapy concentrates on treating factors that may have caused the labral injury, such as poor throwing mechanics. The patient's strength and rotator cuff health can be maximized with therapy, which helps the shoulder recover from what may have been a long period of inactivity due to pain.

Labral injuries that involve repair or tenodesis of the biceps tendon require a period of immobilization to allow the tendon to heal back to bone. After approximately four weeks of sling immobilization, physical therapy may begin.

Overhead athletes with SLAP repairs can expect a substantial delay before they can resume throwing. It usually takes about six months for the patient to regain full endurance and throwing velocity.

This recovery may include resting of the muscle and limited activity or rehabilitation therapy, which involves range of motion and strength exercises to help restore the shoulder to full function. These include flexibility and muscle strengthening exercises targeting the muscles around the rotator cuff and scapula. Depending on the injury, physical therapy may last anywhere from a few weeks to a few months. The surgeon may have you perform different exercises in order to help regain strength to the ligament.