November 29, 2014

Managing Expectations When Recovering from a Labral Repair

I have seen many clients with post-operative shoulder labral repairs. It is a frustrating injury that takes time to recover from. Being the recipient of two labral repair surgeries myself, it is my opinion that the key to recovery with a labral injury is managing expectations.

Figure 1. A and B) Uniaxial loading of biceps tendon leading to SLAP lesion in the neutral position (Bey et al. 1998)

The shoulder labrum is a fibrous, or rigid type of cartilage. This type of cartilage is found only around the attachment of the socket. The two main functions of the labrum are to deepen the socket (thus providing added stability) and to be an attachment for other structural tissues such as the biceps tendon around the joint.

The labrum is typically torn from one of the following.

1. Damage to attaching ligaments of the shoulder resulting from repetitive actions or over-use.
2. A subluxation or dislocation of the shoulder, usually occurring from trauma. Dislocation can occur anteriorly or posteriorly.

Figures A and B show the subluxation uniaxial loading seen when holding a dumbbell. Figure two shows a throwing motion: Notice the detachment of the bicep tendon with the labrum. There are four types of SLAP classifications, which can be a factor in the recovery process.

I wanted to touch on how this injury occurs in order to point out the degree of recovery needed. Recovery depends upon many factors, such as lesion location, severity, and the quality of surgical repair. The Johns Hopkins orthopedic surgery website reports with regards to recovery that

Figure 2) during the late cocking phase of throwing (Rodosky et al. 1994).

“It is believed that it takes at least four to six weeks for the labrum to re-attach itself to the rim of the bone, and probably another four to six weeks to get strong. Once the labrum has healed to the rim of the bone, it should see stress very gradually so that it can gather strength. It is important not to re-injure it while it is healing. How much motion and strengthening of the arm is allowed after surgery also depends upon many factors, and it is up to the surgeon to let you know your limitations and how fast to progress. Because of the variability in the injury and the type of repair done, it is difficult to predict how soon someone can to return to activities and to sports after the repair. The type of sport also is important, since contact sports have a greater chance of injuring the labrum repair. However, a vast majority of patients have full function of the shoulder after labrum repair, and most patients can return to their previous level of sports with no or few restrictions.”

The Johns Hopkins orthopedic surgery website does leave recovery time open for interpretation and dependent on each case. I feel that recovery typically takes longer than expected.

The recovery time can be separated into three stages. The first is acute pain stage (difficulty when sleeping), which usually lasts 4-6 weeks. This time usually involves a formal physical therapy process.

The second stage is continued strengthening and stretching with slight discomfort (minimal to no pain). During this stage the patient/client will report “I still feel like I am going to dislocate and have this funny crackling in my shoulder”. This stage can range from 12-16 weeks (therapy to post rehab transitional stage). Don’t be alarmed. The labrum repair tightened the joint and likely causing minor pressure on the repaired tissues that are unfamiliar. This feeling will recede over time.

The final stage is the transition to your “new normal” lifestyle and exercise. This stage varies and could be 6-12 weeks of feeling “normal again”. Realistically, many patients are looking at 9 months to 1 year of total recovery time before they feel “normal” again.

I hope this information helps you when managing expectations. Frustration is common, and patience is key. The time frame may indeed be longer than you may expect, but it is better to manage your expectations and realize that you will have a “new normal”. Do not rush your rehabilitation, as many people find themselves re-injuring their shoulder.

For more information on SLAP repairs http://hopkinsortho.org/labrum_tear.html

By: Phillip Godfrey MES, PFT

Comments

  1. Gday guys

    5 weeks post Bankhart and Hills sachs repair. Bankhart 3-6 o’clock tear, Hills sachs 25mm long 5 mm deep dent repaired by stitching muscle into the dent.

    I’m a skydiver and need to be able to reach straight up arms outstretched (bicep by my ear) to control the parachute. I haven’t commenced physio yet but will do in a week or so.

    My question I guess is how much movement am I likely to regain. In my head I’m concerned about how much the Hills Sachs repair will reduce my range of motion.

    Cheers

    Simon

    • Simon

      Bankhart repairs are commonly done to keep the shoulder from dislocating or otherwise translating in a forward direction. It is normal for the shoulder to heal back in a slightly tightened position in comparison to what you had before the surgery. I would expect you to lose a few degrees of external rotation from the residual tightness, but certainly to so much that you could not place your hands behind your head.

      The thing to remember here is that you will likely not have your new “normal” range until at least 4-6 months after the surgery (sometimes longer). Be patient with it, and don’t push your range to the point of sharp pain. You will get there.

  2. Hello,
    i had a slap injury since last may.it was a 5cm tear.i couldn’t do push movements.
    physio didn’t work so my doctor said to do arthroscopic surgery.
    so i did 41 days ago.
    he only cleaned the wound and carved the bone.(i thought he should stich it too but he said it didn’t need to)

    so now after 3 weeks of physio the physio this week the physio made me do some exercises with 1kilo weight.there is a specific exercise(chest press) that when i do it i have the same pain in the tendon i had before the surgery.i am really scared.is it reinjured?or it never healed.i am getting depressed i need to get back to the gym and train again,i am semi-pro athlete.

    thanks in advance

    • George it is still very common to have pain this soon after the surgery, you are probably not going to feel like yourself until about six months after the surgery. I would lay off any weights for the time being and do things (with the approval of the doc and the PT) that are less resistive. You most likely just irritated it a bit.

  3. Hi, I had a labrum tear surgery about little over 8 weeks ago. I have been in Physical therapy for a little over a month and I am doing all my stretches that I’m told to do at home and I’m going to PT three times a week. I’m freaking out by reading that I have about one more month to get my full range of motion back. I’m about half way there. I didn’t get surgery to not have my full range of motion. How much time do I have ?
    Please help!

    • Valerie I do not know what you are reading, but it will likely take you at least six months to get back your full ranges of motion. Do not freak out. Stick to the doctor’s protocol. Slow and steady progress is fine. You will also find that your ranges will sometimes plateau for a while or even worsen. It happens.

      • Thanks, I am making steady progress. I am concerned with how stiff my shoulder is still. Will that go away as the scar tissue is stretched?

        Thanks so much,
        Valerie

  4. Dr,
    Really sorry to bother you. I had a labral repair done approx a year ago, my mri showed a slap lesion 3/4 of the labrum had torn. After the surgery, the Dr said that the whole labrum was completely torn off the bone. He re- attached it with 9 anchors. After 5/6 months, my shoulder swelled up, from what is still unknown. Only thing I can think of is that I slept on it wrong. But, I had another Mri, this time it showed that there was evidence of the repair but, a re-tear cannot be excluded. All kinds of inflammation of the bicep tendon and surrounding rotator cuff muscles and tendons. Basically, now I still cannot raise my arm passed 90 degrees without feeling like by bicep is going to tear, the shoulder constantly feels like I have no lubrication, if that makes sense. I went to another dr for a second opinion because I feel like the first one just kept throwing pain pills at me. The new dr told me, limited ROM is normal especially with 9 anchors. He thinks returning to work is not going to happen. Then, referred me to a pain management dr. I am a detective in nyc, I enjoy my job and want to return. I Am not one to just throw in the towel but, I feel like it is never gonna get better or at least good enough to work. I am not a dr, but I think 75% of the pain is coming from the bicep tendon. I feel like that is what is restricting the movement. Is there something that can be done or do you think that’s it? Thanks for listening. I’m not sure if you even have enough info to make suggestion but, thanks

    • Chris that sounds like a very involved tear and surgery. 9 anchors is probably the most number of anchors that I have heard of for this procedure. It does make sense that the biceps feels bothered as it attaches on to the top portion of the labrum.

      I would do two things. First, find the best PT that you can in town and get a fresh set of eyes looking at your shoulder. Ask around, I am sure that there are several really good PT’s in your neck of the woods. You want the mechanics (strength and flexibility) around your shoulder to be idealized.

      Secondly, I would find out exactly what the current state of the shoulder is in terms of the anchors holding. NYC has “The Hospital for Special Surgery”, which is one of the best places in the world. Talk to a shoulder labral specialist there. He / she might want to do a follow up MRI.

  5. Hello. I had a labrum repair done to fix 2 tears and I am eight weeks since surgery. I’ve noticed a burning sensation in my inner elbow and up my arm into the inner part of my shoulder close to my chest. Is this a normal part of the healing process or something of concern?

  6. Hi, I had a Slap repair done on my shoulder a little shy of 2 weeks ago (doc repaired 2 separate tears). I just had my post op meeting with the surgeon and he said that my shoulder felt loose (like someone who didnt have surgery) and said it appeared I wasn’t wearing my sling. My wife and I assured him that I had been with exception to showering. After that, he didn’t seem as concerned and told me to be careful about trying to use it. He left me a bit confused and concerned about my recovery. I do have a tendency to recover faster than normal, but should I be concerned about the loose shoulder?

    • Don’t worry about it Bradley. Everybody has a slightly different “tissue feel”, your shoulder for whatever reason may be slightly more mobile than that of the average person. He was probably just commenting on that. Stick to the rehab protocol that the doc and the PT prescribe you.

  7. I had slap repair surgery (11-1 tear) almost two weeks ago. 2 anchors and cleaned up. Post op pain was very manageable, I had no use for prescription just Tylenol. Biggest bother is bicep discomfort & General ache. Doctor allows to be out of sling, but that feels dangerous and causes shoulder to ache significantly. When home I take it off. Was gently opening roll of paper towels taking plastic off, plastic gave way as I carefully pulled away from me and that sudden movement was excruciating and left with a renewed and long lasting ache. I can’t imagine but is it possible to pop anchors or pull labrum from what has healed? I don’t want to get frozen shoulder so if doc says I can have sling off I assume I can use arm gently as tolerated. Or is this freedom rather generous so soon after surgery?

    • Pace apologies for the delayed response, I haven’t been getting notifications for some reason.

      You would have to do something more substantial than what you described to pop those anchors in my opinion. You certainly could increase the inflammation however, so take it easy. Keep your motions very simple for the first 4-6 weeks, nothing jerky or abrupt. For most of the patients that come here for physical therapy in our office in DC, they are in the sling nearly full time for the first month.

  8. 20 days ago I had surgery to repair a significantly torn rotator cuff along with a bicep tenodesis. I have two small incisions, two large incisions (arthroscopic and open) and eight anchors. The surgery took 3 1/2 hours. I have excessive swelling in my bicep, elbow and hand. Is this normal? My surgeon said no PT for 4 weeks following surgery, I can remove my sling (pillow) to shower and do pendulum movements once a day. Is this normal due to the extent of my injury? By the way, it is a result of dislocating my shoulder playing softball and I am 45 years old and in pretty good health.

    • Julie the swelling in the hand and elbow is a bit of a concern. Make sure that the doc knows about it and keep an eye on it. What we don’t want to see is a very red and beefy hand that hurts when you squeeze it with the other hand. It sounds like the surgeon did quite a bit of work on your shoulder given the number of anchors used and the time spent in surgery.

      Stick to the PT program and you should notice a gradual improvement. The first month though is usually a major pain in the buttock to get through.

  9. Hello,

    I’m 35 years old and I had labrum repair surgery about 9 weeks ago. The doctor used only one anchor to tie the labrum back to the bone and reattach it. Recovery was going great, but 9 weeks later I had something during sleep that caused me to have convulsions and fall off bed, causing a reinjury. I never had anything like that before, and as far as I can remember I only fell off bed twice in my life (this one included). I’ll seek a neurologist about this. I did do a electroencephalography prior to surgery, and all came back fine. I don’t remember anything but waking up in the floor with pain in the shoulder. I had no other injuries besides the shoulder, but the doctor suggested I had convulsions because I had lightly sore muscles all over the body (as if they were overused).

    I was in despair. This surgery was very expensive and I have no health insurance, not to mention the pain these first 9 weeks were. My doctor said that he can’t answer whether the surgery was lost or not, and that only time will tell. So he told me to wait 3 more months before we can find it out. I almost passed out! Wait 3 months just to know whether I’ll need to do it all again?? He said “yes sorry that’s how it is.” and then prescribed me some pain killers and dismissed me. I was in shock, walking out slowly thinking what to do.

    Getting back home I applied ice to the shoulder and just prayed for the best, and within the first 24-48 hours there was a huge recovery of the pain. Some movements I couldn’t do at all (such as placing my hand on my belly, as well as rotating the arm to the opposite side) came back with no pain. Now, 5 days after this reinjury the shoulder is much better, but still not like it was 5 days ago. Some movements still hurt, and sleeping has to be with my hand over my chest. If I try to sleep belly-down, the shoulder will hurt quite a lot, which wouldn’t happen 5 days ago.

    My questions are: Is this true? Will I have to wait 3 more months before I can find out if this surgery is lost? Does this good recovery I’m having from this reinjury means that it was just a scare? Or maybe it is simply a good sign, increasing my good odds? Or it really doesn’t mean much and only time will tell?

    Thanks

    • Ed!

      If you just fell out of bed you may not have re-torn anything. We see people all the time for physical therapy who bump their shoulders post-operatively and the result most of the time is painful inflammation that takes a month or two to go away. The fact that your shoulder is not as painful as it was right after the fall is a good sign.

      I would have to agree with the surgeon in terms of doing a diagnostic test. I would wait a few months. They could take an MRI, but that usually requires you to have your arm over your head while you are in the machine. That just isn’t worth it because it will end up inflaming your shoulder more. If you are still having a lot of sharp pain two months from now that has not improved, that would be the time to ask the doc if it is time for an MRI. Meanwhile continue to do a light amount of range of motion under the supervision of the doc or the PT.

      • Dan,

        Thanks very much for your reply. I wish my paid doctor would give me this information you gave for free. I think he was just being careful, but still…

        Right now my shoulder is much better (1 week after the fall). I’ve seen a neurologist about the convulsions, who prescribed me Depakote to take during the shoulder healing period. He told me that night convulsions are very common and a lot of people have it and don’t even know. But I now found out about it because of the shoulder surgery.

        Once again my big thanks from Espirito Santo, Brazil.
        Ed

  10. First off, Thank you! Thank you for providing information and creating a forum where we can read about others recovery from labrum repair.

    I am 8 weeks post op. I had an anterior bankart repair and capsular placation with 3 anchors. My PT says I am one of the more limited range of motion patients she has seen. I currently have 30 external rotation (when I really push it), and about 135 degrees flexion.

    My concern is regarding flexion. When I lay on my back and attempt flexion by holding a broom stick with both hands and raising my outstretched arms up and then over my head I experience a pinching sensation in my shoulder. That is, as I start to induce a moderate stretch on my shoulder I feel a sharp “twinge” of pain on my anterior shoulder. My PT doesn’t really know exactly whats going on but has noted that when I point to the pain I am pointing to my bicep tendon.

    Have you ever heard of a pinching sensation like this? Should I still expect more range of motion?

    Thanks again!

    • Justin that type of pain happens all of the time. Because your shoulder lacks strength, the head of the humerus bone might be gently pressing against the shelf above it, and the biceps tendon or rotator cuff muscles are getting slightly pinched. As you get stronger that sensation should decrease. I will often prescribe one of the shoulder exercises on our website, exercise #14 (towel slides). If you want to check it out the password to get in is “patient”. It is a bit easier to control and you can still get a decent stretch with it. Run it by your PT to make sure that he or she is okay with it.

  11. Hi there. Thank you so much for the information and discussion. My expectations were WAY off and my surgeon did not explain the time it would take to heal completely. I had slap tear surgery 2 weeks ago and am still in a lot of pain (shoulder blade, shoulder and bicep). Overall I feel like it’s been more painful than I had anticipated. I’m worried that since my surgeon said many people aren’t in that much pain after 1 week, that something is wrong and my surgery wasn’t successful. Is it normal to still be around a 7/8 in pain 2 weeks later?

    • Amy you are still very early in the rehab process. It is totally normal to feel significant pain this soon after surgery. Sleeping will probably not be so much fun for you for the next month. If I were to guess, the percentage of post-op labral patients that we see here at PhysioDC who are in significant pain one month after surgery is greater than 50%.

      Hang in there.

  12. Vladimir Taube says:

    Hi Dan,

    I had a labrum surgery about 5 months ago. My range of motion is good for the circumstances, but I still have pain doing the same movements which caused me pain before the surgery. I am training very light, but Im afraid Ive done some exersises or movements which have reinjured the labrum.

    What makes me so sad is that I no references or no idea of what to expect… I dont even know if the surgery went successfully, and if my shoulder ever will be normal again.

    Thanks for taking your time to answer.

    Vlad.

    • Vlad you have got to give it up to one year to see what the positive benefit will be. I would do a light strengthening routine for the rotator cuff and scapular muscles every other day. Get a good program from a PT that has four or five exercise and stick with it.

      There are also other factors to consider here. The research out there does show that people over 35 tend to take considerably longer to improve, and the end amount of improvement is less than for someone much younger. It is also possible that you have a bit of impingement in the shoulder prior to the surgery that was contributing to the pain that was not being caused by the labral tear. I can’t tell you for sure obviously because I don’t know what your shoulder looks like. Regardless, get the strength and flexibility in order over time (slowly) and see where it leads.

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