March 5, 2015

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. I had Rotator Cuff, Slap Repair that took 6 anchors, 2 Impingements, a lot of bone spurs, and scar tissue removal, oh and a cyst, and they had to stich me forward and put the ball back in the socket in my shoulder, I have played softball for 34 years, and train, and really want to be able to get my arm back, but I am at the 3 month mark, still in pain, can not sleep on my right side, I go to therapy 3 days a week, but I am afraid it is never going to get better, everything has shifted forward and now they are pushing it back, they tell me it the extent of damage I had but I should not be in this kind of pain, I also am a migraine sufferer, and this sets them off pretty bad, any advice, I am very frustrated

    • Karen from the amount of work that you described you need to give it at least another three (3) months before you can make an assessment on how the surgery went. Stick with the PT routine, and always give yourself a day to recover after you do the exercises. I know that it is extremely boring and frustrating, but shoulders are like that.

      You should also make sure that the doc knows what is going on with you. Also try to avoid sleeping on that shoulder.

  2. Conner Richardson says:

    Hello, I’m 17years old and an active male. Height is 5′ 5″ weight 135. I race motocross nationally and train 5 days a week. I dislocated my shoulder 4 years ago and began dislocating it very frequently. 5-10 times a week. I had surgery 6months ago. And starting riding my dirtbike again one month ago (5months post op). My tear was from 11oclock-7oclock. Very large tear. I have almost full strength and I’m training full time again. My recovery process seems very fast compared to everyone else. Is this weird? I have no pain. Large amount of movement and strength.

  3. Hi my name is Hannah. I’m a 17 year old senior. I injured my right shoulder in soccer about 4 months ago. I was dribbling down the field and about to shoot the ball when two girls took my feet out from under me. I landed very hard with my elbow extended, driving it into the ground. The pain immediately was in my elbow, but quickly radiated to my right shoulder. I got an X-ray done but I was told nothing was broken, but that it was sprained. I then went to an orthopedic and was told it was an AC joint strain. I was very frustrated because I knew something else was wrong, and I wanted answers. The pain started to become manageable so I started playing basketball. It became apparent that I could play, but after a few games in, I was reminded that the injury was not going away any time soon. If I got hit wrong or moved it wrong, the pain on a scale of one to ten, was a ten. About 3 months after the occurance of the injury in soccer, I finally got an MRI. I found out that I had torn my labrum and had loose debris floating in my shoulder that had chipped off from its original position. I get surgery in a little over a month and am expecting a long road to recovery. It’s been a long and frustrating journey so far dealing with the injury, but I’m anxious to make the next step in healing.

  4. Hello I have a question. I had labrum repair surgery on 1/13/15 and I’m in my second week of. PT. I work as a Paramedic and I also Crossfit.. I’ve been doing good however. I’m starting to have frequent “catching and popping” feeling and I hate it.. It hurts and now I’m Paranoid.. Will muscle relaxers help. I’m scared to do any PT and my home PT exercises.. I’m trying to get back to work. But I’m scared to do my exercises because of that catching/popping feeling. What should I do.

    • Talk to the doc and the PT about it. Very often clicking and popping can happen because of relative weakness in the rotator cuff and shoulder blade muscles. You are only about 5 weeks post-op, so I would still expect weakness at this point. You PT may want to modify some of your exercises to lessen the sensations you are describing.

      You would have to ask the doc about the pharmaceuticals, that is not my bag.

  5. I had a posterior and anterior tear I had repaired 5 months ago. The injury was a result of losing the barbell backwards briefly doing overhead squats. Pushups are no longer an issue but there’s still a slight clicking when I try and do anything with shoulder presses (still minimal weight 10-15lb dumbells) as well as soreness and quick fatigue. Is this to be expected after 5 months?

    • Ouch. That injury does not sound fun.

      Clicking at 5 months is not uncommon. Slow and gentle strengthening under the doc’s orders. Allow recovery time and stick to it. That clicking should slowly lessen over time. It just might take a while.

  6. Hello,

    I had an arthroscopic labrum repair (and capsule got tightnened) in May, so about 8.5 months ago. I injured it playing Ultimate Frisbee, when I “layed out” (our fancy way of saying “diving on your stomach for the disc) and landed on my outstretched arm, causing an anterior subluxation. But, prior to that, I was always able to kind of pull that shoulder out of the socket a little. Anyway, I got the surgery and got cleared in November to do whatever I wanted and keep strengthening my shoulder. Yesterday, after getting advice from my physical therapist (who told me to not do anything I didn’t feel I was ready for) I decided to go back to trying to lay out. I did about 20 minutes of exercises that precede the actually running and diving for the disc, and they went really smoothly, so I felt ready. But on the first one when I went for the thrown disc, I heard this crack (not like a bone crack, but definitely this messy popping sound) in my shoulder and a brief pain. My range was almost 100% before that, with stiffness in some areas that my surgeon was actually happy with. But now the range is a little looser, and when I just sit and relax my arm straight down, it feels like it’s starting to move out of the socket like it used to pre-injury, but doesn’t go all the way. And today, it feels weak/fatigued and like it’s always working to keep the shoulder up. Do you think I subluxed again or reinjured it in some way?

    • Devin it sounds to me like your shoulder has a natural amount of “hyper-laxity” to it. In my humble opinion it is really not a good idea for you to land on your stomach with your arms outstretched as described in your “lay out” position. There is too much potential for you to partially land on your shoulder and cause damage. It is possible that you jarred something with that motion.

      This may not be what you want to hear, but I would be a bad PT if I told you otherwise. This certainly does not mean that you should hang up your ultimate frisbee shoes, just be a bit careful about how risky your playing is.

      I would see the doc and get the shoulder checked out to be safe.

  7. Hi. I had a SLAP tear and bony bankart lesion repaired 6 weeks ago.

    Admittedly, I removed the sling a week ago already as I stopped feeling any pain and felt confident that I could move my arm around and lift things like a glass of water or plate of food etc.

    Since I have removed the sling, I have become more and more comfortable without it and now I am using my arm freely as I was before, without any pain. I have not yet started gym or weight training yet on the arm. Do you think it is safe to begin low-weight training at this stage, given I have no pain? Or let me phrase it this way – is it safe to excercise the arm as long as pain is not experienced, or is there a chance that I could be damaging my labrum without feeling a pain sensation?

    Thanks,

    Damian

    • I think that 6 weeks is way too early to start resistance training. Even though you are feeling comfortable it only takes a certain amount of torque on certain tendons and structures to cause inflammation or damage in the earlier phases.

      As boring as it is, stick to the doc’s protocols for rehab. Clear it through the doc before doing anything above the protocol .

  8. Maya Reninger says:

    Hello,
    I had a posterior labral /Bankart repair Sept 19th after a fall on some stairs. Post-op things have been going essentially as expected, with a lot of return of motion though not quite 100%, particularly with external rotation. I just ran out of PT coverage, and was wondering about returning to swimming, which I do as my main form of exercise– nothing competitive. I have been running and stationary cycling with no pain, and the only time I am a bit sore is after I wake up from sleeping on my right side. Will the motion of freestyle swimming damage anything?
    Thanks!

    • At this point I do not think that the act of freestyle swimming will cause anything to dislodge or tear. My concern is that you have enough rotation in the shoulder to allow a fluid motion. If you don’t have enough rotation in the shoulder, you may start substituting around the rotation and end up straining your neck or your thoracic spine.

      It would be a good idea to ask your treating PT if you have enough range to swim. External rotation is important for an overhead stroke.

  9. Dear Dan,
    I came across your forum and although I’ve read most of your posts very helpful but nothing like my case. i’ve torn my rotator cuff on the obstacle race in August. 7 months on – I’m now diagnosed: full tear to supraspinatus tendon 19mm and some 2.5cm retraction already. further MRI scan will reveal whether there is an fatty atrophy or not.
    I was told i need definite arthroscopic repair as i’m 40 and very active. I am a personal trainer part time but also I am very active with exercises ranging from intervals, weights, high intensity training.Lots of bodyweight exercises like push ups, pull ups etc.I also play tennis but injury is to my left non dominant shoulder. Saying all that i have received cortisol injection which basically
    settled everything: I have good ROM, no pain during majority exercises even weight lifting overhead, can sleep on the arm and only occasionally feel mild discomfort. In that point I use ice pack and painkillers and is all good. I do avoid any exercises which might trigger pain and at all costs I’m trying not to have surgery done, as the recovery is awfully long and painful. i’m bit of a gym freak and also surgery and being one handed for good few months with my training it would impact my fitness level and my business. should i still proceed with the surgery even if i was told is 70 % chance is not going to be successful? As i said i’m currently feeling very comfortable and would rather carry on exercises with caution than risk surgery and permanent pain and worse? I’ve read that not all tears get worse with time and I’m hoping further PT might reinforce the strength of my shoulder which nevertheless is very good at the moment, only slightly weaker than my right arm. thank you for your response in advance.

    • Alexandra I would say that fall in to the “gray area”. You could probably rehab it and have very little pain like you are describing. My concern lies in the type of exercises that you are doing. Pull-ups, push-ups, and the like will inevitably place some direct frictional stress on that supraspinatus tendon. The unfortunate truth is that as we age, the acromial space narrows, and the result is less room for the rotator cuff tendons to operate without rubbing against the acromion.

      Some of the exercises that you are doing are going to cause friction. If I were a gambling man I would say that if you continued with the same exercises that you have historically done, you are likely to tear the supraspinatus further.

      If you don’t want to have surgery, make some permanent modifications to what you are doing. I would keep all of your gym exercises within reasonable ranges. One rule that I tell my patients here in physical therapy is that “you should always be able to see the backs of your hands” with weight lifting. You should really have no issue with tennis given that it is not your swing arm.

      • Dear Dan,
        Thank you for such a helpful response, well, that’s a gamble but i’d rather gamble that when i’m 60+ it will get more uncomfortable and in that case . I might be then offered decompression to increase the acromial gap.
        The body weight exercises i’m doing and some weights (only light) don’t cause pain. Surgery itself is carrying risks that i might end up with chronic pain in any case. there are additional surgery complication and 30% is quiet high chance it will go wrong. I am having final consultations coming up next week, but also read on forums that the surgery is a last resort if non surgical methods like injection or PT can’t help.
        thank you

  10. Dan,

    I am in 1 day from being 3 weeks out of arthroscopic surgery on my left labrum, ac joint and 1cm of collar bone removal. I have 4 anchors from the 2 o-clock to the 9 o-clock. For 2 weeks after surgery I was confined to a sling, with one week moving from my elbow to hand in upward motions, like a bicep curl. Now into my third and fourth week I have been instructed to move my arm straight out and upward – not to the side, yet, and not backwards or rotating. I am supposed to work on gaining some mobility back. I have been able to raise my arm almost straight up, but feel a lot of tension, I am guessing normal, with the help of my right arm as a guide. When I move my left arm by itself, it is much stiffer and feels like it is going to pop out again, like a rubber band is pulling it back down. Is this normal?

    Thanks!

  11. I am scheduled for a labral tear repair on may 22nd unable to have it any earlier because of time off from work. My shoulder pain has increased to the point where I’m taking 1-2 rx ibuprofen 800 mg per day & still having pain. Would you have any suggestions that might help keep the pain managable until I can get to surgery?

    • My daughter whose 14yr is a goalie 32 weeks post labrum tear repair. She’s engaaged back into soccer but at certain extensions of the arm feels popping sensation and describes it as feeling the anchors pull shoulder back in. Occasionally she will feel pain level 2-5. Is this due to her weakened muscle that requires further strengthening? Or possibly a complication?

    • Michele I am not the guru of pharmaceuticals. Your doctor is better suited to answer that question for you.

      Having said that……….I have found that different pharmaceuticals work for me and some simply don’t. For me, naproxin sodium does wonders and ibuprofen does next to nothing. I have no idea as to why.

      You might try something different, but you MUST ASK YOUR DOCTOR ABOUT IT FIRST!

    • You won’t get any reliefs until you have the surgery so keep going to . Your therapy but the pain it’s worst after the surgery

  12. Im a 23 year old male who had posterior labrum repair on dec 10th 2014. My motion is at a 100 percent, but i still have a constant aching pain in my upper deltoid that never goes away. My doctor told me to stop physical therapy which was 3 weeks ago to see if the pain was relieved. He also gave me a cortisone shot, but the aching pain is still there. I’m not really sure if i should continue doing light pt exercises or give it more time. The pain is not severe, but a constant annoying ache. My shoulder also pops and catches with pain when abducting bducting with the palm down right by the acromion. Is this normal? still after surgery

  13. ok I had full rotator cuff and Labrum repair, a cyst under Neath the rotator cuff ,7 bone spurs, two nerve impingements, Dislocation, They had to stich my shoulder forward, remove a lot of scar tissue it took 7 anchors for my labrum, my surgery was November 15th, a little over 3 months, I am still in pain, can not sleep on my shoulder, its stiff do not have full range, I go to therapy 3 times a week, I get severe migraines, and I had those before the surgery but after they have gotten worse the surgeon says it is my fault, has nothing to due with the constant pain and inflammation in my shoulder, I see a neurologists, he agrees with me , but what does he know, I do not feel like this is normal I am 36, very active, have always healed very well, play sports, Softball, I train, my doctor will not listen to me, he says I can not throw for a year, but I am afraid that something is still wrong with my shoulder

    • Karen

      You had a large amount of work done to your shoulder. Even if you indeed do heal well, it is going to take quite a while for this to normalize (at least 9 months). From what you are describing you sound like someone who does not normally “slow down”. I would ramp it back a bit. Give the shoulder a weeks rest from PT and let it heal up a bit. I realize that this may not fit your personality, but it is probably worth your time to do less short term.

  14. I have a 16 year old son who tore his labrum on the bicep 2 years ago in wrestling. He will be a senior this fall and wants to continue playing football and wrestle again his last year. He has played both years with the tear and has pain- now that the season is over he says it is just a dull ache. He has never dislocated his shoulder with or since it was torn. Should we have the surgery that the doctor thought necessary last summer which we chose to wait so that he could still do football and wrestling with a brace, or wait until after his senior year. We do not want him to go into the football season which is in 6 months just out of rehab? He will not be able to do all the strength training needed over the summer with the surgery. Is PT a good alternative to surgery?

    • Given the timing issues that you describe it sounds like surgery would not be doable until after his sports seasons. I would do the PT and see where that gets him. It is entirely possible that he will be able to negotiate both seasons with rehab alone.

      He does need to pay attention to how he feels. If the shoulder pain gets intense it is time to back off and see the orthopedist.

  15. I am looking at having surgery on my shoulder. I have tears in anterior, and inferior portions of it as well as a Slap tear and bone spurs. I do a desk job, how long would it be reasonable to plan on being out?

  16. Carlos A Salazar says:

    Hello,

    I had slap repair in November 13, 2014 , so about 15 weeks almost 4 months now. I must admit just writing this I realized how little time has passed by. It feels like at least double that has passed, this can be very frustrating. Anyway, my question is actually concerning diet/supplementation and realistic goals. Currently I’m taking liquid collagen, will this help at all? I’m following a diet to cut body fat as I was told trying to make muscle mass with a messed up shoulder will be too hard as I can’t lift heavy weight. Is this correct? I can already bench fairly decent 45 lbs dumbbells, and do most bicep/back workouts. My weakness of course are chest/ shoulder exercises, specially with a bar.

    My current approach is to cut body fat and gain back strength up until the 6 month mark or whenever i feel strong enough to start gaining muscle mass more aggressively.

    Any recommendations?

    thanks!

    P.S. I still go to therapy once of twice a week, but it’s mostly for stretching/massages. The exercises I do in therapy I also do on my own at the gym.

  17. Hi my name is Kurt, I recently had a full labrum tear in my right throwing shoulder.. Everything has been going perfect! Couldn’t be more happy with my surgery and current rehab.. My question is when is it proper time to start very lightly throwing overhand again, I don’t want to push anything but really don’t want to reinjure myself in the process? Thanks

  18. James Swaney says:

    I am a 50 yr old male and had a SLAP IX labrum tear of my left shoulder. I had surgery on 01/23/2015. It took 8 anchors to repair the labrum. it was torn from 9 O’clock 7:30. The doctor said it was the worst labrum repair he had ever done. I have been doing PT 2 days a week with PROM exercises and am having a lot of pain while doing this. How long should it be before I start doing any AROM exercises?

  19. Hi There,

    I came across your forum & decided I needed an outside opinion on my SLAP tear recovery. I am an athletic 29 year old male who recently had surgery. I basically destroyed my shoulder from playing overhead sports my whole life such as baseball, softball, dodgeball & felt extreme pain in my bicep. I had an MRI & it revealed that I had a SLAP tear from the 3 o’clock to 11 o’clock position. On Dec 11th 2014, I had surgery to repair the extensive SLAP tear to my right dominate shoulder. The surgeon placed 2 anchors to fix the tear, cleaned up the frayed labrum & shaved down my bone. I am religious about doing my exercises 2-3 times a day on top of going to PT twice a week. My progress has been amazing & both my therapist & Surgeon are extremely happy with my range of motion. I am at the week 11 recovery of my surgery & everything was doing fine until last Wednesday 2/25. I decided to be a superman & move a big chair that I had no business moving. While doing this, the chair slip & jerked my shoulder. I instantly felt pain & a weird sensation in my shoulder. The next day I had a burning sensation in my inner bicep area. It has recently gone away but I still am having a dull pain where my pectoral muscle into my armpit area. I laid off my strengthen exercises completely until Sunday 3/1. I currently have no pain while doing any exercise & my shoulder does feels strong. Its only when idle it bothers me. Today 3/3 is the first time I had PT since I did this. My PT feels I should be fine since I have no pain while doing my exercises, very little discomfort while being stretched out & am so far into the healing process. I was curious if this is normal or if I should be concerned? Any advice would be great. Thank You

    Ethan

    • I agree with the PT. My money is on a strain rather than a re-tear. The pain associated with that would probably take many weeks to subside. Give it some time to heal and keep the exercises on the light side.

      • Thank You Dan. Much appreciated with the quick response. This morning it felt much better as far as inflamed but I still have the dull/burning sensation. I will continue to do light (with no weights) exercises until the sensation goes away. Thank You again.

        Ethan

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