October 23, 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. Hi,
    I’ve been having severe shoulder pain for several months now. I initially went to see an orthopedic I had seen as a teenager after a bad car accident. He then sent me to see one of their spine doctors to rule out any other issues after being diagnosed with spinal stenosis after my accident. Long story short, after chiro other “symptoms” disappeared, and my shoulder radiated in pain. I received a cortisone injection in the front side of my shoulder, and did some PT. My PT did not allow me to do bands and kept me using a pillow against a wall. The injection gave me minimal relief, and after a couple of weeks the pillow exercises still made me cry. My MRI was okay, saying there was some fluid, but no evidence of a tear. The spine dr summed it up by saying I had arthritis, and was going to rely on anti-inflammatory meds when it flares up. I’m 28 years old. I went in for another opinion today, and he came highly recommended. Other than my car accident 12 years ago there is no significant event I can think of to cause major damage. I have 3 young children and am a dental assistant. After my dr did the physical examination today he suspects a labrum tear. I am constantly feeling as if my shoulder pops out of place. It’s pops all of the time, and some movements make me feel like I could throw up. He said that I could do a contrasting MRI, but it’s not always 100%, the only way for him to be certain is to scope my shoulder. He said that he doesn’t want to rush surgery, but since I’ve been dealing with this for a long time it’s not truly rushing. This is all a huge decision and more money out of pocket if I do testing before hand. My insurance changed within days after reaching my deductible, and now I’m back at square one again. I guess I’m curious if the contrast MRI is worth it? Can labral tears cause this much pain? I cannot stretch my arm across my chest or lift my arm and turn my hand inward without feeling nauseous. When I lay on my opposite arm at night, my injured shoulder feels like it rolls forward, and I can feel/hear it shifting. I’m curious if there are any addition questions I need to ask my doctor.. I’m obviously thorough after writing this novel.

    • Kassi the contrasted MRI should show labral pathology.

      From what you are describing it certainly sounds like a labral tear. If it were my shoulder, I would probably get the test however to see exactly what is going on. Sometimes if a shoulder is chronically weak from trauma and disuse you can have the type of pain that you described as well. My bet is on a labral tear.

      • Dan,
        I want to thank you for your reply. My husband and I talked that weekend, and I decided to have my shoulder scoped. I had my surgery on the 7th, and I did not have a labral tear. He did repair an “almost” full thickness tear on my rotator cuff. He said it was hanging on by 15% I have 2 anchors, he also poked some holes in my bursa as it was the consistency of jello, and did some general clean up. I went in for my post op yesterday, and my sling is now pillow free. I’m starting some wall walks and pendulum exercises so my shoulder doesn’t freeze. It’s all so strange, and I’m counting down the days of no more sling! He did say that my tissue was quite thin, and was probably under developed. My biggest fear is that I could tear it again, and I would rather birth 3 more children than go through this again. :)
        Is there anything that I can do during rehab and after to keep my tissue strong?
        I have to say it’s really great looking in the mirror and seeing that my shoulders are even… my left shoulder was about an inch lower than the other. Seeing that physical change helps me know that I made a good decision.
        Thank you again!

  2. Dan,

    I am 6 months from bankart and hill sachs repair. I have found that each day is totally different in terms of how my shoulder will feel. I have been feeling great the last two weeks, almost to the point of feeling normal more or less.

    There are some instances when I move my arm there is a huge Cracking sound. It is generally not a painful event, but I feel pretty unstable afterwards for at least a couple of hours. This usually happens when I have been slacking from my rehab exercises.

    Is this just stiffness? Or do you suspect a larger underlying problem? Thanks for your help, I get so paranoid when it comes to this recovery.

    Thanks,
    Jon

    • Jon it is probably either some scar tissue from the surgery or one of the tendons gliding over part of the humerus bone. If it is not painful I wouldn’t be too concerned about it. It is not uncommon for people to encounter those types of “cracks” for a year or more after such a surgery. If you feel as if you are going to dislocate (I am assuming that is why you had the surgery in the first place) it is always a good idea to talk to the doctor about it.

  3. Hi

    I have only just had stablisation surgery done, 2 weeks ago. I have a sling on however sometimes when I move it feels as though it is going to dislocate. Is there a problem or is this just part of the process? My shoulder isnt actually moving as far as I am aware its mainly when I stand up after sitting on the lounge. Thanks

    • Very common to feel that Kim. The muscles that help to hold your shoulder in place are super weak right now because of the surgery and the swelling that results from the surgery. Stick with your rehab program and ask the doc about it if those feelings persist.

  4. Hi, I had a labral repair surgery in March 2007. Shortly after the surgery, I began experiencing pain that radiated from my shoulder to my elbow. I often experience a sensation of what I believe is possible dislocation. I’m unable to move my arm without the help from my other arm. It is an incredibly painful feeling. Lately my pain has gotten worse. It radiates from my shoulder, to my fingertips, and into my shoulder blade. I feel as if I just woke up from surgery at times. The pins that were used were explained to me as being able to dissolve in 8 years time. This march will be 8 years and I’m curious what this could mean. Thank you!

    • Im am not sure that the pins dissolving in eight years has anything to do with your pain. The pain that you are describing might at least partially be neurological? It sounds like the nerve bundle that passes through the shoulder is being slightly stretched. The weight of an arm stemming from an unstable shoulder can sometimes place a traction stretch on the nerves. You should have an orthopedist check it out to get a definitive diagnosis.

  5. Hello,

    I had a Bankhart repair to fix a full anterior tear to my labrum four months ago. The originally injury was caused training for a boxing match, in which I likely caused a partial tear. During the fight itself, I threw a hook which caused a brief dislocation and likely completed the tear. I have been doing very well with my PT, going twice a week and have almost regained full range of motion after 4 months (my PT has been very impressed by my rapid recovery). Last week she said that I could start doing very light boxing bag work again, and so I went into the gym and hit the bag a bit for an hour, perhaps a little harder than I should have. My shoulder felt a little sore afterward, but there were no painful events and I chalked it up to being out of shape and having that shoulder in disuse for so long. The next day my shoulder hurt quite a bit, particularly in the front where they went in arthroscopically and right under my shoulder blade. I was very worried about it so I went to see my PT who checked out my range of motion and said that I probably had just over done it a little and that I should probably hold off on the boxing for another month or so. She also said that it would be quite hard at this point for me to reinjure. That being said, it has now been been 5 days and I have been experiencing a fair amount of discomfort, particularly sleeping on that side, and in some movements. I’m very concerned that I may have reinjured, but I can’t tell whether I’m just being overly worried and that it would indeed be quite hard after 4 months (and nearly a month pain free with good mobility). My surgeon is very hard to get in touch with and is in a different city from where I live. Any advice would be greatly appreciated!

    • Kathryn I am going to agree with your PT. Hitting the bag for one hour after 4 months of relative inactivity will cause soreness. Probably lots of soreness. You will be sore for a few weeks. You probably have a bit of tendonitis.

      Once the pain goes away (entirely) you should try hitting for ten minutes. Stop after ten minutes even if you feel good. Build slowly. Talk to the PT or the doc if needed of course.

  6. 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.

  7. 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.

  8. 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

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