July 31, 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. william says:

    Hi,

    I had surgery five months ago and its been getting progressively stronger and feeling better. I’m generally a quick healer but my SLAP ligament was torn for 9 years previously and had never been diagnosed until recently.

    A few days ago I threw something and felt my shoulder go. It didn’t feel quite as paralyzing as it used to but my shoulder rolled and it made a crunching sound. It hurt, though not as bad as it had before but in the morning it felt weaker, more sore and was difficult to hold my arm up in the air. It feels better today with no pain, though it is still a little sore.

    Do you think I may have retorn? Could it just be stress, or is it likely to have fully gone again? I feel like an idiot.

    Thanks!

    • If the function has returned and there is only a little bit of soreness I would guess that you didn’t re-tear anything. Crunching noises can be anything from scar tissue releasing to rotator cuff tendons gliding over the little boney ridges of the humerus.

  2. Sean D. says:

    Hi Dan,

    Great Blog! So I am approx. 15 weeks out of my Bankart and Hill Sachs repairs, and it has been an absolute roller coaster. There have been weeks where I have felt great and near normal, and other weeks (like now) where I feel completely unstable and like I will dislocate my shoulder.

    My question for you is regarding running and cardio. I am still having discomfort when I am doing cardio other than stationary bike. My repaired shoulder feels unstable while moving and there are clicks, pops, and other noises that just do not sound awful. There is little to no pain after the cardio, but the shoulder feels unstable for the next few hours/days. Other than that ROM and strength are progressing just fine.

    Should I have this type of discomfort while running/ eliptical 15 weeks out of my repair? Is this instability after cardio indicate another labral tear. Thanks so much for your input!

    • Sean

      It is not uncommon to have those types of feelings four months after your type of repair. My guess is that all of the stabilizing rotator cuff muscles are a bit fatigued after the running and repetitive motion. The fatigue can easily manifest as a “loose” feeling because you have a temporary decrease in the rotator cuff’s ability to stabilize the head of the humerus.

      Keep the running and cardio distances reasonable in length. You should note that over time the rebounding instability effect should decrease. I would also make sure that you are not going too fast: quick arm motions can have a bit of a jarring effect on the tendons as well. Slowly increase to tolerance.

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