August 20, 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.

  3. Hi, I’m about 15 weeks out from my Slap and Posterior repair. This is the second surgery on this shoulder. I had a torn cuff repaired and bankart repair in 2008. I was back to work and paddling my kayak, shooting a bow 12 to 13 weeks after that one. Not this time.

    Range of motion is pretty good now, some tightness and pain when reaching all the way across my body and around to my back. But I don’t have much use of my arm above shoulder height. I get weakness and pain in the area of my deltoid, and near my collarbone in the area of the bicep tendon. I also get pain on the top of the shoulder and around the front, from the bicep area over to the side of my shoulder. Usually it’s a steady pain that restricts movement. I can push through it but that feels bad. Much of what they have me doing in PT causes pain in those areas, and weakness, and some of the stretching exercises leave my shoulder and arm dead for a minute or two. My thumb actually quivers when I reach the top of the wall crawl exercises. A few times a day I will get intense, stabbing pains in these areas (front, top and side of shoulder) as well.

    Is this to be expected with this type of surgery? My next follow-up appointment isn’t until 9/18, don’t know if I should ask to see the Doc sooner.

    • It sounds like the shoulder is irritated. Some people will develop capsular inflammation after a surgery like the one you described, particularly if there has been work done on that shoulder in the past. Soreness, sharp pain, and progressive tightness in the shoulder are common symptoms of capsular inflammation. It wouldn’t be a bad idea to get an appointment with the doctor prior to your scheduled follow-up. He may be able to prescribe something to take the edge off the pain.

  4. Hi,

    I had surgery roughly 6 months ago to repair a posterior labrum tear with 3 anchors and also to remove a cyst. My surgeon gave me the green light to slowly resume exercise etc … but I’m still feeling consistent dull pain (mild burning ache) in the rear of the shoulder and also tingling burning sensations down the rear of my arm and fingers which I’m guessing is from nerve compression perhaps in the shoulder. Anyways I had another MRI and arthogram done a couple weeks ago to ensure the repair is healed properly as I’ve been very diligent with physio and taking things slow in terms of rehab. I’m waiting to hear back from my surgeon to review results but I’m just wondering if this is a normal recovery process as it seems most people have more ROM issues with minimal pain and I seem to be the opposite. Note I don’t have any dislocation or slipping feeling and strength is fine just seems that I irritate things when I try to slowly start pushing things and it gets worse again. I’m guessing its just fluid building up around the nerves and maybe it will be 12 + months till I’m feeling 100 % but I’m just disappointed with the lack of guidance on how long things can actually take to recover and what a normal recovery should entail in terms of expected pain. I’ll hopefully have an answer next time I see him later this month. Please provide feedback if you have time.

    Thanks

    • It is not unheard of to feel aching well after the 6 month point post-op. Phillip (who works with us) had some pain up to about one year after his labral surgery.

      It does sound like there is possibly something going on with your radial nerve? Ask the doc about it when you see him. I would also have the strength and length of all the RC and scapular muscles checked out by a PT to see how you are doing muscle-balance wise.

  5. Hi, I was wondering what your thoughts were on the structural integrity of a repaired labrum via Bankart repair as opposed to a completely healthy, uninjured labrum. I’m just curious because I had a Bankart repair that is healing wonderfully (6 months out) and I would like to know if, after a full year of laying down fibrous tissue, just how durable it will be in comparison to an uninjured labrum.

    • Hmmmm. I do not think that this follows the same adage of bone healing where the doc says that “a fractured bone will heal back stronger than before”.

      My guess is that the overall integrity of the labrum and shoulder will be oh so slightly diminished as compared to a totally normal shoulder. Do not despair, with adequate strengthening you really shouldn’t notice a difference with maybe the exception of very high level, sustained activities.

  6. Hey Dan,

    I am 4 months out of my labrum repair for dislocating shoulders. I am having no problems with the strength exercises such as rows, pulldowns, tricep, bicep… But I am having a ton of pain and difficulty shoulder raises particularly from hip to shoulder height. Is this something that is normal??? I can only endure 10 lbs anything more is too painful to complete.

    Also, my PT recommended doing BOSU walkovers, which puts my body in a pushup position. This position is extremely stressful to my entire shoulder and I am quite sore after the exercise. Should I be doing this type of exercise this early in recovery, and is it dangerous to continue. I am able to complete the reps but at the cost of great pain.

    By the way it is truly great of you to help everyone out

    Thanks So Much Dan,

    • JC it sounds like your shoulder may not be quite strong enough yet to handle the 10+ pound weights and BOSU walk overs. i would scale it back slightly for a month. Exercises over a physioball, a body blade, or with light resistive theraband sounds better. Clear it with your doctor of course.

  7. I had surgery to repair a SLAP tear and another repair to a torn bicep ligament. I have been faithfully attending physio for the last 6 weeks, surgery was on June 25th. Last week we started a strenghthening regimen in addition to the gentle stretches I have been doing. My therapist was surprised at how well I was doing. Yesterday I washed and dried some dishes and last night all hell broke lose. I am in agony; shoulder is stiff and very painful all the way around,.I also have pain radiating to my collarbone and into the bicep.i have not ever felt pain like this, not even after surgery. I see the surgeon on Mionday. Should I go to the emergency room?

    Thanks,
    Marina

    • Marina it certainly wouldn’t hurt to contact the doctor in the orthopedic practice that you used who is “on call” and tell them what you just told me. It is probably just inflammation but better to be safe than sorry. Statistically speaking it takes the repair 4-6 weeks for the anchors to heal down, so doing some dishes shouldn’t re-tear anything unless you were lugging around some really heavy stuff.

  8. Dan,

    5 months out of bankart repair. Recently I’ve been using my repaired shoulder more frequently and have been experiencing loud clicks. I assume this is just scar tissue as I am regaining motion. But after the clicks I am experiencing a slipping unstable feeling. Is that normally associated with the clicking? No significant pain just the unstable feeling.

    • Also I was traveling on business for an entire week and was only able to go through my exercises one day, is it possible the shoulder stiffened up on me causing the clicking and instability?

      Thanks so much Dan.

      • If you recently increased your activity level the shoulder may have to adjust to the demand. When the muscles around the shoulder get tired they lose a bit of control while they are recovering, and perceived looseness and audible clicks can be results. It certainly doesn’t sound to me from what you said that you did any real damage to the surgical anchors etc..

        I wouldn’t put your shoulder in to any extreme positions for the time being. As always, if it persists talk to the doc about it. You should probably allow for adequate rest (for maybe a week) and then try to do some light stabilization exercise. Guidance from your PT or doc is advisable.

  9. Max Sandoval says:

    Hello,
    Dan I had shoulder labrum surgery 5 months ago in march on my left shoulder from a boxing injury back in 2010 that I never got checked for. But anyway after my surgery everything was fine but I had problems getting into therapy till finally in june I started therapy but only did 1 month. Because my insurance cancelled and I couldn’t go anymore. Anyhow its now August and I’ve been working since and I recently had a manual labor job which required me loading semi-truck trailers by hand and lifting boxes from 20lb to 60lb over head lifting and I quit and now im un employed but have been doing bicep curls of 30lb dumbbells and pushups and recently I started having shoulder pain and kind of like a popping noise every time I raise it. Im really worried as if I tore my labrum again. I hope you can help me out and tell me what’s going on id really appreciate it thanks.

    • Max I would ease off the weight training for a while. The biceps tendon attaches directly on to where the surgeon did the work, so heavy biceps curls might be irritating it. Instead, I would try doing some back exercises maybe over an exercise ball (shoulder blade pinches, rowing motion, nothing too crazy). If you need guidance, get it! Go visit a PT, even if it is for one visit, to get some ideas in terms of what exercise is good to do.

      • Max Sandoval says:

        Do you think I tore it again? The pain has started to go away already . But it pops every time I lift it up it doesn’t hurt at all just sounds like your popping your knuckles or something.

  10. Matt cain says:

    Hi , July 01 I had a slap repair , labrum tear , and grade 5 seperation of cc
    And AC ligament repaired with a dog one shaped plate and sutures .
    Am I looking at even longer time frame than just a labrum tear/ slap
    Rom is painful but they tell me to push thru . I guess I’m just nervous if
    I’ve pushed too hard ?

    • I do think that what you are describing is considerably more involved than just a labral repair. The recovery time will likely be a bit slower, maybe 6 months to a year until you are starting to forget that it happened. Stick with the doctor or PT’s rehab protocol, there may be some very specific restrictions that you have to stick to because of the plate and sutures. I am guessing that the worst is over!

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