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Why should you have surgery to repair the ACL? |
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The ACL is the main stabilizing ligament of your knee. When it is torn any vigorous pivoting may cause your knee to buckle and in doing so this may tear your knee cartilages and cause more damage. This damage leads to arthritis over time. If you are interested in continuing to pivot or twist aggressively in your sports or at work, surgery to repair the ACL will allow you to do this while avoiding further damage to your knee. |
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Why would you not want to have surgery to fix the ACL? |
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If you are not a high performance, pivoting athlete and if you do not want to go through the major surgery and rehabilitation process, surgery may not be the correct choice for you. For instance, the individual who is only an occasional pivoting athlete (who goes snow skiing once a year), may choose instead to have a custom made sports brace to stabilize their knee, and wear this when skiing instead of having surgery. Surgery is only needed if you want to participate in pivoting activities. If you are willing to stop pivoting, surgery is usually not needed. |
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What kind of graft do you use, and why? |
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Several graft options are available. I use the patellar tendon autograft most often. The bone plugs at both ends of this graft heal rapidly in place and permit the fastest return to full sports participation, usually between three and four months after surgery. Autografts are taken from your own body eliminating completely any concerns about viral diseases transmission and rejection reactions. Autografts have been used for many years and are rapidly incorporated into your body. For a younger patient (perhaps 13 or 14 years old) who still has open growth plates, I prefer a soft tissue graft (quadriceps tendon or hamstring). This can be placed in the precise position needed, crossing the growth plates, without doing damage to these critical growth areas. |
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How long will I be out from work or school? |
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Most of my patients are on crutches for one to two weeks. Most are able to stop using the crutches at one week and the rest are off their crutches by two weeks. Depending upon where your classes are located in school (do you have to climb stairs?), and if you need to climb stairs, you should be able to return to some classes starting about one week after surgery. Do not expect to return to your full schedule until two weeks. |
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Is physical therapy necessary? How hard is it? |
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Physical therapy is simply "educted exercise" and has the goal of reducing pain and swelling, increasing strength, and gaining full motion. This exercisewill help you rapidly return to your normal activities and to sports. Patients who have patellar tendon autografts need to attend physical therapy to achieve full extension (straightening their legs all the way out) starting as soon as possible (in the first week) after surgery. The sooner therapy is started the easier it is to meet the goals. Patients with a soft tissue grafts (quadriceps tendon) do not require such an intensive therapy program. In fact, they are often started on a self-administered stationary bicycling program beginning about two months after surgery. |
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When can I start driving after my surgery? |
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To drive safely, you should no longer be using narcotics for pain control and have adequate strength and control for the brake and accelerator pedals. This can usually be achieved between one and two weeks after surgery. |
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Will I need to wear a brace after surgery? |
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A sports brace will protect your reconstruction and allow you to return to pivoting sports as early as 12 weeks after surgery (patellar tendon autograft). However, if you do not care to return this quickly, the graft will naturally strengthen over time and 12 months after surgery, no brace is required. In other words, if you are willing to take it easy until 12 months after surgery a custom made knee brace is not necessary. |
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Will my knee wear out early if I don't have my ACL fixed? |
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It is the loss of the meniscus cartilage and severe damage to the weight bearing articular cartilage that leads to the knee wearing out. Some damage to the weight bearing cartilage usually occurs with ACL tears, but I believe this will heal with time. If you avoid pivoting sports, or if your knee is stabilized surgically so you do not have buckling episodes, there is a good chance that your knee will not wear out early even if you do not have the ACL fixed. If however, you continue to have buckling episodes, you meniscus cartilages are very likely to tear and this can lead to arthritis. |
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Is this type of surgery done with a scope? |
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Yes. ACL reconstruction is done with a scope (arthroscopically). Graft harvesting does require a small incision in the area of the tendon, but the graft is inserted with a scope. I like to videotape all my procedures and the scope allows us to make a videotape of your surgery (only the portion inside your knee). If you would like a copy of this video, please let us know. |
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What are the potential complications of ACL surgery? |
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No surgery is without its potential complications. As with any surgery, there is a small chance of infection and phlebitis (inflammation of the blood vessels that can lead to blood clots). There is a small chance of postoperative stiffness, and should you fall after surgery you may damage your repair. No surgery can be completely successful in every case. Some patients do not do as well as others, but overall the success rate for ACL reconstruction is very high. Please be sure to ask us if you have any other questions. |
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How good can I expect my knee to be after having this surgery? |
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The success rate for this procedure is about 95%. Some patients experience pain after this injury and the surgery but that is usually due to cartilage damage from the initial injury. As far as function goes, we return our patients with patellar tendon autografts to half speed running between 6 and 8 weeks. Pivoting, non-contact, sports begin at 12 weeks, and with the special sports brace, full unlimited contact sports may begin between 12 and 16 weeks after surgery. The intention is to restore full unlimited function as soon as possible. |
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What can I expect from my knee if I do not have this surgery? |
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With a tear of the ACL, your knee has lost the main stabilizing ligament. Pivoting activities will place stresses on the joint that may exceed your knees ability to support you. When this happens, your knee buckles and gives way. That may be painful and cause knee swelling. Whenever a buckling episode occurs, the cartilages are bruised. Any of these buckling episodes can result in tearing of the vital knee cartilages that can lead to arthritis. If you do not have this surgery, you must avoid these buckling episodes (either by avoiding all pivoting sports and activities, or by wearing a brace whenever you pivot). |
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Are you sure that the ACL is completely torn and how do you know? |
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There are several ways to determine if your ACL is torn. First, the history of your injury can be very suggestive of a torn ACL. Next there are two special tests (Lachman and Pivot shift tests) that we perform which are only positive with torn ACLs. If there is still a question about whether or not the ACL is torn, a MRI test can be obtained. |
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Is it possible that there is more injured than just the ACL? |
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Yes. It is not uncommon for the cartilage to be damaged too. You have two types of cartilage in your knee: meniscus cartilage and articular cartilage. The two meniscus cartilages are crescent shaped spacers in your knee. These are torn in about half of the fresh ACL tears. The articular cartilage coats the bones of the joint as a low friction weight-bearing surface. This is commonly bruised with ACL tears, but usually heals with time. Over time, if the ACL is not repaired and buckling takes place, the meniscus cartilage tears in most knees. |
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What happens to the knee joint when the meniscus is removed? |
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We try to repair any torn meniscus cartilage we find. The good news is that most meniscus tears associated with fresh torn ACLs are repairable (longitudinal tears) if surgery is done in the first few weeks after the injury. Also, when the meniscus repair is done in conjunction with an ACL reconstruction, successful meniscus healing occurs over 90% of the time. On occasion the torn portion of the meniscus must be removed. When that happens we try to leave as much of the meniscus as possible removing only the torn part. With this approach, thelong term problems of removing a meniscus can be reduced but osteoarthritisis still possible. |
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ACL Injuries in Skeletally Immature Patients
by F. Alan Barber MD, FACS |
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Athletes of all ages who participate in pivoting or contact sports may injure the anterior cruciate ligament (ACL). Whether this occurs as part of a family ski vacation or playing football for the local school, even young teenagers can sustain this injury. For the athlete who has completed their growth, the timing and treatment considerations are fairly straight forward; and with surgical reconstruction, most patients can either obtain a predictable outcome from surgery or adjust to reasonable functional limitations and avoid surgery. When the athlete is younger and has open growth plates, the situation becomes far more complex.
Bones grow from areas near the joints called growth plates. These growth plates produce bone that increases leg length. Rapid growth occurs at the end of the femur (thigh bone) and top of the tibia (shin bone) during the early teenage years. Damage to them can cause stunted growth or angled legs. Damage to them can cause stunted growth or angled legs.
Recent research about ACL injuries in skeletally immature athletes highlights the problems with nonoperative treatment for ACL tears. Athletes who continue with pivoting activities are very likely to further injure their knee and tear their cartilages. Complicating any nonoperative treatment is the reality that young athletes are unlikely to accept any limitations and often go ahead and pivot despite instructions to the contrary.
ACL reconstruction in skeletally immature patients corrects knee looseness and prevents damage to the knee cartilages. However, it is challenging because the reconstructive surgery involves drilling tunnels across the growth plates and placing a new ligament (graft) into the knee joint using these tunnels. This part of the surgery can potentially damage the growth plate and result in shortening or angulation of the leg as the bones continues to grow. The younger the patient is, the greater the impact of any growth disturbance should it occur.
New ACL reconstruction techniques reduce these concerns. The key to success in these situations is to avoid placing fixation devices (screws or pins) across the growth plates and the use of only soft tissue grafts. It is well established that premature closure of the growth plate can be caused by bone or metal across the plate. Soft tissue implants do not have this effect. In fact, the treatment of growth plate closure occurring after fractures is often to place soft tissue in the area of the growth plate closure.
No surgery is without risks. However, the latest reconstruction techniques provide an effective treatment for these challenging ACL injuries. It is very important that the treating physician have significant experience in treating ACL injuries in immature athletes.
The decision must include a fully informed patient and parents who with the physician select a course of treatment consistent with the teenage athlete’s skeletal maturity, athletic goals, and motivation. |
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What is the AC joint? |
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There are two joints in the shoulder: the ball and socket joint and the joint where the collar bone meets the shoulder blade. The latter is the AC (acromioclavicular) joint. It is the most prominent bump on the top of your shoulder. This joint has a cartilage spacer (or meniscus) inside and the ends of both bones have a cartilage coat much like a knee joint. The joint is held together by strong ligaments that are called the coracoclavicular ligaments. |
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How is the AC joint injured? |
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The most common way is a fall on the point of the shoulder. This is sometimes called a “shoulder pointer” and can sprain or separate the AC joint. A separation occurs when the collar bone (or clavicle) is pulled away from the shoulder blade. A mild injury in which the ligaments supporting the AC joint are only stretched is a Grade I injury. In this situation, the patient may notice pain and some swelling at the ACL joint but this should heal uneventfully.
More severe injuries can partially tear (Grade II) or completely tear (Grade III) the ligaments. As the severity of the injury increases, the end of the clavicle becomes more prominent and a prominent bump is seen. |
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How is a sprained AC joint treated? |
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The initial treatment of an AC joint injury is nonoperative. Ice packs wrapped in a towel and placed on the point of the shoulder help reduce swelling and relieve pain. A sling will support the arm and take weight off the shoulder. Later gentle range of motion exercises should be started to prevent stiffness and regain full motion. Often attending physical therapy is very helpful in returning the patient to full activity. |
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How long does an AC joint injury require for healing? |
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Milder injuries may heal in two to three weeks while more severe injuries may take six weeks or longer. In severe cases, the shoulder may require surgery. |
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When is AC joint surgery necessary? |
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After several months of treatment, it there is continued pain and limited function surgery may be required. Pain with direct pressure at the AC joint, (from straps or clothing), popping, catching, or pain with overhead activities, pain with lifting, throwing, or reaching are all indications for surgery. |
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What type of surgery is done for the AC joint? |
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If the main problem is pain and arthritis at the AC joint, simply removing the end of the collar bone (clavicle) using an outpatient arthroscopic technique (a Mumford procedure) can be done. This technique is very successful for painful joints (weightlifters, arthritis, or minor separation).
When there is significant AC joint separation, a more extensive ligament reconstruction procedure is required to bring the clavicle back into its normal position. This operation requires a two-inch incision over the joint. The end of the clavicle is pulled back into position with a tape attached to another portion of the shoulder blade (the coracoid process).
Sometimes the end of the clavicle is removed and a ligament transferred from the underside of the acromion into the cut end of the clavicle (Weaver-Dunn procedure) to replace the torn ligaments. This is not an arthroscopic procedure. |
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What is the postoperative treatment and rehabilitation? |
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The post surgical treatment depends upon the surgery performed. After an arthroscopic Mumford procedure, the arm is placed in a sling for comfort and physical therapy started rapidly to regain full motion and strength. Bathing, while keeping the wound dry, is allowed immediately. Showers are allowed after the sutures are removed (usually about one week after surgery). Elbow, wrist, and hand exercises are begun immediately.
When a ligament reconstruction procedure is performed, several weeks of protection with a sling is needed before exercises start. This time allows healing of the reconstruction. |
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What is shoulder instability? |
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Unstable shoulders can occur when the shoulder slides partially out of joint (subluxation) or completely out of joint (dislocation). This is particularly troublesome for people who work with their hands above their heads or for the throwing athlete (baseball pitcher, football quarterback, tennis player). Instability can be very painful and cause permanent damage to the cartilage of the shoulder joint. |
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Why does the shoulder go out of joint? |
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The shoulder joint is the most mobile joint in the body. At the same time it is the most unstable. This range of motion occurs because the ball of the shoulder is balanced on the socket of the shoulder blade and held there by ligaments, capsule, and muscles. Damage to any of these can weaken the relationship and result in a dislocation or subluxation. |
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Does age make a difference? |
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Yes. This is one condition in which it is actually better to be older. The highest rates of recurrence are in the younger patients. Teenagers have a particularly difficult time one the shoulder starts to dislocate. As people get older, their joints tend to tighten up and the frequency of dislocations decreases. |
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How is shoulder instability evaluated? |
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The first step is a thorough evaluation by your orthopedic surgeon to understand the nature of the instability. In most instability cases, the ball slips out of the socket to the front (anterior dislocation). Sometimes the dislocation is out the back (posterior). It is important to understand the direction so the correct treatment is carried out. Next, any bone injury needs to be identified. Your doctor may obtain special imaging studies (MRI, CT scan) to clarify this issue. Finally, an understanding of the activity and athletic demands of the patient is important. For instance, collision athletes (football or rugby) have a much higher incidence or recurring dislocations than noncontact athletes. |
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How is shoulder instability treated? |
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Patients with a traumatic anterior dislocation and a small piece of bone pulled off along with the ligaments have a Bankart injury. Recent studies indicate that these cases have a high probability of redislocation regardless of the treatment chosen. Only surgery will significantly reduce their risk of redislocation.
Surgery reattaches the Bankart lesion to the socket and tightens the torn shoulder ligaments injured by the dislocation. Physical therapy or immobilization does not prevent post-traumatic instability. This is because the fundamental cause of the instability is the damaged ligament attachment which is not changed by physical therapy. |
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What type of surgery is done for shoulder instability? |
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Current arthroscopic techniques can be as effective as open surgery with less pain and easier rehabilitation. Outpatient arthroscopic reconstruction (our preference) reattaches the torn ligaments and any bone fragment to the edge of the socket by the use of small biodegradable suture anchors with sutures attached. The sutures are woven through the ligaments and then tied using special arthroscopic knots to secure the repair. Sometimes the capsule is loose and sutures are placed to tighten the soft tissues (capsular plication) as well. Complete healing from this procedure takes approximately 4-6 months. |
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What causes shoulder calcium deposits? |
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Calcific tendonitis, as shoulder calcium deposits are called, has no know cause. It is unrelated to dietary calcium intake, trauma, or overuse as far as can be determined. When calcium deposits are present, they are often associated with a very painful shoulder and limited shoulder motion. |
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Who is most likely to have calcific tendonitis? |
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While women between 35 and 65 years old are most likely to have this condition, men can develop it too. |
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Does calcific tendonitis damage the shoulder? |
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The calcium deposit lies either within the rotator cuff tendon or in the bursa. Those deposits in the bursa cause problems because of swelling and pinching of the surrounding tissue. Those in the rotator cuff can result in tearing of the tendon (cuff) as well. The most common problem with calcific tendonitis is persistent pain unrelieved by medication, injections, and therapy. |
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What is the calcium deposit like? |
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The calcific deposit can be like toothpaste and sometimes like a powder. When these deposits are opened up during arthroscopic surgery, the material will either flow out in a string or flake out of the tissue like chalk. |
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What is the best treatment for calcific tendonitis? |
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Calcium tendonitis can be a very uncomfortable condition. The marked inflammation associated with it is treated with oral anti-inflammatory medications, ice packs, rest, and physical therapy. Cortisone injections into the shoulder bursa may also give relief. |
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Is surgery helpful for calcific tendonitis? |
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If the nonoperative treatments listed above do not relieve the problem after several weeks, arthroscopic surgery can be effective in curing calcific tendonitis. During this outpatient surgery and under a general anesthesia, the surgeon identifies the calcium deposit in the bursa or tendon where it is located and removes it. Any inflammation (bursitis) or bone spurs (impingement) present are also removed. |
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Can the calcification reoccur after removal? |
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This is very unlikely. Removing the calcium deposit is very successful in relieving the symptoms and a recurrence is very uncommon |
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What is a “frozen shoulder?” |
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A frozen shoulder refers to a patient who has lost most of their shoulder motion. The shoulder is usually painful and hard to move. Another term used to describe this condition is “adhesive capsulitis.” Thickening of the soft tissue around the joint leads to contractures and scaring which results in the loss of motion. Over time, because of the shoulder pain, the shoulder is moved less and less and the stiffness becomes worse. |
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What causes a frozen shoulder? |
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One type of frozen shoulder is called “idiopathic” or “primary” frozen shoulder. These shoulders experience a gradual loss of shoulder motion for no apparent reason. The underlying cause of this condition is unknown, but is felt to be inflammatory.
Another form of frozen shoulder is “secondary” to a painful condition in the area of the shoulder. This could be a fracture, soft tissue injury, or referred pain from the neck.
In general, secondary frozen shoulder responds quickly to physical therapy once the underlying source of pain (such as a fracture) is healed. Primary frozen shoulder also tends to run its course but over a longer period of time. |
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How is frozen shoulder treated? |
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Frozen shoulder can be thought to have two distinct phases: a stiffening phase and a stiff phase. During the stiffening phase the shoulder is getting stiffer. This is a painful period during which the shoulder progressively loses more and more motion. When this phase ends after what may be several months, the shoulder is stiff but the pain decreases.
Physical therapy plays a critical role in the treatment of the frozen shoulder. Regardless of which phase of the disease, a therapy program can be very successful in restoring the motion and reducing pain. In addition to therapy, anti-inflammatory medication or steroid injections are helpful in reducing the pain, swelling, and stiffness. This program usually results in gradual improvement, although it may take several months. |
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What happens if therapy does not work? |
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Some individuals especially those with diabetes, do not achieve complete success with physical therapy and anti-inflammatory medications. In these cases, either arthroscopic surgery or a manipulation under anesthesia is considered. With either of these options the procedure is carried out under a general anesthesia (the patient is completely asleep) at an outpatient surgicenter.
With manipulation under anesthesia, the shoulder is moved by the surgeon to completely break up all the adhesions and stretch out the stiff muscles. With the arthroscopic procedure, the surgeon will surgically divide these adhesions as well as evaluate the interior of the joint for additional damage. Once the procedure restores full motion, physical therapy starts later that same day to maintain the motion. |
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What is the Rotator Cuff? |
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The rotator cuff is the tendons from the muscles on the shoulder blade that hold the upper arm bone (ball) into the socket of the shoulder joint. This rotator cuff moves and rotates your arm and helps to stabilize the shoulder joint. The combination of injury (trauma) and natural aging (degeneration) can damage the tendons of the cuff. |
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What causes a Rotator Cuff tear? |
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Rotator cuff tears are caused by a several factors. Normal use over time and the natural aging process can damage the rotator cuff. In this degenerative process, the tendons can rub against the overlying bone of the shoulder (acromion) and cause inflammation in the bursa that lies between the cuff and the acromion. This condition is called an impingement syndrome. This impingement can be aggravated by repetitive activities at or above the shoulder level and by the shape of the shoulder bone (acromion). Rotator cuff problems start with swelling and inflammation in the bursa which can lead to pain and loss of motion
As this process continues, the rotator cuff tendons develop inflammation or tendonitis. Tendonitis can be aggravated by continued overuse, or injury and this may lead to more degeneration.
Over time, this process can partially tear the tendon either on its undersurface or on the top of he tendon (partial thickness rotator cuff tear) and eventually lead to a full thickness (complete) tear of the rotator cuff.
Rotator cuff tears occur from a combination of trauma and degenerative changes. Older individuals who already have degeneration present in the cuff require less trauma to develop a tear. A significant injury with lots of force is required to tear an otherwise healthy rotator cuff. Most rotator cuff injuries result from a combination of both degeneration and a moderate injury. |
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What are the Symptoms of a Rotator Cuff Injury? |
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The symptoms commonly occurring with rotator cuff injuries are pain, weakness, and loss of motion in the shoulder. Some patients will experience a “pop” in their shoulder after which they cannot lift the arm very well. Others will report a gradual onset of these shoulder symptoms but may not notice any loss of motion. |
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What sort of treatment can I expect? |
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Most shoulder problems are treated without surgery. The initial treatment usually consists of a careful examination by the doctor and oral anti-inflammatory medications to reduce the pain and inflammation. Physical therapy may be recommended to strengthen the muscles and further reduce the pain. The goal of treatment is to reduce the pain and inflammation and restore full function. |
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What happens if medicine and therapy does not work? |
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The best treatment must consider the patient’s age and activity level. Surgery may be the clear choice for a young athlete with a torn but otherwise healthy rotator cuff. Since younger individuals usually have very little rotator cuff degeneration, surgery is can usually repair the tendon and return them to full unlimited function.
Older individuals with more advanced degenerative rotator cuff tendons can also have a successful cuff repair, but degenerative changes may complicate tendon healing. Unfortunately, some individuals have so much degeneration in their tendons that even with a successful reconstruction of the torn rotator cuff tendons to the bone, healing does not occur. While surgery can physically repair a torn rotator cuff tendon, nothing can reverse advanced degenerative changes. |
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Can rotator cuff surgery be done arthroscopically? |
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Yes. Advances in shoulder arthroscopy currently allow for the routine arthroscopic repair of most rotator cuff tears. In our practice, arthroscopic rotator cuff repair is a routine procedure. The arthroscope offers clear visualization of the tendons and the joint and new instrumentation has greatly facilitated suturing the tendon and reattaching it to the bone.
The key however is to do the best repair possible for the patient. Arthroscopic techniques are clearly an attractive option for rotator cuff surgery. Using only small puncture wounds rather than an incision reduces postoperative pain and leaves more cosmetically appealing scars. |
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What is the biceps tendon? |
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The biceps muscle on the front of the upper arm has two tendons that connect it to the shoulder. The long tendon attaches at the top of the shoulder ball and socket joint (glenoid) and the short tendon attaches to another part of the shoulder blade (coracoid). With these two tendon attachments, the biceps muscle bends the elbow and rotates the forearm. |
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What kind of problems develop in the biceps tendon? |
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Biceps tendon injuries occur more frequently as we age. These injuries range from a simple overuse or inflammation (tendonitis) to a complete tear or rupture. Older tendons are less elastic and have a reduced blood supply. This degenerative process can be slowed by moderate and regular exercise, but over-training can also damage a healthy tendon |
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What is tendonitis? |
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Irritation or inflammation in the sheath that surrounds the tendon results in pain and swelling. This is called "tendonitis." Mild strains or overuse of the biceps can cause microscopic tears in the tendon. As this process continues, these microscopic tears can enlarge and reach the point where the tendon is partially or completely torn (ruptured). When a biceps tendon rupture occurs, it usually affects the long head of the biceps. This long head retracts down the arm toward the elbow and the biceps muscle bunches up. This is known as a “Popeye” muscle. Fortunately, despite this cosmetic deformity, the biceps muscle function is usually maintained at nearly normal levels. |
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How are biceps tendon injuries treated? |
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Irritation or inflammation in the sheath that surrounds the tendon results in pain and swelling. This is called "tendonitis." Mild strains or overuse of the biceps can cause microscopic tears in the tendon. As this process continues, these microscopic tears can enlarge and reach the point where the tendon is partially or completely torn (ruptured). When a biceps tendon rupture occurs, it usually affects the long head of the biceps. This long head retracts down the arm toward the elbow and the biceps muscle bunches up. This is known as a “Popeye” muscle. Fortunately, despite this cosmetic deformity, the biceps muscle function is usually maintained at nearly normal levels. |
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How are biceps tendon injuries treated? |
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Initially, rest, ice, physical therapy, and anti-inflammatory medications are prescribed. Sometimes an injection with a steroid medication is administered to control the pain and swelling. In severe cases that do not improve with these measures, surgical treatment may be suggested. |
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What does surgery involve? |
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The type of surgery depends upon extent of the tendon damage. If the damage is limited, a simple arthroscopic shaving of the torn fibers is all that is needed. If the damage involves more than half the thickness of the tendon, the tendon is weakened and a rupture likely. In order to treat this amount of damage, the tendon is arthroscopically divided and reattached to either the adjacent bone or the rotator cuff tendon (tenodesis). In some cases, depending upon the patient’s needs, it is more appropriate to simply divide the tendon (tenolysis) and not reattach it. Your doctor can discuss these different treatments in greater detail. |
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What happens if the tendon is already ruptured? |
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Complete biceps tendon ruptures can often be successfully treated without surgery. While the bulging muscle remains, normal function can often be regained with therapy. If surgery is an option, the procedure is performed through an incision in the upper arm. This can only be successful if the end of the tendon remains near the top of the shoulder. If the tendon slides too far down the arm, a tenodesis would require an extensive incision and may not be appropriate. |
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What can be expected after surgery? |
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After a tenodesis, a sling is used for the first few weeks. There are no restrictions for hand or wrist movement, but lifting is restricted. After six weeks, moderate lifting is allowed. A return to a desk job or light duty status is permitted after the first week. Heavy lifting usually requires several months healing. |
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What is a SLAP tear? … by F. Alan Barber MD, FACS |
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A SLAP tear is an injury to the part of the shoulder joint where the biceps tendon attaches to the labrum. The term SLAP was first coined in 1990 and stands for Superior Labrum Anterior and Posterior. The labrum is a cuff of cartilage that surrounds the socket of the ball and socket shoulder joint. Without the addition of the labrum, this ball and socket joint is extremely shallow and inherently unstable. To compensate for the shallow socket, the shoulder joint has this labrum which makes the shallow socket much deeper and provides stability for the shoulder. |
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How does a SLAP tear occur? |
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A SLAP tear can occur after a fall onto an outstretched hand, a shoulder dislocation, repetitive overhead (throwing or serving) activities, or lifting heavy objects. The area of the labrum where the SLAP tear occurs is susceptible to injury because it is the attachment point of the biceps tendon and with increasing age experiences a reduction in its blood supply. Other parts of the labrum with a better blood supply often heal more easily. |
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How do you diagnose a SLAP tear? |
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While there is not specific test that is always reliable, several special shoulder tests exist that can help detect a SLAP tear. These tests are part of a routine orthopedic shoulder examination. In addition to a careful history from the patient, they help the shoulder specialist identify symptoms consistent with a SLAP tear. SLAP injuries may not show up well on routine MRI scans; so, the addition of contrast into the shoulder is usually needed to make the diagnosis. This contrast MRI is performed by injecting a fluid called gadolinium into the shoulder. The gadolinium highlights the normal structures and allows a better identification of SLAP tears or other injuries to the labrum and biceps tendon. |
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What are the symptoms of a SLAP tear? |
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Typical symptoms of a SLAP tear include a catching or popping sensation often associated with pain during shoulder movements. These are usually noticed during overhead throwing or serving activities. Patients often complain of pain deep within the shoulder or at the upper back of the shoulder. While it can be hard to pinpoint these symptoms, in cases where the biceps tendon is involved, patients may experience pain at the front of the shoulder. |
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What is the treatment for a SLAP tear? |
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Most patients with SLAP tears respond well to non-surgical treatments. These treatments may include anti-inflammatory medication, rest, and physical therapy. Sometimes cortisone injections are performed. |
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What if these treatments do not work? |
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In patients who have continued symptoms despite these treatments, arthroscopic surgery of the shoulder may be recommended. There are several specific surgical procedures that may be performed. These procedures include SLAP debridement, SLAP repair, and biceps tenodesis. When a SLAP tear is debrided, the torn portion of the labrum is shaved away to leave a smooth edge. This option is appropriate for fraying of the labral inner rim, bucket handle labral tears, and labral flaps. A SLAP repair is an arthroscopic procedure that uses sutures attached to biodegradable anchors to reattach the torn labrum to the shoulder socket. A SLAP repair is usually performed in patients who want to remain athletically active. A biceps tenodesis is an operation which reattaches the injured biceps tendon to it another area to remove the stress at the labral tendon attachment. The idea behind a biceps tenodesis is that by decreasing the forces that pull on the SLAP region, the symptoms will be removed. A biceps tenodesis is most commonly performed in patients over 40 years of age. All of these procedures are performed arthroscopically but differ somewhat in the postoperative rehabilitation program. A SLAP repair or debridement usually only requires wearing a sling for a few weeks, while more restrictions may be required for a biceps tenodesis. |
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