labrum tears in the shoulder

Monday, November 6, 2017

There is no such thing as minor surgery. Minor operations are done to other people. Even the most routine procedure may develop complications, because regardless of wat the statistics say, for that one person and that one operation, either all will go 100% according to plan, or it 100% won’t. And for the Indianapolis Colts’ Andrew Luck, he has fallen into the category of not going so well. After undergoing a labrum repair of his throwing shoulder, rehab has been delayed by continuing problems with range of motion, strengthen and pain. The plan that had him playing the first game of the season has been revised and he has been put on the shelf to rest his arm and not throw, perhaps not his expected outcome.

With the advent of increasingly sophisticated technology, surgery has almost become routine but that isn’t necessarily the case. A generation ago, arthroscopy was a new technique and could only be used on the largest joint in the body, the knee. It revolutionized the treatment of torn meniscus (cartilage) and ligaments (like the ACL), not only saving athletes’ careers, but also restoring quality of life to mere mortals as well. It took many years for the tech companies to develop scopes that were tiny enough to work in the tiny confines of the hip, shoulder, elbow, wrist and ankle and because of the tight spaces, there is less room for error. Not only did the tools need to get smaller, but the surgical expertise needed to get better.

Mr. Luck’s injury involves the labrum, a cone of cartilage that extends the depth of the shoulder joint to help with stability. The humeral head, the upper ball joint of the arm, is supposed to rotate inside the shoulder joint, but the glenoid fossa, the bony cup where it rests, is very small and shallow. The cartilage that makes up the labrum is not uniform. The superior or upper part of the labrum is loosely attached to bone and is where the biceps muscle attaches. Repetitive throwing has the potential to stretch the cartilage and make it prone to injury. The inferior or lower part of the labrum has cartilage tightly adhered to bone. The transition point from loose to tight is not the same in everybody. This is important because every shoulder injury is a little different from person to person and it takes the skilled surgeon to put things back the way they belonged.

Shoulder imaging has come a long way from plain x-rays and MRI is the way the surgeon can look inside the joint without having to make the initial cut. By injecting dye in to the shoulder, the anatomy of the shoulder, including the bones, the cartilage, the labrum and the muscles can be mapped. And abnormal things can be found: tears, bone spurs, arthritis and much more. But even with faster and more high tech imaging, there is nothing better than the surgeon looking inside the joint to see what’s going on.

Shoulder arthroscopy is a two-step process. Frist one has to look inside and see what the problem might be and second, the problem has to be fixed. Even if the MRI showed the torn labrum, how the tissue looks and feels will help the surgeon decide how to repair it. Often tissue is sewn back together, sometimes anchors are put it place and rarely, the decision is made to abandon the scope and cut the joint open to be able to deal with what has been found.

SLAP tear = tear of the Superior Labrum from Anterior (front) to Posterior (back)

Surgery is just the beginning in healing and physical therapy and rehab is where the patient’s work begins. There needs to be a balance between allowing the tissue to heal and restarting range of motion so that the shoulder doesn’t get too stiff to move. Then it’s on to strengthening and gradually over months, return to play or work.

Things can get in the way, as they have with Mr. Luck. Recurrent pain with activity may be due to inflammation that will settle with rest, or it may be due to inflammation around the sutures or anchors. Or it may be that the surgeon mistook how tight the tissues needed to be and made too tight of a repair. Another MRI may be helpful…or not. That leaves the decision as to whether the shoulder needs more time to heal, or whether another look inside is the best route to take.

 

For Colts’ fans, the decision to rest their star quarterback for the whole year makes their Sunday football that much less appealing. But Mr. Luck wakes up every day wondering if this is the day the shoulder stats to feel better or whether the surgeon is going to recommend another operation and another 4-6 moths of rehab.

 

There is no such thing as minor surgery. That’s an operation that’s done to other people.

 

 

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when it’s not so hip…

Monday, September 30, 2013

Joints are parts of the body that we take for granted when we’re young but as we age, they start to get stiff, take a while to warm up and get moving and become the focus of our body getting older. Sometimes, trauma and injury make our bodies get old in a hurry. A weekend of watching the NFL confirms that the body is not meant to be hit at a high rate of speed. Often the bodies bounce, but Jake Locker, the Tennessee quarterback was not as lucky as his hip buckled. As he was carried off the field, first for x-rays in the stadium and then to the hospital for more tests, the rumors regarding his status ran rampant. A day later and there is still uncertainty about what is going on deep within his hip joint.

The hip joint is pretty well designed ball and socket joint. The head of the femur, the ball, sits in a deep socket of the pelvis called the acetabulum that is made deeper by the labrum. This is a ring of cartilage that extends the joint but is also flexible to allow the hip to move more freely. There is also a fibrous capsule that encases the hip, plus large muscles of the buttock and thigh to add extra protection. While the cartilage can be damaged by overuse and arthritis, it takes a significant force to damage the hip joint with a single blow.

Dislocating the hip is a rare athletic injury and most often occurs as a consequence of a car wreck. If the bent knee is driven into the dashboard, the force causes the hip to dislocate posterior or through the back of the joint. Other types of dislocations can occur but are much more unlikely and require a different type of mechanism. Anterior hip dislocations occur when the leg is turned out and forced backward levering the femoral head out of the socket, but this is very unusual injury. As it turns out, care safety technology with better air bags, decrease the risk of hip dislocations, but they still happen and they are an orthopedic emergency.

The hip needs to be relocated as soon as possible to restore blood supply to the ball of the joint, the femoral head. The longer that is it out of place, the higher the chance of avascular necrosis, the term used to describe death of bone because of loss of blood supply. Othercomplicat8ions include damage to the sciatic nerve, the femoral nerve and the femoral artery, all structures that need to work to have a normally functioning leg. Even with prompt care, the prognosis is not great. Good hip function can be expected in about 50% of patients and potentially 70% will develop arthritis in the joint.

Then good news is that Jake Locker’s doctors don’t think that he had a hip dislocation. The bad news is that there is so much swelling in and around the hip that it obscures the labrum and the jury is out whether it is damaged. Patience is not a virtue for injured athletes, but Mr. Locker will have to wait for a few days before another MRI to look at the hip.

A torn labrum may or may not be a big deal. Small tears can be treated with rest, ice and anti-inflammatory medications and may heal nicely. However, the MRI often underestimates the damage that is seen when arthroscopic surgery looks directly inside the joint. The hip is a small joint and to fit the camera inside, the hip has to be distracted or partially dislocated. The labral tear can be fixed or trimmed but rehabilitation and recovery may take 6-12 weeks. It’s a reminder that all joints are not created equal since a pro athlete can be back on the field in a couple of weeks after knee arthroscopy.

No matter the short term outcome for Mr. Locker, the long term prognosis would favor him developing a chronically sore and arthritic hip as he ages. The question is whether his hip will age gradually with the rest of his body or whether it will get old before its time. A reminder that the body is not meant to be hit at high speed.

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