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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triceps tear

Monday, October 23, 2017

When people take about the ironmen of sport, Cal Ripken’s name often heads the list, but it’s Joe Thomas of the Cleveland Browns who should be considered the ultimate sports warrior. As a lineman, there are never any plays off and each play is a battle against the largest players on the opposing team. Mr. Thomas’ streak of more than 10,000 consecutive players that began in 2007, has ended with a torn triceps muscle. It may be appropriate that to sideline this player, it required a triceps tendon rupture that is the rarest of tendon injuries.

The triceps muscle is located on the back (posterior) of the upper arm and is responsible for extending or straightening the elbow. It is balanced by the bicep, located on the front (anterior) of the arm, which flexes or bends the elbow. As its name implies, the triceps has three heads that arise from bones in the shoulder and join together to form the muscle. It then morphs into a tendon that crosses the elbow and attaches into the olecranon, the bony outcropping that can be felt at the back of the elbow joint.

It takes a lot of force to tear the muscle or pull the tendon off the bone and the mechanism is usually a fall on an outstretched arm with the muscle contracted, and there may or may not be a direct blow to the area. The arm collapses and the elbow hyperflexes, pulling on the triceps muscle that can’t protect itself. The injury causes either the muscle to tear in two,  pulls the tendon away from the bone or fractures the part of the olecranon where the tendon attaches. Regardless, the end result is an arm that the player cannot straighten and the diagnosis is pretty obvious to the trainer on the field.

While many athletic injuries have options for treatment, the complete disruption of the muscle, tendon or bone, needs an operation to reattach the pieces and put them where they belong.

The purpose of a muscle is to move a joint. It usually arises from a bony prominence on one side of a joint and then attaches via a tendon across the joint to another bone. When the muscle contracts, the joint moves. If the muscle tendon unit is torn completely (a third-degree strain), The ability to move the joint is lost. Without repair, power and range of motion may never return completely. Interestingly. Some third-degree tears can be treated without an operation with satisfactory results, but not in athletes or active people.

The concept of the operation is easy, but requires skill to prevent nerve or blood vessel damage. Rehab is measured in months returning range of motion is balanced against ripping the repair and having to start over. For that reason, physical therapy is an important part of returning to play. Elite athletes strain to test their repaired body parts too early and need to rein in their enthusiasm to do too much too quickly. Mother Nature and Father Time don’t like to be rushed.

All streaks must come to an end. Cal Ripken was able to orchestrate his last game but most athletes have their streaks ended without knowing when their last play might be. To be fair, that can be said for every athlete, regardless of age. Faster, higher, stronger pits performance against anatomy and physiology, and sometimes the body loses.

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