Instability and Labral Tear
This handout describes several types of shoulder ligament and labral injuries.
Traumatic Dislocation and the "Bankart Repair":
Ligaments are like "ropes" that hold bones together. After shoulder dislocation, there is usually a tear of the main stabilizing ligament of the joint where it attaches to the bone of the shoulder socket. If the ligament has not healed correctly the first time, the shoulder can dislocate over and over when put in certain positions. Sometimes a partial dislocation or "subluxation" occurs when the ball slides part-way out of the socket then spontaneously slips back. The symptoms of shoulder instability are accompanied by uncomfortable shifting of the ball with respect to the socket. This problem is aggravated by certain motions or arm positions. These activities should be identified and avoided. Adherence to specific exercises can help stabilize the shoulder. If a vigorous exercise program fails and symptoms are debilitating and painful, we may consider surgical repair or reinforcement of the stretched and/or torn ligaments.
Sometimes a piece of the bone has been broken away with the attached ligament. If repetitive dislocation has occurred, the ball may also be damaged. The objective of surgery is to repair the ligament back to the socket preventing further instability (dislocation) while preserving shoulder motion. Sometimes it is necessary to tighten the ligament as well. The exact nature of the repair is determined at the time of surgery. This can most often be accomplished by arthroscopy without an open incision, but not always. The first step in the procedure is to examine the shoulder by arthroscopy and determine the exact nature of the tear. Repair is then done by an arthroscopic or an open technique.
Superior Labral Tears (AKA the "SLAP" Tear)
The labrum is a rim of fibrocartilage that surrounds the shoulder socket and is a point of attachment for the biceps tendon and the shoulder ligaments. It is common for the labrum to be torn away from the socket after injury. When this occurs at the attachment of the biceps tendon at the top of the socket it is referred to as a SLAP lesion. The letters in 'SLAP'stand for superior labrum anterior to posterior tear. This type of tear often causes pain and catching in the shoulder. These injuries are quite common and can be diagnosed by history and physical examination in many cases and confirmed by MRI scan if necessary. This kind of tear may be associated with rotator cuff injuries or bursitis or may be present in combination with other shoulder ligament injuries. This injury is one that is usually possible to repair by an arthroscopic technique. Surgery takes 60-90 minutes typically and post-operatively a sling is used for 3-4 weeks. Return to most activities is usually possible by 3 months with up to 6 months required at times for the most strenuous activities.
Atraumatic (no major injury) Dislocations and the "Capsular Shift":
This is by far a less common reason to need surgery. The other type is usually associated with natural "in-born" looseness of the connecting tissues (such as ligaments) which are supposed to hold the joint in proper position. Shoulders having a joint capsule that is too loose may be tightened by splitting the surrounding tissue envelope and taking out the slack by overlapping ligaments as needed. Care is taken to tighten the ligaments just enough and not too much. This "Capsular Shift" necessarily results in temporarily limiting the normal range of shoulder motion. Frequently, motion is regained over time with gradual stretching out of the capsule. Because the tissue is more "stretchy" than usual, there is a risk of recurrent instability after surgery. The repair may be done in the conventional open manner or more recently by an arthroscopic technique. While the open technique has a longer track record, it is my opinion that the arthroscopic techniques available will have just as good results with significantly less pain and an easier rehabilitation. If this type of surgery is planned, we will discuss the pros and cons of each with you. A sling will usually be needed for 4-6 weeks after surgery. Recovery to full activity may take 6-12 months depending on the exact nature of your injury and the full activities desired.
Recurrent dislocation or instability is a risk, although it is less for the Bankart repair compared to the capsular shift. Statistically, there is a slightly higher rate of recurrent dislocation after arthroscopic repairs and patients need to understand this pre-operatively if they wish to be considered for such a repair. By selecting only the best candidates for arthroscopic bankart repair, this risk is minimized. In my opinion with current arthroscopic technique and carefully chosen patients, the risk of recurrent instability is most likely equal. Other risks include, but are not limited to infection, bleeding, numbness, loss of movement, tendon or joint surface damage, and anesthetic risks. Life threatening heart, lung, or kidney failure may occur as with any surgical procedure. We will work with you to reduce the risk of each of these surgical complications.
After the Operation:
After completion of the operation, your arm will be placed in a sling or brace. You will remain in the recovery room for approximately one hour after surgery. Your first visit after surgery will be 2-3 days in my office. At that time we will change your bandage. Sutures are removed 7-10 days after surgery on your second visit. You will not be allowed to drive for 3-4 weeks post op depending on the procedure.
The rehabilitation program depends of your age and the type of the operation that was necessary to correct the instability. You will get an exercise program postoperatively designed for your specific operation.