Saturday, June 2, 2012

Torn Labrum: Now What?

One of the great things about using pro athletes as a jumping off point for topics is that there is an endless supply of material. One of the worst things is that these injuries often happen to my favourite players. Marian Gaborik, star player with the New York Rangers, injured his shoulder during this season's NHL playoffs.
He thinks he injured the shoulder during the 1st round of the playoffs against Ottawa, but was able to play through the pain for two more rounds until the Rangers were knocked out by cross town rivals, the New Jersey Devils. This injury was finally diagnosed as a torn labrum of his shoulder, and will require surgery to repair, with recovery time of up to 6 months!

Torn labrums in the shoulder are more commonly associated with pitchers, who stress the joint much more, and some of the notable victims include Curt SchillingChris Carpenter, and most recently Michael Pineda of the New York Yankees.

What is the Labrum?

The simplest way to think of the labrum of the shoulder is as a lip of fibrous cartilage around the glenoid; or socket part of the shoulder. This lip of cartilage serves to deepen the socket (glenoid) by up to 50%, helping keep the head of the humerus (the ball of the ball and socket), from popping out.
Unfortunately it is NOT uniformly thick all the way around and certain areas are prone to tearing, especially where the long head of the biceps tendon attaches into it.

When this cartilage tears, it can cause pain, catching, popping and limit strength and range of motion.

Mechanism of Injury

Labral injuries most commonly occur either from trauma, or repetitive overhead activity, like throwing or swimming.

Traumatic injuries are usually due to a result of a fall with the arm outstretched above. This is thought to causes a pinching mechanism of the humeral head catching the labrum.

In the case of repetitive overhead activity, it is thought that the biceps tendon chronically irritates the weak spot of the labrum where it attaches.

How do I Find out of My Labrum is Torn?

Good question. In most of medicine, a well taken history and focused physical exam can often provide a clear diagnosis, without resorting to expensive imaging. In the case of the shoulder labral tear, this unfortunately is not quite true.
Labral tears in overhead athletes can mimic rotator cuff injuries, which can often be settled down with some relative rest, review of mechanics and rehab.  The history for both is similar. The clinical tests for labral injuries, have NOT been shown to be particularly accurate, and can vary dramatically depending on who is conducting the examination!

So, for labral tears, if there is a high degree of suspicion, and a failed course of conservative management, I tend to order an MRI with dye (gadollinium), to assess the labrum specifically. Unfortunately, even the MRI can miss this diagnosis, and sometimes the definitive test is to scope the shoulder to directly visualize and repair the labrum if it is still torn.

Recovery Time

Once the diagnosis has been made, if the labrum is torn, it likely needs surgery to repair, as cartilage has a poor blood supply and tends NOT to heal.

Shoulders tend to take a relatively long time to recover, due the complex interplay of inherent instability, and the degree of freedom the joint has.

It usually take 4-6 weeks just for the initial pain to settle, then true rehab can begin on range of motion and gradual strength. This can be another 4-6 weeks just to get function back.  The next step is then trying to return to activities that caused the problem in the first place like throwing or swimming.

This is the most important part of the recovery as mechanics and strength need to be changed, or the same injury can recur again.

Going back to Marian Gaborik, my hope would be a hockey player is more likely to come back from this injury than the Yankees new pitcher. (sorry baseball fans!)

Let me know if this helps!

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