slaplesions-Bankart-Labral-tears by Kirk Andrew

Labral Tears: SLAP and Bankart Lesions by Vic Goradia, MD, Knee, Shoulder & Sports Medicine Specialist Basic Anatomy of Shoulder The shoulder is a ball and socket joint. It consists of three bones: the upper arm bone (humerus), wing bone (scapula) and collarbone (clavicle). The ball (humeral head) fits into the small socket (glenoid). The glenoid is surrounded by a soft cartilage lip (labrum), which deepens the socket. The upper part of the wing bone (acromion) projects over the shoulder joint. One end of the collarbone is joined to the acromion by ligaments to form the acromioclavicular (AC) joint.

Labral Tears The shoulder ligaments attach the humeral head to the glenoid. These ligaments attach to the labrum which is firmly attached to the glenoid. The labrum is the cartilage â&#x20AC;&#x153;lipâ&#x20AC;? that lines the shoulder socket or glenoid. This lip helps to deepen the socket so the shoulder ball will stay in the socket. When the labrum tears away from the glenoid, patients experience pain, catching, clicking and/or locking. Depending on which part of the labrum tears, it has different names.

For example, tears on the top part are known as Superior Labral Anterior Posterior (SLAP) lesions. Since this is a mouthful it is much easier to refer to them simply as SLAP lesions. Tears in the front part of the labrum that extend to the bottom are known as Bankart Lesions.

SLAP Lesions The term SLAP lesion was first developed by Dr. Steve Snyder from Los Angeles in the early 1990’s. However the actual lesion was described in 1985 by Dr. James Andrews. Prior to this time many patients suffered from shoulder pain that could not be easily diagnosed or treated. Today most sports medicine and shoulder specialist are able to diagnose and treat SLAP lesions. Unfortunately, there are situations in which these tears are actually over-diagnosed. In other words, patients are sometimes treated for SLAP lesions that do not actually exist. It is therefore important to see a surgeon that treats a large number of SLAP lesions and other shoulder problems. SLAP tears can occur when falling on the arm/shoulder, having the arm suddenly pulled, a lifting injury or repetitive overhead activity with the arm. Most commonly they occur during work injuries in which the arm is suddenly “yanked” or in overhead athletes. In this latter situation, the tears are a result of repetitive overuse more often than a sudden injury. It is very common to hear of baseball pitchers having SLAP lesions. With repetitive throwing or other similar activities, the biceps can slowly pull the labrum away from the socket. As you will recall from above, the biceps tendon from the arm attaches onto the Superior Labrum. In other cases, the Superior Labrum repetitively pinches between the glenoid (socket) and rotator cuff causing the labrum to gradually tear. Regardless of the cause of a SLAP tear, the labrum will not heal back to the bone. In those individuals that have to use their arm repetitively, surgery is needed to treat the SLAP lesion. Fortunately, the condition can be treated with arthroscopic surgery.

2 Go Orthopedics

| 281 East Hundred Road, Chester VA 23836 |

Bankart Lesions Bankart lesions are another type of labral tear. They occur as a result of a shoulder dislocation or multiple dislocations. When the ball (humeral head) dislocates out of the socket (glenoid), the ligaments that normally hold these two structures together will either stretch or tear. When they tear it is called a Bankart Lesion. In this case the inferior (i.e. lower) glenohumeral ligament pulls the inferior labrum away from the glenoid. Less commonly the ligament will pull the labrum with a piece of bone—this is known as a bony Bankart lesion. Most shoulder dislocations have to be forcefully relocated (i.e., put back in place) by a doctor, sometimes with sedation. Next, the patient is placed in a sling for immobilization that allows some scarring and healing of the damaged ligament, labrum and /or bone. In many cases, however, these structures do not heal in the correctly. Studies have shown variable results with non-surgical treatment. Many published studies have noted re-dislocation rates of 75-90% in patients under the age of 25 with a first time dislocation. This risk is greatest for dominant arms of active individuals.

Surgical Treatment of SLAP and Bankart Lesions Fortunately, if surgery is required it can be performed completely arthroscopically through small skin punctures with use of a fiber optic camera. When arthroscopic surgical techniques were first developed in the 1980’s and 1990’s, the outcomes were less favorable than traditional open surgical procedures. However as our understanding of the anatomy and available instruments improved, arthroscopic techniques have become the standard for most experienced shoulder surgeons. Currently, surgeons have numerous different types of instruments, sutures and anchors available to them for use in repair of labral tears. The basic technique for labral repair requires the surgeon to appropriately mobilize the labrum. This means they have to free it from the surrounding scar tissue. Next the glenoid bone has to be prepared so it bleeds and allows the labrum to re-attach to it. Most surgeons use dissolvable anchors. These are placed into the glenoid bone. The sutures from these anchors are passed through the torn labrum. At that point the surgeon can tie a knot or use a knotless technique for final repair.

3 Go Orthopedics

| 281 East Hundred Road, Chester VA 23836 |

My Preferred Treatments >SLAP Lesions The most important aspect of SLAP lesions is diagnosis. It is important for me to obtain thorough historical information from the patient regarding their symptoms, any injuries and response to previous treatment. Next I will carefully examine the patient’s shoulders. At this point I will generally have a suspicion about a SLAP and will order and MR arthrogram (MRA). With this test the radiologist injects dye into the shoulder and then an MRI is performed. The MRA is much more sensitive in diagnosing SLAP lesions than a regular MRI. Once the tear is diagnosed, I will discuss the treatment options with the patient. Unfortunately if they are having symptoms from the SLAP, the only definitive treatment is surgery. The only other option is to modify or eliminate activities that produce pain. In my experience, most patients do not want to eliminate activities and therefore usually select surgery.

>Bankart Lesions If a patient has a first-time dislocation and is under the age of 25 years, I will discuss options of immediate surgery vs. trying a period of immobilization. The latest research shows that immobilization in external rotation (with the arm rotated out) is best if non-surgical treatment is attempted. I carefully counsel the patient about the 75-90% risk of recurrent dislocations. For individuals over 40 years of age that have a first-time dislocation, I base my recommendations on the patients’ activity level and work requirements. Many patients can be treated without surgery unless they have strenuous hobbies or work. The middle group of patients, from 25-40 years of age, fall in a gray area. Again, it is important to note their activity level, how loose their shoulder feels when I examine it and how large the tear appears on the MRA. Regardless of age, if patients have recurrent dislocations or are apprehensive about participating in activities because of their shoulder, I will recommend and discuss surgery.

>My Surgical Technique for SLAP & Bankart Lesions I currently use an all-arthroscopic technique with knotless, dissolvable anchors. The key to the procedure is placing the anchors in the right place and appropriately mobilizing the labrum as I noted above.

4 Go Orthopedics

| 281 East Hundred Road, Chester VA 23836 |

>After Surgery After arthroscopic repair of SLAP and Bankart tears, patients are generally given a sling or immobilizer. • • • •

Approximately one week after surgery, I send patients to physical therapy for protected range of motion exercises. As the tear begins to heal over a period of 6-8 weeks, the therapist begins a strengthening program. At 12 weeks most patients can begin heavier strengthening and light sports specific training. Most patients resume non-contact sports by 4-6 months and contact sports by 6-9 months.

Baseball pitchers and other similar overhead athletes require a slightly modified rehabilitation program that focuses strongly on throwing mechanics after the initial healing period. As with all surgeries, I work closely with the physical therapist to develop a specific rehabilitation program for every patient. For athletes we also include the athletic trainer(s) and coaches in our “team” approach to treatment.

About Dr. Goradia Although any general orthopedic surgeon can treat shoulder problems, the shoulder conditions described here are treated more effectively by a surgeon with expertise and advanced training in this type of diagnosis and treatment. There are a limited number of such specialists in most large cities. I have completed a 1-year, fully accredited fellowship in Sports Medicine, Arthroscopic Surgery and Knee & Shoulder Reconstructive Surgery and am certified by the American Board of Orthopedic Surgery. I was among the first in the U.S. to receive a Certificate of Added Qualifications (CAQ) in Sports Medicine. I also teach arthroscopic surgery to other orthopedic surgeons at national orthopedic conferences and produce educational videos of my surgeries on the website of the Arthroscopy Association of North America (AANA) for the purposes of educating other surgeons. I am nationally recognized in the field of arthroscopic surgery. For more information about my qualifications please visit www.GoOrtho.net.

5 Go Orthopedics

| 281 East Hundred Road, Chester VA 23836 |