Brett Gemlick, MD
SportONE
 Review
Shoulder Anatomy
 Describe types of labral injuries
 Review Surgical Techniques
 Discuss post operative rehabilitation
 Return to play
 Clavicle
• 1st bone to ossify, last to fuse (25 y)
• SC joint only true joint connecting
UE to axial skeleton
 Scapula
• GH: greatest ROM of all joints
 golf ball on a tee, not ball in socket
• Provides site for 17 muscle attach.
• Acromion: shape and non-fusion
predispose for problems
 Proximal
Humerus
• RC attachments
• Bicipital groove

Rotator Cuff (RC)
• Supraspinatus,
Infraspinatus,
Subscapularis, & Teres
Minor
• Function: movement &
center H.head in glenoid

Long Head of Biceps
(LHB)
• Superior/anterior
stability

Labrum
• Meniscus of GH joint
 Laxity=symptomatic, passive
of humeral head ; no pain
translation
 Ex: generalized ligament laxity, hx of chronic
ankle sprains
 Congenital :“I’m very bendy”
 Some able to sublux/dislocate without injury

Instability=pathologic condition
w/excessive translation of humeral head
on glenoid fossa; pain and/or discomfort
 Traumatic/Sports related injuries
 Static: ligaments
& tendons
• Labrum
 “meniscus of shoulder”
 Cross-sectional anatomy, microvascularity, and attachments
similar to knee meniscus (Cooper
1992)
• capsule and ligaments
• RC passive tension
• neg. intra-articluar pressure
(vacuum)
 Dynamic: muscle
contraction
 RC and LHB contraction
 Scapular retractors
 Trauma
- dislocations of shoulder may
cause isolated or extensive labral injury
(Mazzocca 2011)
• Anterior labral tear or Bankart lesions
• Posterior labral tears or reverse Bankhart lesion
• Superior Labrum Anterior and Posterior (SLAP)
tears
 Overhead
throwing/hitting athletes
• Long head of biceps anchor at superior labrum
applies traction during overhead throwing,
especially during cocking and deceleration phase
(Yeh 2007)
• “peel-back mechanism” during cocking phase
• Typically SLAP tears
www.ptsmi.org
 Global
Laxity
• Repeated shoulder subluxations with increased
capsular laxity may result in blunting or tearing
of labrum
www.rpocenter.co
m
 Bruce
Springsteen
 “Born in the USA”
 History
• Important Details / HPI
 Pain description (location, provocative actions, etc)
 Acute vs. chronic, frequency
 With c/o instability: subluxation v. dislocation
 self-reduced v. trip to ER for closed reduction with
conscious
sedation
 Direction of subluxation
 mechanism of injury
 temporary numbness/tingling
 hand dominance
 Mechanical symptoms: clicking, catching, etc.





O’Brien’s Test – SLAP tears or AC injury
Apprehension/Relocation – Anterior
instability/labral injury
Load and Shift – Anterior/Posterior
instability
Sulcus Sign – Inferior instability
Janke test – posterior instability
Note: MDI patients will likely have
multiple positive tests
O’Brien’s Test
Apprehension Test
Load and Shift Test
Sulcus Sign
 Plain
films: AP, outlet, grashey, &
AXILLARY!
• Cannot truly diagnose dislocation or prove
reduction without axillary view
• Bony Bankart or Hill Sachs lesions
 MRI
Arthrogram
• Labrum and capsule damage seen better w/ dye
• Bony edema from osseous injury seen that might
not show on plain film

Labral Tears
 MRI arthrogram: 89% sensitive, 91% specific, and 90%
accurate (Bencardino 2000)
 Non-contrast MRI vs MRI Arthrogram (Sheridan 2014)
 Non-contrast MRI: accuracy 85%, sensitivity 36%, PPV 13%
 MRI Arthrogram: accuracy 69%, sensitivity 80%, PPV 29%

Bankart Tear
 injury to the labrum at the point of the IGHL (90%) and
MGHL (10%) from the glenoid rim (Solomon)

Hill Sachs Lesion
 compression fracture at the posterolateral margin of the
humeral head

Increased capsular volume
 Irreversible stretching

RC Tears
 seen typically in dislocation patients over age 40
www.orthoinfo.aaos.org
www.crawfordsportsmedicine.com
SLAP
type
Description
Treatment
I
Frayed labrum without detachment
Debridement
II
Labrum & biceps anchor detached from superior
glenoid rim
Repair
III
Bucket-handle tear of superior labrum wihtout
detachement of biceps anchor
Debridement
IV
Bucket-handle tear extending into and splitting
biceps
Repair
V
SLAP II that extends into anterior labrum
Repair
VI
SLAP II combined with parrot-beak type flap tear
Repair and
debride flap
VII
SLAP II extending into MGHL origin
Repair
VIII
SLAP II extending posteriorly
Repair
IX
Circumferential tear off glenoid
repair
Radiologyassistant.nl
Anterior Labral Tear
www.bacsianh.com
Posterior Labral Tear
appliedradiology.com
Hill Sachs Lesion
 Anterior
Labroligamentous Periosteal Sleeve
Avusion (ALPSA lesion)
• Associated with anterior shoulder dislocation
Radiopedia.org/cases/alpsa-lesion

The cymbal company Zildjian which was founded
in Constantinople in 1623.
Source: American Heritage of Invention & Technology, Winter 2000
 Select
superior labral tears
• Long Head of Biceps Tenodesis or Tenotomy
 Depends on extent of tear and age of patient

Most Labral Tears
• Arthrosciopic Labral repair
 Use of suture anchors or knots to fixate labrum back
to
glenoid rim
• Often performed in conjunction with
capsulorrhaphy if capsule is
stretched/weakened
SURGICAL FINDINGS:
 1. Anomalous long head of
biceps tendon with no normal
tendon in the intraarticular
portion of the joint. There was
what appeared to be an
anomalous long head of biceps
tendon running medial to the
normal entrance into the joint,
and it went superficial to the joint
capsule and headed posteriorly.
There was a band of tissue that
appeared to be the middle
glenohumeral ligament attached
to the superior labrum.
 2. Three hundred sixty degree
labral tear. Good labral tissue.
 3. Normal glenoid and humeral
head articular surface.



4. Normal intraarticular
subscapularis tendon.
5. Ninety percent full-thickness
articular-sided supraspinatus tear
just posterior to the bicipital
grove 10 mm in AP dimension.
6. Normal posterior cuff.
PROCEDURE PERFORMED:
 1. Right shoulder arthroscopy
with arthroscopic superior labral
repair.
 2. Arthroscopic anterior labral
repair.
 3. Arthroscopic posterior labral
repair.
 4. Arthroscopic rotator cuff
repair.
Anterior Bony
Bankhart
Posterior Bony Bankhart
 Arthroscopic
Remplissage
• French for “to fill in”
• Infraspinatus used to “fill” large Hills-Sachs lesion in
conjunction with anterior Bankhart (Merolla 2014)
Boileau 2012
 Algorithm
for surgical
treatment of
anterior
shoulder
instability
that has
failed
conservativ
e treatment
jaaos.org
 Shoulder immobilizer x 6 weeks
• keeps arm at side with forearm across body
• Ultra-Sling immobilizer (Gunslinger) for posterior
labrum/capsule to protect repair
 Begin
outpatient PT within few days of
surgery
• PROM only for 6 weeks
• At 6 weeks, may DC immobillizer and begin AROM
with PT with 5 lb limit
• ROM limitation dependent upon location of repair
• If capsulorrhaphy, will hold PT start for 2 weeks
 SLAP
Program may vary between PT
departments and/or therapists, but goals
same:
• Early PROM
• Structured rehabilitation
• Return to sport
 80-90% athletes return to throwing and contact sports
(uwhealth.org)
 72.5% MLB pitchers returned to competition at a mean of
13.1 months with no significant change in performance
(Ricchetti (2010)
 68% elite pitchers returned to play at mean of 12 months;
22% never returned to MLB (Harris 2013)





Immobilizer for 6 weeks
May shower on post-op day 3 and change
dressing. No ointments or creams. Do not
immerse in water until staples are removed.
Physical Therapy
0-3 Weeks
•
Immobilizer at all times; active hand , active
wrist, passive gentle active elbow exercises
started immediately
•
Codman exercises, PROM 0-90 degrees of
flexion and abduction; external rotation in
adduction to neutral; avoid extension of arm
behind body for 4 wks
•
No external rotation in abduction because of
peel-back mechanism
• Immobilizer when not doing PROM regimen
3-6 Weeks
•
Continue sling and start progressive PROM to
full as tolerated in all planes
•
Begin passive posterior capsular and internal
rotation stretching
•
Begin passive and manual scapulothoracic
mobility program
•
Begin external rotation in abduction
•
Allow use of operative extremity for light
activities of daily living




6-16 Weeks
• Continue all stretching and flexibility
programs as above ROM should be full
• Begin progressive strengthening of rotator
cuff, scapular stabilizers and deltoid
• At 8-12 weeks biceps resistance and
sports/work specific exercises instituted
with goal of normal function at 4 months
For Throwing Athlete
• Begin interval throwing program on level
surface
• Continue stretching and strengthening
regimen with particular emphasis on
posterior capusular stretching
6 Months
• Begin throwing from mound
7 Months
• Allow full velocity throwing from mound
• Continue strengthening and posterior
capsular stretching indefinitely
 Who
was the last Division 1 college football
team to finish the regular season unbeaten,
untied, AND unscored upon?
The University of Tennessee 1939







Solomon,D, et al. “Extensive Labral Tears – Pathology and Surgical
Treatment”. Shoulder Instability: A Comprehensive Approach. 36:
426-34.\
Weber, S. DeLee & Drez’s Orthopaedic Sports Medicine. 49: 54349.
Yeh, ML. “Stress Distribution in the Superior Labrum During
Throwing Motion.” The American Journal of Sports Medicine.
March 2005. 33: 395-401.
Burkhart SS. :The Peel-Back Mechanism: its role in producing and
extending posterior type II SLAP lesions and its effect on SLAP
repair and rehabilitation.” Arthoscopy. 1998; 14: 637-40.
Mazzocca, A..et al. “Traumatic Shoulder Instability Involving
Anterior, Inferior, and Posterior Labral Injury: A Prospective
Clinical Evaluation of Arthroscopic Repair of 270 º Labral Tears.”
Am J Sports Med August 2011. vol 39. 8: 1687-96.
Cooper, DE et al. “Anatomy, histology, and vascularity of the
glenoid labrum – An anatomical Study.” J Bone Joint Surg Am, 1992
Jan; 74 (1): 46-52.
Nam, E. and S. Snyder. “Clinical Sports Medicine Update. The
Diagnosis and Treatment of Superior Labrum, Anterior and
Posterior (SLAP) Lesions”. Am J Sports Med. Sept 2003; 5: 798-810.






Ricchetti et al. “Glenoid labral repair in Major League Baseball
pitchers”. Int J Sports Med. 2010 Apr; 31(4): 265-70.
Harris et al. “Return to sport following shoulder surgery in the
elite pitcher: a systematic review”. Sports Health. 2013 Jul; 5(4):
367-76.
Bencardino JT, Beltran J, Rosenberg ZS, et al: Superior labrum
anterior-posterior lesions: Diagnosis with MR arthrography of the
shoulder. Radiology 214:267 –271,2000
Solomon and Devine. “SLAP Tears: Pearls and Pitfalls in Diagnosis
and Management”. Sports Medicine Update Jan/Feb 2011. p2-6.
Merolla & Porcellini. “Infranspinatus strenght assessment and
ultrasound evaluation of posterior capsulotenodesis after
arthroscopic hill-sachs remplissage in traumatic anterior
glneohumeral instability: a retrosecptive controlled study
protocol”. Transl Med UniSa. April 2014. 24:; 9: 27-9.
Boileau et al. “Anatomical and Functional Results After
Arthroscopic Hill-Sachs Remplissage”. J Bone Joint Surg Am, 2012
April 04; 94 (7): 618-626.