Understanding SLAP tears

After appearing in just two games for Sussex, Bangladesh fast bowler Mustafizur Rahman’s England cricket season came to a premature end in July with a shoulder injury that saw him undergoing surgery last month with Mr Andrew Wallace of the London Shoulder Specialists at Fortius Clinic to treat a SLAP tear.

SLAP tears are diagnosed when the top part of the labrum becomes torn due to injury. Responsible for stabilising the shoulder, the labrum is made up of strong tissue which runs in a ring around the shoulder’s socket. SLAP is an abbreviation for Superior Labrum, Anterior to Posterior, and refers to the area of the shoulder that’s been injured.

There are actually various types of SLAP tears a patient can experience, all relating to the severity of the tear. It’s most common in those who play contact or overhead sports and is therefore a common injury suffered by fast bowlers like Rahman.

Understanding the different types of SLAP tears

When a SLAP tear is diagnosed, it is classified as a specific type:

Type 1: A partial tear, including degeneration of the superior labrum. The edges of the free margin are frayed and rough, but the actual labrum itself is still attached. Treatment typically includes cleaning the edges, a process known as ‘debride’.

Type 2: Diagnosed when the labrum has totally come away from the glenoid, this is the most common type of SLAP tear. It tends to occur after an injury such as dislocation and a gap is left between the labral attachment and articular cartilage.

These types of tears are also commonly broken down into sub-categories such as posterior, anterior and a combined posterior/anterior tear. To treat it, the labrum will need to be reattached via keyhole surgery. The slap repair is carried out arthroscopically with suture anchors.

Type 3: In some cases, the tear in the labrum causes it to hang down into the joint, causing it to frequently pop and lock. Treatment is similar to a type 2 tear, using the same keyhole surgery technique. The only difference is the hanging section of the labrum, commonly referred to as a bucket-handle tear, is eliminated before the remaining labrum is repaired.

Type 4: A severe tear which extends within the long head of the biceps tendon. SLAP repair surgery will need to be carried out to reattach the labrum, as well as potentially repair the tear in the biceps.

How do I know I have a SLAP tear?

The first sign of a SLAP tear is pain, ranging in severity, throughout the top section of the shoulder. This will largely present itself when you’re performing overhead activities. Mustafizur Rahman noticed his SLAP tear after his second game of the season, experiencing significant pain when bowling.

The pain experienced is sometimes assumed to be associated with AC joint issues. A good way to establish whether you’re experiencing a SLAP tear or AC joint issue is to do a bench press. If you experience a lot of pain while going down into the press, it’s a SLAP tear. AC joint issues commonly cause more pain as you press out of the bench press.

As well as pain, clicking is another common symptom, along with weakness in the shoulder. You may also feel like the shoulder is going to pop out of place and there could be a deceased range of motion.

Depending on the type of tear and how it is affecting you – whether that’s your performance as a top-flight cricketer or your ability to discharge day-to-day activities – the London Shoulder Specialists can offer a range of non-surgical and surgical treatments.

Could an electric shock zap shoulder arthritis pain?

An innovative approach to pain relief could provide hope for sufferers of rheumatoid arthritis.

In a limited trial at the University of Amsterdam, 17 rheumatoid arthritis sufferers were fitted with an electronic implant in the vagus nerve that controls many of the important functions of the body, including inhibiting inflammation which is the underlying cause of rheumatoid arthritis.

In this degenerative condition, the body’s immune system mistakenly attacks the joints causing swelling, stiffness and pain. The implant works by releasing an electric pulse that stimulates the vagus nerve, reducing the levels of immune cells that cause the damage.

All patients enrolled on the trial had previously failed to respond to medication and all reported a marked reduction in stiffness and discomfort. Rheumatoid arthritis is just one of many different types of arthritis that can affect any joint of the body, including the shoulder. The most common type of shoulder arthritis is osteoarthritis, which is often associated with ageing.

Understanding shoulder arthritis

Arthritis means inflammation of a joint in the body. As the shoulder is a very mobile joint it can develop wear and tear over a lifetime. The cartilage which lies on the bones of the shoulder joint becomes thinner and ultimately can be destroyed. As a result, one bone then rubs on the other causing pain, stiffness and loss of functional abilities. One option is to then consider a shoulder replacement. Whilst this type of surgery is not as common as hip or knee replacements, on average, approximately 4,500 shoulder replacement surgeries are carried out each year in the UK.

Unsurprisingly, the National Joint Registry found that osteoarthritis was indicated in 58% of shoulder replacements, but there are other types of arthritis or conditions that can affect the shoulder requiring replacement surgery. These include

Rheumatoid arthritis

Affecting the joint lining of the shoulder, rheumatoid arthritis is one of the more common types experienced by patients. The autoimmune condition can present itself in one or both shoulders, causing stiffness and pain. Over time, it can lead to deformity of the shoulder joints, as well as an erosion of the shoulder bones.

Post-traumatic arthritis

Shoulder injuries are common, particularly in young athletes. When an injury occurs, it can trigger post-traumatic arthritis. Patients who have experienced shoulder dislocation or fractures are particularly at risk of developing the condition. In this type of arthritis, fluid can build up within the joint, causing pain and swelling.

Rotator cuff tear arthropathy

Rotator cuff injuries are fairly common and they can lead to a type of arthritis known as rotator cuff tear arthropathy. It is most commonly caused by a longstanding tear of the rotator cuff tendons, which results in muscle weakness and loss of support for the shoulder. As a result, a painful arthritis then develops.

Avascular Necrosis

Avascular necrosis is a condition whereby the blood supply to the humeral head (ball) is disrupted. This then causes bone cells to die. The body attempts to regenerate itself but the process is flawed and the ball can become very irregular. Conditions that can cause avascular necrosis include sickle cell disease, high dose steroids, excessive alcohol consumption, previous fractures and radiotherapy.

What are the treatment options for shoulder arthritis?

As consultant shoulder surgeon Mr Andy Richards of the London Shoulder Specialists commented in a recent lecture on shoulder arthritis: “There is no cure for arthritis so all the surgeon can do is reduce the symptoms and pain. Range of movement and function may be increased through reducing pain.”

This new electric shock implant may prove beneficial for patients suffering with rheumatoid arthritis. It is worth noting, though, that the trial was very limited so although results are promising, more in-depth studies are required. Also other types of arthritis will require a different approach and these include a range of non-surgical and surgical options. At London Shoulder Specialists, we will first assess the type of shoulder arthritis prior to offering expert, impartial advice on the most appropriate treatment.

Frozen shoulder: the symptoms and solutions

It is estimated that one in 20 adults in the UK will suffer a painful shoulder condition at some point in their lifetime. One problem that people can develop is frozen shoulder, which is medically known as adhesive capsulitis. The condition can be confused with arthritis or other shoulder problems such as bursitis. Below, you’ll discover how to spot the signs of frozen shoulder and what solutions are available.

What is frozen shoulder?

Frozen shoulder occurs when the articular shoulder capsule – the lining that surrounds the shoulder joint – shrinks and stiffens. It’s a very painful condition that can affect sleep, reduces mobility and makes everyday tasks extremely difficult such as reaching for something or even just getting dressed. It usually affects just one shoulder at a time, but in some cases, both shoulder joints can be affected. If one shoulder does develop the problem, then there is a 20% chance that at some time point the other shoulder will develop the same problem.

The good news is that for most patients the condition is self-limiting and it will get better. The bad news is that it can take 18 to 24 months to completely resolve, and, in some cases, it can persist for even longer.

The exact nature of the problem is till under investigation.

Who is at risk of developing frozen shoulder?

Frozen shoulder most commonly affects those between the ages of 40 and 60 and women are more likely to suffer than men. Whilst in many cases there is no obvious cause,  some people are more susceptible to the condition, such as those with diabetes, Dupytrens disease, Parkinson’s or possibly thyroid problems. Additionally, patients who have had a stroke or immobility caused by an injury or previous surgery can be at increased risk.

Studies suggest frozen shoulder in diabetics is brought on by collagen glycosylation in the shoulder joint caused by high blood sugar. Those who are insulin dependent have also shown to be six times more likely to develop shoulder issues than others.

What are the signs of frozen shoulder?

Most cases of frozen shoulder follow a pattern, with symptoms worsening and then resolving within an 18 to 24 month period. Typically, the stages of frozen shoulder are classified as freezing, frozen and thawing.

Stage 1: Freezing

This is the painful stage and the sufferer starts to notice discomfort and the shoulder gradually tightening, limiting mobility. This can occur over a period of weeks but the pain is such that there will be significant night pain causing sleep disturbance. Discomfort and pain may also be experienced simply at rest. When the limits of movement are reached, again the shoulder is very painful. This period can last for six months or more.

Stage 2: Frozen

In this stage, whilst there is still some pain, this generally improves. However, the shoulder remains very stiff. making it difficult to carry out everyday tasks. Again this period can last for over six months.

Stage 3: Thawing

In this final stage, the movement in the shoulder gradually returns and any residual pain dissipates. It is unusual but not impossible to develop the same problem again in the same shoulder.

How is frozen shoulder diagnosed?

London Shoulder Specialists diagnose frozen shoulder by assessing the level of pain experienced and the range of motion present within the joint. An X-ray is likely to be requested to check whether there are any other issues in the shoulder which could be causing the pain and stiffness. Occasionally we may carry out an MRI to establish the full extent of the damage caused to the soft tissue surrounding the joint. An alternative might be to perform an Ultrasound scan.

What are the treatment options for frozen shoulder?

Once diagnosed with frozen shoulder, there are numerous treatment options available aimed at relieving pain and increasing or preserving mobility and flexibility in the shoulder. A recent web survey carried out in the Netherlands and Belgium, revealed shoulder specialists most commonly opt for non-steroid anti-inflammatory drugs along with intra-articular corticosteroid injections to treat the first stage of the condition. This can be very helpful in reducing the significantly debilitating pain symptoms, particularly those experienced at night. Usually, injections are limited to 1 – 2 episodes and sometimes the cortisone is combined with water (saline) to try to expand the capsule (hydrodilatation).

If the pain persists or if stiffness remains significant following injection, then an arthroscopy (keyhole surgery) can be considered, whereby a camera is put into the shoulder and the tight, thickened capsule is released. This technique has largely superseded manipulation of the shoulder under a general anaesthetic.

The role of physiotherapy in the first stage of the condition is slightly controversial, but there seems to be no question that it is beneficial in the second and third stages of the disease.

Summer of sport: spotlight on shoulder instability and the young athlete

For young athletes, summer is prime time to get out there to train, compete or even just to engage in sport for fun and relaxation with friends. However, increased sporting engagement also means a rise in shoulder instability cases.

It is recognised that a trauma to the shoulder, such as a fall, can cause shoulder instability and many people know someone who has dislocated a shoulder.

However popular summer sports such as swimming, volleyball, tennis and cricket, can lead to shoulder instability, due to repetitive actions involving arm rotation. Shoulder instability can be painful and it can also put you out of action.

What is shoulder instability?

Shoulder instability presents itself in numerous ways including a full dislocation,  a partial dislocation (subluxation) and mild looseness (laxity). It occurs most dramatically when the ball (head) of the upper arm (humerus) is forced out of the socket (glenoid). In doing so, the ball can tear a ring (the labrum) that runs around the socket The problem is that once shoulder instability occurs, it is likely to recur. In repetitive sports, the injury to the labrum can be less acute and develops over a period of time.

There are a number of ways to classify shoulder instability. These include the cause of the instability – trauma, natural laxity, poor muscle patterning – the direction of the instability – anterior, posterior or multidirectional – the degree of the instabilty and the anatomic site of any injury within the shoulder.

The most common problem experienced by young athletes is anterior instability. It occurs largely in men aged between 18 and 25 and accounts for approximately 85% to 95% of shoulder instability cases. The most likely cause is trauma causing a complete dislocation, though subluxations are also common.  If there is a complete dislocation, patients can sometimes relocate the shoulder themselves, however often they need to attend hospital to have it reduced.

In the case of a subluxation, the shoulder only partially comes out and then slides back into joint by itself. This can still be painful and result in ongoing symptoms, such as pain when trying to rotate the shoulder. Very occasionally, the instability can be associated with altered sensation within the arm.

At the London Shoulder Specialists, we first assess the cause of the instability, as to whether it is the result of a trauma, natural joint looseness (hyperlaxity) or due to poor muscle control. It may be possible to utilise physiotherapy to help strengthen and coordinate your shoulder muscles and thereby reduce any instability symptoms, or the risk of a further significant event. We are often asked about the use of braces and, in certain circumstances, these can be helpful.

However, particularly in the younger population, surgery may be the best course of action to reduce the risks of further problems.

Surgery could reduce need for follow-up procedures

Research carried out by the American Orthopaedic Society for Sports Medicine, has shown first time dislocation surgery  significantly lowers the risk of re-injury and reduces the need for follow up procedures.

Within the study, 121 patients, with an average age of 19, were examined on average, 51 months after surgery. The group included 68 patients who had a first-time dislocation and 53 who had experienced several dislocations after initial non-operative treatment. Results showed that just 29% of first-time dislocation patients experienced further shoulder instability issues after arthroscopic surgery, compared to 62% in the patients who hadn’t undergone surgery.

This was a long-term, in-depth study which recorded data from 2003 to 2013. The results clearly highlight the benefits of first-time surgery for shoulder instability cases, providing hope for young athletes. It supports a number of other studies, which have shown similar findings. Indeed many of these have shown even better results for patients undergoing surgery. One area that has improved the results of surgery is better selection of patients and matching patients to the surgical options.

Most patients who suffer from first-time shoulder instability are understandably worried. This new research eases that worry and demonstrates that sometimes surgery can be the best way forward to protect their athletic career.

Mr Ali Narvani publishes article on rotator cuff repair technique

Consultant orthopaedic surgeon Mr Ali Narvani and fellow researchers recently published an article in Arthroscopy Techniques, the companion to Arthroscopy: The Journal of Arthroscopic and Related Surgery, on a rotator cuff repair technique that aims to reduce the significantly high failure rates associated with repair of very large rotator cuff tears.

Entitled ‘“Owl” Technique for All-Arthroscopic Augmentation of a Massive or Large Rotator Cuff Tear With Extracellular Matrix Graft’, the article explained that although the techniques and technology utilised in rotator cuff surgery have greatly improved over the years, there is still a high failure rate in repairing massive tears.

Patch augmentation is reducing these failure rates, but arthroscopic patch augmentation is highly challenging for the surgeon, so the article detailed a ‘simple and reproducible technique for all-arthroscopic extracellular matrix graft augmentation’.

Click here to read the article in full.

New painkilling techniques trialled in shoulder surgery

New painkilling techiques are being tested in the hope of reducing the amount of medication prescribed after surgery. Opioids are a common pain relief medication but there are concerns that they are being overprescribed after surgery. They reduce the intensity of pain signals before they reach the brain and affect the areas of the brain that control emotion. They range from hydrocodone, oxycodone, morphine and codeine and differ greatly in strength.

These prescription drugs can be extremely addictive. A 2015 US study published in the Mayo Clinic Proceedings, found one in four people who have been prescribed opioids go on to develop an addition. It is a worrying pandemic that’s particularly affecting young athletes. UK data is less comprehensive than that gathered in America, but a survey released by the charity Action on Addiction last year estimated that nearly one in ten UK adults believe they could be or could have been addicted to opioid painkillers, with a quarter taking opioids for more than five years.

Doctors are hoping the new painkilling techniques being tested may be used in conjunction with or instead of opioid medication to minimise patients’ reliance on this form of pain relief.

Combination of non-addictive treatments is key

Rotator cuff surgery can involve a painful recovery process, hence strong opioid prescriptions are often required in the initial post-operative period. However, the new painkilling techniques being trialled aim to deliver the same relief without the addictive nature of opioids and the dangerous side effects.

While the techniques have been used individually to relieve pain after surgery, it’s the combination of the different methods which is key according to surgeons at NYU Langone Medical Center’s Department of Orthopaedic Surgery in New York who are aiming to greatly minimise the pain experienced after elbow or shoulder surgery and, therefore, the use of opioids. Their techniques include:

  • Non-addictive anaesthetic – including the use of injections around the nerves in the neck and shoulder
  • Catheter implant – delivering anaesthetic over a set period of time
  • Mechanical stimulation and wearable icing devices – helping to reduce swelling and pain throughout physiotherapy
  • Drug regimens – helping patients to move onto non-addictive medication like Tylenol

There are of course some potential drawbacks with these techniques. Patients have to become accustomed to having weak or numb arms for a number of days. Catheter implants can sometimes be difficult to keep in place and they can seem like an ‘intimidating’ option.

Instead, single injections can be used which would effectively block pain signals for up to 24 hours. Opioid medication can still be used for a short amount of time before transitioning patients onto other medication

Many units, including Fortius London Shoulder specialists now employ regional anaesthesia, where injections are placed about the nerves in the brachial plexus to reduce post operative pain requirements. There are some risks that come with these injections such as nerve damage and the potential for the anaesthetic to leak, though these are relatively small.

Understanding rotator cuff surgery

Rotator cuff surgery is carried out in one of two ways. It can be performed via open surgery or arthroscopically. In the open surgery method, an incision is made in the skin and the procedure is performed through a large wound – the torn tendons are reaattched to the bone.

Arthroscopic surgery is performed using an arthroscope, or mini camera, so the surgeon can view the inside of the shoulder on a monitor. Small, specially designed surgical instruments are used so less extensive incisions are required. Arthroscopic surgery typically causes less trauma to the muscles surrounding the shoulder, which in turn reduces the discomfort felt after the surgery.

A study entitled ‘Effectiveness of Open and Arthroscopic Rotator Cuff Surgery’ published in the NIHR Journals Library, provided a better understanding of each method. Interestingly, the post-operative pain management required was similar with the open and arthroscopic method. Two-thirds of participants were still taking painkillers after two weeks and after eight weeks, though painkiller use was decreased from 66% to 55%.

Overall, regardless of the type of technique used, recovery from rotator cuff surgery should not be underestimated.

What are my treatment options after a rotator cuff tear?

The rotator cuff tear is one of the most common reasons why patients consult their GPs about pain and disability affecting the shoulder. In fact, the first description of a rotator cuff injury can be traced back to 1600 BC, when it appeared in the Surgical Papyrus, one of the oldest known medical texts.

Injuries to the rotator cuff become more common the older you get, accounting for 5% of all GP encounters. They may occur as part of the natural ageing process of the tendon and often show no symptoms at all. It’s estimated that more than 40% of patients over 60 will have a rotator cuff tear and will not even be aware of it, instead blaming their aches and pains on just getting older.

There may not be an isolated injury or event that causes the tear; the shoulder has a relatively poor blood supply and it is also an area that sees a lot of wear over time. As the tendons start to thin, even a small amount of strain can result in a tear.

Alternatively, a rotator cuff tear can be caused by a sudden, acute injury. Often, workers engaged in heavy lifting work can suffer from these types of injuries. Injuries can also occur during simple everyday activities such as cleaning, hanging curtains or gardening.

Athletic activities that involve excessive, repetitive, overhead motion, such as swimming, tennis and weightlifting can often be a cause. Tennis player Maria Sharapova had surgery to repair two rotator cuff tears in 2008. After a long recovery she finally returned to singles after a 10-month absence, but struggled for the next two years, before returning to form.

Will I need surgery to mend a rotator cuff tear?

At your consultation with the team at London Shoulder Specialists, non-surgical methods will usually be recommended first. The exact cause of the rotator cuff tear will often dictate the treatment options we advise.

Even though most tears can’t heal on their own, satisfactory function can often be achieved without surgery, so most patients with small degenerative rotator cuff tears can be treated with a combination of anti-inflammatory medication, steroid injections and physiotherapy. These options may all be of benefit in relieving pain and restoring strength to the involved shoulder. However, if the pain and lack of mobility associated with a rotator cuff tear fail to resolve, then your surgical options will be discussed with you.

Reasons where surgery might be indicated to repair a rotator cuff tear are:

  • persistent pain or weakness in your shoulder despite non-surgical treatment
  • if you are active and use your arm for overhead work or sports
  • symptoms have lasted for nine to twelve months
  • there is marked loss of function in the shoulder
  • a large tear is detected in the tendon (usually more than 3 cm)

Rotator cuff tear surgery typically entails re-attaching the tendon to the head of the upper arm bone called the humerus. A less invasive procedure, known as debridement, can be used to repair a partial tear by trimming or smoothing the tendon. A complete tear may require the two parts of the tendon to be stitched back together.

Three techniques are used for rotator cuff repair: traditional open repair, mini-open repair, and arthroscopic repair (keyhole); your consultant will advise you as to which approach is best suited to your individual circumstances.

What is the recovery like after rotator cuff tear surgery?

Rehabilitation plays a vital role in both the non-surgical and surgical treatment of a rotator cuff tear. Initially, the tendon will need to heal and you will be advised to keep your shoulder immobile for the first month or so and we recommend wearing a sling. Once the tendon has begun to heal then you will be required to undergo a programme of physical therapy aimed at returning your shoulder to its full pre-injury strength and motion.

Complete recovery can be expected approximately six months after surgery, as long as the patient rehabilitation programme has been followed. It is important to realise that there is always a chance of the rotator cuff re-tearing and the larger the initial tear, the higher the chance of that happening.

Could wearable technology reduce sports injury for top-flight cricketers?

More and more sports are utilising wearable tech, to keep their players at peak fitness and reduce possibility of sports injury. Rugby has been an early adopter, with every club in the Aviva Premiership using GPS units to measure speed and distance, and now cricket is set to follow.

Researchers at a leading Australian university have developed an algorithm, employing the technology behind guided missiles, to try and reduce injury and improve performance in cricket players. This so-called ‘torpedo technology’ has now been adopted by the Australian national team in advance of their test series against Sri Lanka in July.

Currently, the amount of balls that a bowler delivers is measured but not the intensity that is employed. Using missile-guiding microtechnology, including accelerometers, magnetometers and gyroscopes implanted into wearable technology, data will be gathered for a more in-depth workload analysis.

Sports injury rates in professional cricket game

Developments in professional cricket, with the introduction of T20 just over ten years ago, has meant more varied and complex demands on the player. As the cricket calendar has become more crowded, sports injury rates have risen; a study into injury rates of the Australian team found that the annual injury prevalence rates for fast bowlers exceeded 18%, with the shoulder being particularly vulnerable to injury.

Treating top-class cricketers

The team at the London Shoulder Specialists are experts in the treatment of professional cricket players. Mr Andrew Wallace, Consultant Orthopaedic Surgeon, has treated elite athletes playing for the England and Wales national teams, as well as professional cricketers from abroad. Later this month, he will be giving a lecture on ‘Shoulder Injuries in Elite Cricketers: Prospects for Success’ at the Sports Symposium at the British Elbow and Shoulder Society. The focus of this particularly segment of the meeting, held in Dublin from 22nd to 24th June, will be on managing sports injury from the pitchside to return to play.

Mr Wallace will be focusing on SLAP tears, a shoulder injury that is common to cricketers or those that partake in overhead sports. Standing for ‘Superior Labrum Anterior and Posterior’, this is a tear to the top part of the shoulder joint, known as the labrum. It can be an incredibly painful injury and Mr Wallace employs arthroscopic surgery to visualise and successfully repair the labrum.