In order to understand a shoulder injury, one must first note that the shoulder is made up of three bones:
- The scapula (shoulder blade)
- The Humerus (upper arm bone)
- The clavicle (collarbone)
Labral Tear (Lesion)
The distal end of the shoulder blade is called the glenoid. Although it is very shallow and flat, a rim of soft tissue exists, making it more like a socket or cup. This soft tissue is called the labrum. The labrum is considered integral to shoulder stability.
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It turns the flat surface of the glenoid into a deeper socket that molds to fit the head (or ball) of the upper arm bone at the location where it touches the shoulder bone. It is important to remember that the upper arm does not come up under the shoulder blade to make contact; it makes contact at the end of the shoulder blade. Several tendons and ligaments attach the labrum, which provide stability to the joint.
Sometimes physical exertion such as lifting, pulling or pushing may cause a person’s bicep muscle to be flexed too hard or too quickly. This may in turn cause the bicep tendon to pull sharply against the soft labral tissue. The labrum can be caught between the end of the shoulder bone and the end of the upper arm bone with such force that the labrum is pulled away from its attachment to the shoulder at the glenoid, often making a “popping” sound.
It may then become a flapping tissue that causes joint instability, pain and a “catching” sensation. Labral tears usually cause deep, yet moderate, shoulder pain and vague aching for hours. The shoulder joint can feel loose, and slip occasionally.
One method to test for a labral tear is to conduct a physical examination to see if pain is created when an extended arm is pressed down against resistance. A scapulodyskineasis test may show that one’s shoulder blade appears popped out from a posterior view.
MRI and CT scans are not very accurate in detecting labral tears. We strongly suggest an MRI combined with an arthogram (radiologist injects contrast dye to make pathology more evident), sometimes called an MRA. The MRA also makes it easier to determine if the labral is torn or if the defect is in another part of the shoulder.
Shoulder injuries are usually treated by orthopedic surgeons. These surgeons typically use a small TV camera, called an arthroscope, to more accurately diagnose a labral tear.
Cortisone injections are usually offered to temporarily reduce pain and inflammation and improve function (increased range of motion). To strengthen the supportive muscle groups to increase stability, doctors usually suggest exercise with a physical therapist, as well as heat and ice treatments. Chronic instability worsens the condition.
De-Bridement (pronounced de-breed), a corrective surgical procedure, is typically performed to remove frayed edges of the labrum. If the tear is more significant, sometimes a re-attachment of the labrum to the glenoid may be necessary.
If the superior (upper) portion of the labram is torn from the anterior (front) to the posterior (back), the corrective procedure is often called a SLAP surgical procedure. This usually results in a 5th edition PPI of between 0-5% with a good recovery and little residual impairment.
Rotator Cuff Tear (RCT)
A rotator “cuff” is like a cuff of a shirt in the sense that it provides protection from fraying. The rotator cuff is a group of tendons that connect the upper arm bone to the shoulder blade.
The rotator cuff is formed by the tendons of four muscles:
- teres minor
Remember, the function of a tendon is to attach muscles to bones. Muscles move bones by pulling on tendons and releasing the pull. The rotator cuff helps raise and rotate the arm. As the arm is raised, the rotator cuff also keeps the upper arm bone tightly in the cup or socket area of the shoulder bone (glenoid of the scapula).
The “cuff” is the where the glenoid tendon attaches to the shoulder bone inside the subacromial space of the shoulder. The tearing of the cuff occurs when it is being pulled away from where the tendon attaches. A tear causes a loss of blood supply to the injured area.
A partial tear can be just as terribly painful as a complete tear. Oddly enough, a person can have either one and not experience any pain at all.
Usually the diagnosis for a rotator cuff tear is separated between:
- Partial Thickness RCT (PTRCT)
- Full Thickness RCT (FTRCT)
In the past, the medical field has noted improvement in the ability to detect partial tears. However, patients are often misdiagnosed and the problem is really an AC joint problem such as osteonecrosis. Sometimes it is simply not possible to determine exactly what caused the injury. Doctors often discover that it looks like the condition is “old” as opposed to “recent” during surgery. Intrinsic degeneration of the tendon is normal with the aging process.
MRI testing alone is not the best detector of the condition. In fact, MRI testing does not even show the tear 22% of the time. That is why we suggest and MRI with an arthogram (radiologist injects contrast dye to make pathology more evident), sometimes called an MRA. The MRA also makes it easier to determine if the RCT is full or partial thickness tear.
It is also helpful in determining if the matter is not a cuff tear but actually an impingement in the AC joint (end of the collar bone).
It is possible to measure a rotator cuff tear. If a tear is over 5 cm there probably has been a steady infiltration of muscle atrophy which means long term status and greater likelihood of re-tear after surgical repair.
Sometimes a shoulder injury is considered unimportant because of residual use of the arm in its lower positions. One of our clients, a USPS worker from Austin, Texas, could not lift his left arm above the height of his shoulder, but he could use it below the height of his chest.
The employing agency sent investigators to secretly videotape him washing his car with his garden hose. Luckily, he contacted us before they were able to schedule an appointment with his doctor in an attempt to gather negative evidence against him.
We were fortunate enough to help him obtain both a schedule award for the 32% impairment of his arm and to get him medical disability retirement with the OPM.