MRI Results = SLAP Tear (Shoulder Labrum)

by Colin McNulty on 3 October 2011

This morning I had a Consultant’s appointment to get the result of my MRI and Arthrogram for my shoulder injury. Previously I’d been diagnosed with a PASTA lesion, which is a tear of the supraspinatus rotator cuff tendon, and the MRI was to look for a SLAP tear as well, which is where the cartilage cup inside the shoulder socket (the Labrum) which connects to the bicep tendon, comes away. Here are the findings:

1. The PASTA lesion that he identified with an earlier ultra-sound didn’t show up on the MRI.
2. I have a “not obvious” 1.5cm SLAP tear.
3. Also there’s a small Inferior Glenohumeral Ligament (IGHL) tear.

The PASTA tear may or may not be there and the SLAP tear may not be as big as 1.5cm (which is small anyway) as he said that MRI’s are not great at showing up tears (missing maybe 40% of tears) and where they do, they tend to exaggerate. It seems there’s nothing that can be done about the IGHL tear.

At 39 I’m too old for a normal suture and anchor SLAP tear repair!

However the big news was that apparently at 39 the likelihood of success of normal SLAP tear repair (suture and anchor the labrum back into place) is not good, and so he would do a bicep tenodesis instead, which is where they simply cut the bicep tendon away from the Labrum and anchor it to the humerus (the upper arm bone) instead and bypass the shoulder altogether. That doesn’t sound like much fun!

But it gets worse as the bicep tenodesis has risks of life long shoulder stiffness, or frozen shoulder syndrome and that’s on top of the more obvious risks of infection, the operation simply failing or the tendon rupturing. Either way my Consultant reckons that recovering 75% pre-injury capacity from a bicep tenodesis would be a good result, and that’s after a year or 2 recovery period.

I’m able to do more and more things, e.g. push-ups and burpees

The issue is that I’ve been careful not to make my shoulder injury worse and through exercise and some home base physio, my shoulder has improved to the point that I’m 99% pain free. In fact this morning before my appointment, I actually couldn’t find any shoulder or arm movement that caused me any pain! Now it’s true that I’ve only been going to the gym say once a week, and only been doing a small subset of exercises, e.g. nothing overhead, but I have found that I’m able to do more and more things, e.g. I can now do push-ups where I couldn’t 4 months ago, and I can do burpees too where I couldn’t before. And a weekend full of martial arts recently didn’t give me too many problems.

So this leaves me with something of a dilemma. Do I elect not to have the surgery and keep up with my own recovery and stay 99% pain free through normal life, but maybe will never be able to do some exercises or workouts (no more butterfly pullups for example!)?

Or do I go for the surgery and get a proper repair done, albeit my bicep tendon now won’t be connected to the normal place, but after enduring a long recovery period, there’s still a significant risk that it’ll make the situation much worse than it is now?

I’m to get my butt back down the gym and see what my limits are

It’s a tough decision. Fortunately the delays of the NHS mean that I don’t have to decide today. The current plan is that I’ve booked in the for the surgery, but as there’s a 4-5 month waiting list anyway, I’m to get my butt back down the gym and see what my limits are, starting slowly and working up of course. I have 4 months then to decide if my current ability is sufficient for my needs for the rest of my life, and I suppose if it gets worse again later, I can always get the surgery then.

These things are sent to try us, as they say. But as my father pointed out when I told him: “At least you’re not coming back from Afghanistan with an arm or leg missing!”

• Sue 3 October 2011, 8:48 pm

  Decisions, decisions…lots to think about Colin. Try not to let the idea of time constraints sway you either way.

  Coming from a place of much reconstructive surgery experience (latissimus dorsi for me) one of my thoughts would be that considering the reliability of an MRI to show tears, what would the protocol be should they get there on the day of the procedure only to find some other unexpected tear or injury.

• Colin McNulty 3 October 2011, 10:11 pm

  Thanks Sue, 4 months should be enough I think to come to a decision.

  My understanding is that they’ll fix what they find. E.g. a friend went in for a calcific spur removal in his shoulder, but they noticed a rotator cuff tear (which hadn’t shown up on the MRI) and they fixed that whilst they were there.

• Ian Sturrock 5 October 2011, 11:43 pm

  Hmmm, I do think that if you are recovering, anyway, then surgery’s not a good bet. It’s not like you absolutely have to do overhead stuff (and, if you want to, you can always do it with one dumbbell… not ideal, I know, but maybe better than getting surgery if the surgery has a chance of making things worse in the long run).

• Colin McNulty 6 October 2011, 8:46 am

  Thanks for the input Ian. I’ve ruled out doing 1 arm stuff due to the imbalance that would cause. Tim Ferriss in The 4-Hour Body book believes that body imbalances are the route cause of many injuries and that by balancing your body in terms of strength and flexibility, you can minimise the risk of future injuries.

  But I’m quietly confident that I’ll be able to get back to something workable overhead. I’ve done nothing overhead for 6 months, for the simple reason that I was scared of making it worse. But since the hospital appointment I’ve been working with light dumbbells of <10 kg and doing sets of 10 shoulder presses, so far so good.

• Ian Sturrock 6 October 2011, 10:14 am

  Yeah, makes sense. Still — even light shoulder presses are probably all you really need for functional fitness. It’s not like most of us need to press heavy objects overhead on a regular basis. I guess that kind of explosive pushing strength has good carry-over to self-protection, but still — not sure it’s worth risking making things worse, when you have some functionality in the shoulder and that functionality seems to be increasing. Reckon if you just keep taking it slowly, never working to failure, watching out for any pain, etc., you can gradually up those weights, too — even if it takes years when you’d prefer it to take weeks.

• thomas McNulty 13 October 2011, 7:17 pm

  Colin, right shoulder rotor culf tear of 4 cm, in 2001, left shoulder tear in 2006, 3 cm. currently 72 years old, and I oped out of surgery both times for the following reasons,

  1. real success rate of complete recovery at 100%, 60%.(opined by friendly MD’s)
  2. when they place the pins and restring the tendons, time will readjust your range of motion anyway.
  3. Infection is always a possiblity.

  Answer, not a good one, but I used PT for both tears, and had very good experience with them for over 10 years. Problem is that you have to keep up the excerise and retrain the collateral muscle groups. I can reach an almost full range of motion, do french curls ( I use to lift until I was 40), and have good reverse range. Problems are Arthritic pain in some weather, and the tendency to hurt when doing to much vertical lifting, Have gone back to an CAT, (trainer) and getting back to what should be normal for my age. Not sorry that I skipped the knife.

• Colin McNulty 14 October 2011, 2:54 pm

  “Watching out for any pain” doesn’t really go hand in hand with CrossFit, eh though Ian? 😉 I’ve started doing some single dumb bell work (with each hand) and have worked up to 7kg doing 15 bicep curls, 15 shoulder press in the frontal plane, 15 cleans (no body movement), 15 should press in the sagittal plane and then with 2 hands, 15 tricep curls behind the head. So far, no pain or problems.

  That’s harsh Thomas to get a tear in each shoulder. What do you put your shoulder injuries down to?

• Ian Sturrock 14 October 2011, 3:01 pm

  Watching out for pain — I disagree, actually. 🙂 I’m sure you’re at least as adept as I am at gauging this stuff, but generally —

  1) Any pain in a joint is a signal that you’re doing something wrong and/or damaging — you need to alter your movement, or stop entirely, and (depending on the intensity of the pain, and whether it continues after you stop) possibly seek medical attention.

  2) A sharp, sudden, tearing pain in a muscle, likewise — that’s significant damage, not just workout pain.

  3) Discomfort, achiness, etc. — just man up and get on with the workout.

• thomas McNulty 14 October 2011, 3:02 pm

  Did a lot of working out until I was about my early 50’s. Upper body, light (10LB) dumb bells, curls, and reverse curls. Got off track when I was selling my business, started back in my early 60’s and thought that I was still young. Ripped the first one with a reverse curl of 25 lbs, second one came as an accident picking up a heavy bag the wrong way. My problem is that I did not keep up a steady workout schedule all the time. I now do 3 days a week, light to moderate weights, but more resistance machines. seems to be working.

• Cpp 10 December 2011, 12:52 pm

  Colin, just came across your blog looking up something for a friend with a slap tear issue. I thought i would chime in on yours. I am 43 now and for 15 years had shoulder problems, i.e. Throeing a softball from the outfield numbed my arm down to my fingers and caused nasty pain only topped by.my kidney stone pain to give you a comparrison. Anyway had mri arthro this time last year and surgery jan. Of 2011. My slap tear was from 3 o clock to 9. Also had my acromion shaved as it was going to be cutting into my rotator by 50. I had two anchors put in to hold the labrum. The talk of clipping the bicep tendon was never a thought by my dr. I can now tell you that the surgery was painless he had me stretching the next day. Started p.t. 2 weeks later. Iam a contractor so.i was cheating and using my arm to work during this time also. after 5 weeks of p.t. He said he could do no more for me full range of motion was back and perfect strength. I was golfing in april and throwing as hard as i could from the outfield in june. Bech pressing over 225 and military pressing 175 or so. Lastly played our annual football game withfriends few weeks back and i qb’ed all game threw the ball 50 yrds for the furst time in15 years. So you are not to old for the surgery not even close,. I will say my dr. Does a lot of nfl and bball players he is at the top of his game. So maybe get another opinion, oddly i am taking mu friend to him on monday as he had a similar issue had surgery with a diff dr. And still cant hit a tennis ball. So its all in the quality of the dr. By the way i was told the arthro mri is 95% accurate vs. A regular mri, mine was 100% accurate. Hope this helps good luck

• Colin McNulty 10 December 2011, 1:12 pm

  Hi Cpp, thanks for you comment. I’m very pleased your surgery went so well. From the information I’ve been given, from 3 different UK surgeons now, it seems that the SLAP tear repair with plugs, as you had, had a very high failure rate (I was quoted 50%) which is why they don’t like to do it.

  Of course that means that in half of all patients it’s a success, as it seems was the case for you. I’m guessing the issue here maybe an NHS thing (the National Health Service in the UK is free for all), they probably don’t want to be doing the operation twice for half of all patients, if the first time fails 50% of the time. So it may be they’re going for the higher percentage option from the start. Just guessing.

• Cpp 10 December 2011, 3:25 pm

  Wow ….. I am totally bummed for you u.k.ers….. The success rate for that surgery in my area indiana is well into the 85% range. Any consolation i had a 3 yr. Period of no pain then it hit again…. Good lick to you, if u can still do pub crawls over there u should be fine!

• joanne caro 28 January 2012, 2:06 am

  For about 8 months I had pain in my humerous area. Never shoulder. Then i Fell. Mri showed slap tear , Rotator cuff tendinois, mild chronic degenerative AC joint, chronic dengeneration involving glenohumeral joint. Had orthscopic surgery. After 4 weeks of theraphy 3x a week, pain has increased to excruciating. Shoulder not frozen, but therapist said it seems that’s the type of pain I am experiencing. She also mention thoracic outlet sydrome. I also have dysesthetic pain (magnified pain ) from a prior radiation. Pain mostly in humerous area , whole arm and hand. Any thoughts out there!

• Colin McNulty 29 January 2012, 6:31 am

  Cpp, sorry to hear your shoulder pain has returned. After 3 years, that’s a blow. 🙁

  Joanne, that’s not good either! Fortunately I’m mostly pain free at the moment and my shoulder has been steadily improving. So I can only suggest you try what I’ve done: I’ve been doing the exercises recommended by Brian Schiff who’s a physical therapist from Ohio with 14 years shoulder experience. So far, I’m pretty pleased with the results.

• justsomeguy 28 June 2013, 11:03 pm

  I had similar repair at age 53. Currently 16 months post-surgery. Infraspinatus (4 cm full thickness),supra (smaller tear), bicep tenodesis. I have spoken to many people. 50% say – great, no issues, should have done it sooner. 20% – failure, have to have another surgery to fix it. 30% – not great, but living with it. Not sure if I am in the 2nd or 3rd category. Shldr is stronger than b4 surgery in some respects, but worse in others and I have ongoing tendinitis. that “75% after a year or two” that you mentioned – sounds about right. Your consultant is WAY more honest than my surgeon was.
  Notes to readers who opt for surgery : If at all possible, require that they do the procedure FULLY arthroscopic (not “semi-open”. My surgeon sliced thru my deltoids – which have never been the same. For semi-open tenodesis the “sub-pec” method is apparently a better method than the method used by my surgeon. It pays to educate yourself !

  Colin : From your post I would say – Do NOT have the surgery if you are 99% pain free.
  Even if surgery goes well you have a period of many months where you can not do your normal exercise (even NON shoulder stuff like abs and cardio) – on its own that will take a toll on your health.

• Alex 27 August 2013, 3:41 pm

  Hi Colin,

  I also have a labrum tear (or so the arthogram showed). I am continuing with my life and martial arts, coping more or less with some pain (at times) and doing tons of PT (every other day, for the rest of my life I guess:). Docs told me that most of people at 40 or older probably have a labrum tear,but without any pain. You can be sure that most of athletes like baseball pitchers also do, but again without pain….Scientific literature indicates that at a 3 or so year follow up, those who had surgery are not doing any better (in average) than those who went for PT….The Docs I consulted with (4 specialists + few more on the internet) all said, if you don’t have pain go on with your life. Granted, in 10/15 years (assuming you won’t get another injury) you might have some problems with a degenerative cartilage, but then by that time it is very likely that these injuries will be treated MUCH MORE effectively e.g. in day hospital WITHOUT the need to stay off activity for many months or so AND allowing for stem cell reconstruction (the same applies to knee injuries by the way). One Doc at the end of the visit just summarized it with “we are aging”:) BTW what you say about the accuracy of MRI is 100% right: so much so that most of the time they will not even send you for one, and opt for PT first; once pain gone, no need to know more (sometimes ignorance is bliss:)

  Alex

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