SLAP lesion

Typical symptoms include pain at the top of the shoulder, especially with overhead activities. Sometimes a clicking sound may be heard with movement of the shoulder. People with SLAP tears also experience pain with specific activities, such as lowering into a bench press or throwing.

Biceps tendonitis

The most evident symptom is pain. Pain is often felt at the front of the shoulder. This is frequently worse when you try lifting weights in front of your body or when lifting something overhead.

Biceps tendon rupture

When LHB ruptures without a rotator cuff tear, pain is normally felt straight away and the patient may have heard a popping sound. Bruising will be seen on the bicep soon after the injury and the muscle will bunch up, giving a ‘Popeye-like’ shape to the muscle form.

Physical examination

Mr. Cole will talk to you about your shoulder symptoms and your shoulder’s history. He will examine your shoulder and assess your range of movement and whether there are any visible signs, such as the Popeye-like muscle, or audible signs, such as a clicking sound. He may use a number of clinical tests to examine for tenderness and pain to indicate a biceps problem.

Ultrasound scans

Ultrasound is a good way of revealing evidence of biceps tendonitis and rotator cuff tears.

MRI / Arthrogram

An MRI can highlight any damaged areas to cartilage, ligaments, tendons or muscles. MRI stands for Magnetic Resonance Imaging. It uses a powerful magnet to obtain three dimensional pictures of body structures. It is a non-invasive and painless procedure. To obtain a clearer picture, Mr. Cole may request a MR Arthrogram. This is largely the same as a MRI, but it also involves injecting a type of dye into the shoulder, so that greater detail can be seen on the final image. This is the best way of diagnosing SLAP tears.

Diagnostic arthroscopy

Especially in cases of SLAP lesion, Mr. Cole may suggest using arthroscopy. This is keyhole surgery, conducted under full anaesthetic, which uses a tiny camera to pinpoint and diagnose the injury. In most cases Mr. Cole will complete treatment during the same procedure. The operation takes place as day surgery and you will not normally need to stay overnight in hospital.

Non-surgical treatment

SLAP lesion

Painkillers and anti-inflammatory medication will help control the pain and reduce any swelling. These may be in the form of an injection directly into the damaged joint.

Biceps tendonitis

Complete rest from lifting heavy objects will give your tendon the chance to heal. Treatment will include painkillers to make you feel more comfortable and anti-inflammatory medicine to reduce any swelling. These may be administered directly into the site of the inflammation via an injection. To help locate the exact point, ultrasound may be used. A course of physiotherapy will be devised for you to help strengthen your shoulder muscles and regain full movement in your biceps.

Biceps tendon rupture

Painkillers will help you to control any pain you may feel. However, to reattach your tendon to the bone, you will need an operation.

Surgical treatment

SLAP lesion

The tear or break in the cartilage can be repaired during keyhole surgery. Using special bone anchors (screws) and stitches, the torn labrum is attached back into its normal position. Sometimes, the injury is too severe to be repaired, or too minor to need reattachment. In such cases, it is smoothed down (debrided) to create a stable surface.

Biceps tendonitis

If conservative treatment fails, Mr. Cole may suggest an operation. Isolated biceps tendonitis can be treated with an arthroscopic (keyhole) operation and either dividing the long head of biceps (tenotomy) and this stops it from rubbing and causing pain, or by pinning it to the top of the humerus bone (tenodesis). If your rotator cuff is damaged, Mr. Cole may suggest an arthroscopic rotator cuff repair. This is normally completed as day surgery and you will be able to go home on the same day as your operation.

Biceps tendon rupture

In a procedure called a biceps tenodesis, the LHB tendon is reattached to the bone just below the shoulder. Special screws are used to anchor it to the bone. The screws are strong enough to enable you to move your arm relatively soon after surgery, without the need for a lengthy period of immobilisation. The operation is arthroscopic keyhole surgery and will not require you to stay overnight in hospital.

Following your surgery, your team of physiotherapists will work with you to devise an exercise programme. This will be designed with advice from Mr. Cole to help you recover as quickly and efficiently as possible.

What is a SLAP lesion?

A SLAP lesion is an injury to the upper part of a rim of cartilage called the labrum. The labrum runs around the top of the socket element of your shoulder’s ball and socket joint. The SLAP part of the labrum anchors one of two tendons of the biceps muscle. Any injury to it will therefore impact on the biceps.

SLAP is an acronym for Superior Labrum Anterior-Posterior (SLAP). This is medical shorthand for describing the cartilage’s position. It literally means upper rim front-back.

SLAP lesions and tears are normally caused by trauma. It is most commonly seen in sportspeople as a throwing or lifting injury, or a rugby tackle. A shoulder dislocation can also cause a SLAP lesion.

About SLAP repair

The tear or break in the cartilage can be repaired during keyhole surgery. Using special bone anchors (screws) and stitches, the torn labrum is attached back into its normal position. Sometimes, the injury is too severe to be repaired, or too minor to need reattachment. In such cases, it is smoothed down (debrided) to create a stable surface. Mr. Cole will discuss your specific situation in more detail with you.

Preparing for your operation

Your SLAP repair operation will be day surgery. This means that you won’t normally have to stay overnight in hospital. However, you may feel more comfortable if you bring your own dressing gown, slippers and toiletries.
You will be having a general anaesthetic. This can make you feel woozy for a little time after the operation, so you will need to arrange for someone to take you home. It is important that you don’t eat or drink anything for six hours prior to your admission into hospital, although you may drink water up to two hours prior to admission.

If you normally wear make-up or nail varnish, please remove it prior to your admission. You will also need to bring all prescribed medicines and supplements, in their original containers, with you to the hospital.

Understanding your operation

After admission, you will be seen by Mr. Cole and by your specialist anaesthetist. They will talk about the operation and the anaesthetic with you and, where possible, discuss your preferences. Nothing will be done without your permission on the day.

Anaesthetic and pain relief

The operation is carried out under a general anaesthetic. After your admission, you will be given a pre-med. This is usually in tablet or liquid form. It will help you relax before your operation.

You will then be taken to the anaesthetic room, where you will be given the anaesthetic. This may either be a gas to breathe or an injection. This will be all you remember about the operation, as you will fall asleep at this point and awake after the operation in the recovery room.

Normally you will be given an interscalene nerve block during the operation. This acts as an excellent pain relief and for a short while after your operation your shoulder and arm may feel numb. When this wears off, your shoulder can feel more sore. You will be given some painkillers to take after the operation. When you begin to feel sensation returning to your shoulder (often a ‘pins and needles’ feeling), you should start taking the pain medication that you have been given. Don’t wait for your shoulder to start hurting, as pain is best managed before it gets acute. To keep the pain under control, use your medication regularly to begin with. After a couple of days, you can begin to lower the amount you take and then cease the medication altogether once any pain has subsided. If the pain does not seem to get better, or if you need more pain medication, please contact Mr. Cole.

A cold compress can also help with pain relief and swelling at the site of your operation. If you use an ice pack it is important you keep the wounds dry.

Risks

All operations involve a small element of risk. In SLAP repairs these can include:

• Complications relating to the anaesthetic such as sickness, nausea or rarely cardiac, respiratory or neurological issues (less than 1% each, i.e. less than one person out of one hundred).

• Infection. These are usually superficial wound problems. Occasionally deep infection may occur many months after the operation (less than 1%).

• Persistent pain or stiffness in or around the shoulder (10–20% of patients could still have some symptoms after the operation).

• Damage to the nerves and blood vessels around the shoulder (less than 1%).

• A need to re-do the surgery. In some cases it is possible for the cartilage to re-tear. The risk of this happening depends on the size of the original injury and how well it heals following the operation.

Please discuss these issues with Mr. Cole if you would like further information.

Biceps Tenotomy and Tenodesis

About biceps tenotomy

In a biceps tenotomy procedure, the LHB tendon is removed from its shoulder attachment. Any damaged or inflamed tissue is removed from the joint. In some cases weakness or discomfort in the bicep muscle can be felt after surgery, but this is usually minimal. Occasionally, a ‘Popeye’ appearance may happen. The operation is arthroscopic keyhole surgery and will not normally require you to stay overnight in hospital. You will also not need to keep your shoulder immobile after the surgery.

About biceps tenodesis

In biceps tenodesis, the LHB tendon is detached from inside the shoulder joint and is reattached to the bone just below the shoulder (the humerus bone). Special screws may be used to anchor it to the bone. The screws are strong enough to enable you to move your arm relatively soon after surgery, without the need for a lengthy period of immobilisation.

Preparing for your operation

As your biceps operation will be completed as day surgery, you won’t normally have to stay overnight in hospital. However, you may feel more comfortable if you bring your own dressing gown, slippers and toiletries.

You will be having a general anaesthetic. This can make you feel woozy for a little time after the operation, so you will need to arrange for someone to take you home. It is important that you don’t eat or drink anything for six hours prior to your admission into hospital, although you may drink water up to two hours prior to admission.

If you normally wear make-up or nail varnish, please remove it prior to your admission. You will also need to bring all prescribed medicines and supplements, in their original containers, with you to the hospital.

Understanding your operation

After admission, you will be seen by Mr. Cole and by your specialist anaesthetist. They will talk about the operation and the anaesthetic with you and, where possible, discuss your preferences. Nothing will be done without your permission.

Anaesthetic and pain relief

The operation is carried out under a general anaesthetic. After your admission, you will be given a pre-med. This is usually in tablet or liquid form. It will help you relax before your operation.

You will then be taken to the anaesthetic room, where you will be given the anaesthetic. This may either be a gas to breathe or an injection. This will be all you remember about the operation, as you will fall asleep at this point and awake after the operation in the recovery room.

Normally you will be given an interscalene nerve block during the operation. This acts as an excellent pain relief and for a short while after your operation your shoulder and arm may feel numb. When this wears off, your shoulder can feel more sore. You will be given some painkillers to take after the operation. When you begin to feel sensation returning to your shoulder (often a ‘pins and needles’ feeling), you should start taking the pain medication that you have been given.

Don’t wait for your shoulder to start hurting, as pain is best managed before it gets acute. To keep the pain under control, use your medication regularly to begin with. After a few days, you can begin to lower the amount you take and then cease the medication altogether once any pain has subsided. Although the operation is to relieve pain, it may be several weeks until you begin to feel the benefit. If the pain does not seem to get better, or if you need more pain medication, please contact Mr. Cole.

You may have some bruising around your shoulder and upper arm. This will gradually disappear over a period of a few weeks.

A cold compress can also help with pain relief and swelling at the site of your operation. If you use an ice pack it is important you keep the wounds dry. You can repeat this several times a day.

Risks

All operations involve a small element of risk. These include:

• Complications relating to the anaesthetic such as sickness, nausea or rarely cardiac, respiratory or neurological issues (less than 1% each, i.e. less than one person out of one hundred).

• Infection. These are usually superficial wound problems. Occasionally deep infection may occur many months after the operation (less than 1%).

• Unwanted pain or stiffness in or around the shoulder (up to 5-10%).

• Damage to the nerves and blood vessels around the shoulder (less than 1%). In a biceps tenotomy, there can be some cases of weakness or discomfort in the biceps muscle after surgery, but this is usually minimal. Occasionally, a ‘Popeye’ appearance may happen.

Please discuss these issues with Mr. Cole if you would like further information.

Follow-up appointments

You will usually be invited to attend an outpatient clinic 2 weeks following your operation, where the wounds will be examined and your dressing removed.
After about 6-12 weeks you will be asked to return so that Mr. Cole can check on your progress. You may discuss any concerns you have during these appointments. Alternatively, should you have a concern, you may telephone Mr. Cole’s clinic at any time following your operation.

The wound

You will only have two to three small puncture wounds. You will not have any stitches, only small sticking plaster strips. Keep the wounds dry until they are healed, which is normally within five to seven days. You can wash or shower and use ice packs, but protect the wounds with a waterproof dressing. These will be provided to you after your discharge from hospital.. Avoid using spray deodorant, talcum powder or perfumes near or on the wounds until they are well healed. The dressing will normally be removed at your first follow-up appointment.

The sling

Your arm will be immobilised in a sling for about three weeks. This is to protect the surgery during the early phases of healing and to make your arm more comfortable.

You will be shown how to get your arm in and out of the sling. However, you should only take the sling off to wash, straighten your elbow, or if sitting with your arm supported.

You may find your armpit becomes uncomfortable while you are wearing your sling for long periods of time. Try using a dry pad or cloth to absorb the moisture.

Sleeping

Sleeping may be uncomfortable for a while. It’s best to avoid sleeping on the side of your operation. If you choose to lie on the other side, you can rest your arm on pillows placed in front of you. A pillow placed behind your back can help prevent you from rolling onto your operated shoulder during the night. If you are lying on your back to sleep you may find placing a thin pillow or small rolled towel under your upper arm or elbow will enhance your comfort.

Your recovery

Different people recover at different rates. However, by about three weeks following your operation you should find that movement below shoulder height becomes more comfortable. Do not use your operated arm for activities involving weight (e.g. lifting kettle, iron, saucepan) for 6 weeks. Light tasks can be started once your arm is out of the sling. To begin with you may find it more comfortable keeping your elbow into your side. You should also be able to move your arm into most positions, including above shoulder height, although this might still be a little painful.

By three months you should feel a lot better. However, it can take from six to nine months to fully recover. You will continue to improve for up to a year following the procedure.

Driving

You may not begin driving until four to six weeks after your operation or when you feel comfortable after that.

Check you can manage all the controls and it is advisable to start with short journeys. The seat belt may be uncomfortable to begin with, but your shoulder will not be harmed by it. In addition, it is a good idea to check your insurance policy. Many insurers will require you to inform them of your operation.

Returning to work

The best time for you to return to work depends on how you feel following the operation and on the type of work you do. If your job is largely sedentary with minimal arm movements close to your body, you may be able to return between three and five weeks after your operation. However, if you have a heavy lifting job or one with sustained overhead arm movements you may require a longer period of rehabilitation. It is best to discuss this with Mr. Cole and with your physiotherapy team.

Returning to sport and leisure activities

Your ability to start these activities will be dependent on pain, range of movement and strength that you have in your shoulder. It is best to start with short sessions involving little effort and then gradually increase the effort or time for the activity. Your physiotherapy team will be able to give advice tailored to you and your situation. As general guidance, however, you can expect to have to wait this long for these sports:

• Cycling: 4-6 weeks
• Gentle swimming: 8-12 weeks
• Light sports or racquet sports using the non-operated arm: 10 weeks
• Racquet sports using the operated arm: 16 weeks
• Contact sports: 6 months

Physiotherapy

You will be shown exercises by the physiotherapist and you will need to continue with the exercises once you go home. They aim to stop your shoulder getting stiff and to strengthen the muscles around your shoulder. We have outlined these early exercises here. Your physiotherapy team will also devise a longer term programme tailored for you and your situation.

Use pain-killers, ice packs or both to reduce any pain before you begin exercise, if necessary. It is better to do short frequent sessions of physiotherapy several times a day, rather than one long session. Aim to exercise for five to ten minutes, four times a day.

Biceps Tenotomy and Tenodesis: Recovery

Follow-up appointments

You will usually be invited to attend an outpatient clinic 2 weeks after your operation, where the wounds will be examined and any remaining dressings removed. After about 6-12 weeks you will be asked to return so that Mr. Cole can check on your progress. You may discuss on any concerns you have during these appointments. Alternatively, should you have a concern, you may telephone Mr. Cole’s clinic at any time following your operation.

The wound

Tenotomy procedures are carried out by keyhole surgery. This means you will only have two to three small puncture wounds. You will not have any stitches, only small sticking plaster strips. Keep the wounds dry until they are healed, which is normally within five to seven days. You can wash or shower and use ice packs, but protect the wounds with a waterproof dressing. These will be provided for you on your discharge from hospital. Avoid using spray deodorant, talcum powder or perfumes near or on the scar. The dressing will normally be removed at your first follow-up appointment. In a tenodesis procedure there may be a small cut over the front of the shoulder.

The sling

You will be given a sling to wear immediately following the operation. In a tenotomy procedure you will be able to take the sling off within a day or 2 and start early movement. In a tenodesis procedure you’ll need to wear the sling for about three weeks to allow the tendon to heal itself to the humerus bone. You can take the sling on and off as you wish for bathing, dressing and exercise, however. You might also find it more comfortable to wear your sling at night.

Sleeping

Sleeping may be uncomfortable for a while. It’s best to avoid sleeping on the side of your operation. If you choose to lie on the other side, you can rest your arm on pillows placed in front of you. A pillow placed behind your back can help prevent you from rolling onto your operated shoulder during the night. If you are lying on your back to sleep you may find placing a thin pillow or small rolled towel under your upper arm or elbow will enhance your comfort.

Your recovery

Different people recover at different rates. However, you should be able to start simple exercises, with the guidance of your physiotherapy team within a few days of your surgery. You should find that you recover quickly, within a few weeks of the operation, although you should try to avoid heavy lifting for at least six months following the procedure.

Driving

You may begin driving about three weeks after your tenodesis operation or when you feel comfortable. You may get back to driving within 1-2 weeks after a tenotomy procedure. Check you can manage all the controls and it is advisable to start with short journeys. The seat belt may be uncomfortable to begin with, but your shoulder will not be harmed by it.
In addition, it is a good idea to check your insurance policy. Many insurers will require you to inform them of your operation.

Returning to work

The best time for you to return to work depends on which arm has been operated on, if you need to drive and on the type of work you do. If your job is largely sedentary and uses your non-operated arm, or requires minimal arm movements close to your body, you may be able to return to work between two-six weeks after your operation. (likely to be 2 weeks for a tenotomy operation and 3-6 weeks for a tenodesis operation). However, if you have a heavy lifting job or one with sustained overhead arm movements you won’t be able to work for 6-12 weeks after a tenodesis operation. It is best to discuss this with Mr. Cole and with your physiotherapy team.

Returning to sport and leisure activities

Your ability to start these activities will be dependent on pain, range of movement and strength that you have in your shoulder. It is best to start with short sessions involving little effort and then gradually increase the effort or time for the activity. Your physiotherapy team will be able to give advice tailored to you and your situation. As general guidance, however, you can expect to have to wait this long for these sports:

• Gentle swimming: after six weeks
• Gardening (light tasks such as weeding – do not try to do any digging): six to eight weeks
• Bowls: two-three months
• Golf, tennis, badminton, squash: three months

Physiotherapy

You will be shown exercises by the physiotherapist and you will need to continue with the exercises once you go home. They aim to stop your shoulder getting stiff and to strengthen the muscles around your shoulder. We have outlined these early exercises here. Your physiotherapy team will also devise a longer term programme tailored for you and your situation.
Use pain-killers, ice packs or both to reduce any pain before you begin exercise, if necessary. It is better to do short frequent sessions of physiotherapy several times a day, rather than one long session. Aim to exercise for five to ten minutes, four times a day.

It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises. However, intense or lasting pain (such as pain that lasts for more than 30 minutes) is an indication to change the exercise by doing it less forcefully or less often.

Phase 1 Exercises

You can begin these exercises immediately after your operation.

1. Neck exercise (shown for right shoulder)

• Do this exercise either sitting or standing

• Turn your head and look to the left. Return your head to the centre, facing forward. Repeat 5 times

• Turn your head to the other side and look to the right. Return your head to the centre, facing forward. Repeat 5 times

• Tilt your head gently and slowly towards one shoulder. Return your head tothe centre position. Repeat 5 times

• Tilt your head gently and slowly towards the other shoulder. Return your head to the centre position. Repeat 5 times

2. Elbow exercise (shown for left arm)

• Do this exercise either standing or lying on your back

• Straighten your arm and then bend it at your elbow

• Repeat 5 times

Phase 2 Exercises

Begin these exercises a minimum of three weeks after your operation, as advised by Mr. Cole or your physiotherapy team.

1. Pendulum (shown for left shoulder)

• Lean forwards with support

• Let your arm hang down

• Swing your arm forwards and back

• Repeat 5–10 times each movement

2. Arm overhead (flexion in lying) (shown for left shoulder)

• Lie on your back on your bed or the floor

• Support the arm of your operated shoulder with your other hand at the wrist and lift it up overhead

• Do not let your back arch

• Try to get your arm back towards the pillow or floor

• You can start with elbows bent

• Repeat 5–10 times

3. Arms behind back (shown for right shoulder)

• Stand with your arms behind your back

• Grasp the wrist of your operated arm

• Gently stretch your hand towards the buttock of your un-operated side

• Slide your hands up your back

• Repeat 5 times

4. Hands clasped (shown for right shoulder)

• Stand with your elbow bent and your arm close to your side (this can be done against a wall or door frame)

• Clasp your hands together and push the palm of your hand into your other hand, taking care not to let it move

• Hold for 10 seconds

• Repeat 10 times

• Build up to 30 repetitions

5. Wall hand push (shown for right shoulder)

• Stand with your operated arm against a wall

• Bend your elbow

• Push the back of your hand into the wall, but do not let your arm move

• Hold for 10 seconds

• Repeat 10 times

• Build up to 30 repetition

6. Back-to-wall elbow push (shown for right shoulder)

• Stand with your back against the wall

• Keep your operated arm close to your side with your elbow bent

• Push your elbow back into the wall, but do not let your arm move

• Hold for 10 seconds

• Repeat 10 times

• Build up to 30 repetitions

7. Side-to-wall elbow push (shown for right shoulder)

• Stand sideways to a wall with your operated arm leaning against the wall

• Keep your operated arm close to your side with your elbow bent

• Push your elbow against the wall, but do not let your arm move

• Hold for 10 seconds

• Repeat 10 times

• Build up to 30 repetitions

8. Face-to-wall fist push (shown for right shoulder)

• Stand facing a wall, about 10cm away from the wall, so that your fist is touching the wall without you needing to move your arm

• Keep your operated arm close to your side with your elbow bent

• Push your fist into the wall, but do not let your arm move

• Hold for 10 seconds

• Repeat 10 times

• Build up to 30 repetitions

9. All fours movement (shown for right shoulder)

• Kneel on all fours

• Gently rock forwards taking the weight of your body through your arms

• Keep your shoulder blade flat

• Progress to lifting your unaffected arm up in the air (in different directions)

• Repeat 10 -15 times

10. Wall, knee and full press-ups

• Stand about 50cm - 100cm away from a wall with your palms flat on the wall at about shoulder height

• Keep your back straight and your elbows under your body

• Slowly bend your elbows so that you lean towards the wall in a press-up movement

• Repeat 10-20 times

• Progress to doing press-ups on all fours. Remember to keep your back straight and your elbows under your body

• Repeat 10 to 20 times

• When stronger, on the advice of your physiotherapist, you may progress to doing full press-ups

Phase 3 Exercises

Begin these exercises a minimum of eight to 12 weeks after your operation. A special programme will be devised for you by your physiotherapy team in consultation with Mr. Cole. They will concentrate on increasing the strength and mobility of your shoulder.