Shoulder Surgery: SLAP Tear and Biceps Tenodesis
On November 22, 2016, I had a shoulder surgery. Prior to my surgery, I was dealing with my shoulder injury for about 2 years. The shoulder injury I had was a SLAP (Superior Labrum Anterior and Posterior) tear. It was a tear in a labrum, a ring shaped cartilage in between humeral head (top of the arm bone) and scapula (shoulder blade bone) that helps stabilize the shoulder joint. SLAP defines the location of the tear, superior (=top), anterior (=front), and posterior (=back).
SLAP tear is a common injury for climbers and overhead motion athletes. Even though surgery is not always necessary, I couldn’t get my shoulder strong enough with the alternative treatments so I decided to have a surgery.
Sharp pain, that was hard to pin point where exactly the pain was, triggered with certain climbing moves, such as moves that built pressure in the shoulder joint (ring locks, wide cup hand jams, off-width moves, pinches and body tension moves…etc) and extended reach with my injured side.
Instability/weakness in shoulder joint. It felt like my arm would rip off from my body when I tried to do dead hang. Lifting dumbbell with straight arm, or loading/unloading heavy grocery bags in a car was difficult because of the weakness in the joint.
Stiffness, especially with overhead motions.
Dull ache in the joint, even when I wasn’t using the shoulder.
Clicking/popping in the shoulder is one of common symptoms of torn labrum, but I didn’t have this symptom.
<How the injury happened>
I was on a training program that involved many pull ups when the pain started. It came gradually with a slight ache in my shoulder joint for a few weeks, and beginning of January 2015, I noticed a sharp pain and weakness in my shoulder a day after my training session. I was backcountry skiing on that day and every time I tried to push with my ski poles, the sharp pain kicked in. I didn’t hear or feel any tear on my training session so I was surprised to have the sharp pain the day after.
After a week of rest, my shoulder still felt weak and unstable when I tried to climb or hold something heavy. It felt like my arm would rip off from my body. I had to stop training, and even worse, climbing. Ugh. My physiotherapist gave me various physio exercises to strengthen my shoulders. My shoulder seemed to get stronger and has lesser pain with these exercises. After 6 months of rehabilitation, I was back climbing moderate grade (5.10 – 5.11) and after 9 months, I started to work on my projects (5.12) again.
2015 just wasn’t my year. As I started to work on my projects again, I got a concussion in a mountain bike accident. I couldn’t work or do any exercise. Concussion recovery was the worst of any other injuries I’ve had (if you’re curious, you can read more about it here). I slowly came back to climbing after 4 months and then training.
In April 2016, 16 months after initial shoulder injury, my shoulder pain gradually came back when I started to train with body tension moves. At the beginning, it was a minor dull pain or soreness somewhere inside my shoulder joint. I wasn’t sure if it was because I was training and muscle was getting sore or I was getting an injury. I felt the minor soreness after bouldery moves for a couple sessions, and on a session after, it got worse as I progressed my training. My coach scheduled more rest days and I cut my training short whenever my shoulder started to get sore.
My physiotherapist mentioned it could be a tear and he suggested that I get Ultrasound and MRI. My Ultrasound didn’t show much so that ruled out muscles and tendon damages. I got to see a sport doctor at UBC (University of British Columbia) before my MRI. In his assessment, I didn’t have any sharp pain except for when he pushed his thumb on the front side of shoulder joint, as if he was digging his thumb into my joint. Ouch!! I had a sharp pain deep in my shoulder joint. He said pain deep inside shoulder joint can be a sign of a labral tear.
Instead of a MRI, I had a MRA (Magnetic Resonance Angiogram) which is a MRI with contrast dye, and according to my doctor, it shows more details for labral damage. When I got the result, it showed I had a tear on upper third (2 o’clock to 10 o’clock) of labrum and a few paralabral cysts. Paralabral cysts are byproduct of labral tear and are blisters like fluid filled pockets. Cysts that I had didn’t seem to cause any damage, but doctors can’t give the definite answer to that unless they see the condition in a surgery.
The sports doctor mentioned that surgery is not always necessary for SLAP tear and he would normally suggest working with physiotherapists first. However, I’ve already had about a year of physiotherapy and 4 months of rest while I was recovering from concussion. He told me if my shoulder were to heal, it would’ve healed by now. He suggested surgery maybe the solution.
Good part of this diagnosis was that I still could climb. My doctors and physiotherapists said as long as I didn’t have pain in my shoulder, climbing is good for keeping range of motion and maintaining my shoulder stabilizer muscles strong. I needed to do a lot of warm ups and had to avoid certain moves that aggravated my shoulder, but I was happy that I could climb.
<Surgery or no surgery? Decisions>
I still wasn’t sure if I wanted to have a surgery when I met with my orthopaedic surgeron Dr. Alex Brooks-Hill. Dr. Brooks-Hill at Sea to Sky Orthopaedics performs surgeries in Vancouver-Whistler area and was recommended by my sports doctor and many of my friends. The procedure she told me was the Biceps Tenodesis, in which she would cut the long head of bicep tendon at its attachment point on the labrum, drills a hole on humeral (arm bone) and re-attatches the cut tendon in the hole.
For SLAP tear, you could get a SLAP repair that simply reattaches the labrum back on the bone. It sounds like a less invasive and better option, but my doctor told me that the long head of biceps tendon can tug on a torn labrum and still cause pain. She didn’t recommend it for me considering how much I climb.
According to the doctor, Biceps Tenodesis had relatively high success rate (about 90%). If I were to do the surgery, I would do Biceps Tenodesis, but I still wasn’t sure if I wanted to have a surgery. I wanted to be optimistic, but I had to consider the risks too. What if I become the unfortunate 10%? How bad can it be when the 10% does happen? Hearing about the worst case scenario terrified me, but my shoulder was limiting me for what I can climb. I like pushing my absolute limit, but my shoulder was stopping me from pushing my limit. I even thought about taking up on something else if I can’t push my limit with climbing.
I decided to put my name on surgery wait list and tried as many treatment options as I could before I went under the knife.
I had been working with physiotherapists since my shoulder pain came back in April. I added a few more visits to different physiotherapists to hear their opinions. I also tried treatments with RMT (Registered Massage Therapist), IMS (Intramusclar Stimulation), and Perineural Injections. Some helped, but nothing significantly helped my shoulder recovery. After a while, even my practitioners thought surgery may not be a bad idea. At the end of my 5 months waiting period, I was ready to get the surgery.
There was one information that I couldn’t figure out. Even though the Biceps Tenodesis can be done only by arthroscopic procedures, my surgeon recommended to have a small incision by armpit to keep the new biceps attachment point lower. She said this was the better option since the biceps tendon can be impinged with a higher attachment point and cause pain. I’m not sure if it was because of the procedure, but the recovery time I was told was 6 months to be able to start easy climbing, instead of 3-5 months to full recovery which was what I read on TrainingBeta’s founder Neely Quinn’s posts, who’s had a Biceps Tenodesis. I’ve talked to my friends who have had Biceps Tenodesis and my friends seemed to have about a year for full recovery. My surgeon said there was no way I could start climbing before 3 months no matter where the attachment point is. Since I didn’t want to fly down to Colorado (where Neely had her surgery), I decided to go with my surgeon and this short recovery time remained mystery to me…
My surgery was done with general anesthetic. Nerve Block would’ve been a better option, but it wasn’t available at a hospital in Squamish. I could’ve travelled to a bigger hospital, but my surgeon told me it’s fine to do the surgery with general anaesthetic so I decided to avoid the hustle of traveling and got the surgery at the local hospital.
Before the surgery, Dr Brooks-Hill couldn’t tell if she would need to anchor my labrum as well as Biceps Tenodesis, or if she needs to take care of paralabral cysts. She promised to take a look at them and take care of them as necessary. I laid on the surgical bed and soon general anesthetic kicked in and I don’t remember a thing after that.
When I woke up, Dr Brooks-Hill told me the surgery went well. She said the Biceps Tenodesis procedure was done without any complication. She didn’t have to anchor my labrum and only had to clean what was torn. Paralabral Cysts weren’t causing damage so she didn’t have to take care of it (or that’s what I understood).
Luckily I wasn’t sick with anesthetic when I woke up, but I had a severe dizziness and low blood pressure that Dr Brooks-Hill and anesthesiologist couldn’t explain. I thought it was because of my concussion, but they didn’t think it was related. I was kept in the recovery room for about 6-7 hours longer than expected.
When I was leaving the hospital, I realized I couldn’t put my button up shirt on because of the huge dressing pads on my shoulder. I thought button up shirt would be easy to put on, but it turned out it wasn’t the right choice of clothing for a shoulder surgery…
Recovery protocol I got from my orthopaedic surgeon was as follows:
Shoulder sling for 6 weeks.
Start shoulder pendulum exercise (drop arm and swing) and passive forward elevation (using my right hand to lift my left arm forward) at day 3.
No lifting, pushing, or forearm supination (opening a jar, screwing with a screwdriver kind of motion) for 6 weeks.
No bicep resistance/strengthening exercise for 3 months.
No climbing for 6 months.
Week 1-Week 5:
I didn’t feel much pain thanks to my pain medications (Hydromorphone and T3). I was hesitant to use pain meds for a long time so I eased off and stopped taking after a week. After the first week, it was really painful only when I accidentally bumped into a wall or a person. Otherwise it wasn’t as painful as I thought. I iced my operated shoulder for a couple weeks with DonJoy Iceman that my friend lent me. I learned to do everything with one hand, got used to sleeping with a shoulder sling, and had lots of help from my awesome friends. I had to keep my dressing on for 5 days and had to be careful not to get the incision wet for 10 days. My stitches would dissolve so I only had to have the ends cut instead of removing suture. My physiotherapist told me there’s nothing he could do until 6 weeks post surgery so I followed my orthopaedic surgeon’s instruction on the shoulder pendulum and passive forward elevation for the first 6 weeks.
At 1 month post surgery, for some reason, all my concussion symptoms (headache, dizziness, unable to do anything that raise heart rate, sensitivity to noise and light…etc) came back. Severity of these symptoms were the same as when I had the concussion accident. It took about 9 months to get back to where I was before surgery. I saw many specialists, but no one could tell exactly why this happened. I thought it was because of the general anesthetic, but some specialists thought it was caused by the surgery procedure of tagging and pulling, and the others thought the opioid medications I was on caused it. My concussion rehab was the same as before so I won’t talk about it here.
My shoulder sling came off and my recovery focused more on breaking scar tissues and gaining range of motion. At this point, my operated shoulder had active forward flexion range of 90 degrees (I could raise my arm forward to shoulder height). My range was limited not only because my shoulder was weak, but also my shoulder joint’s tissues were so adhesive, like layers of velcro stuck together (which was normal after being in a sling for 6 weeks). I was nervous to touch the surgical area before my post surgery appointment, but my physiotherapist told me I had to start working on breaking scar tissues by massaging and pinching the incision area. He gave me many exercises with poles, exercise balls and pulley system to gain range of motion for my shoulder. Some physiotherapists told me I could start band resistance exercises after 6 weeks, but it was against my surgeon’s recovery protocol so I waited longer to start resistance exercises. I had physio appointments 3 times a week which was recommended by my orthopaedic surgeon.
I had a forward flexion range of about 150 degrees. According to my orthopaedic surgeon, it is ideal to have full range (which was 170 degree for me), by this time. She told me to push harder through the pain on my rehab exercises. Time frame for gaining the range of motion for shoulder varies, but she told me I can and should push harder especially after 3 months. When I get injured, I normally push too hard too soon and re-injure. I was trying to be patient with my shoulder, but it turned out I had to push harder this time. One of my physiotherapists told me that some people could get post surgery frozen shoulder, which is a stiffness and pain that can last 1-3 years. Frozen shoulder patients can’t raise their arms above 90 degrees, so I wouldn’t have gotten the frozen shoulder at this point, but he said my shoulder capsule was really tight and I needed to be careful.
I started resistance band exercises and strengthening exercises with weights, started with 1 lb. Building shoulder stabilizer muscles were constant repetition of strengthening muscles, getting tight muscles, and releasing the tight muscles with needles and massages.
As I started to do more strengthening exercises, I noticed a sharp pain in my Ulner Nerve on my operated side. The pain radiated from my pinky to elbow and was weakening my grip. I was worried if I was getting another injury, but my physiotherapists and chiropractor told me the nerve could be impinged in the recovery process and it could be a temporary pain. Thanks to them, the pain went away after 10 days.
In order to gain the last missing range of motion, my orthopaedic surgeon told me to start doing dead hang. My physiotherapists thought it was too soon, and I also felt my shoulder wasn’t quite ready to take my body weight. I asked my physiotherapist if starting easy climbing would be a better idea. My shoulder ached when I tried to do dead hang, but with my feet on the wall and focusing on not using my biceps (so I won’t damage the new anchor point), I was much more comfortable to climb. My physiotherapist agreed so I started climbing at 4 month post op.
Climbing easy grades seemed to help gain the last bit of range I was trying to get. About 6 weeks late, but I finally got the full range for forward flexion at 18 weeks post surgery. According to my physiotherapist, forward flexion was the most important range. I still needed to work on abduction (raising arm sideway) and internal & external rotation, but getting a forward flexion was a big mile stone in my recovery.
My shoulder finally felt comfortable enough to do dead hang on a good day. On not so good days, even with being careful how I hang, I still got pain when I came off from dead hang. The pain kicked in at where my long head of biceps tendon used to be attached as I come off from dead hang and tension in my shoulder got released. My physiotherapists were hesitant to push through this pain and they told me to rest my shoulder when the pain happened. It took a few days to a week of rest to be able to hang without pain again.
I also had a pain in Radial Nerve around this time. I wasn’t nervous this time knowing it is a part of recovery process, and it went away after a couple weeks with treatments from my physiotherapist and chiropractor.
My orthopaedic surgeon told me my new bicep anchor is stable and I wouldn’t do any damage to it. She told me I don’t have any restriction on activities. Realistically though, no restriction didn’t mean I could start working on my projects. It meant I wouldn’t pop my new biceps anchor, but I still had to work on strengthening and stabilizing muscles in order to avoid hurting something else. I was climbing 5.10s around this time.
Month 7 – 1 Year:
I had a pain in outside of elbow on my operated side at 7 month post op. I was just starting to do push ups and I felt the sharp pain on my elbow one day. It wasn’t a radiating pain and was different from Ulner Nerve and Radial Nerve pain I had. I was told this could develop to tennis elbow and had to be really careful. Needling, massaging, stretching, adding tennis elbow specific exercises, and easing off exercises that aggravated elbow pain seemed to work and the pain dissipated after a few months.
As I started to climb more on outside rocks, my shoulder got stronger and could handle harder moves. Fortunately, my shoulder seemed to do better with trad climbing. I don’t like to talk about just grades, but it’s the easiest way to give idea to my progress, so here you go. I was climbing 5.11 trad at 8 months post op and I could work on 5.12 project that wasn’t hard on shoulder at 9 months. I was climbing 5.11 sport routes around 10 months post op and could work on some 5.12 sport routes at 11 months. My shoulder was sensitive to the moves that aggravated my shoulder pre surgery, and I had to be careful choosing routes and moves. When my shoulder got aggravated, I had to take a few weeks rest before my shoulder felt stable again.
Now, it’s been a year since my surgery. Most of the time, my shoulder feels more stable/stronger than pre surgery, but there’re some days that my shoulder feels not much stronger than pre surgery. Considering I could start climbing at 6 months post op, I thought 10-12 months for full recovery is a reasonable time frame, but due to the pain I had on my shoulder and elbow, my recovery has been slowed down. My physiotherapist said as my shoulder gets stronger and stable, the pain should improve. I’m currently trying to figure out the balance of strengthening my shoulder without aggravating it.
It’s taking a long time, but my shoulder is still improving. It seems like I just have to be patient with the rehabilitation a bit longer. I will keep posted with my progress as I come back to more climbing.
Many Thanks to:
Physiotherapist Maggie Phillips-Scarlett at Sea to Sky Sport Physio for helping me physically and emotionally through my rehab.
Dr. Alex Brooks-Hill at Sea to Sky Orthopaedics for fixing my shoulder.
Physiotherapist Mike Foster and Chiropractor Gerry Ramogida at Fortius Sport & Health for taking care of both my shoulder and concussion.
Physiotherapist William Bateman at Project Physio for helping me get back to climbing.
Physiotherapist Mina Kavia and Derek Kyle at Elaho Medical Clinic for IMS and perineurial injection treatments.
Physiotherapist Paolo Bordignon and Len Chong at Salus Physiotherapy Clinic.
Dr. Navin Prasad at UBC Allan McGavin Sport Medicine Clinic.