When bad technique leads to a major injury - A Labral Tear

Recently Instructor Donny was forced to make a hard choice. Surgery or no surgery.

Anyone who has faced major a orthopedic injury knows there is never a good time, no matter what you have going on something will have to give. In this case, many things will need to be sacrificed. If he elects for surgery he will not have use of his shoulder for 3 months, with 4 months expected rehab. In not having surgery, he will be electing to never be any better than he is today.. in his injured state. Gone are: His goal for testing to be StrongFirst Kettlebell Certified. His personal hybrid self defense training. His hands-on coaching. This is just the professional challenges of his second job!

People reading this who have been injured, you get it. Those who are reading this who have not been injured, read closely because we are going to try to help you PREVENT this type of injury.

Brief anatomy lesson:

The shoulder joint is a complex joint with the multi-directional movement of a hemispherical humeral head on a relatively flat socket. The best analogy I know of is a golf ball (humerus) perched on a tee (glenoid), then set into a wall and held in place by twine (ligaments ) and suction-cup type force (labral cartilage and joint capsule). Made up of the humerus, scapula and clavicle and acted on by the muscles of the Rotator Cuff (supraspinatus, infraspinatus, subscapularis, teres minor). The joint capsule provides primary stability, the labrum gives depth to the socket to aid in stability. The long head of the biceps tendon originates deep with the joint at the superior part of the labral cartilage, passes through the rotator cuff interval along the anterior humerus and attaches to the radius of the forearm.

Xray imaging with same view as the later MRI image, Axial views.  This view makes it easy to see the ball as it aligns with the socket

Xray imaging with same view as the later MRI image, Axial views.

This view makes it easy to see the ball as it aligns with the socket

Xray of the shoulder in the Anterior-Posterior plane. Essentially the same as the below coronal MRI imaging.

Xray of the shoulder in the Anterior-Posterior plane. Essentially the same as the below coronal MRI imaging.

Common shoulder injuries we hear about are “shoulder separations” common in contact sports - strain or tear of the ligaments of the acromioclavicular joint; “rotator cuff tears” - from overuse or impact injuries common in heavy labor workforce; SLAP tear - common in throwers and the injury Coach Donny sustained.

The problem is a Type II labral tear occurring from an excessive load to the biceps during a controlled fall. Why controlled? Because that was the goal.

The situation was thus:

When at risk of falling - ice, loose gravel, FIGHTING… it is ideal to know how to limit the forces on the body and sustain minimal injury. The technique is a break-fall. In this case, he was practicing a forward break-fall off Double Ankle Picks and Machine-gun Takedowns. For those of you that train grappling or Krav Maga this is familiar language. But lets break it down a little:

The mechanics:

Body weight is uprooted and forward momentum carries you face first toward the ground, legs are blocked so you cannot step. Your options are to belly flop and eat concrete, fall on an outstreched hand (aka FOOSH, one of the most common ways to break your wrist, jack up your shoulder and or neck, etc) or arrest your momentum. To displace the energy you catch your self on your hands, elbows with slight bend and engage your muscles to slow the rate of the fall and soften the impact by engaging those muscles. He would describe it as “you are basically doing the down stroke of a push up from a 3 foot fall”.

Because your momentum is forward this puts excessive force through your upper torso and arms. Landing with your elbows locked is a near guarantee to cause injury. By softening the elbows on impact and lowering down you are using multiple muscles to slow the rate of descent. What muscles? Anterior: Pectoralis major and minor, BICEPS brachii, deltoid, forearm flexors, rectus abdominus, internal and exertnal obliques. Posterior: Trapezius, serratus, erector spinae, rhomboids, latissimus dorsi, teres major, triceps, ROTATOR CUFF, forearm extensors.

To give you an idea, and capitalize on some yoga biomechanics lab work (1), jumping back into a Chaturanga applies 10x the ground force through the upper body than jumping back into plank (which accounts for 7% of body weight). Meaning when you take the lower body out of the equation the applied force is significantly greater through the upper body and arms increasing the torque on your shoulders, elbows and wrists. Using all muscles in concert is the key to preventing injury.

So what went wrong:

For years Coach Donny has implemented and taught forward break-falls. On this occasion, he was the student. The instructor was teaching a forward break-fall from standing, when a person pulls both feet out from underneath you. The technique was to catch your body weight on your forearms and land in a forearm plank. This limited the muscles being engaged to the biceps brachii, deltoid, rhomboid, pectoralis major, triceps, rectus abdominus, obliques, and to lesser degree the serratus anterior and latissimus dorsi. Additionally, this provided direct ground force through the humerus to the shoulder joint.

On his strong side, he was able to compensate and stabilize the shoulder. The left side, however, overpowered the biceps to compensate and resulted in a tear of the cartilage at the origin of the biceps. A tear of the labral cartilage, specifically a Type II Superior Labrum Anterior to Posterior (SLAP) tear with a paralabral cyst.

T2 weighted MRI, Axial plane.

T2 weighted MRI, Axial plane.

Gadolinium enhanced MRI sequence including axial (top right corner) T2 Coronal (bottom left corner) demonstrating SLAP lesion with 10mm paralabral cyst

On their own, not all labral tears are recommended to be treated with surgery and many can be rehabilitated with PT, time off and more than a little TLC. For several months Coach Donny did exactly the right rehab and still his symptoms progressed. The cyst was the game changer. The cyst formed from the tear allowing articular fluid to leak from the intra-articular joint space to the space behind the glenoid neck where the suprascapular nerve lies. Each attempt to return to normal activities after the injury generated force on the shoulder (perfect, we are trying to build here), stimulated increased joint fluid (normal) BUT with a breakdown in the structures that fluid leaked filling the cyst further. Each attempt at easing back into training lead to further injury.

This is where you have to speak up about an injury.

If you have lingering symptoms for 10-12 weeks after a shoulder injury despite all the best rest, ice, and ibuprofen you need to see a specialist. Someone who will listen to how you injured your shoulder, what you have done to help it and what it is really impacting. In insurance driven medicine specialists know the red flags and how to get what you need. In this case, Coach Donny needed a gadolinium enhanced MRI and then he needed someone who has seen enough of them to know that he was in bigger danger of permanent functional loss. Typically, this is my day job. Not when it comes to family though. After failing with encouragement, I resorted to fear mongering to convince him that he needed to get his injury looked into further. He ended up seeing a Sports Medicine Certified Orthopedic Surgeon.

What he learned:

The cyst formed secondarily to the cartilage tear put him at risk of nerve compression. This meant that in order to maintain his current function (recall he is doing rehab and on activity restrictions) he would have to accept that he would never be able to train any activities that put a pushing or pulling force through the shoulder joint. Doing so would increase the risk of expansion of the cyst and compression of the nerve leading to weakness, pain and loss of muscle mass - atrophy. Permanently.

Decision time

He has made his choice on how to manage his injury. With surgery in his future, he continues to train and coach. Everything is modified. In our world of Firearms, Fitness and Fighting he continues to learn, adapt and evolve. Through this injury he is for example:

  1. Becoming a better jiu jitsu player

  2. Learning to articulate his coaching over physical demonstration

  3. Finding what it would take to protect his family if he has one arm out of commission

  4. Firearm tactics including practicing clearing malfunctions one-handed

  5. He is learning how to open a pickle jar with his teeth - jk.

I don’t tell you these things because he is some kind of bad ass, I tell you them to reinforce a point that our coaches told us years ago… If you are injured it does not mean take a break from the mats. Observing is learning. Often our biggest breakthroughs come from watching the form and techniques of others.

In summary:

Training always comes with risks.

Practice forward break-falls by applying the deceleration force described above or shown in the video on the Salvos Training Facebook page.

If you jack up your shoulder, take it seriously. The cost of evaluation by a specialist is invaluable over time.

Additional Sources:

(1.) https://www.yogajournal.com/teach/anatomy-101-can-you-safely-jump-back-to-plank

Imaging may be shared for the furthering of academic study with our permission.

Erin Haines, MPA-C, CPT, CCD specializes as a PA-C in Orthopedic Surgery in the Columbia River Gorge Region of Oregon with Dr. Gregory Stanley, Cascade Orthopedics & Sports Medicine Center.