Why a Torn Labrum Leaves Mark Sanchez with an Impossible Decision

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Why a Torn Labrum Leaves Mark Sanchez with an Impossible Decision
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Last month, New York Jets quarterback Mark Sanchez infamously sustained a shoulder injury during the fourth quarter of the Jets' third preseason game. Three weeks later, the story is far from over.

According to ESPN's Chris Mortensen, renowned orthopedic surgeon Dr. James Andrews diagnosed Sanchez with a torn labrum on Wednesday.

The diagnosis likely leaves the signal-caller with two options: get surgery now or try to rehab it and play later this season. Regrettably, neither of them is very favorable—at least as far as the 2013 season goes.

 

Basic Shoulder Anatomy

To start off, it helps to break down the anatomy of the shoulder itself.

In the most basic sense, the shoulder is the joint where the humerus—the bone of the upper arm—meets the scapula, or shoulder blade.

To allow for the very complex motions of which the shoulder is capable, the humerus sits very shallowly within a socket in the scapula—called the glenoid.

This X-ray shows the basic anatomy of the shoulder. Photo from Wikimedia Commons and edited by the author.

Unfortunately, with a wide range of motion comes fragility—when compared to a hip, for example.

For a better image, picture a golf ball sitting on a tee. The golf ball represents the head of the humerus, and the tee is the glenoid. Just as golfers can very easily accidentally knock the golf ball off the tee, so can relatively minor trauma dislocate a shoulder.

That's where the labrum comes in.

 

What Is a Shoulder Labrum?

The labrum is a ring of cartilage that sits around the glenoid. It encircles the head of the humerus as it sits on the scapula, thereby providing extra support to the shoulder and helping it remain within the glenoid.

The biceps tendon also attaches to the top of the labrum ring.

In this case, imagine a beach ball sitting in an inner tube. The inner tube—representing the labrum—keeps the beach ball much steadier—compared to the golf ball, so to speak.

One can also think of the labrum as an additional cup supporting the golf ball as it sits on the tee, represented by the blue arc. Photo from Wikimedia Commons and edited by the author.

 

How Does an Athlete Sustain a Labrum Injury?

Just like any other tissue in the body, direct trauma can cause the labrum to overstretch or tear.

There are many kinds of labral tears, but this discussion will focus on one of the most common types involving throwing athletes—the SLAP tear.

Standing for "Superior Labrum Anterior to Posterior," SLAP tears usually develop over time following repetitive use.

Jay Glazer of Fox Sports reported earlier this week that Sanchez suffered a dislocated shoudler—where the humerus pops out of the glenoid. Such dislocations are often accompanied by labral tears.

However, they can also occur when an athlete suffers direct trauma to the shoulder—like Sanchez did last month.

When an outside hit causes the humerus to sharply rotate within the glenoid—or separate from it entirely, as appears to be the case with Sanchez—the top of the labrum can shear off the glenoid. The shearing produces a SLAP tear.

Many believe the SLAP tear occurs because the stressed humerus places immense tension on the biceps tendon, causing it to abruptly pull on top of the labrum.

Despite such a common mechanism of injury, doctors divide SLAP tears into several different types.

Type I and II lesions involve labrum tears near—but not involving—the biceps tendon.

Type III lesions also involve only the labrum, but the labrum tissue hangs down into the joint space—called a "bucket handle" injury.

Type IV lesions include damage to the biceps tendon itself in addition to labral tearing.

 

When Do Athletes Need Labrum Repair Surgery?

Similar to ligaments and tendons, cartilage such as the labrum carries a relatively low blood supply when compared to, for instance, the skin. As a result, it is only minimally capable of healing itself, and tears usually persist for months or years if not intervened upon surgically.

This animation shows the general idea behind the surgical repair of a torn labrum.

Nevertheless, tears only become significant if they are symptomatic, and minor injuries may go entirely unnoticed.

However, if a tear results in persistent pain, it often needs definitive surgical repair.

Furthermore, some types of labral tears—such as type III SLAPs—can cause the shoulder to lock up. The dangling tissue interferes with the normal biomechanics of the shoulder, and range of motion suffers—certainly a disastrous scenario for an NFL quarterback.

 

Can Sanchez Really Rehab His Injury and Forgo Surgery?

As mentioned, due to the nature of cartilage tissue, Sanchez's labrum will likely never fully heal on its own.

However, that doesn't necessarily mean he needs surgery at this very moment, as Mortensen mentions in his report:

Sanchez could opt to rehab the shoulder in an effort to play at some point this season, sources said, but still likely would need surgery at the end of the year.

Sanchez, replying to a text message, told ESPN late Wednesday night: "If I needed surgery right now, I never would have left Andrews' office. I would've stayed and got the surgery." Asked if he wanted to deny that he was likely to have surgery, Sanchez texted: "There's nothing to report. It's reckless."

If Sanchez successfully rehabs his injury—in other words, if he strengthens the muscles and tissues around his shoulder enough to sufficiently support the damaged labrum—he could return to the field this season if he can maintain his throwing motion.

Regrettably, hoping for such a scenario might represent nothing but extreme optimism, as USA Today's Kristian Dyer wrote on Thursday:

... (Dr.) Andrews told Sanchez that surgery was the best option, (a source) said.

Sanchez insisted Thursday that he has chosen treatment for his throwing shoulder, but the (source) said it's just a matter of time before the surgery is performed.

An already-damaged labrum is also at risk for more serious injury with every hit.

Even so, Sanchez's decision may remain unmade. Dyer continued:

A second person with knowledge of the situation, who also requested anonymity because the team hasn't addressed the diagnosis, told USA TODAY Sports that Sanchez will continue to rehab his shoulder and no decision has been made about surgery yet, and that surgery is not imminent.

 

What's Next for Sanchez?

A labral tear does not usually constitute a career-ending injury, but it could very well turn into a season-ending one.

If Sanchez elects to undergo surgery, post-surgical recovery time can require—and sometimes exceed—four to six months. Such a timetable would all but eliminate the chance of Sanchez returning this year.

Should Sanchez continue with the conservative rehab approach, he very well could succeed in strengthening his shoulder to the point of returning later in 2013.

However, such a path may end in offseason surgery anyway to definitively repair the poorly healing labrum.

What should Sanchez do?

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Furthermore, if Sanchez cannot adequately rehab his shoulder—which seems to be the general expectation conveyed by reports surrounding the injury—surgery would then follow regardless.

Due to the extended recovery time following labrum surgery, delaying the operation could jeopardize his 2014 preseason and beyond.

Either way, there is no easy choice for the veteran, as highly touted rookie quarterback Geno Smith continues to call the shots for the Jets offense.

Despite Smith further cementing himself in New York, Sanchez must very carefully weigh the risks and rewards of each route.

After all, whatever decision Sanchez makes will carry with it significant consequences—not just in 2013, but likely for the remainder of his career.

 

Dr. Dave is a resident physician at the University of Washington who plans to pursue fellowship training in Primary Care (non-operative) Sports Medicine.


Pre-existing labrum fraying may predispose to a lower threshold for traumatic injury, though the theory is controversial.
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