Dr. Tom Hackett MD on Labral Injuries

Can you tell us a bit about yourself?

My name is Tom Hackett. I’m an orthopedic surgeon at the Steadman Clinic in Vail, Colorado. I’ve been practicing here for 12, 13 years almost now. I have a real sub specialty in action sports athletes, in particular climbers and overhead athletes. I still climb myself, though not at the greater level I used to just as a matter of time.

It’s really been a topic near and dear to my heart to take care of climbers. I had a pretty big whipper before I went to medical school and actually broke my leg and I had no health insurance. Having that injury, I was about to go on this big trip to Makalu. I had this injury and it basically changed everything.

I ended up going to medical school rather than pursuing this climbing career that was starting to blossom. Getting into taking care of climbers has allowed me to stay connected with the community and connected with a lot of my friends who are still heavily invested in the climbing community. I really enjoy that aspect of my practice.

I did a standard medical school orthopedic surgery residency, which is five years long. Then, I did specialty training in sports medicine Los Angeles at the Kerlan-Jobe Clinic. Then, I did additional training in trauma and then ended up getting a phone call from Dr. Steadman who offered me a job I couldn’t refuse. I’ve been in Vail now 13 years.

Tell me a little about how your advanced training in surgery gears yourself towards working with this outdoor population.

For sure. Basically, it means having a real respect for athletes and knowing intimately what the loads and demands are of a certain sport. For example, when you go do a shoulder surgery on a defensive lineman from an NFL team you’re going to approach that very differently than for a five-14 rock climber or a major league baseball pitcher.

Even though the surgery may technically be very similar, the intricacies of the surgery are going to be radically different in respect of what that individual needs to do to get back to their sport. That might be everything from the rehab that’s associated with it, which is a huge part, the management of that injury before you ever even get to surgery, which is a big part of it.

Then, ultimately in the operating room, the tactical execution of the surgical procedure can be very different for a different individual in a different sport. Sports medicine and the advanced training that I’ve done has been to learn from the best of the best and I’ve sought them out years ago and even today currently. I still go and visit guys in other parts of the country that are doing cool things that are dialed into the athletic community, lifelong learning.

Exactly. You’re actually going out there as well and trying to just decide what’s new, how you’re going to change your different approaches and techniques even now.

Even now, I love doing it. We do a lot of research too. We have a biomechanics laboratory here in Vail. We have almost 100 people full-time on staff down there. We’ve got robots and different types of machines that pull on things and test things and break things. We can try different surgical techniques and we try them in the lab first.

Then, we actually put them through biomechanical load testing to see if they work and if they’re better than what we already have. Then, that fits in with product development too so that we use better sutures and better anchors and better devices so that we get better at what we do. That’s a big part of our practice as well, the scholarly aspect of it. I love going and visiting other surgeons, even just seeing something really simple that they’re doing. It’s cool to watch another guy do things.

Let’s say someone comes into your office and they want to ask you, “Give me the simple version. Tell me what’s going on with my shoulder and my labrum. I see on this image that I have a tear here. What’s going on?” Can you tell me the anatomy? What would you tell them?

Sure, let me break it down in a couple different ways. The shoulder is, generally speaking, a ball and socket joint, but the socket is very shallow. It’s not a deep socket like the hip has this big, deep, deep cave of a socket that the femoral head fits into. It’s a constrained joint. The shoulder, the reason why we have so much great motion of our shoulder is because it isn’t that constrained.

The socket is very shallow. You get stability and depth to that socket for the ball to fit into, not from bone, but from soft tissue structures around it. The number one thing that we deal with in climbers is probably the labrum. The labrum needs lift and lag. It’s a lip of tissue like a bumper that goes all the way around the edge of the socket circumferentially and then blends into the bicep tendon.

The reason why a lot of people have issues that go hand in hand between the bicep tendon and the labrum is because they really blend into one another. The bicep tendon comes in and actually bonds onto and blends into the labrum. Then, the labrum goes all the way around the socket 360 degrees. That’s where we get a lot of the stability. Then, attached to the labrum is the capsule, which is the lining or the wrapper of the joint. That is intimately associated with the labrum too.

Lastly, the other main thing in the shoulder is the rotator cuff and everybody has heard about the rotator cuff. The rotator cuff is actually a tendon and it’s a common tendon made up of four separate tendons that come together. They form this one big common wide tendon that’s called the rotator cuff. It’s actually made up of the subscapularis, the infraspinatus, the supraspinatus, and the teres minor muscles that blend together to form this one big tendon.

In the climbing community, the things that really are most commonly involved with guys from acute injuries or from overuse injuries are the rotator cuff and or the labrum, which then goes hand in hand with the bicep tendon. Those are really the things we deal with in climbing issues around the shoulder.

We’re going to talk a little bit about the surgeries in a little bit, but how much of the biceps long head do you think plays a role in these labral injuries? You can have labral injuries from too much motion of the shoulder. You can have them from a trauma or it can happen from the biceps pulling on that labrum. Do we know how much of a role it has or what are your thoughts on that?

That’s a great question because that’s one of the topics I’m really working on now. A lot of guys have labral tears they don’t even know they have. There’s this broad spectrum of labral tears. We have a whole classification system of type one, two, three, four, five, six, seven different types of labral tears and some labral tears are different than others.

If you end up just getting an MRI that says the labrum is torn, it is not enough information. Is it a type one tear, a type two tear, a type three tear? Is it displaced? Is it unstable? Ultimately, anybody that’s climbed hard or climbed for a long time is going to have some problems with their labrum if you get an MRI. In fact, we’re in the process right now of doing a study looking at the MRI appearance of labrums in climbers that have no shoulder pain at all.

I’m convinced that there’s a lot of guys walking around out there that have substantial labral tears that have no pain. If you then start having pain and you get an MRI and it just shows a labral tear, the labrum might not be the thing causing the problem. Some labral tears can really be silent clinically, meaning that’s really not the thing causing the problem.

It might be more of a rotator cuff problem or a scapulothoracic dysfunction or something else within the shoulder. There’s really this huge spectrum of labral injuries. Anybody that has a problem with the labrum that subsequently gets an MRI needs to really have somebody take a close look at that MRI to identify whether it’s a labrum that’s the problem or a labrum that maybe can be left alone.

That would be just a huge study in the climbing community for a landmark study really. Just to get that baseline of knowing this is what your average competitive climber’s shoulder would look like and let’s compare that to where you’re at right now, that’s exciting.

I’ve got permission to do it through the IRB, which is our institutional review board, and I’ve got some funding. We’re about to pull the trigger on that study this fall. A lot of guys come to me for second opinions or they’ve already seen another doctor that’s gotten them an MRI and they have a shoulder problem.

The well-meaning surgeon who may not be that dialed in with climbers looks at the MRI and says, “Oh, you’ve got a labral tear. I need to fix that labral tear so let’s sign you up for a labral repair.” Guess what? That might not be the right thing to do. It might be something else entirely that’s causing the problem and labral repairs don’t always do that well in climbers. Especially if you’re starting to get into the higher grades of climbing, a labral repair has to be done very, very thoughtfully.

The anatomy of the shoulder really interesting, in particular the biceps longhead. It was been thought of as a humeral stabilizer depending on the position of the arm. What are your thoughts on that?

The short answer to that is that we don’t exactly know, first of all, and there’s a lot of debate about it. We’ve done some work in our lab here on motion analysis that showed that it really didn’t have a significant impact on humeral depression, for example, meaning holding it down in the socket. There’s been some debate over that.

Your point about the position of the arm is very important because when you get into this position here, like if you’re up on some, all out on gaston. What happens is the biceps, the arm rolls around and the biceps tendon does this mechanism that we call peel back. The biceps tendon, as it comes in, it would normally be attached to the top of the socket. It starts getting pulled posteriorly and rotating around.

Basically, what that does is it stresses the posterior superior labrum and it stresses the under surface of the articular side of the infraspinatus. That then leads to something we call internal impingement and we only really see that in really high-end major league baseball pitchers, exactly. Internal impingement is classic in baseball players, pitchers in particular.

I see it a lot in climbers. Whenever I end up putting my scope in a guy’s shoulder and I’m looking at it, I always look for that posterior superior labrum. It’s always frayed. I lift it off a little bit and then the underside of the infraspinatus will be frayed and partially torn. Those things are things that are almost always there and oftentimes can be managed with the right type of stretching and strengthening programs of the scapula.

Just because you see that doesn’t mean you have to go and start dropping anchors and sutures in that labrum. That’s a mistake that some surgeons make. They think they’re doing the right thing, “Oh yeah, put an anchor in there.” It’s not the right thing to do because that’s a byproduct of some dysfunction of the motion of the shoulder rather than an acute injury in and of itself usually. The biceps plays a big role there because when you get into that position it’s tugging on the labrum posteriorly.

It’s nice that there’s a big body of research with pitcher’s and other sports that we can draw from as climbers. Are the technical aspects of surgery different when you compare pitchers and rock climbers?

It can be. You wouldn’t think there’s that much correlation between a 5.14 climber and 100 mile an hour fastball thrower, but there is a lot of similarity there.

What’s your push now to reach out to the climbing community, get involved? I know that you got into surgery or medical school through some of your injuries, but are there any other things that really tie you to climbing as a sport?

I still climb myself now. It’s not, as I said, as much as I would like, but I love getting up on the Desert Tower in the fall. I still love doing it. Then, most of my closest friends from 20, 30 years ago who I used to climb with are now running climbing schools and part way in upper levels of climbing organizations or within the outdoor industry. I stay connected to it through them.

This allows me to coordinate with them beyond just getting together over a beer. We talk about these things all the time with these guys and their fellow guides. It allows me to stay really connected to that community by taking care of all these guys who fly in from all over the place to come to Vail to be a value. One of my real motivations on this project of the climber’s shoulders is to try to prevent surgeries from happening.

Wow, that’s huge coming from a surgeon.

I know. Don’t get me wrong, when I get up in the morning I love to operate on some shoulder, but I only want somebody to have surgery that really needs it. I’ve just seen too many guys that had a labral repair done and it was technically done well by a good surgeon. They rehabbed it properly and they just didn’t come back well from it because it wasn’t really the right thing to do.

I really want to get the word out in the orthopedic community for guys that take care of a lot of climbers that, hey, these labral tears may not necessarily need to be fixed. That’s a big motivator for me because I’ve just seen too many guys that didn’t have a great outcome after what was essentially a good surgery. It was just the wrong surgery.

You probably get this a lot and they have some shoulder pain. Is there any factors when they come into you that lead you to say, “You know what? You got to get surgery right now?” Are there any factors that lead you to say, “Well, go ahead and go try conservative therapy first and then come back and see me?” Is there anything that points in either of those directions when you’re seeing them?

Absolutely. Basically, what are the indications for serving some of these guys? First of all, I’ll try as much as I can to treat someone conservatively and to treat them without surgery if at all possible. At the same time, I don’t want to waste some guy’s time with six months of physical therapy and training and acupuncture and rolfing and muscle activation therapy, whatever it is, if it’s going to be a waste of time.

Ultimately, there’s some structural problem that needs to be fixed, some mechanical problem that needs a mechanical solution. The guys that I start pushing towards surgery right away are somebody that has usually an acute injury. They either had problems beforehand or didn’t, but then had one specific acute injury. It’s like, “I tried to stick this dyno. I didn’t make it. My shoulder popped out and now it feels unstable and it’s clicking and catching all the time.”

I see that and I’m like, “All right, you dislocated your shoulder. The labrum is ripped off. That has to go back. Otherwise, you’ll dislocate it again.” Especially with instability, meaning a shoulder is popping in and out, I usually lean towards more aggressive surgical management. A lot of times climbers are what I would call a consequence athlete, meaning the actual shoulder.

The problem is the shoulder is popping out. The shoulder popping out in and of itself is not really the big issue. It’s the consequence of the popping out, meaning if you’re two days up a wall in Patagonia, you can’t afford to have your shoulder pop out. If you’re in a remote part of Pakistan in the Chhogori or something, you can’t afford to have your shoulder pop out in a bad situation. It’s better to be aggressive and fix it and stabilize it so you can trust it when you’re in an austere environment.

That’s one thing with the instability. The second thing is a rotator cuff tear that is full thickness and detached from the bone. A partial cuff tear is very common and I’ll usually try to treat those without surgery. If the tear is actually detached from the bone in a full thickness tear, that’s just not going to get better on its own. It’s better to fix those. Those are probably the two things I really push towards fixing pretty aggressively.

That makes sense as well. Let’s say that then you make your surgical decision or you make your conservative decision. Let’s say you go the conservative route with a climber. How important do you think is the therapist or the acupuncturist or the chiropractor, the person you work with, how important is it that they’re a climber?

I think it’s helpful if they’re a climber and it’s helpful to have that common vocabulary and understanding of what your passion is, but I don’t think it’s critical. I think that the therapist is critical.

Who that person is is absolutely critical to make sure that they’re doing the right thing, knowing what to push, knowing when to hold back. It’s somebody that has a true understanding of the shoulder kinematics, the way the scapula moves on the rib cage, the way it ties into the neck. The therapist is absolutely critical, but I think it’s less critical that they’re a climber.

One of the best therapists that I have that I use in the Boulder area is not a climber, but she’s treated so many climbers over the years. She knows climbing, but you’re not going to go row a boat with her, but she gets it. I think that the individual is really key, but not necessarily that they can climb like you do.

How important is for a climber to have good climbing technique and movement patterns?

That’s critical. That’s super key because if you’re out of bounds, your scapula is out of whack, and you don’t have good motion and mobility, then you’re going to have to compensate to get your arm into certain positions. When you’re loading it in a strange, off kilter position, you’re going to put something under stress that shouldn’t be under stress. When you move your arm up, I know you know this.

If you move your arm up like this, only about half of that motion is coming from the ball moving in the socket. The other half is coming from your shoulder blade moving up on the rib cage. By the way, your shoulder blade has 19 muscles that are attached to it. Think about that, 19 muscles attached to that, muscles that come up your neck, that go down your back.

If that thing is out of whack, then your shoulder and rotator cuff is all of a sudden seeing loads it shouldn’t see. That’s why you get overuse injury and chronic tendinitis and biceps tendinitis and these other things and some of the internal impingement that we were talking about. That comes from the scapula. If the scapula isn’t moving properly, then all of a sudden everything else gets loaded improperly. Then, you get overuse injuries. That’s at least my perception of it.

I know you’ve probably been asked this quite a bit before. How does the surgery on a competitive rock climber who has to use their arm over their head quite a bit compare to the surgery of someone who just needs to open their refrigerator door or someone that’s living a little bit more of a sedentary life? How does your surgical procedure change with just knowing that someone is a climber?

It’s a good question. You have to have a very light touch basically I think. I mean you should with surgery anyway, but in particular with climbers I’m a little more cautious about over-constrained shoulder. Meaning if somebody is a football or lacrosse player or a big time kayaker, I’m going to treat that labrum and the capsule differently than if someone is a climber.

I have a little bit of a lighter touch with a climber. I’m a little bit more respectful perhaps of not tightening it too much, not over-constraining it. Somebody that just needs to put a dish in their upper cupboard needs to get their arm up here, but that extra five or six degrees, 10, 20 degrees that a climber needs of hyperextension is key. You have to be able to reestablish that after the surgery.

A lot of that comes from the therapy, but a lot of it comes too at time zero with the way that technically the surgical procedure is done when you’re reattaching one tissue to the next or pulling the labrum or the capsule back to the bone. It’s a matter of millimeters, a millimeter here, a millimeter there, an extra degree here. I tend to be a little less aggressive with the climber’s shoulder than if it was any other type of athlete. You don’t want to sew it up too tight. That is a big mistake.

There’s not really much out there that’s clear cut about when climbers should return to sport, which is a little bit different than let’s say like a thrower baseball player should return to sport. What’s your thoughts in general or specifically? If someone has a simple tenodesis or simple shoulder surgery, what would be your general recommendation first for return to climbing for timelines?

That’s a great question. Part of that depends on the tenodesis technique. I just collected over 500 of my tenodesis patients over a four year period of time. I looked and we studied them. We took out all the patients that had a rotator cuff repair or a labral repair or a socket repair or something that required normalization.

I went down and it ended up being like 100 patients. We looked at those patients and I did zero restrictions on it, none, immediate full range of motion, immediate strength, immediate supination, no restrictions at all. Out of about 104 patients or something of that 500, there were two people that had a problem.

That’s I think partly because of the technique. One of those guys was doing single arm curls at three weeks with 50 pounds or something and the other one just had a bad fall. If you have a technique, and I have a pretty swift technique with dual fixation, that you can trust, then you can be pretty aggressive with getting people moving right away. You can establish mobility immediately.

You can get those muscles firing immediately, maybe not aggressive strengthening, but at least blood flow and proprioception and the muscles are working. In that type of patient, I usually get them at maybe six to eight weeks getting back into the gym. We start mobility and motion right away.

Then, around about that six to eight week mark top row being in the gym, plastic, easy, juggy holds, a lot of footwork. It’s just getting your fingers in shape again and getting the feel for the rock again. That usually will go on for a few weeks. Then, we’ll get back to climbing again, ramping up the grid.

It’s really ultimately the longer you wait, probably the better off you are. We keep trying to find ways to get people back faster because that’s what everybody wants to do. They want to start climbing. Basically, the longer you wait, the better off it is in some ways. I’ll let people get back nice and easy, but I want the progression to be slow over several times before you’re actually really cranking and loading.

That’s huge. What about for a more complex surgery? Take us through that example of what a timeline would be.

It’s a totally different situation if you’re anchoring the labrum, if you’re anchoring the rotator cuff, if you’re doing something where you need something to heal to something else, you just quadruple the time frame for that. That’s usually maybe a month on mobilization with some early motion, whatever you can get based upon what happened in time zero in surgery. It’s stretching during the second month, strengthening during the third month, working on power during the fourth month.

Guys that I have that I do a rotator cuff repair on, I’ll start trying to get them back, same type of thing, in the gym, juggy easy holds just to get out there maybe four, five months maybe. Then, at six we’re starting to ramp it up a little bit. I try to let them know ahead of time that this is going to be more like eight months, nine months, 10 months, 12 months before you’re really back to where you want to be. You have to wrap your head around that time.

If you let people go back too soon and you’re like, “Oh yeah, go ahead. Start climbing five-12 again,” you’ll get hurt. Then, you’ll have a big setback and it will take twice as long to come back from.

Absolutely. What are your thoughts then, because I get asked this all the time, on indoor versus outdoor when returning? Climbers that are normally outdoor climbers, they’ll say something like, “I’m just going to be on easy slab. I’m not going to fall,” or, “Maybe I’ll be outdoor on top row.” I’m interested what your thoughts are on that.

My thoughts are that there’s less variables in the gym other than the knucklehead climbing next to you. Ultimately, there’s just less variables. You don’t have to deal with weather, wet rocks, sandy rock, bird poo, whatever it is. There’s just less variables. Personally, I think the gym is better to get back into it. Not that you’re going to become some gym rat, but it’s just there’s less variables. It’s more controlled. I personally am a big fan of starting out in the gym for sure.

I get a lot of people trying to negotiate on the terms. When a climber comes back to see you, let’s say for a followup after they’ve had the surgery, how important is it the test that you do that day with them or that you do in the office versus what they report versus maybe what a physical therapist may send you? How important is each of those components in you determining their return to sport or their next step?

Let’s say what they tell me, what the physical therapist tells me, what I feel in the office are, there was something else I was thinking of just now I just blanked on, are very important. The things that I can test in the office are pretty limited really. I can test something and say, “Yeah, that feels in tact,” or, “Yeah, that’s attached and it’s strong.”

That doesn’t give you anything in regards to the dynamic requirements on a guy’s shoulder in the field. I take what I see in the office as maybe, I don’t know, 20% or 30% of that decision-making. Then, what the therapist tells me I take at least 30% or more in terms of trying to make that decision. The therapist usually has a lot more time with that individual and has seen maybe more subtle progress that I might not necessarily have the time to really evaluate in the clinic visit.

Ultimately, for me, I don’t necessarily have an hour to spend with somebody to go over every little thing. I take the therapist’s information, like that means a lot to me. Then, ultimately it’s what the guy tells me. He’s like, “I went to the gym. I just got on some five-nines just to see how it would feel and it felt fine.” I’m like, “Okay, well maybe we could advance a little bit more.” That’s a big part of it, what the individual actually tells me. It’s maybe 33/33/33, something like that.

The fourth thing I was going to say that’s really important is the calendar, time. I know, to some degree, how long it takes a tendon cell to bond to a bone cell. No matter how you feel, you might feel great, but I know that that is not a mature repair yet. It takes a number of weeks for these cells to bond, A, to initially bond in spot well and then, B, for the fibers of those cells to line up the correct way so that they’re aligned with the load that the repair site is going to see.

Even if you feel really good, if you’re way back on the calendar and you’re four or five weeks before where I think you should be, I’m going to hold you back. Even if you feel good, your therapist says you’re ready, I know that tendon isn’t ready yet. That’s the fourth thing, the calendar. That’s a big part of that.

You’re saying the tissue healing properties, you know the timelines that everything should heal at and when things should be ready. It’s huge. That brings me to the last point, which is the future, what maybe the future may hold for surgery in the next five to 10 years. Are there any guesses that you have or any hunches or ideas or expectations, maybe changes in how we deal with these injuries in the next five to 10 years?

I think so and we’re working on a lot of that here at our labs here. For example, in repairing someone’s shoulder we’ve gotten really good at getting a tendon and reattaching it to a bone or taking the labrum and tightening it up or putting the biceps where it belongs. The actual mechanical fixation, our techniques for mechanical fixation are fantastic.

They get better all the time, but the anchors are trucker strong. The sutures will never break. The knots we tie are not coming undone. The actual mechanical aspect of that repair is rock solid. The mechanical environment will probably get a little better, but probably not that much better than what we have now. I’ll tell you what, the future in the next few years is the biologic environment.

It’s all about biology. That means platelet enriched plasma and stem cells and growth factors. That’s where I think we’re really going to get more accelerated and better healing, ultimately with stem cells probably or some stem cell type variant. If we can jump start the biologic environment to heal properly, that’s when things are going to get way better. We’re not there now, but we’re working on it. I think that hopefully in five years or more we’ll have something down, but the FDA is really hard to work with.

There’s certain guys like in Munich or other countries where they don’t have as much of a regulatory process to go through. They’re doing some cool stuff.

Any last words of advice for climbers?

I would just say that a little preventive maintenance goes a long way. If you’re starting to get some tweaks in there, seeking out some input and some finds with somebody that knows what they’re doing typically with the right physical therapist is going to go a long way towards preventing injuries from happening in the first place. I mean that’s number one for sure.

Then, number two would probably be if you do have something substantial up with your shoulder, I’d look around before you just go with the first guy that says you need surgery. That’s all. Most orthopedic surgeons are really well-meaning guys that are trying to get you back to doing what you want to do. You want to try to find somebody that knows something about climbers or at least overhead athletes. If someone is trying to push you down saying you need surgery right away, it might be good to get another opinion.