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Shoulder Labral Tear
A labral tear is an injury to the glenoid labrum of the shoulder joint. Three bones, the clavicle (collarbone), scapula (shoulder blade), and the humerus (arm bone), form the shoulder joint. The upper end of the humerus is large and rounded, and it sits in a shallow concavity of the scapula called the glenoid fossa. It is the shallowness that allows for such extensive mobility of the shoulder joint, but it makes the joint fundamentally unstable. There is therefore a rim of thick fibrous tissue around the edge of the glenoid fossa that deepens the socket and helps to keep the humerus in position. Several ligaments (bands of strong connective tissue) have their attachments on the glenoid labrum.
There are particular types of labrum tear. These are:
- SLAP (superior labrum from anterior to posterior) tear: this is a tear at the top of the labrum where the biceps tendon has its insertion onto the labrum. Athletes who use repetitive overhead throwing motions are prone to SLAP tears.
- Bankart lesion: this tear happens during a shoulder dislocation and increases the vulnerability of the shoulder to future dislocations. Younger people (under 30) are more likely to suffer a Bankart lesion during a dislocation.
- Posterior labral tear: in this injury, the rotator cuff of the shoulder and the labrum are compressed together in the posterior (back) shoulder.
Causes:
Glenoid labrum tears often happen in conjunction with other shoulder injuries, such as dislocations.
Repetitive shoulder movements can result in injury to the labrum. Examples might include repeated overhead throwing motions, or lifting heavy weights above the head.
Trauma is another cause of a labrum tear. A hard blow to the shoulder, falling onto an outstretched arm, a sudden force as when trying to lift something heavy, or grabbing at something overhead to prevent a fall, could provide enough force to tear the soft tissues of the labrum.
Age will cause the labrum to become more brittle, increasing the risk of injury.
Symptoms:
- Pain, made worse with particular activities
- Achy pain in the shoulder joint
- Sensation of locking or catching of the shoulder joint with movement
- Sense of the shoulder being unstable
- Weakness in the shoulder
- Loss of range of motion of the shoulder
Diagnosis:
Your doctor will ask you for your medical history, including any previous injuries to your shoulder. You will probably be asked about your normal level of activity and whether you participate in any sports. You will be asked for details about your current injury, any circumstances surrounding the onset of pain, and the type and severity of your symptoms.
Diagnosis of a labral tear is difficult. Your shoulder will be physically examined, which will likely include the doctor moving your shoulder and arm to assess the passive range of motion, and asking you to move your arm and shoulder yourself, to assess active range of motion.
X-rays will be taken to view the bony structures of the shoulder, and a CT (computed tomography) or MRI (magnetic resonance imaging) scan taken to look at the labrum itself, and surrounding tissues. A contrast dye may be injected before the scan, to show any tears more clearly.
It may only be possible to make a definitive diagnosis using arthroscopic surgery, which involves inserting very slender instruments into the joint through tiny incisions around the shoulder. Confirmation of a diagnosis of a labrum tear would then occur at the same time as surgical repair.
Treatment:
Most labral tears are treated conservatively (non-surgically). Specific treatment depends on the type of labrum tear.
SLAP tears do not heal as well as other labrum tears because the area involved has a poor blood supply. However, conservative treatment usually works. Treatment will include rest, anti-inflammatory medication and perhaps a cortisone injection into the joint.
A Bankart lesion increases the risk of future shoulder dislocations so, although conservative treatment may relieve symptoms, surgery may be necessary to stabilize the joint. Without surgery, a Bankart lesion will take at least six months to heal. Because young athletes may be reluctant to wait for so long, and because the chance of a repeat dislocation is so high, many doctors will recommend immediate surgical repair of the lesion. Older patients are less likely to need surgery as, after age 30, the chance of a repeat dislocation diminishes rapidly.
Depending on the type and severity of your injury, your doctor will probably prescribe anti-inflammatory medication and rest before considering surgery. Resting the shoulder may involve wearing a sling for a few weeks. You will certainly need to avoid any movements that make the pain worse. If conservative treatment fails, or your injury requires it, surgery will be performed. Surgery will be either open or arthroscopic, depending on your surgeon’s preference.
During surgery, the labrum will be carefully examined, along with the biceps tendon. The stability of the joint depends on the location of the tear; if the biceps tendon is intact, the joint is stable and the surgeon will simply remove or trim the torn piece of labrum. If the biceps tendon is detached or torn, the labrum will need to be reattached and the shoulder stabilized with the use of wires or sutures, which may be absorbable.
You will be instructed to use a sling for three to four weeks after surgery. You will also have to rehabilitate the shoulder through a graduated series of exercises designed to gently increase the range of motion of the shoulder. These will probably begin with pendulum exercises, where you bend at the waist and simply let your arm hang downwards then begin to make small circles with the arm, clockwise and anticlockwise. When you are no longer wearing the sling you will begin exercises to strengthen the biceps, which will have weakened through disuse, and to continue to increase flexibility in the shoulder. Your doctor or physical therapist will supervise your exercise program.
It is extremely important to resume activities slowly and not rush rehabilitation as further injury to the labrum might occur. Follow medical advice carefully.
Full recovery after surgery may take six months or longer.
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