Injury Analysis of a Torn Labrum (Shoulder)
Injury: Labral Tear, Torn Labrum, SLAP Tear
What is the labrum?
The labrum is a ring of fibrous tissue within the ball and socket of the shoulder joint that helps with the stability of the joint (see below). The best analogy I can think of is that it acts like a suction cup to help keep the shoulder joint stable. The labrum, along with the joint capsule and the rotator cuff muscles, all function together to stabilize the joint and allow for maximum function.
Front View of Shoulder
Mechanism of Injury
In athletes, the injury typically occurs from two primary mechanisms. One way a labral tear can develop is secondary to a traumatic injury. A common occurrence is from multiple shoulder dislocations causing tearing of the tissue as the upper arm comes in and out of socket. It can also occur from repetitive throwing due to strain from the biceps tendon that attaches to the labrum as well.
Evaluation and Diagnosis
A torn labrum in the shoulder can be quite difficult to diagnose, therefore the medical provider must always take the athlete's situation in to consideration and have a high suspicion when warranted. For example, the probability of a labral tear in an overhead athlete such as pitcher or volleyball player is much more likely than a soccer player with shoulder pain. The athlete will typically complain of a sharp vague shoulder pain especially with overhead activities. Athletes may also have painful catching, clicking, popping or grinding with certain movements. Specific exam tests such as an Obrien's Test or Dynamic Shear Test can help differentiate between a torn labrum and less concerning conditions such as tendonitis or impingement. Additionally, if an athlete has history of multiple shoulder dislocations there will be a high likelihood of having a labral tear. If a labral tear is suspected, an MRI with dye injected into the shoulder joint is the study of choice to confirm the presence of a tear.
Treatment:Non-Overhead ATHLETE or NOn-Dominant ARM
In general, the recommendation for a labral tear varies depending upon the type of tear, location of the tear, hand dominance of an the athlete and the primary sport of the athlete. I would also include the stability of the shoulder as well as number of dislocations that have occurred in the past. Let's go through the scenarios. If I have a non-overhead athlete with an injury to either shoulder or an overhead athlete who has an injury to their non-dominant arm, I usually would recommend physical therapy even before getting an MRI. My reasoning is even if I do see a labral tear I will give the athlete an attempt at improving with physical therapy. If the patient fails physical therapy and subsequent MRI shows a tear I would advise surgical treatment if they continue to have pain and disability.
Treatment:Overhead ATHLETE Dominant ARM
On the other hand, if a tear is shown to be in the dominant arm of an over head athlete, surgery may be more aggressively pursued depending upon the size and location of the tear. One must be very thoughtful in discussing the right indications for surgery in a athlete such as a pitcher, as no surgery is without the possibility of complications. In general, superior labrum anterior and posterior (SLAP) tears are most common in the overhead athlete.
Return to PLAY
A non-overhead athlete with an injury to either shoulder or an overhead athlete who has an injury to their non-dominant arm and is found to have a small labral tear can attempt non-surgical treatment first. If it is successful, general return back to activities can be approximately 4-6 weeks. Surgical repair of a SLAP tear will usually keep an overhead athlete out of sports for 6 - 9 months. Rehabilitation protocols typically restrict any overhead activities or throwing for 5 months after the surgery.
In an athlete that has both a labral tear and frequent shoulder dislocations, a procedure to tighten the joint capsule usually will be performed at the same time as the labral repair. A keen surgeon will take care to not over tighten the shoulder, which can result in altered mechanics and inability to return back to pre-injury level.