Labrum Tear Overview
The labrum is a rim of rubbery fibrocartilage that attaches to the edge of the shoulder socket (glenoid). The labrum deepens the socket by as much as 50%. This deep socket, combined with the ability of the rotator cuff muscles and tendons to compress the humeral head (upper part of the arm bone) is a key factor in keeping the shoulder stable, even though full range of motion. The labrum also interacts with the lining of the shoulder (capsule) and ligaments to provide a checkrein against too much movement. And there is a suction-like capacity of the socket, much like a suction cup where the center is hard, and the edge is rubbery and flexible, which helps to hold the ball (humeral head) in the socket. Finally, the edge of cartilage on the socket combined with the labrum creates a mechanical bumper to further help keep the shoulder stable but very flexible.
Where on the Shoulder do Labrum tears Occur?
A labral tear can happen anywhere along the shoulder socket:
- When the labrum tears in the upper half of the perimeter, the injury is called a SLAP tear (Superior Labrum from Anterior to Posterior).
- When the labrum tears in the lower front side of the perimeter, it is called an anterior labral tear which is associated with anterior instability.
- When the labrum tears on the lower back side of the perimeter, it is called posterior labral tear which is usually associated with a posterior instability injury, but often causes more symptom of pain instead of instability.
Anterior Labral Tear
When the shoulder dislocates out the front (anterior), the labrum and capsule are torn, as well as some injury to the edge of the bone. When this injury heals, the shoulder pain goes away, but patients become apprehensive to put their arm above their head and rotate at the shoulder as if they were going to throw a ball. When labral tears occur in the front of the socket, patients often feel their shoulder is too loose or unstable rather than painful.
This is much different when the shoulder goes out the back, or posterior. Usually, after the initial injury heals, more patient report persistent pain rather than instability. And finally, when tears occur in the top of the shoulder, which is known as a superior labral tear, or SLAP tear, pain and dysfunction of the shoulder persists especially with overhead activities, while symptoms of instability are much less common. In this area of the superior labrum, the long head of the biceps tendon originates in the same area, which can lead to initial pain and worsening pain traveling from inside the shoulder and done the front of the arm where the upper part of the biceps tendon is located.
Labrum Tear FAQ
Why is the labrum important to shoulder stability and flexibility?
The labrum is tough, resilient fibrocartilage that deepens the socket to help stabilize the shoulder, and connects to important structures involved in the motion of the shoulder—namely, the shoulder capsule. Because the labrum performs important roles in stabilizing the shoulder, and provides important connections in limiting excessive motion, a tear in the labrum can cause persistent pain. This leads to the muscles tightening up and limiting motion, as well as symptoms of looseness, which discourages the patient from using their full range-of-motion and participating in their normal activities.
How is a labrum tear diagnosed?
The diagnosis of a labral tear begins with understanding the injury that started the shoulder problem, examining the shoulder using specific tests that often can reproduce the symptoms, and reviewing x-rays to see if there are changes in the bone that are associated with specific labral injuries.
Often, this is enough information to decide if the problem needs further assessment before starting a treatment program. If a labral tear is suspected, and prior treatment has not made a difference, or the shoulder symptoms will not allow return to activities, the next level of evaluation is with an MRI.
MRI, or magnetic resonance imaging has advanced our ability to see tissues “inside” the body without having to perform surgery. In most cases, an MRI without injecting fluid into the shoulder joint will provide the information that will supplement the prior evaluation and lead to a more definitive diagnosis and evidence-based treatment plan. Occasionally, having the radiologist place fluid in the shoulder (arthrogram) before the MRI will improve the ability to interpret the findings on the MRI. This may be particularly useful when the effects of prior surgery for a labrum, cartilage, or rotator cuff problem can alter findings on the standard non-contrast MRI.
However, even though it is used frequently for assessment of the tissues around the shoulder, there remains considerable variation in the quality of the studies performed, as well as the interpretation of the findings on the MRI images. Dr. Romeo may need to order a new MRI with specific instructions to ensure that you are getting the full benefit of this test.
Most patients do not realize the incredible variation in the type of MRI machines that are used, the method or sequences that are obtained at the time of the study, and the experience of the person reading the MRI images. Dr. Romeo will not accept the MRI report without the actual films, which he will review himself. The key to maximizing the value of the MRI is correlating the findings to the history, physical examination, and x-ray studies so that the most accurate diagnosis and appropriate treatment can be provided to you. Unfortunately, MRI studies may show an abnormality in an area of the shoulder, including parts of the labrum, that may not have a direct relationship to the cause of your symptoms.
The gold standard for the diagnosis and confirmation of a labral tear is arthroscopy. While the MRI provides significant detail in black, white, and grayscale color, there is nothing as valuable as looking directly at the area of concern with 15x magnification and bright light, combined with the ability to use a probe or instrument to move the tissue and clearly define the location of the tear, the size of the tear, and surrounding tissue that may have also been injured but undergone partial healing that can disguise the true extent of the injury on MRI.
During a shoulder arthroscopy, a tiny camera is inserted through a small incision in the skin. This allows the surgeon to examine the tear close-up and to use a probe to determine the extent of the injury. The evaluation during the arthroscopic procedure should confirm the plan that was discussed before surgery. However, the extent of the injury, and collateral damage related to the injury that caused the labral tear may guide the final surgical repair technique.
Sometimes, even with MRI evidence of a significant labral tear, the findings at the time of arthroscopy show the lesion to be much smaller or already healed so that a full repair is not necessary. Knowing how to identify each type of tear requires extensive surgical experience and the close follow-up of patients after surgery to understand what treatment is most effective. Labral tears can come in many varieties and the techniques to repair them can be very different. With the effort to advance arthroscopic shoulder surgery over the past 25 years, Dr. Romeo has every instrument, suture, anchor, and technique available to ensure the labral tear is treated with a method that provides the best opportunity for healing and potential to return to all pre-injury level of activities.
Is doing nothing an option?
Sometimes. A labral tear does not require treatment unless it is causing discomfort or preventing the enjoyment of favorite activities. If the labrum is simply frayed at the edge—which is a normal part of aging—you can easily live with this if you are not experiencing symptoms. Furthermore, with frayed edges or small tears of the labrum, if the rotator cuff is working well to keep the humeral head centered in the socket, it is likely the labral tissue will see less pressure over time, allowing it to recover or heal to the point that it does not cause any more symptoms. We have seen recovery even in some of our high-level athletes such as professional baseball pitchers.
While many cases may initially respond to physical therapy, it is not unusual for patients to become frustrated with the fact that the labral tear symptoms do not let them return back to the same level of activity as they were able to accomplish before the injury. Because of these limitations, athletes, workers, or even those that enjoy occasional recreational sports will make the decision to proceed with surgery to reattach the torn labrum back to the socket. If a tear of the labrum is the result of a shoulder dislocation, the labrum is mobilized so that it can be returned to its normal position, then fixed with sutures or small surgical tape anchored into the bone at the edge of the socket. We have developed techniques to fix every part of the labrum no matter where the injury occurs.
Labral Repair Surgery
A labral repair is an outpatient surgery which is done arthroscopically using advanced techniques, instruments, and implant to secure the labrum to its normal position on the socket edge. During the procedure, three or more small skin incisions are made around the shoulder to establish the ability to see and treat any part of the labrum. A camera with a strong light source (arthroscope) is placed in the shoulder joint, the joint is gently distended with sterile saline solution to open the entire joint space, and then special instruments and implants are used to fix the injury to the labrum. Once the labrum and capsule are mobile and can be place back in their ideal position, special sutures or small tapes are passed through the labrum and capsule, attached to an tiny anchor, followed by the anchor being implanted into the glenoid bone. The number of anchors used depends on the size and area of the tear. Usually three or more anchors are used for labral tears in the front (anterior) and back (posterior), however two anchors are often enough for tears at the top part (superior) of the socket.
Labral Repair Recovery
After surgery, you will be sent home in a sling and pillow brace that will keep your arm immobile and supported. Dr. Romeo will give you specific instructions for post-op pain management. Many patients will be able to stop taking strong pain medications (opioids) within a few days of the surgical procedure. You should allow four weeks for the labrum to become securely attached to the bone. Even at that point, it will not have its normal strength.
Because of the rate of healing, the first month rehabilitation is focused:
- resting the shoulder so that it become comfortable
- simple movements of the shoulder combined with movement of the elbow, wrist, and hand,
- protection against putting the arm close to the position where the injury occurred.
The second month of healing is much better, especially since the sling and pillow brace are no long necessary. A supervised physical therapy program is started, with the goals of achieving 80% or more of your normal motion, while starting to strengthen the muscles around the shoulder with light resistance exercises including therabands. Typically, progression to training the shoulder with weights begins around three months after an arthroscopic labral repair.
Throughout the recovery process, you must gradually ease into physical activity. Despite the very strong sutures and anchors that have been developed to securely fix the labrum, the actual tissue of the labrum needs time to heal, which includes the ability to improve its supply of growth factors and cells that allow for the tissue and bone to regain its ability to provide a strong edge to the socket. Putting too much stress on the joint and the repair site too early will result in damage to the repair which can lead to a less desirable result with lingering limitations despite a great repair and appropriate physical therapy.
Experienced Chicago orthopaedic surgeon Dr. Anthony Romeo will tailor a recovery plan to your specific injury and the procedure you have undergone. If you follow this plan, we will work together to give you the best potential to reclaim full use of your shoulder, and even resume vigorous physical activity including collision sports, aggressive physical training programs, and physically demanding work responsibilities.
Want to see more? In this video, watch Dr. Romeo perform an arthroscopic shoulder repair on former White Sox pitcher John Danks. His comments will guide you through a better understanding of the day of surgery, from the preoperative assessment all the way to the recovery room.
For more information about causes and treatment of shoulder labrum tears, please request an appointment with experienced Chicagoorthopaedic surgeon Dr. Anthony Romeo. Call our office today to schedule your visit.
Anatomy of Shoulder as it Relates to Surgery Video
Additional Links on Labrum Tears
Want to know more? Here a few of Dr. Romeo’s recent medical journal articles about labral tears:
- The Posterolateral Portal: Optimizing Anchor Placement and Labral Repair at the Inferior Glenoid
- Four-quadrant approach to capsulolabral repair: An arthroscopic road map to the glenoid
- The posterolateral portal: Optimizing anchor placement and labral repair at the inferior glenoid..
- Arthroscopic Treatment of Multidirectional Shoulder Instability with Minimum 270 degree Labral Repair: Minimum 2 Year Follow-Up
- Trends in the Management of Isolated SLAP Tears in the United States