The Labral Tear - Shoulder

updated on May 4, 2008 12:09 PM PDT

Portions taken from Damian Williams Tears Labrum

The Shoulder or Glenohumeral joint, is considered by some a ball and socket joint. It is comprised of the Humerus (ball/shaft) and the Glenoid (socket). While there are some similarities to that of the hip, a traditional ball and socket joint, the shoulder joint is more shallow than the hip and has more of a gliding type of range of motion, as it is the most mobile joint in the body . Because the joint is shallow, the glenoid is essentially flat, it is inherently more unstable than the hip so the shoulder relies on the soft tissue structures around it to achieve stability. The glenoid has a rim, or cuff, of tissue around it called the labrum. This helps keep the head of the humerus in place essentially making the socket "deeper". It also acts as a bumper to limit eccessive motion of the humerus.

The labrum can be torn because of a direct fall or blow to the arm resulting in abnormal movement of the humerus. It can also be caused by repetitive trauma of the greater tuberosity and rotator cuff on the posterior aspect or back of the labrum. This is termed internal impingement, the pinching of the soft tissue, and is most commonly seen in baseball, swimming and tennis athletes whose arms are frequently in overhead positions.

The most common patterns of labral tears are:

SLAP Tears - A SLAP tear is a type of labral tear most commonly seen in overhead throwing athletes such as baseball players and tennis players. The torn labrum seen in a SLAP tear is at the top of the shoulder socket where the biceps tendon attaches to the shoulder.

Bankart Lesions - A Bankart lesion is a labral tear that occurs when a shoulder dislocates. When the shoulder comes out of joint, the labrum is torn, and makes the shoulder more susceptible to future dislocations.

Posterior Labral Tears - Posterior labral tears are less common, but sometimes seen in athletes in a condition called internal impingement. In this syndrome, the rotator cuff and labrum are pinched together in the back of the shoulder.

Slap Tears

SLAP is the acronym for Superior Labrum Anterior-Posterior These tears or lesions have 4 classifications: From Wheeless' Textbook of Orthopaedics

- type I:

- fraying and degeneration of the superior labrum, normal biceps (no detachment);
- most common type of SLAP tear (75% of SLAP tears);
- often associated with rotator cuff tears;
- these are treated w/ debridement;

- type II:

- detachment of superior labrum and biceps insertion from the supra-glenoid tuberlce;
- when traction is applied to the biceps, the labrum arches away from the glenoid;
- typically the superior and middle glenohumeral ligaments are unstable;
- may resemble a normal variant (Buford complex);
- 3 subtypes: based on detachment of labrum involved anterior aspect of labrum alone, the posterior aspect alone, or both aspects;
- posterior labram tears may be caused by impingement of the cuff against the labrum with the arm in the abducted and externally rotated position;
- as noted by Tae Kyun Kim et al. type-II lesions in patients older than 40 years of age were associated with a supraspinatus tear where as
in patients younger than 40 years were associated with participation in overhead sports and a Bankart lesion;
- treatment involves anatomic arthroscopic repair;

- type III:

- bucket handle type tear;
- biceps anchor is intact;

- type IV:

- vertical tear (bucket-handle tear) of the superior labrum, which extends into biceps (intrasubstance tear);
- may be treated w/ biceps tenodesis if more than 50% of the tendon is involved;

Non-operative Treatment for Labral Tears

There are probably a large number of untreated labral tears that heal spontaneously since the labrum has a rich blood supply that helps the healing process (except in the anterior and superior locations).

Physical therapy is helpful for certain cases such as internal impingement, in which the rotator cuff rubs the posterior labrum. Physical therapy options include:

changing the throwing mechanism.

strengthening muscles that externally rotate the shoulder.

stretching the posterior capsule with the help of a physical therapist.

Operative Treatment for Labral Tears - Arthroscopic

Tears that need treatment are usually seen in the chronic stage when spontaneous healing has not occurred. Tears of the biceps tendon anchor are unlikely to heal without treatment because the biceps constantly pulls on the labrum.

Chronic tears may require surgery if patients are unwilling or unable to modify their activities sufficiently to allow for healing and comfort. Surgery should be considered if:

pain is unresponsive to anti-inflammatory medications such as ibuprofen, rest, and activity modification.

the labrum has not healed after an acute injury.

The arthroscope allows direct visualization and evaluation of the entire shoulder joint. Using this small instrument, the orthopaedic surgeon first examines the labrum and all attachment sites for instability requiring repair. Once other disorders are treated or ruled out, the labral injury is addressed.

Arthroscopic treatment is the standard of practice for most labral injuries not associated with instability. The majority of these can be treated with simple debridement (removal of abnormal, damaged, or excess tissue). This procedure will eliminate flaps that may impinge the movement of the humerus on the glenoid and/or remove any unstable portion of the labrum.

Certain painful and unstable SLAP tears, in which the biceps is detached, need special attention. If the biceps tendon anchor is no longer firmly attached to the glenoid, it must be re-attached to the bone. The surgeon uses suture anchors and /or arthroscopic knot tying techniques to repair the torn labrum of younger patients.

It is often safer for older individuals to have a debridement of the labrum and a biceps tenodesis. A tenodesis is a procedure in which the biceps is repaired to the bone outside the glenohumeral joint to relieve pain, yet allow it to retain some strength and function. This procedure can be a good choice for older patients because the blood supply to the labrum diminishes with age, making the healing process more difficult. The decision to perform a tenodesis repair should be made by the doctor and patient together, after a thorough discussion of the surgical options and the healing process.

The Open Procedure

If the tear is too large to repair through the arthroscope, the surgeon will need to make an incision in the front of the shoulder. The repair of the tear is essentially the same though it is under direct visualization. The main drawback of making the larger incision is that it will probably take you longer to recover from surgery.

What types of complications can occur?

Complications associated with surgery for labral tears are few:

The risk of infection in arthroscopic procedures is extremely low and can be a complication of any surgical procedure.

Stiffness after surgery is unlikely since debridement allows early arm movement. Physical therapy will usually relieve stiffness resulting from the sling that is needed for four or more weeks for labral repairs.

Failure of healing can occur due to technique, biology, or the patient's unwillingness to follow post-operative instructions and the prescribed rehabilitation program.

Here is a great write up by Dr. Russell Warren at the Hospital for Special Surgery (HSS) in NYC on Shoulder Arthroscopy that will help give an overview of the procedure. There are also some great images that you can click on in this article that show the procedure.

Images and treatment information taken from the Steadman-Hawkins Clinic in Vail, Colorado.

These are some intra-operative images of the procedure:

Images take from the website of Daniel C. Wnorowski, MD Syracuse, NY