What is the recommended evaluation and management approach for a patient with a shoulder labral tear?

Evaluation and Management of Shoulder Labral Tears

MR arthrography is the gold standard for diagnosing shoulder labral tears, followed by a period of conservative management before considering surgical intervention for most cases. 1

Initial Evaluation

Imaging Protocol

1. Standard radiographs (first-line imaging)

   • Anteroposterior (AP) views in internal and external rotation
   • Axillary or scapula-Y view (critical for detecting dislocations)
   • Radiographs should be performed upright (malalignment can be underrepresented on supine radiographs) 1

2. Advanced imaging (when radiographs are noncontributory)

   • MR arthrography: Highest sensitivity and specificity for labral tears 1
   • Standard MRI: Good alternative with optimized imaging equipment 1
   • CT arthrography: Consider only if MRI is contraindicated 1

Clinical Assessment

• Mechanism of injury (traumatic vs. overuse)
• Instability symptoms (dislocations, subluxations)
• Pain patterns (location, activities that provoke symptoms)
• Age and activity level (overhead athletes vs. non-athletes)

Management Algorithm

Conservative Management (First-Line Treatment)

Most soft-tissue injuries including labral tears can undergo a period of conservative management before considering surgery 1:

1. Rehabilitation Protocol

   • Scapular stabilization exercises
   • Rotator cuff strengthening
   • Core and hip strengthening (especially important for overhead athletes)
   • Range of motion exercises
   • Duration: Minimum 8-20 sessions (patients who complete at least 20 sessions have better outcomes) 2

2. Pain Management

   • NSAIDs for pain and inflammation
   • Activity modification
   • Consider corticosteroid injection for refractory pain

Surgical Management

Consider surgery for patients who fail conservative management after 3-6 months:

1. Arthroscopic Labral Repair

   • Best candidates: Young patients (<40 years), traumatic etiology, instability symptoms 3
   • Expected outcomes: 85% good to excellent results with proper patient selection 4

2. Biceps Tenotomy/Tenodesis

   • Best candidates: Older patients (>40 years), degenerative tears, overuse etiology without instability 3

3. Special Considerations for Throwing Athletes

   • More rigorous conservative management
   • If surgery needed: Consider peel-back SLAP repair, PIGHL release 3

Specific Labral Tear Types

SLAP Tears (Superior Labrum Anterior to Posterior)

• Conservative management success rate: 53.7% overall return to play; 78% in those completing full rehabilitation 2
• Factors predicting failure of conservative management: Older age, overhead athletes (especially baseball pitchers), traumatic injury, concomitant rotator cuff injury 2

Anterosuperior Labral Tears

• Often difficult to diagnose clinically
• Arthroscopic repair provides good outcomes for pain relief 5

Multidirectional Instability with Labral Involvement

• Extensive labral tears (≥270°) can be successfully treated arthroscopically
• 85% good results with appropriate surgical technique 4

Complex Anterior Instability

• <20% glenoid bone loss: Arthroscopic Bankart repair
• 20-30% glenoid bone loss: Latarjet procedure
• >30% bone loss: More extensive reconstructive options 6

Common Pitfalls to Avoid

1. Misdiagnosis: Anterosuperior labral tears are often missed on clinical exam and require high index of suspicion 5

2. Inadequate imaging: Using only standard MRI instead of MR arthrography can miss intra-articular pathology 1

3. Premature surgery: Many patients improve with proper rehabilitation; complete at least 20 PT sessions before considering surgical intervention 2

4. Overlooking associated pathology: Assess for concomitant rotator cuff tears, biceps pathology, and bone loss which may affect treatment decisions 1

5. One-size-fits-all approach: Treatment should consider age, activity level, and specific tear pattern 3

By following this evidence-based approach to evaluation and management, most patients with labral tears can achieve good functional outcomes and return to their desired activities.