What are the treatment options for a patient presenting with symptoms of a shoulder labrum tear?

Treatment Options for Shoulder Labrum Tear

For patients presenting with symptoms of a shoulder labrum tear, initial nonsurgical management with exercise therapy and NSAIDs should be attempted before considering surgical intervention, as this approach effectively decreases pain and improves function in most cases. 1, 2

Diagnostic Approach

Initial Imaging

• Plain radiographs should be the first imaging study for all patients with shoulder pain to rule out fractures and other bony abnormalities 1
• If radiographs are noncontributory and labral tear is suspected:
  • MR arthrography is the gold standard (rated 9/9 for appropriateness) for detecting labral tears, especially in patients under 35 years 1, 2
  • Standard MRI without contrast is also highly effective (rated 7/9) with optimized imaging equipment 1, 2
  • CT arthrography may be considered if MRI is contraindicated 1

Clinical Presentation

• Common symptoms include:
  • Pain during overhead activities
  • Mechanical symptoms (catching, locking)
  • Instability or apprehension
  • Pain with specific arm positions 2, 3

Treatment Algorithm

1. Nonsurgical Management (First-Line)

• Exercise therapy:

  • Multiple level II studies demonstrate beneficial effects of exercise in decreasing pain and improving function 1
  • Should include scapular stabilization exercises, rotator cuff strengthening, and core strengthening 4, 5
  • Both supervised and home exercise programs show improvements in outcomes 1

• NSAIDs:

  • Recommended as initial treatment along with exercise therapy 1
  • Helps manage pain and inflammation

• Activity modification:

  • Temporary avoidance of aggravating activities
  • Particularly important for overhead athletes 6

2. Surgical Management (Consider after failed conservative treatment)

• Indications for surgery:

  • Failure of conservative measures after 3-6 months
  • Significant functional limitations despite therapy
  • Evidence of instability
  • Young, active patients with high physical demands 2

• Surgical options:

  • SLAP repair: Preferred for younger patients (<40 years), especially those with traumatic injury and instability 4
  • Biceps tenotomy/tenodesis: Better option for patients over 40 years or those with overuse etiology without instability 4
  • Arthroscopic debridement: For certain types of tears, especially bucket handle tears 7

Special Considerations

For Throwing Athletes

• Require specialized approach:
  • More rigorous physical therapy focused on hip, core, and scapular exercises
  • Restoration of shoulder motion and rotator cuff balance
  • Higher failure rates with standard treatment approaches 4, 6
  • May require specialized surgical techniques if conservative management fails

For Older Patients (>40 years)

• Biceps tenotomy or tenodesis generally preferred over SLAP repair 4, 6
• Higher success rates with this approach in this population

Common Pitfalls to Avoid

• Misdiagnosis: SLAP tears are difficult to identify clinically and may be confused with other shoulder pathologies 5
• Premature surgery: Conservative treatment should be attempted first, as approximately 2/3 of patients will respond to nonsurgical management 4
• Inadequate rehabilitation: Failure to address scapular dyskinesis and core weakness can lead to poor outcomes 4, 5
• Overlooking concomitant pathology: SLAP tears often occur with other shoulder injuries that must be addressed 6

By following this structured approach, most patients with labral tears can achieve significant pain relief and functional improvement, with surgery reserved for those who fail an appropriate trial of conservative management.