What are the symptoms and treatment options for a labral tear of the shoulder?

Symptoms of Labral Tear of the Shoulder

The primary symptoms of a labral tear of the shoulder include pain, catching or clicking sensations, instability, and limited range of motion, which can significantly impact quality of life and should be evaluated with appropriate imaging such as MRI or MR arthrography for definitive diagnosis. 1, 2

Clinical Presentation

Common Symptoms

• Pain: Typically deep, aching pain in the shoulder that may worsen with certain movements
• Mechanical symptoms: Catching, clicking, popping, or locking sensations during shoulder movement
• Instability: Feeling that the shoulder might "slip out of place" or subluxate
• Weakness: Decreased strength, particularly with overhead activities
• Limited range of motion: Difficulty with certain movements, especially overhead activities
• Pain with specific activities: Throwing, lifting, or reaching overhead

Symptom Variations by Tear Location

• Anterior labral tears:

  • Anterior shoulder pain
  • Apprehension with the arm in abduction and external rotation
  • History of anterior dislocation or subluxation

• Posterior labral tears:

  • Posterior shoulder pain
  • Pain with pushing activities or when the arm is in forward flexion
  • May have longer symptom duration before diagnosis (average 32.5 months for occult tears) 3

• Superior labral tears (SLAP lesions):

  • Pain at the top of the shoulder
  • Pain with overhead activities
  • Symptoms may be vague and difficult to diagnose clinically 4

• Pan-labral tears (270° or 360° tears):

  • May present with symptoms of both anterior and posterior instability
  • More complex symptom pattern due to extensive labral damage 5

Diagnostic Approach

Physical Examination Tests

• Anterior instability tests:

  • Apprehension test
  • Relocation test
  • Anterior load-shift test

• Posterior instability tests:

  • Posterior load-shift test
  • Jerk test
  • Kim test

• SLAP tear tests:

  • O'Brien's active compression test
  • Biceps load test
  • Compression rotation test

Imaging Studies

1. Plain radiographs: Initial imaging to rule out fractures and other bony abnormalities 2

2. MRI without contrast: Highly effective for evaluating soft tissue pathology including labral tears, especially in acute settings with joint effusion 1

3. MR arthrography: Gold standard for labral imaging with sensitivity of 86-100%, particularly valuable in subacute or chronic settings 1, 2

4. CT arthrography: Alternative when MRI is contraindicated, provides comparable sensitivity for labral lesions 1

5. Ultrasound: Limited role in diagnosing labral tears, inferior to MRI 1, 2

Treatment Options

Non-surgical Management

• Physical therapy: Progressive rehabilitation focusing on:

  • Phase 1: Pain control, gentle range of motion exercises
  • Phase 2: Progressive ROM exercises, light strengthening
  • Phase 3: Advanced strengthening and sport-specific training 2

• Medications:

  • NSAIDs as first-line for pain management
  • Corticosteroid injections for significant pain (limited to 3-4 per year) 2

Surgical Management

• Arthroscopic repair: Effective surgical treatment for labral tears with good outcomes

  • Success rates of 85-95% for isolated labral repairs 6
  • Significant improvements in functional scores (Rowe, ASES, SST) following repair 6, 4

• Surgical indications:

  • Failed conservative treatment (3 months)
  • Young, active patients (especially under 30)
  • Athletes in high-demand or contact sports
  • Significant instability affecting quality of life 2

Pitfalls and Caveats

1. Diagnostic challenges:

   • Isolated anterosuperior labral tears are difficult to diagnose clinically and often missed 4
   • MRI/MRA may underestimate the extent of labral detachment, particularly with posterior labral tears 3

2. Treatment considerations:

   • Arthroscopic diagnosis remains the gold standard for SLAP tears 5
   • Occult tears (not visible on imaging) may require arthroscopic evaluation if symptoms persist 3

3. Follow-up recommendations:

   • Initial follow-up at 1-2 weeks after treatment initiation
   • Clinical reassessment at 6 weeks to evaluate progress
   • Consider repeat imaging or surgical consultation if no improvement by 3 months 2

By understanding these symptoms and following an appropriate diagnostic algorithm, clinicians can effectively identify and manage labral tears of the shoulder, improving patient outcomes and quality of life.