What is multifocal labral fraying to the acromion?

Multifocal Labral Fraying to the Acromion: Diagnosis and Management

Multifocal labral fraying to the acromion refers to multiple areas of wear or degeneration of the glenoid labrum that extend toward the acromion, typically affecting the superior portion of the labrum.

Anatomy and Pathophysiology

• The glenoid labrum is a fibrocartilaginous rim attached to the margin of the glenoid cavity that deepens the socket of the shoulder joint and provides stability to this inherently unstable articulation 1
• The superior labrum is particularly vulnerable to injury due to its connection with the biceps tendon anchor and its proximity to the acromion 2
• Multifocal fraying indicates multiple areas of degeneration rather than a single tear, suggesting either chronic wear or multiple microtrauma events 1

Clinical Presentation

• Patients typically present with shoulder pain, especially during overhead activities 3
• Pain may be accompanied by clicking, catching, or a sense of instability in the shoulder 2
• Unlike complete labral tears, fraying may cause more subtle symptoms of "microinstability" rather than frank instability 1

Diagnostic Approach

Physical Examination

• Anterior shoulder or superior shoulder pain with overhead activities 4
• Positive anterior impingement test is common 4
• Special tests for superior labral pathology may include O'Brien's test, Speed's test, and the biceps load test 2

Imaging

• MRI is the preferred non-invasive method for evaluating labral pathology 1
• MRI with arthrogram (MRA) provides better visualization of labral fraying by introducing contrast into the joint 4
• Diagnostic arthroscopy remains the gold standard for definitive diagnosis 4

Treatment Options

Conservative Management

• First-line treatment should be non-operative management including scapular exercises, restoration of balanced musculature, and activity modification 2
• Non-steroidal anti-inflammatory medications and physical therapy focusing on rotator cuff strengthening and scapular stabilization 4
• Approximately two-thirds of patients will experience symptom relief with conservative treatment 2

Surgical Management

• Surgical intervention is indicated when conservative measures fail after 3-6 months 2
• Treatment options include:
  • Arthroscopic debridement of frayed labral tissue 5
  • Labral repair using suture anchors if there is detachment 5, 3
  • Biceps tenotomy or tenodesis in patients over 40 years with concomitant biceps pathology 2

Treatment Algorithm Based on Patient Characteristics

For Non-Athletes or Recreational Athletes

• Begin with 3-6 months of conservative management 2
• If symptoms persist, consider arthroscopic debridement of frayed tissue 5
• For patients over 40 with associated biceps symptoms, consider biceps tenotomy or tenodesis along with debridement 2

For Throwing Athletes

• More aggressive physical therapy focusing on hip, core, and scapular exercises 2
• Longer trial of conservative management (6+ months) 2
• If surgery is required, careful repair of the labrum with attention to the peel-back mechanism is recommended 2

Prognosis

• Most patients with isolated labral fraying respond well to conservative treatment 2
• Following arthroscopic treatment, good to excellent results have been reported in approximately 80-90% of cases 5, 3
• Return to previous level of activity is more challenging for overhead athletes 2

Common Pitfalls

• Misdiagnosis of normal labral variants as tears can lead to unnecessary surgical procedures 1
• Failure to address underlying biomechanical issues (such as scapular dyskinesis) may result in persistent symptoms despite treatment 2
• Overlooking concomitant pathologies (rotator cuff tears, biceps tendinopathy) that may contribute to symptoms 4