How is a nondisplaced tear of the superior labrum managed or treated?

Management of Nondisplaced Tear of the Superior Labrum

Conservative management is the first-line treatment for nondisplaced superior labrum tears, including physical therapy focused on rotator cuff and periscapular muscle strengthening, with surgical intervention reserved only for cases that fail non-operative treatment. 1, 2

Diagnostic Approach

• MR arthrography is considered the gold standard for imaging labral tears, particularly in patients under 35 years of age 1, 3
• Initial evaluation should include standard radiographs with at least three views: anteroposterior (AP) views in internal and external rotation and an axillary or scapula-Y view 1, 2
• MRI without contrast is appropriate for suspected labral tears with negative or indeterminate radiographs 2
• CT arthrography may be appropriate if MRI is contraindicated 1, 3

Non-Surgical Management Protocol

• Physical therapy should focus on:
  • Strengthening of the rotator cuff muscles 1, 3
  • Periscapular muscle strengthening 1, 3
  • Core musculature strengthening 1, 4
  • Capsule flexibility exercises 1
  • Scapular stabilization exercises 3
• Activity modification to avoid aggravating movements 2
• Anti-inflammatory medications as needed 2
• Expected success rate: approximately 71% of patients respond well to non-operative treatment 5

When to Consider Surgery

• Failure of conservative management after a thorough trial (typically 3-6 months) 2, 4
• Factors associated with higher likelihood of non-operative treatment failure:
  • History of trauma 5, 6
  • Positive compression-rotation test 5, 6
  • Participation in overhead activities 5, 6
  • Older age 6
  • Concomitant rotator cuff injury 6
  • Longer symptomatic period 6

Special Considerations for Athletes

• For throwing athletes:
  • More aggressive physical therapy focusing on hip, core, and scapular exercise 4, 7
  • Correction of scapular posture 7
  • Stretching of the posterior capsule 7
  • If surgery is required, avoid throwing for a minimum of 6 weeks 1
  • Follow with a strengthening phase for an additional 6 weeks (total of at least 3 months rest from throwing) 1, 3
• Non-throwing athletes typically have better outcomes with non-operative management 4, 7

Treatment Algorithm

1. Confirm diagnosis with appropriate imaging (MR arthrography preferred) 1, 3
2. Begin conservative management with physical therapy protocol for 3-6 months 2, 4
3. If symptoms persist despite adequate physical therapy (at least 20 sessions), consider surgical options 6
4. Surgical decision based on:
   • Age: Patients <40 years may benefit from SLAP repair; patients >40 years may require biceps tenotomy or tenodesis 4
   • Activity level: Overhead athletes have special considerations 4, 7
   • Presence of instability: SLAP repair may be more appropriate with instability symptoms 4

Common Pitfalls to Avoid

• Rushing to surgical intervention before adequate trial of conservative management 2, 4
• Inadequate physical therapy (successful non-operative treatment typically requires about 20 sessions vs. 8 sessions in those who fail) 6
• Overlooking associated injuries, particularly in traumatic cases 2
• Failing to identify factors that predict poor response to conservative management 5, 6