What are the treatment options for a shoulder labrum tear?

Treatment Options for Shoulder Labrum Tear

Begin with conservative management including physical therapy, activity modification, and anti-inflammatory medications for at least 3-6 months, reserving surgical intervention only for cases that fail non-operative treatment. 1

Initial Diagnostic Workup

• Obtain standard radiographs with three views: anteroposterior (AP) in internal and external rotation plus axillary or scapula-Y view to rule out fractures and dislocations 1, 2
• Order MRI without contrast for suspected labral tears when radiographs are negative or indeterminate 1
• Consider MR arthrography as the gold standard imaging modality, particularly for patients under 35 years old with suspected labral pathology 1
• Use CT arthrography only if MRI is contraindicated 1

Conservative Treatment Protocol (First-Line)

Non-operative management succeeds in approximately 71% of patients with isolated labral tears and should be the initial approach for most cases. 3

• Implement scapular stabilization exercises and restoration of balanced shoulder musculature 4
• Prescribe NSAIDs for pain control 1
• Modify activities to avoid provocative movements, especially overhead activities 3
• Continue structured physical therapy for at least 20 sessions before considering treatment failure 5
• Expect symptom relief in approximately two-thirds of all patients with this approach 4

Expected Timeline for Conservative Management

• Most patients who respond to non-operative treatment show improvement within 6 months 3
• Athletes who successfully complete rehabilitation typically return to play in less than 6 months 5
• Return-to-play rate reaches 78% in athletes who complete their full rehabilitation program 5

Predictors of Conservative Treatment Failure

Certain patient characteristics strongly predict failure of non-operative management and may warrant earlier surgical consideration:

• History of traumatic injury (not overuse) 3, 5
• Positive compression-rotation test on physical examination 3, 5
• Participation in overhead sports, particularly baseball pitching 3, 5
• Presence of mechanical symptoms or instability 3
• Concomitant rotator cuff injury 5
• Older age (>40 years) 5
• Presence of Bennett spur on imaging 5
• Longer symptomatic period before treatment initiation 5

Surgical Intervention

Reserve surgery for patients who fail 3-6 months of structured conservative management or those with clear traumatic instability. 1, 4

Type II SLAP Tears (Most Common)

• For patients under 40 with traumatic injury and instability symptoms: Perform SLAP repair alone 4
• For patients over 40 with traumatic injury and instability: Perform SLAP repair with concurrent biceps tenotomy or tenodesis 4
• For patients with overuse etiology without instability: Perform biceps tenotomy or tenodesis without SLAP repair 4

Throwing Athletes (Special Category)

• Implement rigorous physical therapy centered on hip, core, and scapular exercises plus restoration of shoulder motion and rotator cuff balance 4
• Reserve peel-back SLAP repair, posterior inferior glenohumeral ligament (PIGHL) release, and treatment of partial infraspinatus tears only for those who fail comprehensive rehabilitation 4
• Note that surgical outcomes in overhead athletes are generally less favorable than in non-overhead athletes 5

Type I SLAP Tears

• Treat non-operatively in most cases, especially in older patients 6
• Consider arthroscopic debridement only for refractory cases 6

Anterosuperior Labral Tears (Without Biceps Anchor)

• Repair arthroscopically using single bioabsorbable suture anchor technique when conservative treatment fails 7
• Expect good to excellent results with significant improvement in pain and function scores 7

Common Pitfalls to Avoid

• Failing to obtain adequate three-view radiographs initially can miss associated fractures or dislocations 1, 2
• Overlooking associated injuries, particularly rotator cuff pathology in traumatic cases, leads to incomplete treatment 2, 5
• Abandoning conservative treatment prematurely (before 20 physical therapy sessions) significantly reduces success rates 5
• Performing SLAP repair in older patients (>40 years) without considering biceps tenodesis yields poor outcomes 4, 6
• Missing isolated anterosuperior labral tears on clinical examination—these are extremely difficult to diagnose without arthroscopy 7

Key Decision Algorithm

1. All patients: Start with 3-6 months of structured physical therapy (minimum 20 sessions) 5
2. If traumatic injury + instability + age <40: Consider earlier surgical SLAP repair 4
3. If traumatic injury + instability + age >40: Consider SLAP repair with biceps procedure 4
4. If overuse injury without instability: Continue conservative treatment; if surgery needed, perform biceps procedure alone 4
5. If overhead athlete: Maximize conservative treatment with sport-specific rehabilitation before any surgical consideration 4, 5