For a recurrent labral tear of the shoulder, is injection or surgery the more effective treatment option?

Recurrent Labral Tear of Shoulder: Surgery Over Injection

For recurrent labral tears of the shoulder, surgery is the definitive treatment option, as injections lack evidence for structural repair and long-term stability restoration in this specific pathology.

Critical Distinction: Labral Tears vs. Rotator Cuff Pathology

The available guidelines address rotator cuff tears, not labral tears—these are fundamentally different pathologies requiring different treatment approaches 1. The AAOS guidelines state that subacromial injections for rotator cuff tears have inconclusive evidence, with no significant difference between corticosteroid and lidocaine alone at 6 weeks 1. This evidence cannot be extrapolated to labral pathology, which involves structural instability rather than tendinopathy.

Treatment Algorithm for Recurrent Labral Tears

Initial Conservative Management (First Episode Only)

• The American College of Radiology recommends starting with conservative management including physical therapy, activity modification, and anti-inflammatory medications for initial labral tears 2
• However, for recurrent tears, conservative management has already failed by definition

Surgical Intervention for Recurrent Tears

• Arthroscopic labral repair is the appropriate treatment for recurrent labral tears causing symptomatic instability 2, 3, 4
• Arthroscopic repair using suture anchor fixation demonstrates significant improvements in validated outcomes 3, 4:
  • Pain scores improve from 4.3 to 1.1 3
  • Instability scores improve from 7.3 to 0.2 3
  • ASES scores improve from 76 to 93 4
  • Return to preinjury activity level in all patients 3

Specific Surgical Considerations

• Extensive labral tears (270° or circumferential) require arthroscopic repair with multiple suture anchors (mean 7.1 anchors) 3
• Modern knotless suture anchor techniques provide effective mechanical stability restoration 5, 6
• Arthroscopic approach allows complete visualization and repair of all labral pathology 4
• Failure rates after arthroscopic repair: 15% recurrent instability, 5% revision rate 4

Why Injections Are Inappropriate for Recurrent Labral Tears

• Injections do not address the structural pathology—labral tears represent mechanical instability requiring anatomic repair 2, 3
• The only injection evidence available relates to rotator cuff tears, showing no benefit beyond 6 weeks and concerns about adverse effects on tendon biology 1
• Corticosteroid injections may theoretically impair healing capacity, though this is based on general orthopedic concerns rather than labral-specific evidence 1

Diagnostic Confirmation Before Surgery

• MR arthrography is the gold standard for imaging labral tears, particularly in patients under 35 years 2
• Standard radiographs (AP in internal/external rotation plus axillary view) should be obtained first 2
• Physical examination must demonstrate 2+ anterior-inferior and posterior-inferior load-shift testing 4

Common Pitfalls to Avoid

• Do not delay surgery in young, active patients with recurrent instability—conservative management has already failed 2, 5
• Do not use rotator cuff treatment algorithms for labral pathology—these are distinct entities 1, 2
• Ensure adequate imaging to avoid missed diagnoses and identify associated injuries 2
• Recognize that older patients may have different outcomes; arthroscopic repair results are less encouraging in this population 7