Treatment Options for Shoulder Labral Tears
Begin with conservative management including physical therapy, activity modification, and anti-inflammatory medications for 1-3 months, reserving surgical intervention for cases that fail non-operative treatment. 1
Initial Diagnostic Workup
Imaging Protocol
- Obtain standard radiographs first with three views: anteroposterior (AP) in internal and external rotation plus an axillary or scapula-Y view to rule out fractures and bony pathology 1, 2
- MR arthrography is the gold standard for diagnosing labral tears, with sensitivity ranging from 86% to 100% for detecting labral injury 3
- MR arthrography specifically outperforms non-contrast MRI for detecting anterior labral and SLAP tears 3
- For acute dislocations, non-contrast MRI may be preferred over MR arthrography 3
- CT arthrography is comparable to MR arthrography for Bankart and Hill-Sachs lesions but should be reserved for patients with MRI contraindications 3
Clinical Examination Limitations
- Physical examination alone has limited diagnostic accuracy (72% sensitivity, 73% specificity when combining multiple tests), so imaging confirmation is essential before proceeding to surgery 4
- The O'Brien test (63% sensitive, 73% specific) and Jobe relocation test (44% sensitive, 87% specific) can strengthen clinical suspicion but should not be the sole basis for surgical decisions 4
Conservative Management (First-Line Treatment)
Treatment Duration and Components
- Implement a structured 3-month conservative program before considering advanced surgical intervention 5
- Pain control with acetaminophen or NSAIDs (ibuprofen) if no contraindications exist 5
- Subacromial corticosteroid injection can be considered if pain is related to rotator cuff or bursal inflammation 5
Physical Therapy Protocol
- Initial phase: Gentle stretching and mobilization techniques focusing on external rotation and abduction 5
- Later phase: Progressive strengthening exercises for rotator cuff and scapular stabilizer muscles 5
- Return to normal activities only after achieving pain-free motion and adequate strength 5
Surgical Intervention
Indications for Surgery
- Failure of conservative management after 1-3 months 1, 5
- Recurrent instability despite appropriate rehabilitation 3, 2
- Significant glenoid bone loss (up to 10% of patients with recurrent instability) that may require bone grafting 3
Age-Specific Surgical Considerations
- Young, active patients (<35 years): Arthroscopic repair is preferred for type 2 SLAP lesions 6
- Older patients (>50 years): Biceps tenodesis may be more appropriate than repair, as arthroscopic repair results are not encouraging in this age group 6
- Younger patients have higher risk of persistent instability and benefit more from surgical stabilization 3, 2
Surgical Outcomes
- Arthroscopic capsulolabral repair with suture anchors (mean 7.1 anchors) provides reliable improvement in pain, instability, and functional outcomes 7
- High labral healing rate (95%) with arthroscopic posterior labral repair 8
- 88.6% of athletes return to preinjury sport levels after arthroscopic repair 8
- Revision surgery required in approximately 15% of cases for recurrent instability, biceps tendinitis, or postoperative stiffness 7
Critical Pitfalls to Avoid
- Never rely on AP radiographs alone—axillary or scapula-Y views are mandatory to avoid missing posterior dislocations (missed in >60% with AP alone) 2
- Do not overlook associated injuries, particularly rotator cuff tears in older patients (>40 years) and bone loss in younger patients with recurrent instability 3, 2
- MRI/MRA may underestimate labral pathology—70% of "occult" tears on imaging are confirmed as incomplete or complete tears at arthroscopy 8
- Patients with ambiguous MRI/MRA findings but persistent symptoms despite conservative treatment should still be considered for arthroscopy, especially active young men 8
- Do not proceed to surgery based on clinical examination alone given the relatively low sensitivity and specificity of physical tests 4