How to assess a patient with suspected labrum tear of the shoulder, considering age, occupation, level of physical activity, and past medical history of shoulder injuries or conditions?

Assessment of Suspected Shoulder Labrum Tear

Begin with standard three-view radiographs (AP in internal and external rotation plus axillary or scapula-Y view) to exclude fractures and bony pathology, followed by MR arthrography as the definitive diagnostic test for labral tears, which has 86-100% sensitivity. 1, 2, 3

Initial Imaging Protocol

• Obtain standard radiographs first with three mandatory views: anteroposterior in internal and external rotation PLUS an axillary or scapula-Y view 1, 2, 3
• Never rely on AP views alone—they miss posterior dislocations in over 60% of cases 2, 3
• These radiographs rule out fractures (Hill-Sachs deformity, bony Bankart lesion) and other bony pathology before proceeding to advanced imaging 1, 2

Physical Examination Findings

For posterosuperior labral tears specifically:

• 100% of patients test positive on both the O'Brien test and the ABER test (abduction and external rotation test) 4
• Nearly all patients (92%) test negative on the external rotation test with the arm in neutral position 4
• Patients typically report a characteristic history of pain occurring with the shoulder in excessive abduction and external rotation posture 4

General labral tear examination:

• Physical examination demonstrates 90% sensitivity and 85% specificity for detecting labral tears 5
• The combination of O'Brien test, Jobe relocation test, and anterior apprehension test provides 72% sensitivity and 73% specificity when any one is positive 6
• Patients with anterior labral tears complain primarily of instability (62.5%), while those with posterior tears complain primarily of pain (68%) 7

Advanced Imaging Selection

MR arthrography is the gold standard with an appropriateness rating of 9/9 for suspected labral tears 1, 2, 3

• Sensitivity ranges from 86% to 100% for detecting labral injury 3
• This is superior to physical examination alone and should guide surgical decision-making 5

For acute dislocations:

• Non-contrast MRI may be preferred over MR arthrography, with an appropriateness rating of 7/9 2, 8
• This evaluates for labral tears, capsular injuries, and bone loss that predict recurrence 2

If MRI is contraindicated:

• CT arthrography is comparable to MR arthrography for Bankart and Hill-Sachs lesions 3
• Reserve this for patients with pacemakers or other MRI contraindications 1, 3

Age-Specific Considerations

Younger patients (<35 years):

• Higher likelihood of labroligamentous injury and persistent instability after dislocation 2
• Greater risk of recurrent instability requiring evaluation for capsular injuries and bone loss 2
• More likely to benefit from surgical stabilization if conservative management fails 3

Older patients (>40-60 years):

• Significantly more likely to have concomitant rotator cuff tears 2, 8
• Higher likelihood of weakness in external rotation, abduction, or internal rotation 2
• Overlooking associated rotator cuff tears can lead to secondary osteoarthritis and persistent symptoms 8

Occupation and Activity-Level Factors

Overhead athletes and throwing athletes:

• Constitute 64% of labral tear patients in surgical series 5
• Associated with higher failure rates of conservative management, especially baseball pitchers 9
• Presence of Bennett spur indicates chronic overhead activity and predicts conservative treatment failure 9

Factors predicting failure of conservative management:

• Older age, participation in overhead sports (especially baseball pitchers), traumatic injury mechanism, positive compression rotation test, concomitant rotator cuff injury, longer symptomatic period 9

Past Medical History Considerations

History of trauma:

• 60% of labral tears are traumatic, with dislocation being the most common mechanism (31.4%) 7
• Traumatic injury predicts failure of conservative management 9
• Patients often recall specific traumatic events (61% in surgical series) 5

History of instability:

• Recurrent instability despite appropriate rehabilitation is an indication for surgical evaluation 3
• Up to 10% of patients with recurrent instability develop progressive glenoid bone loss requiring specialized surgical procedures 2, 3

Critical Diagnostic Pitfalls

• Never attempt to diagnose labral tears with AP radiographs alone—the axillary or scapula-Y view is mandatory 2, 3
• Do not overlook associated rotator cuff tears, particularly in patients over 40 years with high-energy trauma 2, 3, 8
• Physical examination alone should not be the sole basis for surgical decision-making despite 90% sensitivity—MR arthrography provides superior diagnostic accuracy 5, 6
• Do not miss posterior labral tears, which constitute 74% of all labral tears involving some portion of the posterior labrum and present primarily with pain rather than instability 7