Labral tears are very common, particularly in younger active patients, and require careful assessment, investigation and treatment to avoid long term damage to the shoulder joint.
Anterior labral tears typically occur after shoulder dislocations; and SLAP tears often occur in throwing athletes; whilst posterior labral tears may be more gradual in onset.
About 95% of shoulder dislocations occur out the front resulting in a bankart/anterior labral tear. The most important predictor of your outcome is your age at first dislocation and your sporting/occupational demands.
Patients under the age of 20 who sustain a first time shoulder dislocation and labral tear have between 80-100% chance of recurrence; and those aged between 20-30 have a 70-80% chance of repeat dislocations. Patients who are involved in collision or contact type sports (especially overhead) are at much greater risk of repeat shoulder dislocations.
The extent of your labral tear and associated bone loss in the shoulder joint will predict your outcome. It is imperative that your injury be assessed using a combination of X-ray, CT and/or MRI; this will allow your treatment to be tailored to your individual circumstances. Shoulder stabilisation surgery reduces your chance of recurrent dislocations. Longer term, without surgery, patients who continue to dislocate are at increased risk of shoulder joint arthritis.
The Labrum is a soft tissue ring around the glenoid (socket) that deepens the shoulder joint and keeps the humeral head (ball) in the joint. After shoulder dislocations (especially recurrent episodes) the Labrum may tear off the socket and no longer function in stabilising the shoulder joint.
The labrum can tear at the:
A soft tissue Bankart is essentially a “Labrum tear” as above. A bony Bankart is when the front of your socket (glenoid) fractures off or is worn out and becomes blunted over time with repeated episodes of instability. This loss of bone at the front of your shoulder will result in increased instability. The more bone you have lost at the front, the more likely it is that a Latarjet procedure is better for you. The main exception being high-level contact/overhead athletes, where the Latarjet may be a better choice from the outset (even without a bony bankart).
This is the damage (crush fracture) that occurs to the back of the ball (humerus) when it dislocates out of joint and impacts with the front of the socket. After the shoulder joint is reduced one can see a defect on the back of the ball (this is called a Hill-Sachs). The larger the Hill-Sachs lesion the more likely your shoulder is to be unstable.
Injuries to the labrum (tissue rim surrounding the shoulder socket) may occur from acute trauma (such as a shoulder dislocation or subluxation) or repetitive shoulder motion. Common examples of traumatic causes include:
Throwing athletes, rugby players, and weightlifters may experience glenoid labrum (bankart) tears due to repetitive shoulder motion.
The symptoms of a labral tear may vary depending on where the labrum is torn and how big the tear is. Common symptoms include:
Dr Pant will take a detailed history about your shoulder symptoms. He will ask about when they first began and whether there was any particular injury that caused your shoulder pain. Most patients with a Labral tear (bankart tear) recall a shoulder dislocation event which required a reduction maneuver. This may have even happened a few times with multiple trips to the emergency department. High level sports people often have an on field reduction and a period of inability to play. However, some patients may not recall a particular event. In some cases work or sport may aggravate your symptoms of shoulder instability. It is important to describe the location of pain, whether you have had any physiotherapy and injections to your shoulder.
Dr Pant will conduct a careful physical examination and check your shoulder range of motion, strength, and stability of your shoulder function. He will then perform specific tests to isolate the anterior (front) labrum, posterior (back) labrum and SLAP (top labrum) areas to see if this reproduces your symptoms of pain, apprehension and/or instability. A thorough examination is key to identifying all areas of concern around the glenoid (socket) to see how extensive your labral tear may be.
X-rays: this will show the bones of the shoulder joint in clear detail. It is a good screening test to look for any damage to the humeral head and glenoid (ball and socket). The labrum will not be seen on the plain X-ray; however, if you have a bony bankart (fracture) or a Hill Sachs on the humeral head this may be seen on a plain X-ray.
MRI scans show soft tissue better – such as the labrum. In some cases, a dye may be injected into the shoulder to help show the labrum tear (MRI arthrogram).
For most patients with a labral tear – the treatment is non-surgical. A period of rest, activity modification, and NSAIDs may be useful to treat shoulder pain.
Physiotherapy may be suggested to restore movement and strengthen your shoulder. Range of motion, rotator cuff strengthening, scapula stabilising exercise may be useful as guided by your physiotherapist. Keeping up the therapy may relieve your pain, restore your shoulder function, and prevent further injury. It may be necessary to continue this exercise program for 3-6 months in some cases.
If you have not improved with non-surgical treatment or if you have a high grade labral tear (with either anterior, posterior, and/or superior extension) then you may do better with surgery. In some cases this is the best option from the outset. Dr Pant will review your case (and your CT/MRI scan) to determine if this is the right course of action to provide you with the best shoulder outcome. If surgery is required this is done keyhole (arthroscopic) and the rehabilitation is using the JPL method.
There are several different types of labral tears and Dr Pant will determine how best to treat your labral injury; in some cases, this final decision is made at the time of arthroscopic surgery. The treatment options are either “soft tissue” repair or “bone” transfer:
The factors that are considered in the treatment choices are your age, occupation, type of sport, level of sporting participation, quality of your tissue, and associated injuries in the shoulder. All of these factors need to be considered in combination to achieve the best outcome for your shoulder injury repair.
If you have glenoid bone loss (bony bankart) or you are a high-level contact athlete it may be best for you to proceed to a Latarjet from the outset. This way you only have to rehabilitate your shoulder once and you are back to full-contact sport at six months.
Repeat anterior instability/dislocations can lead to a fear of using the shoulder (not “trusting” it) and reduction in function. Patients may avoid positions of “apprehension”.
A labral tear at the back of the shoulder (Posterior) may cause ongoing shoulder pain and difficulty sleeping on the affected side. Posterior labral tears usually do better with surgery. Tears of the Anterior Labrum usually lead to “apprehension” and loss of “trust” for fear of dislocation (more than pain per se)
Patients will have apprehension with the hand in the upper outer quadrant
Inability to play overhead contact sports without instability +/- pain.
Patients will have pain +/- apprehension with hand in the upper inner quadrant.
When the labrum tears off the glenoid it will not heal itself – because the blood supply to the labrum is poor and it may have moved away from its normal position (displacement). If you have a small tear you may be able to modify your activity (avoid overhead) and maintain your function with physiotherapy. Younger patients who are active and overhead workers generally do better with shoulder stabilisation surgery. Older patients who are happy to minimise overhead activity may do fine without surgery. The injury shoulder is staged using MRI (and or CT) and then the treatment options tailored to each individual.
The published return to sport rate after shoulder stabilisation surgery (key-hole) is 70-90%. With stabilisation surgery, patients are 5-6 times more likely to return to play.
The risk of re-dislocation with overhead contact after soft tissue key-hole stabilisation is between 5-20% (depending on a number of factors).
The gentleman is a keen surfer and dislocated his shoulder. He presented with instability symptoms and an X-ray that showed a bony bankart (fractured glenoid). He was unstable on examination and wished to return to his previous level of function overhead.
The MRI scan confirmed an anterior labral tear with a bony bankart; in addition he had a posterior (back of the shoulder) labral tear and a SLAP tear. He had a corresponding Hill-Sachs lesion (fracture at the back of the Humeral head).
He underwent an Arthroscopic bony bankart and labral repair as pictured below. We were able to repair the tissues back to their anatomical (original) position using suture anchors and achieved a nice “bumper” at the front of the shoulder. We also repaired the posterior labrum and the unstable SLAP lesion – all keyhole – a total of 3 small 1cm incisions around the shoulder.
He commenced JPL therapy at two weeks and went on to strengthen his shoulder at 3 months. He is back surfing at six months post-surgery and happy with his outcome.
After a shoulder dislocation some patients may be a candidate for a “bone transfer” procedure: a Latarjet. This is a good procedure for high level athletes, those who participate in overhead contact type sport, those with significant bone loss, and revision cases of failed previous “key-hole” stabilisation surgery.
This 16 year old high level wakeboarder dislocated his shoulder and sustained both a rotator cuff tear and an anterior labral tear. This is an uncommon injury pattern and presents unique decision making and surgical challenges.
Given his high level sporting ambitions and demands we repaired the Rotator Cuff and did a Latarjet procedure to treat his instability. He was in a sling for six weeks and commenced JPL rehabilitation at two weeks post surgery. He commenced formal Physiotherapy at 3 months, eventually regaining full ROM and function with his shoulder. He is back to his active lifestyle and riding waves around the waterways of Australia.
This 30 year old gentleman had a several year history of recurrent shoulder dislocations. He had exhausted a period of activity modification and physiotherapy. He was apprehensive to use his shoulder overhead, so he elected to proceed with surgery.
The images taken from surgery demonstrate a tear in the Labrum at the front of the shoulder. This has been carefully prepared and repaired back to the glenoid (socket) using 2.9mm anchors and suture-tape: achieving a nice “bumper” at the front of the shoulder joint.
He underwent JPL therapy and then physiotherapy to strengthen the shoulder. He no longer feels unstable and is back to participating in the sports he loves.
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