154. Shoulder Labral Injuries: SLAP, Bankart, and Beyond

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In this episode, we delve into the fundamentals of shoulder labral tears. Learn about the anatomy and function of the shoulder labrum, common types of labral tears, and how they occur. Discover methods to diagnose these injuries, including special tests and imaging techniques. We'll also explore treatment options, from conservative management to surgical intervention, and the importance of tailored rehabilitation. Remember to check out our show notes for helpful resources and special offers!

00:00 Welcome to BT Snacks Podcast
00:25 Introduction to Shoulder Labral Tears
01:29 Understanding the Shoulder Labrum
02:45 Types and Causes of Labral Tears
05:03 Diagnosing Labral Tears
06:31 Special Tests for Labral Tears
09:20 Conservative and Surgical Treatments
12:07 Post-Operative Rehabilitation
12:50 Conclusion and Additional Resources

Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6(4):274-279.

Kim SH, Ha KI, Kim SH. Classification and diagnosis of SLAP lesions: operative arthroscopic assessment and a new classification. J Bone Joint Surg Am. 2004;86(7):1310-1317.

Wilk KE, Reinold MM, Andrews JR. Rehabilitation of the overhead throwing shoulder: current concepts and clinical applications. J Orthop Sports Phys Ther. 2011;41(5):388-400.

Lesniak BP, Hsu AR, Potter HG, et al. Glenoid labral tears: part I—anatomy, pathophysiology, and diagnosis. Am J Sports Med. 2013;41(5):1114-1122.

Hegedus EJ, Goode A, Cook CE, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. J Orthop Sports Phys Ther. 2008;38(7):341-352.

Transcript

0:30

Hey guys. Welcome to BT Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, welcome. But what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in by sci segments of time. Note this podcast is not meant to be medical advice, so use your discretion with the information I have. Now. Today we're gonna be covering more on shoulder labral tears, which I know there are some shoulder fanatics out there that will love this. But before we do if you've been listening to the show at least three times and you found the information to be helpful, if you wouldn't mind leaving a review wherever you listen to this, that would mean the world to me. And for those of you who have already done so. Thank you so much for being willing to spend your time and do something that really helps this podcast grow. Now, today, I've talked about various labral tears before, but let's put it all in one episode, so it's gonna be a little bit more high level on the function of the shoulder labrum. Most common types of labral tears that we do see some ways that we can rule them in or rule them out, and what types may start with conservative care versus surgical care. So as much as I would love for everyone to get better with physical therapy, it is important to know where we are limited, right? So let's start off with the basics. The shoulder labrum is a fibro cartilaginous ring that surrounds the glenoid cavity. You might be wondering why does it do that? Think of it as a bumper or basically a gasket that helps deepen the socket and helps to better stabilize the humal head because we want that joint to be nice and flexible so that we can do all sports of. Reaching and sports and all that sort of stuff, but because the joint congruency is smaller, the labrum actually adds a little bit more joint congruency and still helps us to have a pretty mobile shoulder in fact. It increases glenoid depth by about 50%. That's five 0%. That's amazing. It also serves as an attachment point for the glenohumeral ligaments and the long head of the biceps tendon, and it basically enhances stability. As I mentioned before, there are different regions of the labrum. We have superior, inferior, anterior, and posterior. Which is also important to familiarize what yourself with, because tears can happen in different locations, and the implications can vary depending on what structures are involved. So when we are asking ourselves, how does this even happen? Labral tears can happen several ways. One acute traumas like a fall on an outstretched arm or a shoulder dislocation. Two repetitive overhead activity like our throwing, swimming and lifting athletes. Or workers, overhead workers, right? Or three. It can just be degeneration that happens over time. Now, the most common types of labral tears would be slap tears or superior labrum from anterior to posterior tears. Obviously, slap is a lot easier to say, and that involves the attachment of the biceps tendon. So we'll see this a lot more in throwers or people who do repetitive overhead loading, and there's a lot of subtypes within that. We could have done our own episode, but there are subtypes one through four. Depending on what the tearing is doing. So type one is just fraying subtype. Two is detachment subtype. Three is a bucket handle, and subtype four is extension into the biceps tendon. Now that's slap tears. But moving on to bank heart lesion, that is an anterior inferior labral tear. So we see this often associated with an anterior dislocation. Pretty common in younger athletes after a traumatic dislocation. Now, posterior labral tears are less common, but often from posterior instability or repetitive posterior forces. So you could think of maybe weightlifters or football linemen. It's NFL season right now if you're watching American football. Those linemen pushing into someone or someone running into them is gonna add a lot of posterior force to that shoulder. And though that posterior instability is much less common because of the anatomy of the shoulder it is still possible. So being aware of someone who has a propensity to develop this is helpful on your diagnosis. And then we have degenerative labral tears, degenerative things in general are gonna be more common in our older populations, and it can often be asymptomatic Now. We don't wanna just assume someone has a labral tear, right? Though someone who has a labral tear may complain of clicking, popping or catching sensations, they may feel like deep shoulder pain versus something that feels superficial or lateral. And they may have pain with overhead activity or throwing in a sense of instability or even dead arm. But other things that we wanna rule out might be some sort of rotator cuff tendinopathy. Sub acromial pain biceps tendinopathy or glenohumeral general instability, which labral tears can be on a similar spectrum of instability. But some things to consider when you're going through your exam. Now we don't wanna rush right into special tests. As many of my mentors have said, special tests are for special moments. The last thing we wanna do is flare up our patient before we even know what's going on.'Cause they're just, you're gonna get a lot of positives that are not positive. They're false positives. So make sure you're also rolling out the joints that are above and below the shoulder, maybe the neck, the upper back things that are coming from the spine. Being able to assess the simple things like their range of motion, their strength, special tests are just thing positions that maximally stress, the tissue that we're trying to adjust. So it's good to maybe look at their mid range or their basics before we jump right into that. But here are some common special tests that you've probably learned about. If you want a brief review. So we have O'Brien's active compression tests. This is usually used for slap lesions. So you basically put the shoulder in a position where the biceps, tendon and labrum are loaded.'cause if we're testing for a slap, teach. Lesion. Those are the tissues that we're trying to add stress to, to see if it hurts, and a positive test, which would be pain with internal rotation that lessens with external rotation, so just a labral or AC joint pathology. There's a crank test, so you can do this with your patient sitting or in a supine position, and you put the shoulder in about 160 degrees of flexion. The examiner or you is gonna apply an axial load with internal and external rotation, and a painful click or reproduction of symptoms would potentially indicate a lab tear or a general labral injury. Basically, you're just trying to crank, hence the name, crank on the labrum and see if it hurts or if it's clicking. There's also a biceps load two test that's designed to detect slap, tear, slap type. Guess it. Two lesions, if you remember, the subtypes two is detachment. So when the patient is supine, the shoulder is abducted to 120 degrees and externally rotated, then the patient is gonna resist elbow flexion. So if they have pain with resistance, it's considered a positive finding as the bicep tendon pulls on the superior labrum. There's also a jerk test used for detecting posterior labral tears. So when the shoulder is flexed and internally rotated, an axial load is applied while horizontally. A ducting, adducing, and a sudden jerk or clunk can indicate posterior instability or tear. And then we have the anterior slide test. So the patient is gonna put their hand on their hip. Therapist is gonna apply an anterior superior force at the elbow, and a click or pain may suggest a superior labral lesion. Now, these don't have the best individual accuracy, so it's best to use these as a cluster or alongside imaging findings like an MRI to put it all together. An MRI arthrogram is gonna be probably the most reliable imaging technique to confirm labral pathology because it allows visualization of the intraarticular contrast, which can help to highlight labral detachment or irregularity a. Now in terms of treatments, let's say we've identified they have some sort of labral pathology, right? Some of these patients are gonna start right off with conservative. Some may need surgery. So let's start with the conservative first. That's gonna often be the first thing that patients try or do would be for those who have a slap type one or some type two just depends. If they have degenerative or minor tears or posterior tears that don't have gross instability, because they have enough to help them go through conservative, it's the less stable ones that need a little bit more fixation. So within this conservative approach, we will help to modify their activity. We're trying to reduce the job of the labor while we're allowing it to heal. So we may have them back off on things that are irritating their shoulder, right? They may also do strengthening for their rotator cuff and scapular stabilizers, trying to build up their active stabilizers to make up for the passive stabilizers that are healing. We can use manual therapy to help improve mobility if it's missing or for some pain modulation. As well as looking at them as a whole if they're trying to either get back to a particular activity or continue making sure that we are helping their whole body be able to maintain that level. For surgical indications though, that's gonna be probably for the labral pathologies that are a lot less stable, where we really need that to be fixated. So that's gonna be SLAP type two to four. I know I said some type two could be conservative. Again, it just depends. But especially in our younger active overhead athletes they might have some sort of detachment or extension into the bicep tendon. So healing is like gonna be a lot less likely without some sort of surgical stabilization. And we want these people to heal bank art lesions. With recurrent anterior instability, again, we see these a lot after shoulder dislocations, and if it's left untreated, we don't really want to have recurrent instability and therefore risk further damage. Symptomatic posterior labral tears can cause instability or functional deficits that failed rehab. While it's less common if posterior instability is significant, surgery might be needed. And then also if someone has failed conservative management, if their symptoms are continuing despite three to six months of high quality rehab, keyword, high quality surgical intervention may be considered to help them, the patient get more stability and reduce mechanical symptoms like catching and locking. Now I'm not a surgeon, keep in mind, so I can't speak to the techniques of all these. These are just things that we're probably gonna see more of. But if they do go post-op rehab, there's going to be an early protection phase, could be zero to six weeks, depends on your surgeon's protocol. And then they're gonna gradually improve their range of motion and strengthening. Adding just enough stress for the body to react productively, meaning it's responding to the stress in a way where it can tolerate it, not overloading it, and then hopefully returning to sport or high level activity greater than four months. Again, it just depends on if this is. A complicated case if it's occurring with other things that are going on. What exactly is the activity that we're looking at? This all depends. So again, this is not medical advice. This is just a brief review over some research so keep in mind, shoulder labral tears are complex and there's a lot of different types. They, not every labral tear is gonna look the same, which if you've listened to the episode, obviously that's the case. But helping to understand the anatomy and the mechanism of how these happen, how they present, can help us to better capture them as soon as possible. If you have any questions, there is a link in the show notes where you can directly message me instead of having to email. But if you do want to email, you can reach out at PTs snacks podcast@gmail.com. And if you have any questions or have future show requests, definitely let me know. I love to hear that. Because it's always nice to know people are listening, right? If you are trying to. Either take a deeper dive into a lot of these topics. You wanna learn more, you're trying to get your license renewal done, or maybe you're preparing for a specialty exam like your OCS or SCS Med Bridge is actually offering listeners over a hundred dollars off their year subscription. So that's insane. But if you wanna utilize it, use the promo code in the show notes. That's gonna give you access to tons of courses and webinars. And the specialty exam prep is great'cause you can go through, you can study, you can go through practice exams. You can get used to looking at a computer screen for a long period of time with explanations on the questions. I used it for my OCS and I thought it was really helpful. So definitely check that out in the show notes, and if you're a student, there's an even better deal for you below. But other than that, I hope you guys have a great one and into next time.