What is a shoulder labral tear?

An unstable shoulder joint can be the cause or the result of a labral tear. “Labral” refers to the glenoid labrum—a ring of cartilage that surrounds the base of the shoulder joint. Injuries to the labrum are common, can cause a great deal of pain, and may make it hard to move your arm. A labral tear can occur from a fall or from repetitive activities or sports that require you to use your arms raised above your head. Some labral tears can be managed with physical therapy; in severe cases, surgery may be required to repair the torn labrum.

What are common causes of a shoulder labral tear?

The glenoid labrum provides extra support for the shoulder joint, helping to keep it in place. A labral tear occurs when part of this ring is disrupted, frayed, or torn. Tears may lead to shoulder pain, an unstable shoulder joint, and, in severe cases, dislocation of the shoulder. Likewise, a shoulder dislocation can result in labral tears.

When you think of the shoulder joint, picture a golf ball (the head of the upper-arm bone, or humerus) resting on a golf tee (the glenoid fossa, a shallow cavity or socket located on the shoulder blade, or scapula). The labrum provides a rim for the socket (golf tee) so that the humerus (golf ball) does not easily fall off. If the labrum is torn, it is harder for the humerus to stay in the socket. The end result is that the shoulder joint becomes unstable and prone to injury.

Because the biceps tendon attaches to the shoulder blade through the labrum, labral tears can occur when you put extra strain on the biceps muscle, such as when you throw a ball. Tears also can result from pinching or compressing the shoulder joint when the arm is raised overhead. There are 2 types of tears:

• Traumatic labral tears usually happen because of a single incident, such as a shoulder dislocation or an injury from heavy lifting. People who use their arms raised over their heads—such as weight lifters, gymnasts, and construction workers—are more likely to have traumatic labral tears. Activities the force is at a distance from the shoulder, such as striking a hammer or swinging a racquet, also can create shoulder joint problems.
• Nontraumatic labral tears most often occur because of muscle weakness or shoulder joint instability. When the muscles that stabilize the shoulder joint are weak, more stress is put on the labrum, leading to a tear. People with nontraumatic tears tend to have more “looseness” or greater mobility throughout all their joints, which might be a factor in the development of a tear.

Where does it hurt?

In most cases of a shoulder labral tear, patients report front and side shoulder pain directly in the shoulder joint area. Usually they have a mechanism of injury like a fall or sport accident and they report a lot of clicking and popping in the shoulder. Shoulder impingement can also cause similar symptoms too. Understanding the root cause of your pain is fundamental to treating your pain in the long run & will decrease your dependence on painkillers or treatment that only addresses the symptoms.

What are common symptoms of a shoulder labral tear?

With a shoulder labral tear, you might have:

• Pain over the top of your shoulder
• “Popping,” “clunking,” or “catching” with shoulder movement, because the torn labrum has “loose ends” that are flipped or rolled within the shoulder joint during arm movement and that may even become trapped between the upper arm and shoulder blade
• Shoulder weakness, often on one side
• A feeling that your shoulder joint will pop out

Can a shoulder labral tear be treated?

Yes, shoulder labral tear pain can be treated and with great results. Even better, many times it can be treated conservatively without needing injections, pain medications, or surgeries if you catch it early enough. It may be a false positive finding and you may have had this prior to having shoulder pain. The more acute, sport related and trauma cases will probably need surgery to repair. The key to treatment is to solve the root cause of your pain so you can get the best results and a long-term outcome.

Some root causes of non-traumatic shoulder labral tear pain can be:

• Forward head posture
• Rounded shoulders with impingement
• Weak mid back and shoulder blade muscles
• Overload to the shoulder joint with active motions
• Tight neck and mid back
• Poor biomechanics causing impingement
• Decreased mid-back rotation
• Tight rotator cuff muscles

If you have failed multiple treatment approaches already, your clinician missed the real root cause of your pain and was just chasing the symptoms. The pain or symptom is the effect, not the cause. What do I mean by this? Say your fire alarm goes off in your house. Its purpose is to protect you and make you aware that something is wrong, i.e., that there is a fire in your house. The “alarm” is like your pain (your body’s way of telling you something is wrong) and the “fire” is the root cause. When the fire alarm goes off, you don’t run upstairs and just turn it off, right? You run through the house with the fire extinguisher, trying to find the room where the fire is at. You try to find out what caused the alarm to go off so you can put it out. Once the fire is out, then the fire alarm can go off. Solve the “root” cause of your pain, and then the pain (“the effect”) eventually goes away.

Additionally, there is a common root cause which many clinicians misdiagnose. They treat the shoulder pain with a cookie cutter approach, hoping it will work and treat it as a simple muscle problem. They tend to rely on stretching, ultrasound, massage and focus treatment directly on the shoulder joint. However, often the root cause is missed and the symptoms return. If you can normalize shoulder and thoracic range of motion and biomechanics, you should be able to decrease your pain and increase the range of motion. So many healthcare clinicians treat pain like this and thus show poor treatment outcomes which results in the pain coming back. Why? They missed the root cause of your shoulder pain. This is also the case when patients turn to injections, nerve blocks and other surgeries which are still not effective because the actual problem still is not solved, their treatment was just chasing the pain.

The first step in treatment is to identify the root cause of your pain. A specific and individualized treatment approach for your type of pain can lead to a successful outcome for you and resolve your symptoms for the long term. This is why you can’t rely on a standard cookie cutter approach; you need a customized and individualized treatment approach specifically for your type of shoulder labral tear pain.

“On my first visit with Ron, he did a thorough evaluation and identified the underlying issue with my shoulder. […] Within a week, the pain in my shoulder was significantly decreased. […] What’s been amazing is that I’m realizing how much I’d been accommodating a reduced range of motion and pain in my shoulder for who knows how long! Bottom line: I highly recommend Ron and Pursuit Physical Therapy.“

Anne E.
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What happens if it goes untreated?

Minor case – If it is a minor case of pain from a shoulder labral tear research shows that many acute cases of pain may spontaneously go away in 4-8 weeks. You may have had the labral tear before you had your shoulder pain, so it may be a false positive finding and not the cause of your shoulder pain? But who wants to wait 8 weeks to get pain free? Let’s try to solve the root cause of your pain in 2-3 weeks and address all of the risk factors present (so it never returns!) and get you back to your favorite activities faster! We still recommend that you get it checked out by one of our board-certified physical therapists to ensure that it is just a minor case, to solve all risk factors, and to get the optimal outcome in the fewest visits needed. Most minor cases resolve on their own in time or get better with some stretching and strengthening. But, the sooner you take action, the sooner you are pain-free. (And research supports this!)

Severe case – If it’s more of a severe and chronic case of shoulder pain from a labral tear, your pain will probably start to worsen and increase because the root cause of the pain is not being treated. Many people turn to pain medication at this time but this only blocks the pain for short term. You may not feel the pain when taking pain medications, but the underlying problem is still there. Many people say after the pain medication is stopped, then usually the pain returns and sometimes it returns even worse. This is when you will need to decide whether you need surgery or not. You will either respond to physical therapy or not. If the tear is big enough, you may need surgery. If you respond to physical therapy, though, many people can continue to regain full range of motion, increase strength, and return to their favorite activities. Even though it’s more chronic now, we can still help. Once the root cause and all risk factors are addressed, then we can start decreasing your pain, regardless of how chronic and severe the pain is. This is the crucial first step. It just may take more time to recover from a chronic case. Usually with chronic and severe cases, the longer you have your pain and injury, the longer it takes to resolve.

What outcome can you expect from treatment?

As we’ve discussed, the first step is to solve the root cause of your shoulder labral tear pain. This is the most essential step to plan a treatment specialized for you and your unique type of pain. Your root cause will guide your treatment and dictate what is the best way to treat your pain. This, along with identifying risk factors that may be predisposing you to have your pain and injury, will allow you to start getting pain free again. The next step is to start decreasing pain, modifying activities, and start addressing all of the impairments causing your pain which we discovered during your evaluation. With each session, pain should start to decrease and you should start to regain range of motion with less pain and symptoms. Any radicular and referred pain should resolve fast as well. At this point, we begin light and basic strengthening only if it does not increase pain. Treatment will consist of a lot of manual therapy and light exercises.

The next step is to achieve full range of motion, (which should correlate to being pain-free) and now we can start progressive strengthening. Strengthening the muscles is crucial and research shows that this gives you the best long-term outcome! As you start to get stronger and maintain your mobility, your pain will continue to decrease if it is not already gone. Your increased strength will allow you to perform more activities and prevent flare-ups. This usually does take up to 4 weeks. As you clear our goals, then we can start easing you back into sport, golf, running, and whatever your favorite activities are. This is when we start winding down treatments and getting you back into functional strengthening, sport specific training, return to run programs, golfing, and whatever your goals are. In the end, we reassess everything, making sure we achieved all of our goals, your goals, that all risk factors are gone, and finalize your long-term home exercise program. There are many factors which can influence your outcome, but 85-90% of our patients respond well to our treatment approach and achieve a successful outcome when completing their plan of care.

How is it diagnosed?

Not all shoulder labral tears cause symptoms. In fact, when tears are small, many people are able to function without pain. In some instances, the labrum might even heal on its own, if care is taken not to stress the injured tissues. Due to the lack of blood supply available at the labrum, complete healing may be difficult. The shoulder with a labral tear may pop or click without being painful; however, if a tear progresses, it is likely to lead to pain and weakness.

If your physical therapist suspects that you may have a labral tear, the therapist will review your health history and perform an examination that is designed to test the condition of the glenoid labrum (the ring of cartilage at the base of the shoulder). The tests will place your shoulder in positions that may recreate some of your symptoms, such as “popping,” “clicking,” or mild pain. Using this examination, your physical therapist will determine whether your shoulder joint is unstable. Magnetic resonance imaging (MRI) also may be used. Labral tears may be difficult to diagnose with certainty without arthroscopic surgery, where a tube-like instrument called an arthroscope is inserted into the joint through a small incision to view or repair an injury.

Do you need an X-ray and MRI imaging for shoulder labral tear pain?

For most common orthopedic cases, imaging is not needed and the diagnosis can be made with a simple physical therapy evaluation. No need to waste thousands of dollars on unwarranted diagnostic imaging. We also have clinical tests which we can perform to help rule in and rule out pathologies that correlate to MRI findings (which is WAY cheaper than an MRI!). An expensive MRI may just tell us what we already know. Also, often times the positive findings found on x-rays, MRIs, and EMGs may not actually be the root cause of your pain. What does that mean? Many positive findings on an MRI are also found in asymptomatic (pain-free) individuals, so diagnostic imaging may not be able to tell us what is actually causing your pain. For example: many people have a herniated disc in their low back but do not have any low back pain. So if herniated discs can cause no pain, just because someone with low back pain has a herniated disc does not mean that is what’s causing their pain. The key is to find out if your clinical evaluation findings during your evaluation at Pursuit match the MRI findings. If so, then we can decide what is the best way to treat it.

How can a Physical Therapist treat it?

When shoulder labral tears cause minor symptoms but don’t cause shoulder instability, they usually are treated with physical therapy. Your physical therapist will:

• Educate you about positions or activities to avoid
• Tailor a treatment plan for your recovery
• Design specific shoulder strengthening exercises, such as external rotation and internal rotation exercises, to help support the joint and decrease strain on the glenoid labrum
• Design stretching exercises, such as the cross-body stretch or the doorway stretch, to help improve the function of the muscles surrounding the shoulder
• Perform a special technique called manual therapy to decrease pain and improve movement

In more severe cases, when conservative treatments are unable to completely relieve the symptoms of a labral tear, surgery may be required to reattach the torn labrum. Following surgery, your physical therapist will show you how to slowly and safely return to your daily activities.

A surgically repaired labrum takes 9 to 12 months to completely heal. Immediately following the repair, you should avoid putting excessive stress or strain on the repaired labrum and should increase stress to your shoulder slowly over time. Your physical therapist is trained to gradually introduce activity in a safe manner to allow you to return to your usual activities without re-injuring the repaired tissues.

“After at least three years of doctor-hopping […] looking for someone to alleviate my constant dizziness and neck pain, I finally found Dr. Miller. I have more energy and less pain, and have halved my dependence on painkillers. He shouldn’t be the last stop on your road to recovery, he should be the first.”

Lisa B.
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How long does it take for recovery?

Recovery time for a shoulder labral tear depends on multiple factors:

• The severity and chronicity of your pain
• Whether your pain is an easy or complex case
• If the root cause of your pain was solved or if it was missed (this is the key to getting a great recovery!)
• How long you have been in pain for and when you need to be pain free by
• Other therapies and treatments you have tried
• Which medical professional(s) you saw prior to seeing us
• How active you are in trying to resolve your pain
• Which treatment approach is chosen and if it is proven to work for your pain

There are many factors that influence your recovery time and every patient’s recovery time is different. If you do nothing and don’t pursue treatment, it could gradually get better on its own, you could continue to have the same pain persist, or it could continue to get worse. As stated earlier, most acute cases may or may not resolve in 4-8 weeks. If you get expert treatment that solves the root cause of your pain, some cases resolve in 1-3 weeks! Then you can get back to sports, exercise, and your favorite activities without flare-ups and recurrences. Some of our patients are pain free in 1-3 visits and back to 100% in 2 weeks!

If it is a complex case with chronic pain, your recovery may take longer, but you can still get a good outcome. Some chronic cases can resolve as fast as 2 months but can take as long as 4-6 months. It varies with every patient because every case of a shoulder labral tear is different. Every patient’s recovery varies depending on the factors listed above. After a thorough evaluation here at Pursuit Physical Therapy, you will know your exact timeline of recovery, your prognosis, and when you should reach your goals.

How much does it cost?

The average cost of care for a case of spine pain in the US is $1800-$6600. This high price is due to many factors: the over-inflated cost of healthcare, the over expensive cost of unwarranted imaging (x-rays, CT scans, and MRIs) that is not needed, over-utilization of care (which increases the number of visits needed to be treated, requiring multiple visits to different doctors and physical therapists for the same diagnosis), and getting billed for unnecessary and unproven treatments that you don’t even need. All of these factors increase cost and this is why healthcare is so expensive. We strive to end that unnecessary, expensive cycle. In fact, we are currently publishing our first-year data with the University of Central Florida that shows the cost-effectiveness of our treatment approach.

This year, the average cost of our care was shown to be $814-$1141. Some of our patients get even as low as $315 for the full treatment! So if you have a deductible of $3,000-$10,000 and you have to pay out of pocket for your treatment, we can save you lots of money.

Remember, every case of pain is different and not all shoulder labral tears are the same. It is hard to predict exactly how much your treatment is going to cost you. But after a thorough evaluation, we can tell you exactly what is causing your pain, how long it is going to take, what the best way to treat it will be, and exactly how much it is going to cost. We have no hidden fees, no co-pays, and no miscellaneous bills that you will be surprised by 3 months after you receive treatment. Your pain, your diagnosis, your goals, and what is best for you dictate your treatment and how much it will cost, and while it varies for every patient, treatment at Pursuit is still much more affordable than standard healthcare.

How long are sessions?

Our evaluations are always one-on-one with one of our board-certified specialists and 60-90 minutes long. We like to perform thorough evaluations so we can solve the root cause of your pain, identify all risk factors, and make sure that we do it right. After the evaluation, you will know your diagnosis, the root cause of why you have your pain and symptoms, your prognosis, an expected timeline of when you should see results, what the best way to treat your pain is, how much it will cost, and your expected recovery outcome. We want you to fully understand everything about your pain and injury. What is best for you and will get you the best outcome is what will dictate your care and treatment. There will be plenty of time for you to ask questions so we can make sure you fully understand why you have your pain and what the best way to treat it will be. After the evaluation is completed, all treatment sessions are 60 minutes going forward and still one-on-one with your physical therapist. You and your physical therapist will design a customized treatment plan that works for you and that will achieve your goals.

How can it be prevented?

Forceful activities with the arms raised overhead may increase the likelihood of developing a labral tear. To avoid putting excessive stress on the labrum, you need to develop strength in the muscles that surround the shoulder and scapula. Your therapist will:

• Design exercises to help you strengthen your shoulder
• Show you how to avoid potentially harmful positions
• Determine when it is appropriate for you to return to your normal activities
• Train you to properly control your shoulder movement and modify your activities to reduce your risk of sustaining a labral injury

What are next steps?

Getting started is simple. The first step, and the key to getting you pain free again, is to solve the root cause or your case of pain. Remember, not all pain is the same. Your pain is different than someone else’s pain, even though it may be in the same area. If you’re ready to get pain free, give us a call at (407) 494-8835 or fill out the form below. The next step is to schedule your evaluation so we can solve the root cause for you. We’re happy to answer any questions you may have and we would love the opportunity to help you.