Ever meet a high school pitcher who had chronic shoulder pain and couldn’t get over it? That racket ball player at the local sports club who complains of a “clunking” in his shoulder every time he goes overhead yet the doctor says nothing is really wrong? That volleyball player who can’t serve with power anymore despite those exercises the physio gave? We’ve all seen a few of these cases. Here is one possibility worth considering.
The glenoid labrum is a fibrocartilaginous rim attached around the glenoid cavity of the shoulder adding depth and stability to the shoulder and covers about 1/3rd of the head of the humerus. The long head of the biceps brachii and the long head of the triceps brachii insert directly on the labrum.
A superior labral tear from anterior to posterior (or SLAP lesion). It is generally found in athletes who have high volumes of overhead work (pitchers, tennis players, etc.). In the non-athletic population, the primary mechanisms of injury are falls on outstretched arms and rear impact car accidents. The lesion is generally in the superior portion of the labrum. 4 types of lesions are recognized though some authors have argued for a 7 system classification.
The 4 recognized lesions are:
Type I: fraying and degeneration around the edge of the superior labrum leading to a loss in horizontal abduction, external rotation and supination without pain.
Type II: the labrum and the biceps long head physically separate creating a chronically unstable shoulder
Type III: This is a bucket-handle type tear and while painful, the functional aspect of the labrum is intact.
Type IV: This involves a bucket-handle type tear that involves the biceps tendon, moving the fixed point of the muscle and destabilizing the joint.
Unfortunately, diagnosis is difficult and often reached by a process of elimination. While many tests for labral tears exist for physiotherapists, similar tests are also used for rotator cuff pathologies which would give similar results on these tests. Some physicians are opting for medical imaging rather than manual testing and treatment. Should one have a radiologist confirmed tear, the need for secondary testing is eliminated. This is rarely the cases and generally a patient is sent to a physiotherapist who will diagnose a rotator cuff pathology and begin strengthening. Should the tear be small and only be leading to instability, this will likely help manage the problem. Should the patient show no improvement , the therapist should begin to suspect a separate pathology and consider SLAP lesions among others.
Should the tear be small, physiotherapy would look to stabilize the glenoid cavity through manual therapy and exercise. Should this not be the case, surgical repair of the labrum is generally the next step which has had good results.
In many cases an athlete will lose a season of play and post-surgery must adhere to several weeks of physiotherapy to regain range of motion, joint stability and strength before then reconditioning for the sport and beginning technique development.