Glenoid Labrum Tear

A Tear of the Glenoid Labrum represents an array of conditions that implicate various tissues of The Shoulder Girdle in different ways leading to distinct, often negative outcomes. While some Labral lesions may develop in response to degenerative changes or repetitive strain, the majority have a traumatic onset through mechanisms such as Glenohumeral Dislocation and/ or FOOSH . Understanding the precise location, severity and implicated tissues provides valuable insight into treatment direction.

Pathomechanics

With diverging mechanisms, specific pathomechanics for each type of Labral Tear are listed on their respective pages. Generally these lesions are the result of Glenohumeral Instability , whether it be chronic repetitive stress and/ or a single traumatic event such as a Glenohumeral Dislocation . Through these mechanisms Labral tears rarely occur in isolation, often occurring concomitantly with Avulsion Fractures of the Head of Humerus or Glenoid Rim of Scapula or tears of neighbouring capsuloligamentous structures such as the Inferior Glenohumeral Ligament or Muscles such as the Long Head of Biceps .

Superior Labral Tears

• SLAP Lesion - a Tear of the Superior Labrum that extends from anterior to posterior, which often implicates the Long Head of Biceps attachment. This common labral tear has several subtypes

Anteroinferior Labral Tears - the Anteroinferior Labrum is most vulnerable due to the lack of bony support and frequent exposure to notable stresses from movements such as those overhead. For Anterior tears Glenohumeral Instability is the predominate symptom with Pain only reported in less than a quarter of instances (SOURCE-1):

• Bankart Lesion - an Avulsion Fracture of theAnterior-Inferior Labroligamentous Complexfrom the Glenoid Cavity which causes the Anterinferior Glenoid Labrum and Anterior Inferior Glenohumeral Ligament to become detached (SOURCE-9)

• Anterior Labrum Periosteal Sleeve Avulsion (ALPSA)- an Avulsion Fracture of the Labrum that leaves the Periosteum of the Glenoid Neck intact leading to labral displacement from the Glenoid Rim (SOURCE-6). This is often the result of Dislocation s

• GlenoLabral Articular Disruption (GLAD)lesion - intra-articular damage of the anteroinferior Glenoid while the Periosteum remains intact (SOURCE-7). While the Labrum detaches the Inferior Glenohumeral Ligament remains attached (SOURCE-7)

• Perthes Lesion- a Bankart Lesion variation where the Anterior Labrum is avulsed from the Glenoid while the Periosteum remains intact, compromising stability (SOURCE-8)

• Humeral Avulsion of the Glenohumeral Ligaments (HAGL) - Avulsion Fracture of the Glenohumeral Capsular Ligaments from their Humeral attachment, rather than of the Glenoid Labrum . Includes several sub-types

• Glenoid Avulsion of the Glenohumeral Ligaments (GAGL)- a rare Avulsion Fracture of the Glenohumeral Capsular Ligaments where the Glenoid Labrum remains fixed to the Glenoid Cavity while the Inferior Glenohumeral Ligament Complex is detached from both these structures (SOURCE-11)

Posterior Labral Tears - while the Posterior Labrum is reinforced by bony support from the Scapula , ligaments such as the Posterior Band of the Inferior Glenohumeral Ligament tend to be the weakest portion of the Capsuloligamentous Complex. Unlike Anterior Tears, Pain is the predominant symptom associated with Posterior Tears with Glenohumeral Instability only accounting for a subset (~21%) of labral tears in this direction (SOURCE-1+12-21):

• Reverse Bankart Lesion - tearing of the posteroinferior Glenoid Labrum

• Posterior Labrum Periosteal Sleeve Avulsion (POLPSA)- the posteroinferior Glenoid Labrum and intact Scapula Periosteum are torn from the Glenoid Cavity. Through traumatic means, the Labroperiosteum is stripped medially towards the Glenoid Neck from the posteroinferior Glenoid margin (SOURCE-25). Given the traumatic nature of this pathology, it is more likely to be symptomatic (SOURCE-21). The formation of fibrous tissue beneath the Avulsion Fracture as part of the tissue healing process may prevent the extravasation of contrast dye into the tear site, making diagnosis through visualisation difficult (SOURCE-25)

• Posterior Humeral Avulsion of the Glenohumeral Ligaments - posterior or reverse HAGL variation that affects the Posterior Band of the Inferior Glenohumeral Ligament

• Kim’s Lesion - an incomplete Tear of the Posteroinferior Glenoid Labrum that leaves a defect between the Labrum and Glenoid Cartilage without complete separation (SOURCE-25). Often the deepest layer of the Posteroinferior Labrum is compromised while the superficial layer remains intact. This may conceal the tear during arthroscopic inspection, leaving only a marginal crack known as Kim’s Lesion (SOURCE-25). OnMagnetic Resonance Arthrography (MRA)those with Kim’s Lesions may appear to have a reduced height or flattened Posteroinferior Labrum, incomplete Avulsion Fracture with preserved relations between the Cartilage and Labrum, Chondrolabral Retroversion and cartilaginous degeneration (SOURCE-25)

Global/ Circumferential Tears - “Global” is the general term used to describe a widespread Tear that compromises multiple quadrants of the Glenoid Labrum . This includes “Circumferential” (or 360º/ Pan-Labral) tears where the tear is continuous and therefore affects the entire circumference of the Glenoid Labrum. Triple or total compromise of quadrants occurs most often in response to repetitive stress/ Glenohumeral Instability and may progress from lesser labral damage (SOURCE-26). While recurrent anterior instability is the predominant causal direction, Global tears may result from instability in any plane or from a single traumatic event (SOURCE-26).

Pathology

Glenoid Labrum Tears are complex injuries that rarely occur in isolation. The following pathologies are commonly associated with them, often serving as predisposing factors, a source of the injury, or occurring concomitantly due to shared pathological mechanisms:

Glenohumeral Instability - both recurrent instability and traumatic Dislocation share a bidirectional relationship with Tears of the Glenoid Labrum . Acute or chronic instability forms a major predisposing component to labral compromise via traumatic or repetitive-strain means. Instability increases stress on the bony and capsulolabroligamentous stabilisers that resist excessive translation of the Head of Humerus , may weaken the Proprioception reflex, disturb the length-tension relationship of several dynamic stabilisers such as the Rotator Cuff or Long Head of Biceps and compromise the joints intra-articular negative pressure (SOURCE-22+23+24). The type of instability bears relation to the type of lesion. For example, following traumatic Glenohumeral Dislocation , the vast majority of patients (~97%) with anterior instability were found to have a Bankart Lesion (SOURCE-15). Forming a somewhat positive feedback-loop, labral injury, particularly with concomitant bony disturbance of the Glenoid rim predisposes further instability through many of the aforementioned mechanisms. Instability is often the primary symptom following a Glenoid Labrum tear (SOURCE-1).

Fractures - with shared traumatic mechanisms that lead to Labral tears, fractures often occur concomitantly. The two most common fractures associated with these lesions are:

• Compression Fracture - most often of the Head of Humerus in the form of a Hill-Sachs Lesion

• Avulsion Fracture - fractures of the Scapula ’s Glenoid Fossa, such as a Bony Bankart Lesion , are associated with almost a third of all Labral tears (SOURCE-3)

Concomitant bony defects of the Humerus and Glenoid, known as a “Bipolar-Lesion”, are also common, one study observing this coupling in up to 81% of Anterior Glenohumeral Instability instances (SOURCE-13).

Rotator Cuff Tear - and Labral tears may share a common pathological mechanism or predispose one another. Age related degeneration is one such mechanism that often compromises both the Rotator Cuff and the Glenoid Labrum leaving them subject to injury (SOURCE-31+32). 74% of those with a full-thickness Rotator Cuff tear were found to have associated intra-articular lesions (SOURCE-32). In the stable shoulder, internal impingement often associates partial tears of the Rotator Cuff at the Supraspinatus / Infraspinatus junction with Posterior Labral tears (SOURCE-33). Shared mechanisms aside, Rotator Cuff insufficiency may perpetuate Glenohumeral Instability and therefore predispose Labral injury, particularly SLAP Lesions (SOURCE-34). It is thought insufficiency leads to superior migration of the Head of Humerus which increases load on the Long Head of Biceps Tendon and Superior Labrum it attaches to (SOURCE-34).

Long Head of Biceps - several SLAP Lesion subtypes involve the Long Head of Biceps to varying extents that may compromise the Muscles function and/ or serve as a significant Pain generating tissue.

Scapular Dyskinesis - shares a bidirectional relationship with Labral Tears where abnormal Scapula patterns may increase labral stress; while Dyskinesis is described as a non-specific response to shoulder Pain , of which Labral lesions are a common cause (SOURCE-28+29+30).

Differential Diagnosis

The following pathologies may share a similar presentation or particular symptoms with Glenoid Labrum Tears (SOURCE-2+27): Rotator Cuff Tear Biceps Tendinopathy Subacromial Impingement Glenohumeral Joint Articular Cartilage Injury Acromioclavicular Joint Pathology

• Osteoarthritis

• Sprain

Adhesive Capsulitis - particularly the early Pain ful stages Neuropathy

• Entrapment

  • Suprascapular Nerve

  • Axillary Nerve

  • Long Thoracic Nerve

• Radiculopathy

  • C5

  • C6

Assessment

With specific assessment protocols found on each lesions individual page, the following lists general assessment techniques commonly used for evaluating Glenoid Labrum Tears:

Observation

• Pain - the primary complaint is highly associated with location of Tear (SOURCE-1)

• History of Subluxation or Dislocation (first time or recurrent) (SOURCE-9)

Orthopaedic Tests

The following Shoulder - Special Tests can be performed to assist in the diagnosis of a Labral Tear:Glenoid Labrum Tear:

• Kim Test - 0.80 sensitivity and 0.94 specificity for posteroinferor Labral Tear s

• Jerk Test - 0.73 sensitivity and 0.98 specificity for posteroinferior Labral Tear s

• Upper-Cut Test - sensitivity 0.22, specificity: 0.56 for Labral tear

SLAP Lesion

• Modified O’Brien’s Test - sensitivity: 0.47-0.99, specificity: 0.11-0.98

• Anterior Slide Test - sensitivity: 0.05-0.78, specificity: 0.82-0.93

• Biceps Tension Test

• Biceps Load Test I&II - sensitivity 0.90-0.91, specificity 0.97

• Clunk Test - sensitivity 0.44, specificity 0.68

• Crank Test - sensitivity 0.13-0.81, specificity 0.67-0.88

• Dynamic Labral Shear - sensitivity 0.57-0.78, specificity 0.51-0.52

• Forced Shoulder Abduction and Elbow Flexion Test - sensitivity 0.67, specificity 0.67

• Speed’s - sensitivity 0.32, specificity 0.61

Palpation

• Palpation of the Bicipital Groove has a sensitivity of 0.25 and specificity of 0.80 for SLAP Lesions (SOURCE-4)

Imaging

While specific techniques, views and findings for each subtype of Glenoid Lesion are detailed on their respective page, the following discusses the general imaging modalities used for Glenoid Labrum Tears and common concomitant pathologies:

Radiographs (X-Rays)- often the first-line of assessment following Dislocation which may reveal osseous injury including Fracture s/ Avulsion Fractures of the Glenoid Rim and Head of Humerus (SOURCE-9+17). While the AP, Lateral and Axillary views are typically obtained, other views may provide more relevance (SOURCE-20):

• modified West Point Axillary View - used to evaluated Glenoid bone loss

• Stryker Notch View - specific for Hill-Sachs Lesions as the GH Joint - Internal Rotation of the Humerus brings the posterolateral defect into direct view

Magnetic Resonance Imaging (MRI)- considered the gold standard imaging modality for the evaluation of soft-tissues including Glenoid Labrum and Capsuloligamentous injury (SOURCE-19). Additionally with the capacity for Bone and Soft-Tissue to be implicated in Labral pathology, MRIs may be preferable due to their ability to produce clear images of both. High sensitivity for the detection of edema also allows MRIs to recognise pathologies in their early phase (SOURCE-18).

• Proton Density Weighted Images (PD)- localise bone and soft-tissue pathology at the same time. The high water content in inflamed tissue causes this tissue to appear white. Damage is somewhat proportional signs of edema and may serve as a predictor for concomitant conditions. This imaging technique is preferred by many clinicians for a suspected Hill-Sachs Lesion (SOURCE-18)

• Magnetic Resonance Arthrography (MRA)- use of contrast dye which distends the joint capsule better highlights compromise of the capsulolabral complex (SOURCE-11)

Computed Tomography (CT Scan)- in particular 3D-CT is superior for the evaluation of Bone -loss, providing a clear image of the orientation of the Humeral defect or accurately quantifying disturbance of the Glenoid Rim (SOURCE-20). This modality is therefore useful for preoperative planning (SOURCE-20).

Treatment

The appropriate treatment protocol is highly subjective and must consider the severity of labral tear, presence of concomitant injury, patients circumstances (age, activity level, etc.) and whether or not they have already undergone surgery. For detailed treatment protocols for specific lesion types, see their individual pages.

Stretching

Stretching within the limits of Pain can be used to restore tissue length and improve overall joint mechanics that often develop in response to Pain and dysfunction. While specific stretching protocols for each lesion type are detailed on their respective pages, the following details tissues and techniques of particular focus in the literature. As a general trend, shoulder movement is restricted for about a month following surgery to provide adequate time for the implicated tissues to heal. Typically by the three month mark, full Range of Motion should be possible. These numbers provide a rough framework for when rudimentary stretches may be commenced and how they should be progressed. Those patients that are managed conservatively would not require such an extensive immobilisation period. These time frames are approximate and stretches should be implemented as tolerated by the patient.Stretching of the following tissues has been supported:

• Posterior Glenohumeral Joint Capsule - restriction in the posterior to inferior portion of the joint capsule increase stress on the Labrum, in particular its superior portion ( SLAP Lesion ) (SOURCE-5):

  • Genie Stretch

  • Sleeper Stretch

  • Sleeper Stretch MWM

• Pectoralis Minor - the extent of shortness of the Pectoralis Minor appears to be proportional to the presence of Scapular Dyskinesis , with greater GH Joint - Internal Rotation and Anterior Tilting of Scapula (SOURCE-35+36). As discussed throughout this page, Dyskinesis increases Labral stress

  • Practitioner Guided- a stretch can also be achieved with the help of another person. One hand is used to fix the Scapula in posterior tilting while the other is used to move the patients arm into ~90º GH Joint - Abduction and GH Joint - External Rotation (SOURCE-37)

  • Door Frame Shoulder Stretch (Pec Minor variant)

• Rotator Cuff - in addition the the posterior capsule stretches which will also target the posterior cuff

  • Door Frame Shoulder Stretch ( Subscapularis variant)

  • Dowel External Rotation Stretch

  • Door Frame Neck Stretch ( Supraspinatus variant)

• Overhead/ Elevation Range:

  • Forward Elevation Stretch

  • Passive/ Assisted Range of Motion

Strengthening

While specific time-frames and protocols are contingent on the tissues involved, extent of their injury and/ or surgical procedures chosen, Strength training forms an integral part of rehabilitation. The following details a generalised rehabilitation framework, with more specific protocols found on the individual pathology pages:Initial Phase - for up to 6 weeks the primary aim is to reduce Pain and Inflammation , followed by restoring Range of Motion :

• Rotator Cuff Pendulums - oscillatory motion that afford a distracting glide to the Humeral Head

• Shoulder Sling - passive shoulder movement produced by asymptomatic side

• Active-Assisted GH Joint - Flexion with arm in Elbow - Supination - assistance afforded by asymptomatic hand or practitioner

• Rotator Cuff Banded Rotations (isometric only)

• GH Joint - External Rotation (isometric only)

• GH Joint - Internal Rotation (isometric only)

• Pallof Press - low load horizontal push exercise that emphasises anti-rotation of Core

Mid-Phase - from roughly 6-12 weeks rudimentary control and strengthening of the Rotator Cuff and Scapula stabilisers becomes the focus:

• Band Pull-Apart - basic isotonic exercise for Scapular Retractors

• Side-Lying Shoulder External Rotations - maximises effect of gravity against External Rotation with upper arm fixed against torso

• Standing Shoulder External Rotations - incorporates upright torso posture

• Prone Horizontal Abduction - rudimentary Scapulothoracic Joint - Retraction exercise

• Face Pulls - bilateral isotonic horizontal pull exercise that emphasises GH Joint - External Rotation

• Circumduction Row - isotonic exercise with variable load used to emphasise mid-to-lower Trapezius

• Inverted Rows - rudimentary isotonic horizontal pull exercise that utilises bodyweight

• One Arm Row - unilateral DB version of Seated Row

• Lat Pulldown - rudimentary weighted isotonic vertical pull movement with a high range of motion

• Bird-Dog Row - One Arm Row variation that emphasises Posterior Sling

• Prone Lat Pulldown - Lat Pulldown variation that emphasises Thoracic - Extension

• Farmers Carry - upperbody/ Core isometric exercise with perturbation of walking

• Suitcase Carry - unilateral farmers carry which emphasises crossbody functional patterns

Late Phase - exercise progression is continued with the aims of a full recovery, including return to sport. Exercise selection should consider increasing loads, range of motion and incorporating functional patterns, in particularly those that closely reflect the patients demands:

• Front Raises - isotonic GH Joint - Flexion exercise with many variations

• Side Raises - isotonic GH Joint - Abduction exercise with many variations

• Lu Raises - large GH Joint - Abduction range with no Humerus rotation to promote Scapulothoracic Joint - Upward Rotation

• Push Press - explosive overhead movement with large range that incorporates entire body

• Pull-Up - bodyweight or greater load through large overhead motion

• Kneeling Landmine Press - explosive Vertical Push exercise with a large overhead range

• Split Stance Landmine Press - explosive unilateral, whole-body Vertical Push exercise

• DB Hang Clean - unilateral clean progression, often performed explosively

• DB Snatch - unilateral isotonic, explosive shoulder exercise with large overhead range

• DB Snatch to Step-Up - wholebody DB Snatch variation that emphasises diagonal functional patterns

• Rope Climb - pull-up variation with entire load bestowed on alternating arm

• Medball Pullover Throw - plyometric Pullover variation

Surgery

With an array of structures implicated in Glenoid Labrum Tears to varying extents, the surgical approach is contingent on the extent of soft-tissue injury and comcomitant bone loss.Surgical treatment of Glenoid Labrum Tears can generally be taken down one of three potentially complimentary avenues (SOURCE-13+14+15+16):

• Reattachment of the Glenoid Labrum and/ or Capsuloligamentous Complex

  • Bankart Repair- through either arthroscopic or open means, the torn Glenoid Labrum and joint capsule are anchored to the Glenoid using sutures. Without significant associated Bone -loss, an arthroscopic Bankart repair may adequately reattach compromised soft-tissue, irrespective of the lesions size. In these instances, arthroscopic and open Bankart repairs are comparable. Where more than roughly 25% of the bony Glenoid Rim is also compromised open surgery complimented with additional procedures may be required

• Glenoid Rim Augmentation- aims to restore articular surface and integrity of the Glenoid Rim that is often compromised in Bony Bankart Lesion s. The specific approach is often determined by extent of damage to the rim. Small bony lesions of the rim may be managed conservatively, while for up to 20% arthroscopic intervention may suffice. Large bony disturbance in excess of ~25% begins to resemble an inverse pear-shape, a morphology subject to instability-related complications that may require open surgery and additional procedures:

  • Latarjet Procedure- transfers the portion of the Coracoid Process of Scapula , where the Conjoined Tendon of Short Head of Biceps and Coracobrachialis attach and screws it to the Anterior Glenoid. This affords stability by both serving as a bony block and formation of a dynamic sling with the new anterior course of the tendon. Latarjet is indicated for recurrent Anterior Glenohumeral Dislocation and may better address the complications associated an inverse pear-shape morphology. This procedure may pose risk of Scapular Dyskinesis and reduced GH Joint - Internal Rotation

  • Bone Graft- other Bone -graft sites include the Iliac Crest, Distal Tibia , Head of Femur or Humerus , Scapula Spine and Distal Clavicle

• Humeral Head Augmentation- corrects defect of the Head of Humerus such as its compression with a Hill-Sachs Lesion to restore quality joint articulation. This is achieved through Bone -grafts (allografts of the Head of Humerus or Femur or autograft of the Iliac Crest), synthetic materials or soft-tissues:

  • Remplissage- utilises soft-tissue, typically the Infraspinatus , to “fill” Humeral defect. Studies have reported the compliment of Remplissage to a Bankart repair reduces post-operative recurrence rates by anywhere from ~10% to 10x. Although and inconsistent finding, Remplissage may be associated with a loss in Range of Motion , particularly GH Joint - External Rotation

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