Managing Shoulder Labral Tears with Physical Therapy

A shoulder labral tear can result from the labrum becoming frayed over time due to intense repetitive activity or from an acute trauma like a direct blow, fall, or dislocation. The shoulder labrum is a ring of fibro-cartilage tissue that surrounds the rim of the glenoid on the scapula, cushioning the head of the humerus and providing stability to the shoulder joint. A shoulder labral tear can vary in severity, ranging from minor fraying to complete detachment of the labrum, leading to pain and shoulder joint instability. Physical therapy plays a crucial role in the management and rehabilitation of shoulder labral tears and can help athletes with shoulder labral tears regain strength, stability, function, and range of motion in the shoulder joint for a safe return to sport.

What is the Shoulder Labrum?

The shoulder labrum plays an important role in stabilizing and maintaining the integrity of the shoulder joint, as it secures and cushions the head of the humerus. The shoulder labrum is a ring of fibro-cartilage tissue that surrounds the rim of the glenoid on the scapula. The labrum sits deep in the shoulder socket, providing an additional layer of stability and support to the shoulder joint and deepening the articulation of the shoulder joint. The labrum helps keep the upper arm bone (humerus) securely in place.

The labrum also plays a role in providing extra bony surface area to the joint, which increases the range of motion in the shoulder. Several muscles of the shoulder attach to and extend over the labrum, providing additional stability and strength to the joint capsule. By keeping the shoulder joint stable and increasing its range of motion, the shoulder labrum is an essential structure for allowing proper movement of the arm at the glenohumeral joint. 

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Shoulder Labral Tears

A shoulder labral tear can result from the labrum becoming frayed over time due to intense repetitive activity or from an acute trauma like a direct blow, fall, or dislocation. Athletes who play sports like baseball, tennis, swimming, or weightlifting may be at a higher risk of a shoulder labral tear due to the repetitive overhead movements required in these sports. Because the biceps tendon attaches to the shoulder blade through the labrum, labral tears can occur when you place extra strain on the biceps muscle (e.g. when throwing a ball). A tear can also result from pinching or compression of the shoulder joint when the arm is raised overhead or from shoulder joint instability due to shoulder muscle weakness, which places more stress on the labrum.

Symptoms of a shoulder labral tear:

• Pain over the top of the shoulder

• Popping, clunking, or catching with shoulder movement because the torn labrum has loose ends that flip or roll within the shoulder joint during arm movement

• Shoulder weakness on one side

• Shoulder joint instability

• Deep ache of pain in the shoulder, or an experience of a sudden sharp pain in the shoulder

• Sensation that the shoulder joint will pop out of place

A shoulder labral tear can vary in severity, ranging from minor fraying to complete detachment of the labrum and disconnection of the tendon attaching the biceps muscle to the shoulder. There are 3 different types of shoulder labral tears, which include:

• SLAP tear: A SLAP tear [superior labral anterior-posterior lesion] means the labrum has torn from the top of the shoulder labrum along the back and front where the biceps tendon connects to the shoulder. The humerus bone loses its cushion and the biceps tendon can become disconnected. A SLAP tear is the most common type of shoulder labral tear. This type of tear is more likely to occur in tennis, baseball, or softball players as these sports involve quick snapping arm movements over the top of the shoulder.

• Bankart tear: A Bankart tear involves a rip in the lower part of the labrum at the bottom of the shoulder socket where the glenoid and humerus bones connect. This type of tear is more common in those under 30 who dislocate their shoulder.

• Posterior labral tear: A posterior labral tear is the least common type of shoulder labral tear that can result either from the rotator cuff and labrum becoming pinched together at the back of the shoulder or from a traumatic injury that causes posterior instability. It can result from overuse or degenerative changes in the shoulder joint.

Physical Therapy for Shoulder Labral Tears

Physical therapy plays a crucial role in the management and rehabilitation of shoulder labral tears and is the preferred option for initial management of the condition. A physical therapist can help athletes with shoulder labral tears regain strength, stability, function, and range of motion in the shoulder joint for a safe return to sport and play an important role in recovery should surgery be necessary. Surgery is done if the tear is severe or if an athlete plans to return to high-level athletic activity.

There are five stages to physical therapy-led shoulder labral tear rehabilitation:

1. Pain and symptom management: First, the physical therapist focuses on reducing pain and managing symptoms of shoulder labral damage, using ice and heat therapies. Hands-on manual therapy is used to decrease pain and begin to restore movement in the shoulder. The therapist also provides education on activity modifications and how to prevent future injury.

2. Range of motion exercises: Re-establishing full range of motion is essential to lower the likelihood of developing compensation patterns as the athlete heals. Once pain is under control, the physical therapist focuses on restoring and improving the range of motion in the shoulder joint. Exercises can include gentle stretching techniques to increase flexibility and mobility in the shoulder as well as range of motion exercises in the shoulder to promote fluid movement.

3. Motor control and postural training: Next, the therapist works on enhancing neuromuscular control and stability around the shoulder joint, incorporating exercises that target muscles surrounding the shoulder like the rotator cuff, deltoid, and scapular stabilizer muscles. The therapist also incorporates proprioceptive training (awareness of joint position) and balance and coordination training to improve motor control. Postural training is another aspect of rehabilitation, as the therapist teaches specific exercises to ensure shoulders are positioned properly and prevent forward-head and rounded-shoulder posture.

4. Targeted strengthening and stretching exercises: The physical therapist then emphasizes strengthening the muscles around the shoulder joint to provide stability and a return to full function and performance. The therapist introduces resistance training, targeting upper limb, scapular, shoulder, and arm muscles. Targeted stretching of the chest, thoracic, and shoulder muscles can also be useful, as an imbalance in muscles or deficits in flexibility can lead to poor posture and excessive stress within the shoulder joint.

5. Return to sport preparation: Finally, the therapist begins sport-specific exercises, tailored to the demands of the athlete’s sport, gradually reintroducing functional movements, overhead motions, and sport-specific drills. The therapist creates a progressive return to sport program that gradually increases in intensity, volume, and complexity of movement, ensuring the athlete meets specific criteria before being cleared to return to competitive play.

Should surgery be required to re-attach the torn labrum to the shoulder joint, post-surgery rehabilitation begins with sling immobilization of the shoulder for four weeks. Then, the therapist starts with early shoulder pendulum exercises and periscapular muscle activation exercises. Around four-to-six-weeks post-surgery, active range of motion exercises are introduced. By week 6 to 12, the athlete can begin progressive resistance exercises and functional training. After week 12 post-surgery, the athlete can then progress to more advanced range of motion and strengthening exercises and sport-specific drills. Return to sport after labral surgery can be as early as 6 months after the operation.

Are you experiencing shoulder joint instability and pain after a shoulder labral tear? Work with a physical therapist to address pain and restore strength and mobility in the shoulder safely!