Nonoperative options for glenoid labrum tears

introduction

Shoulder pain is the third most prevalent musculoskeletal pain, with a lifetime prevalence of up to 70% [1,2]. This debilitating condition causes pain, reduced range of motion, and decreased quality of life among millions of Americans each year [1].  Glenoid labral lesions can often lead to significant discomfort and restriction during daily living activities, as well as various sporting activities and labrum injuries have up to a 35 percent prevalence in the contact sport population [3].   

The glenoid labrum is a triangular fibrocartilaginous structure that assists in deepening the labrum to provide some mechanical stability for the humeral head. This vulnerable structure can result in labral lesions occurring in both the general and sporting population [4]. 

An analysis of the Medicare sample database found that more than one-third of patients with newly diagnosed knee OA were treated with at least one intra-articular corticosteroid injection [1]. Although its exact mechanism of action remains unknown, intra-articular corticosteroid injection (CSI or IACs) is thought to provide pain relief in patients with knee and hip OA by decreasing joint inflammation.

Tears of the superior labrum account for 80%–90% of labral pathology in the stable shoulder [16]. These lesions were first described in 1990 by Snyder et al  as superior labrum anterior posterior (SLAP) tears. Originally SLAP tears were classified into four types (I–IV). Subsequently, lesion types V–IX were included in the classification as well [17]. 

labrum clock

Figure 1. Labral division: time zones. For both shoulders, 12- to 6-o’clock position faces anteriorly, and 6- to 12-o’clock position faces posteriorly.  Adopted from [18].

Symptomatic glenoid labrum tears tend to occur in overhead athletes and middle aged laborers.   Injuries can be provoked by a single, acute traumatic event, such as a traction injury while falling or in a more chronic manner, secondary to repetitive overhead motion.  The most common complaint is shoulder pain, particularly with overhead activities. There may be feelings of instability, secondary to interposition of the labrum between the glenoid and humeral head, preventing congruent fit.  Athletes may feel painful ‘catching’ or ‘popping’, particularly during the cocking phase of throwing or describe a loss of throwing velocity or ‘dead arm’ syndrome [6]. 

Nonoperative management has been proposed as first line treatment in many cases.  Non-operative measures for SLAP lesions largely involve rest, avoidance of aggravating factors and physical therapy. Therapy should focus on correcting scapular dyskinesis and posterior capsular contracture [7]. 

It can be challenging to evaluate the literature due to the terminology when describing labrum injuries.  Many times there will be glenoid labrum abnormalities following an instability event.  However, there are cases where the labrum can be normal with generalized hypermobility. There are also many cases where there is no dislocation or instability event preceding a glenoid labrum injury. 

When dealing with instability, there is consensus in the literature that a detailed analysis of individual risk factors for recurrent instability should be made for each patient presenting with anterior instability to determine the most appropriate treatment [10].  In general, known factors associated with a high risk of recurrent instability when treated nonoperatively are young age, an active lifestyle, bone loss of more than 20% of the glenoid surface, and engaging or off-track Hill–Sachs lesions [10-11].

Labrum zones

Figure 2.  Labral divisions.  Adopted from [18].

In patients younger than 30 years of age, the risk of re-dislocation when treated nonoperatively is between 70 and 90% compared with up to 25% when treated operatively [14,15].  When nonoperative treatment is applied to overhead athletes and active patients, the re-dislocation rate is even higher [15].

With increasing age, the re-dislocation rate in patients treated nonoperatively decreases substantially making nonoperative treatment an option [13]. Intra-articular corticosteroid injections can be successful, particularly in middle-aged patients [8].  

Nonoperative rehab phases 1-3 labrum

Figure 3.  Nonoperative rehab protocol generalized for athletes/throwers.  Adopted from [19].

PRP is an autologous agent with a very high concentration of naturally occurring growth factors. It has been in use for at least two decades in maxillofacial surgery and is rapidly gaining popularity in orthopedic medicine. PRP carries very minimal risks and is distinctly different to cortisone in that it is not a catabolic, with no risk of destruction of normal tissue. PRP has anti-inflammatory properties that inhibit inflammatory processes in osteoarthritic chondrocytes.  

PRP is an autologous agent with a very high concentration of naturally occurring growth factors. It has been in use for at least two decades in maxillofacial surgery and is rapidly gaining popularity in orthopedic medicine. PRP carries very minimal risks and is distinctly different to cortisone in that it is not a catabolic, with no risk of destruction of normal tissue. PRP has anti-inflammatory properties that inhibit inflammatory processes in osteoarthritic chondrocytes.  

Nonoperative rehab labrum phase 4

Figure 4.  Phase 4 of the treatment protocol proposed by Wilk and Macrina [19].

Summary

In summary, glenoid labrum tears with and without an associated instability event are common in contact sports and fairly common in the general working middle aged males.  Nonoperative treatment is usually the first line and there are certain characteristics of labrum tears and signs on physical exam that make patients more or less likely to proceed to any operative management.  Corticosteroid injections are an option for the middle aged population.  PRP is frequently used in sports medicine clinics.  There is limited data behind this and more research is needed for future direction.

References

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