Labrum tear

Introduction

Labrum tears are injuries to the fibrocartilaginous rim surrounding the shoulder or hip joint. These tears can lead to pain, instability, and impaired joint function. Early recognition and management are essential to prevent long-term joint damage and restore normal activity levels.

Anatomy of the Labrum

Shoulder Labrum (Glenoid Labrum)

The glenoid labrum is a fibrocartilaginous structure attached to the rim of the glenoid cavity of the scapula. It deepens the socket, providing stability to the shoulder joint. The labrum serves as an attachment site for ligaments and the tendon of the long head of the biceps, contributing to joint stability during motion.

• Structure and Composition: Composed of dense fibrous tissue and fibrocartilage, the labrum is resilient to stress and strain.
• Function and Biomechanical Role: Increases glenoid depth, distributes load across the joint, and maintains shoulder stability during rotational and overhead movements.

Hip Labrum (Acetabular Labrum)

The acetabular labrum is a ring of fibrocartilage attached to the rim of the acetabulum in the hip joint. It enhances the depth of the socket and contributes to joint stability by maintaining negative intra-articular pressure. The labrum also plays a role in load transmission and joint lubrication.

• Structure and Composition: Composed of fibrocartilage and dense connective tissue, the hip labrum is flexible yet strong, resisting compressive and shear forces.
• Function and Biomechanical Role: Deepens the acetabulum, stabilizes the femoral head, and distributes weight-bearing forces across the hip joint.

Types of Labrum Tears

Shoulder Labrum Tears

Shoulder labrum tears vary in location and pattern, often associated with trauma or repetitive overhead activities.

• SLAP (Superior Labrum Anterior to Posterior) Tear: Involves the superior portion of the labrum and often affects the biceps tendon attachment. Common in athletes performing throwing motions.
• Bankart Lesion: Anterior-inferior labral tear often resulting from shoulder dislocation, leading to recurrent instability.
• Posterior Labral Tear: Less common, involves the posterior rim and may occur due to posteriorly directed trauma or repetitive pushing motions.

Hip Labrum Tears

Hip labrum tears can occur due to trauma, degenerative changes, or underlying anatomical abnormalities.

• Traumatic Tears: Result from acute injuries such as falls or sudden twisting motions, often accompanied by pain and limited motion.
• Degenerative Tears: Develop gradually due to chronic wear, aging, or joint pathology, commonly associated with osteoarthritis.
• Associated Conditions: Femoroacetabular impingement and hip dysplasia increase stress on the labrum, predisposing it to tearing.

Etiology and Risk Factors

Traumatic Causes

• Sports Injuries: High-impact or repetitive activities such as football, baseball, hockey, and gymnastics can cause labrum tears.
• Falls and Accidents: Direct trauma to the shoulder or hip, including falls onto an outstretched arm or twisting injuries, may result in labral injury.

Degenerative and Overuse Causes

• Repetitive Motion: Activities involving repeated overhead or pivoting movements place stress on the labrum over time.
• Aging and Wear: Natural degenerative changes reduce the labrum’s resilience, increasing susceptibility to tears.

Predisposing Anatomical or Biomechanical Factors

• Hip Dysplasia: Abnormal acetabular structure increases labral stress, predisposing to tears.
• Shoulder Instability: Congenital or acquired laxity increases the risk of glenoid labral injury during movement.

Clinical Presentation

Symptoms

• Pain: Patients often report deep joint pain, which may worsen with activity or certain movements. Shoulder pain is commonly anterior or superior, while hip pain is typically groin-centered.
• Clicking, Locking, or Catching: Mechanical symptoms occur when torn labral tissue interferes with normal joint motion.
• Instability or Limited Range of Motion: Feeling of the joint slipping or decreased mobility may be present, particularly in shoulder labral tears.

Physical Examination

Clinical tests help identify labral tears based on joint-specific maneuvers.

• Shoulder Tests: O’Brien test, Apprehension test, and Relocation test can detect SLAP lesions or anterior instability.
• Hip Tests: FABER (Flexion, Abduction, External Rotation), FADIR (Flexion, Adduction, Internal Rotation), and Log Roll test help assess hip labral pathology.

Diagnostic Evaluation

Imaging Studies

Imaging plays a key role in confirming labral tears and evaluating associated injuries.

• MRI and MR Arthrography: High-resolution imaging allows visualization of labral tears and related soft tissue structures.
• CT Scan: Useful in evaluating bony anatomy and associated fractures or impingement lesions.
• X-ray: Primarily used to rule out bony abnormalities or osteoarthritis; does not visualize labral tissue directly.

Arthroscopy

• Definitive Diagnosis: Direct visualization of the labrum via arthroscopy confirms the presence, location, and extent of the tear.
• Assessment of Tear Size and Location: Arthroscopy allows precise evaluation, which guides surgical planning if needed.

Management

Conservative Treatment

Non-surgical approaches are often the first line of management for labrum tears, especially in cases of mild symptoms or degenerative tears.

• Rest and Activity Modification: Avoiding activities that exacerbate symptoms allows inflammation to subside and prevents further injury.
• Physical Therapy and Rehabilitation: Strengthening surrounding muscles, improving joint stability, and enhancing range of motion support functional recovery.
• Medications: Nonsteroidal anti-inflammatory drugs and analgesics help reduce pain and inflammation.

Surgical Treatment

Surgery is indicated when conservative measures fail or in cases of significant mechanical symptoms or instability.

• Arthroscopic Repair Techniques: Minimally invasive procedures reattach torn labral tissue and restore joint stability.
• Debridement and Labral Reconstruction: Damaged tissue may be removed or reconstructed using grafts, depending on tear severity.
• Postoperative Rehabilitation: Gradual restoration of mobility and strength is critical for optimal recovery and return to activity.

Prognosis and Complications

• Recovery Time: Varies depending on tear severity and treatment method; conservative management may take weeks to months, while surgical recovery can take several months.
• Return to Sports and Activities: With proper rehabilitation, many patients regain pre-injury function, though high-level athletes may require longer recovery periods.
• Potential Complications: Re-tear, joint stiffness, persistent pain, and progression to osteoarthritis are possible if the injury is severe or inadequately managed.

Prevention

• Strengthening and Conditioning: Regular exercises targeting shoulder or hip stabilizers reduce stress on the labrum and improve joint support.
• Proper Technique in Sports: Correct form during throwing, lifting, or pivoting activities minimizes the risk of traumatic tears.
• Early Recognition and Management of Risk Factors: Identifying joint instability, dysplasia, or overuse patterns allows for early interventions to prevent injury.

References

1. Beaty JH, Kasser JR. Rockwood and Wilkins’ Fractures in Children. 8th edition. Philadelphia: Wolters Kluwer; 2015.
2. Palmer WE, Van Holsbeeck MT. Imaging of the Shoulder: Techniques and Clinical Applications. 2nd edition. Philadelphia: Lippincott Williams & Wilkins; 2014.
3. Mariani EM, Mariani D, Gupta A. Labral tears: Diagnosis and management. Curr Rev Musculoskelet Med. 2020;13(4):456-467.
4. Hartzler RU, Tannenbaum R. Hip labral tears: Evaluation, management, and outcomes. J Am Acad Orthop Surg. 2019;27(15):569-578.
5. Maffulli N, Longo UG, Gougoulias N, Loppini M, Denaro V. Sport injuries: The hip and shoulder labrum. Br Med Bull. 2011;97:197-210.
6. Andrews JR, Carson WG, McLeod WD. Glenoid labrum tears of the shoulder. Am J Sports Med. 1985;13(5):337-341.
7. Fitzgerald RH Jr, Mankin HJ. Hip labral pathology: Diagnosis and surgical treatment. Clin Orthop Relat Res. 1995;311:73-85.
8. Hughes RE, Moorman CT 3rd. Arthroscopic management of labral tears. Orthop Clin North Am. 2018;49(2):135-146.
9. Burkhart SS, Morgan CD. Arthroscopic repair of the superior labrum: SLAP lesions. Clin Sports Med. 2001;20(1):59-75.
10. Higgins LD, Beaule PE. Hip labral tears: Anatomy, diagnosis, and treatment. J Bone Joint Surg Am. 2008;90(2):252-261.