Dr. Chris Koutures: Dealing with shoulder discomfort, labral tears

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Volleyball players are no strangers to shoulder discomfort.

There is nothing like the immediate pain from landing awkwardly while trying to dig a short ball. Then there is that familiar nagging ache that comes after a full week of hitting, blocking, serving, and setting. It seems that only movement that doesn’t put some form of high stress on the shoulder is passing.

Perhaps after too much shoulder pain, you’ve seen a sports medicine specialist and been told you have a labral tear.

Should you be worried? Do all labral tears automatically need surgery? Do labral tears mean an immediate exit from play?

Let’s take some time to learn about different types of volleyball-related labral tears, including which ones tend to require surgery and what types may do worse after surgical repair.

A Brief Discussion of Shoulder Anatomy
The shoulder is actually not one joint, but actually three different joints:

  1. The connection between the collarbone (clavicle) and the shoulder girdle (scapula) is known as the acromioclavicular or “AC Joint.”
(BRIEF SIDEBAR: Remember that bad dive without a roll where you landed hard on the tip of your shoulder? This direct impact can damage the AC joint and cause a “separated shoulder”. Often there is pain and a big bump at the collarbone tip that requires sports medicine specialty care.)
  1. The connection between the shoulder girdle (scapula) and the rib cage is known as the scapulothoracic joint.
  2. The “ball and socket” joint between humeral head (ball) and glenoid portion (socket) of the shoulder girdle is also known as the glenohumeral joint. This is what most people think of when speaking about shoulder joints.

Poor function of each of these joints can impact the health of the shoulder labrum, especially in the case of repetitive overload injuries (stay tuned for more details below).

The labrum is a fibrocartilage pad attached to the glenoid and works to provide stability of the glenohumeral joint by limiting excessive forward, backward, and downward movement of the humerus. The rotator cuff muscles that are in front, above and behind the glenohumeral joint also help to provide more stability. 

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TYPES AND CAUSES OF SHOULDER LABRAL TEARS
Acute Traumatic Shoulder Labral Tear — This often occurs when the arm is used to protect or support the body during a fall. Another common mechanism is having the upper arm and elbow pulled backward causing excessive forward motion of the humeral head. In volleyball, this type of injury is less common, but may occur when diving forward to save a ball or when reaching back to start an overhead hit or serve.

The ball of the shoulder might come partially (called a glenohumeral subluxation) or completely (called a glenohumeral dislocation) out of the socket. A subluxation usually quickly goes back into normal position. Most dislocations are anterior (ball of the shoulder ends up in front of the socket) and require manipulation and medication to be put back into normal position.

Labral tears are commonly seen after dislocations (somewhat less often with subluxations). The most frequent tear after an anterior dislocation is in the anterior and inferior part of the labrum and glenohumeral joint capsule. This is called a Bankart lesion and may pull off part of the glenoid bone (boney Bankart). 

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Picture of Bankart lesion courtesy of: https://orthop.washington.edu/patient-care/articles/shoulder/bankart-repair-for-unstable-dislocating-shoulders.html

These acute traumatic labral tears have a high risk for future glenohumeral joint instability episodes such as subluxation and dislocations.  Some report a sense of abnormal movement in the shoulder, especially when in the “danger position” of preparing to strike a ball when hitting or serving- not exactly welcome news for most players.

Due to the high chance of re-injury and instability, tears in the front and lower part of the shoulder labrum more frequently require surgical repair. This includes fixing the labrum and often tightening the capsule surrounding the glenohumeral joint. Any damage to the rotator cuff muscles can also be repaired if needed. Surgical repair does not fully eliminate risk of future instability but does reduce the chances of future episodes.

Repetitive Overload Shoulder Labral Tears — Overhead motions such hitting a volleyball put repetitive stresses on the labrum and glenohumeral joint. The area of most common repetitive overload injury is at the top (superior) aspect of the labrum, and the injury may be in both the front and back part of this area. This is where one of the two tendons from the biceps brachii muscle (long head) attaches to the labrum and rim of the glenoid bone. A common name for this type of tears is a SLAP lesion which stands for Superior Labrum Anterior to Posterior.

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Figure: Types of SLAP tears courtesy of https://www.orthobullets.com/shoulder-and-elbow/3053/slap-lesion

If there are symptoms with a superior labral tear, they could include pain or clicking with activity, and decreased speed (velocity) and accuracy hitting or serving.  Notice that I used the term “if there are symptoms.” Multiple studies, including some with our USA Volleyball National Team athletes, show labral tears are quite common in post high school athletes, and that in many cases, they do not lead to any symptoms or decrease in performance. 

Let me hammer home a key point: if you’ve been told you have a superior labral tear but truly aren’t having pain or limitations, take a deep breath and realize that many superior labral issues are found “incidentally” on MRI studies done in more experienced volleyball players.

Now, if you want to reduce symptoms from a superior labral tear or want to reduce the chance of future issues, pay good attention to the following tips.

Reviews of shoulder mechanics have identified certain abnormalities that increase the chance of superior labral tears in overhead athletes. Just as there are 3 different joints that make up the shoulder complex, there are 3 common mechanical issues that increase the risk for superior shoulder labral tears.

  1. Tightness in the front of the shoulder where the pectoralis minor and short head biceps brachii tendons attach to the coracoid that comes off the scapula bone. This can rotate the position of the glenoid and cause abnormal contact forces at the superior labrum.
  2. A scapula that is lower, pulled outward, rotated downward and comes off the chest wall can also lead to abnormal contact forces at the superior labrum. 
  3. Tightness of the capsule and muscles behind the glenohumeral joint will limit internal rotation (follow-through) and increase shear forces at the biceps tendon/labrum connection.

CLICK HERE FOR AN ARTICLE THAT INFLUENCES MY THOUGHTS ON THE SHOULDER LABRUM

From school-age through collegiate, professional, and Olympic-level athletes with overload labral tears that cause symptoms or affect performance, starting with non-surgical therapy that address these 3 common mechanical issues is often preferable to surgical repair.

A treatment plan addresses these 3 issues is essential to help you return to the court. This link will illustrate some key exercises but does not replace a comprehensive evaluation and treatment plan developed by your personal sports medicine team.

Surgical repair recreates good looking labrum anatomy often at the cost of loss of motion leading to reduced power, velocity, and accuracy. So, unlike in traumatic shoulder labral tears where surgical reconstruction in often a first-line option, it is a down the road option only after failure of a diligent and consistent therapy program to reduce symptoms of repetitive overload shoulder labral tears.

Let’s close with a concise summary of the two most common types of shoulder labral tears

TEAR NAME LOCATION STRUCTURES INVOLVED SURGICAL TREATMENT
TRAUMATIC BANKART Anterior/Inferior Glenohumeral capsule, glenoid rim More often 1st line
REPETITIVE OVERLOAD SLAP Superior Biceps tendon Only after non-operative therapy

If you have a shoulder labral tear, knowing how it occurred and the type/location is absolutely vital in determining a treatment program. If you suspect you have a labral tear, or have been told you have one, it is also absolutely vital to work with a sports medicine specialist who has experience with recognizing and managing different types of shoulder labral injuries. 

Dr. Chris Koutures is a dual board-certified pediatric and sports medicine specialist who practices at ActiveKidMD in Anaheim Hills, CA. He is a team physician for USA Volleyball (including participating in the 2008 Beijing Olympics), the U.S. Figure Skating Sports Medicine Network, Cal State Fullerton Intercollegiate Athletics, Chapman University Dance Department, and Orange Lutheran High School. He offers a comprehensive blend of general pediatric and sport medicine care with an individualized approach to each patient and family. Please visit activekidmd.com or follow him on Facebook (https://www.facebook.com/activekidmd/), Instagram (https://www.instagram.com/activekidmd/), or Twitter (@dockoutures).

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