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Welcome to Health and Fitness 101, a blog for people who enjoy the Montana lifestyle.
The aim of our blog is to interpret, distill, and then deliver to you the threads that bind physical medicine with applicable health and fitness ideas and principles.
It's all about helping to connect the dots that foster optimal human function and, ultimately, superior performance. Feel better. Perform better.

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Physical Therapy Case Study: Sport-Related Shoulder Injury (Labral Tear)

See if this describes your shoulder pain. The pain lies deep within the shoulder. It started a while ago. Lifting weights, perhaps? Thinking back, it might have been from doing either shoulder presses or bench presses. At first, pain was mostly down inside the point of the shoulder. But now the shoulder grinds and pops. And it hurts to reach behind your back or to lift items overhead. You figure you can live with it, but working out aggravates the pain. Sound familiar? Don’t feel you’re alone.

I recently evaluated a patient with these exact complaints. A healthy looking guy, he was obviously in good shape. He was convinced this was a strength issue. Not so. When I examined his shoulder, he at first appeared to have weakness in his rotator cuff. However, when I gently tugged on his arm and then tested his cuff, he was strong as an ox.

Notably, this showed that the problem was not in the muscles but deeper in the shoulder joint. Upon further testing, it became clear he’d injured a structure deep within the shoulder. A casual glance may have led an unwary examiner to think it was a problem solely with the biceps tendon. It’s true. His biceps tendon was in fact painful with testing. But it went deeper than that.

Ultimately, anatomy prevailed. You see, the very top of the biceps tendon interconnects with a rim of cartilage that lines the shoulder socket, or glenoid. This rim of cartilage is called the glenoid labrum. The glenoid labrum deepens the socket, which keeps the ball of the upper arm bone, the humerus, from slip-sliding out of joint. The labrum is commonly injured with weight lifting, particularly when doing shoulder presses like bench and military presses.

shoulder_labral_tear_anat05.jpg

After applying a specialized manual therapy to the top of the biceps where it connects to the labrum, I treated the area with cold laser. (Cold laser is a form of light therapy used in sports medicine to help rebuild the strength in inured tissues, like the glenoid labrum.) When I retested, he was completely pain free and had full shoulder motion. Is his problem fixed? Not yet. Along with the treatment I did on his first visit, he’s going to need retraining for the muscles. Not to make them stronger, but to coordinate their actions so that the ball of the humerus stays centered within the glenoid during high-level sport and work activities.

For more information on injuries of the glenoid labrum, complete with amazingly detailed artistic views of the shoulder joint, click here.

16 comments to Physical Therapy Case Study: Sport-Related Shoulder Injury (Labral Tear)

  • Deborah Weaver

    I have just been diagnosed with a labral tear. I have been told that it will require surgical repair. I want to know if there are other options / alternatives. I will be shopping for a good ortho that does shoulders as their expertise. Is there a list of such specialists or can one be recommended in the Eugene OR. area? I do not live in Eugene, but close enough. The shoulder images on this site are very helpful, it has given me a greater understanding of what is going on in my shoulder & good questions to ask @ my next Dr. appointment. I am otherwise healthy & strong. Any information would be greatly appreciated.

  • I just sent a query out to all our PT staff to see if they know of a top-notch shoulder orthopedist in or nearby Eugene. I’ll let you know what I come up with. Having a labral tear does not always mean the situation is surgical. Sometimes, your orthopedist may want you to try 6 to 8 physical therapy sessions to see if your symptoms begin to improve. Physical therapists help by easing pain and improving mobility. Ultimately, our goal is to maximize strength and stability through the rotator cuff and scapular musculature. It then comes down to whether you can begin to do your normal activities without constantly having pain or instability in the shoulder. Best to you.

  • I searched labrum tear and found this page. I am wondering what the window for effective treatment after the injury is and does it usually require an orthopedic eval or would you just recommend cold laser and see how it goes?

  • Upon determining that a labral tear may be present, I employ stability training for the rotator cuff and for the scapular stabilizers. As strength and stability improve, I retrain functional movement. If the patient continues to have symptoms of catching, instability, and pain, I’ll encourage that the patient undergo orthopedic assessment. I have no data or opinion on whether a labral tear is more responsive in the acute or chronic phases. In either case, it still comes back to proper stability training. I would offer that an acute tear may actually respond better based on the physiology of healing. If the tear becomes stable through normal scar tissue healing, the patient may, especially with proper management, become symptom free.

  • Zak

    Would you be able to explain the clinical reasoning behind cold laser and how it builds strength in damaged tissue? Is there any current literature surrounding this form of injury management?

    Also what was the manual therapy technique you used with this patient?

  • Mrs. TH smith

    Do you know of any practices that use Cold Laser Therapy near Darby, Montana? My father lives in Darby, and I would like him to see someone who uses CLT. I live out of state and have a chiropractor who uses CLT, and I have been helped tremendously.

    Blessings, Mrs. TH Smith

  • There’s some evidence that cold laser enhances deposition of chondrocytes, leading to increased collagen . . . as well as greater organization in the collagen. That’s why cold laser is a beneficial modality for chronic tenondosis. There’s limited information in the research, although there’s a fair amount of anecdotal evidence.

    Manual therapy for labral tear often includes posterior glides of the humerus to improve posterior capsular mobility. I follow this with manual neuromuscular re-education emphasizing joint centering and stability, diagonal/functional patterns, followed by scapular PNF to improve glenoid orientation with humeral elevation.

  • I am familiar with several PT clinics in and around Darby. None, however, uses cold laser therapy. I wish I could be of more help.

  • Nille

    @brent dodge:
    Hi brent!I’m just curious how you come up with a diagnosis that the guy has labral tear.I’m pretty sure you did some thorough clinical assessment on his shoulder but wouldn’t it be better to refer the guy to a specialist and suggest a diagnostic testing before you start moving the shoulder?im just concern of the safety of your patient.

  • Fair question. I gather that you may not be familiar with current best practice in physical therapy. In essence, competent physical therapists, who often are the first professionals to examine a patient with this condition, rely on a thorough history and clinical examination. Based on findings that include a battery of tests with good specificity (in this case to identify potential labral involvement), clinical reasoning is applied to determine the appropriate treatment plan (which may include a referral as you pointed out). For example, a positive anterior compression sign in the presence of focal tenderness in the proximal attachment of the long head of the biceps tendon, of course in combination with the mechanism of injury, the subjective exam, and other components of a complete clinical exam, are known approaches toward identifying-and, yes, diagnosing- labral involvement. Positive findings, do not always necessitate a referral to a “specialist.” In support of this, I see numerous patients are sent to me by specialists with a diagnosis of labral tear, and these patients often do better with guided physical therapy, which includes movement. (It is not unsafe to implement skilled therapy and movement simply because a patient has a diagnosis of labial tear. Granted, outcomes with physical therapy for this condition are not always 100 percent successful, but conservative care is often warranted and is, not surprisingly, successful. Clearly, when a referral is warranted, competent physical therapists will then refer the patient to the appropriate specialist. As a Board Certified Orthopedic Specialist and Certified Manual Physical Therapist, I have no reservations in applying accurate assessment, screening measures, and clinical diagnostics that are demanded in my practice. As a direct access practitioner, I routinely see people prior to their seeking medical attention elsewhere (thus, the beauty of practicing physical therapy in the state of Montana, a direct access state). Resultantly, I responsibly rely on my evaluative skills and clinical reasoning in directing the care of my patients, which may in fact include a referral to one of our many referral sources.

  • Ajay T

    Hi Brent!

    I hv been diagnosed with Partial Labral tear through MRI. It occurred while bowling (cricket).
    The injury is 5 month old now. Can it be cured without surgery?

  • Wow. I’m sorry to hear you’e having trouble with your shoulder, Ajay. I can tell you that over the past 20 years in clinical practice, I’ve seen people respond well to physical therapy, even in the face of a labral tear. These are most often partial tears that go on to heal and yield reasonable shoulder joint stability. Truly, these patients often do better with guided physical therapy, which includes movement retraining and joint stabilization exercises. Granted, outcomes with physical therapy for this condition, particularly when the tear is large and the joint is unstable, are not always 100 percent successful, but conservative care is generally warranted. I have a patient currently whom I saw prior to his being seen by an orthopedic surgeon. He showed signs and symptoms and had positive clinical test results for a labral tear. I treated him 4 times, and it became evident early on that he would likely need surgery. When he ended up seeing an orthopedic surgeon, the MRI was positive for a large posterior labral tear. He’s scheduled for surgery in early June. So to answer your question, it’s quite likely that a course of physical therapy may be beneficial, but because you’ve been dealing with this now for 5 months, a more prudent approach may be to seek out an orthopedic surgeon sooner, rather than later. I hope the best for you either way. Best, Brent.

  • Adrian

    Recently i was diagnosed with a small tear in my labrum (left shoulder). The Physical Therapist that my doctor referred me to are out of network. Does anyone have advice on how to find a good Physical Therapist or recommendations on PTs that would take Blue Cross. i live in Los Angeles, CA 90012.

    I’m 35 years old and normally in good health. I am not too familiar with finding a new doctor or therapist, and would appreciate any advice or referrals.

  • Hi Adrian,

    You might begin by asking friends and coworkers if they have worked with a PT. You could also check the national association website at http://www.APTA.org and click on “Find a PT,” which is at the top of the page. Also, visit http://www.naiomt.com. Click on About Us and hit “Find Certified PTs.” In these searches, you can put in your zip code and see find a PT near you. Best to you as you search out a top notched PT!

  • We are based in Leeds, west yorkshire. We have used Cold laser and Laser Acupuncture for over 10 years to heal and repair many sports injuries in atheletes and regular patients. We use THOR laser to heal and repair, Thor are the world leaders in laser research and quality. We have treat over 20 cases of these conditions with high to moderate levels of success and recovery is good, As stated in this article, an redirection of attitude towards training is required for maintenance and rehabilitation.
    Our website is http://www.thehealing-centre.co.uk
    Find us on facebook also. The Healing Centre Uk

  • Fantastic information and update. I appreciate your comments and link. Thanks!

    Brent Dodge, PT
    Owner
    Alpine Physical Therapy, South
    5000 Blue Mountain Rd.
    Missoula, MT 59804
    http://www.AlpinePTmissoula.com

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