A labral tear is an injury to the ring of cartilage that lines the shoulder socket, known as the glenoid labrum. This fibrocartilaginous rim deepens the shoulder’s shallow socket, contributing significantly to joint stability and serving as an anchor point for ligaments and tendons. A tear in the labrum can lead to pain, instability, and mechanical symptoms within the joint. While tears in the front of the shoulder, like a Bankart lesion, are common following a shoulder dislocation, a posterior labral tear is a far less frequent injury. Treatment for this condition is highly individualized, and surgery is not automatically the first course of action.
Anatomy of the Posterior Labrum and Associated Symptoms
The shoulder joint is a ball-and-socket mechanism, where the head of the humerus rests against the glenoid of the scapula. The labrum functions like a gasket to increase the contact area between the two bones, creating a suction effect that helps maintain stability. The posterior portion of the labrum is subject to stress from compression forces and microtrauma. This is often seen in athletes who perform repetitive pushing or forceful follow-through motions, such as weightlifters and baseball players.
A tear in this posterior region, sometimes called a reverse Bankart lesion, results in specific symptoms. Patients commonly report deep, vague pain in the back of the shoulder that worsens with activities like a bench press or a push-up. This pain is often accompanied by instability, looseness, or mechanical symptoms like clicking, popping, or catching when the arm is moved. Pain may also occur when the arm is brought across the body, a position that stresses the posterior capsule.
Criteria for Non-Operative Treatment Failure
Non-operative management is typically the initial standard of care. Surgery is only considered necessary when conservative treatment has failed to resolve symptoms, generally after six to twelve weeks of consistent rehabilitation. The primary factor driving the need for surgical intervention is the degree of mechanical instability experienced by the patient. Patients whose main complaint is pain are more likely to succeed with non-operative treatment than those who present with significant instability or a history of subluxation.
Specific clinical and imaging findings serve as risk factors for non-operative treatment failure. High-grade tears, particularly those involving a large or displaced segment of the labrum visible on MRI, are less likely to heal without surgical repair. Associated injuries, such as significant bone loss from the glenoid or increased glenoid retroversion (a structural tilt of the socket), also predispose a patient toward surgical stabilization.
Persistent instability often requires surgery, especially if the patient reports an inability to trust their shoulder or feels it is going to “pop out.” The patient’s activity level and demands also play a large role. High-demand athletes requiring a full return to sport involving repetitive overhead or contact motions may need surgical intervention sooner. If symptoms persist despite physical therapy, surgical repair becomes the next logical step.
Conservative Management Strategies
A structured program of conservative management is the most appropriate first line of treatment. The initial phase involves activity modification, including rest and avoiding movements that aggravate the shoulder, such as heavy pushing or overhead lifting. Non-steroidal anti-inflammatory drugs (NSAIDs) may be used to manage pain and reduce inflammation during this period.
The cornerstone of conservative management is physical therapy (PT), which aims to compensate for the labral damage by enhancing the dynamic stabilizers of the shoulder. PT programs focus heavily on strengthening the rotator cuff muscles and the periscapular muscles. Strengthening muscles like the serratus anterior and rhomboids helps ensure proper movement and positioning of the scapula, providing a stable base for the arm.
Exercises are designed to improve neuromuscular control and proprioception (the body’s sense of joint position) without stressing the torn posterior labrum. A corticosteroid injection may be used as an adjunct treatment to temporarily relieve pain and allow the patient to participate more effectively in physical therapy. A dedicated PT program typically lasts eight to twelve weeks, aiming to restore functional strength and stability.
Surgical Repair and Recovery
When conservative treatment fails, surgical intervention is typically performed using an arthroscopic approach, a minimally invasive technique. Small incisions are made to insert a camera and specialized instruments, allowing the surgeon to visualize and work inside the joint. The primary goal is to securely reattach the torn posterior labrum to the rim of the glenoid socket.
Reattachment is accomplished using bioabsorbable suture anchors placed into the bone, with sutures passed around the labral tissue to hold it firmly in place. If the patient has significant instability, the surgeon may also perform a capsular plication, which involves tightening the joint capsule to reduce looseness. The immediate post-operative period requires the arm to be immobilized in a sling, often for four to six weeks, to protect the repair and allow initial tissue healing.
Rehabilitation begins with passive range of motion exercises, where a therapist moves the arm gently to prevent stiffness without stressing the repair. This is gradually advanced to active range of motion and strengthening exercises targeting the shoulder and scapular muscles. Full recovery and a return to heavy activity or competitive sports is a lengthy process, typically requiring four to six months or longer, depending on the individual’s healing capacity and activity demands.