Shoulder Labral Tear Specialist Singapore
MBBS (SINGAPORE) MMED (ORTHO) FRCS ED (ORTH)
Posterior instability occurs in only about 10% of all cases of shoulder instability. Although the most well-known type of instability involves outright dislocation, posterior instability may be subtler, often presenting with pain rather than dislocations.
While they are, indeed less common, I see them rather frequently in active sporty individuals. In this section, I have chosen to discuss the 2 topics together because their presentation and treatment are rather similar.
To learn more about posterior instability and labral tears, basic knowledge of the anatomy of the shoulder joint is necessary.
what is posterior instability and labral tear?
Posterior instability means that during some movements at the shoulder joint, the humeral head shifts backwards in relation to the glenoid.
In many cases, the slight shift does not result in a dislocation, but rather a subluxation. Meaning the shoulder joint does not completely pop out backwards but only comes out partially before snapping back in place.
This subluxation may be something that occurs all the time when patients lift their arms, or may be an acute event during an accident.
Similar to the common anterior dislocation, the force of the humeral head sliding backwards may cause the labrum at the back of the glenoid to shear off the glenoid edge. While posterior labral tears can and do occur with violent forceful events like motorcycle accidents, they occur more commonly with repetitive movements like weight lifting, overhead movements like serving during tennis games, spiking a volleyball etc.
Who Gets Posterior Instability Or Posterior Labral Tears?
Sports injuries are the leading cause of posterior instability/ tears. They are often seen in young active patients. Sports such as weight-lifting, baseball, tennis or volleyball etc are common causes of this injury. Any activity that involves posterior loading of the arm (like doing heavy bench presses) and forceful overhead movements can cause posterior labral tears to occur.
What Causes Posterior Instability and Posterior Labral Tear?
- Overuse of shoulders from repetitive shoulder movements
- Falling forwards at significant velocity and attempting to break the fall with outstretched arms
- Sudden jerking force to the shoulder eg slipping on a foothold while hanging on to a grip while rock climbing
What symptoms do posterior instability or posterior labral tears cause?
The most common complain is pain. The pain is also typically experienced at the back of the deltoid region, and usually occurs only during and after sports. Similar to SLAP tears, most patients do not have much pain at all with activities of daily living. (Please refer the section on SLAP tears to learn more).
They can actually go about their lives absolutely pain free and that includes lifting heavy loads. However, they will get pain when they participate in sports that involve throwing like baseball, handball, dodgeball, water polo etc.
They will also have pain with sports that involve a lot of overhead movements like tennis, badminton, volleyball etc. Sometimes, patients may find that they pain is most bothersome when they first start playing.
It may then mellow down a little throughout the game, but they may get a sore shoulder that lasts for a few days after the game. Others may find that they are no longer able to serve or throw as hard as they used to.
Many will find that they are not able to perform some gym exercises like bench presses or dumbbell presses. Some patients may experience a clunking sensation midway through the movement whenever they try to lift their arms overhead.
Why do I need an elaborate MRI scan? How about an x-ray?
MRI scans are required to diagnose posterior labral tears. Other investigations are either woefully inaccurate or outright useless! MRI scans are not elaborate at all and are actually extremely commonly performed these days.
I have found that subtle posterior labral tears can be missed even by an MRI scan. As such, some doctors may prefer an invasive form of MRI scans known as MR arthrography. In an MR arthrography, the radiologist first injects a dye into the shoulder prior to performing the MRI scan. While an MR arthrography does increase the accuracy of the scan slightly. I do not routinely order MR arthrography despite their marginal higher sensitivity because I have had missed posterior labral tears with MR arthrography studies as well.
It is hence, very important, to see a doctor who is familiar with shoulders and shoulder surgery because a high index of suspicion is required to accurately make the diagnosis, based on the clinical presentation.
Dr. Tan will assess your symptoms in detail before recommending the right surgical option for your specific injury.
How Can Posterior Instability and Posterior Labral Tear Be Treated?
Non-surgical treatment methods are usually recommended for the initial treatment of posterior instability and posterior labral tear.
These methods may include:
- Physical therapy consisting of simple stretching and strengthening activities to regain lost motion and strength of the shoulders.
- Non-steroidal anti-inflammatory medications such as naproxen, ibuprofen and etoricoxib can help alleviate symptoms such as pain and swelling. The underlying tear will, however, remain unchanged.
Surgery is typically required if a labral tear is indeed present and the patient continues to be symptomatic as a result. Generally, the labral tear will not cause much symptoms in “normal” daily life, but will cause pain and reduced function in sports.
Surgery to fix posterior instability or repair a posterior labral tear can be easily performed via a minimally invasive keyhole surgery (also known as arthroscopy). Under general anaesthesia, a small camera is inserted into the shoulder joint. The labral tear is readily seen and can then be fixed by placing stitches around the torn labrum and anchoring the torn labrum to the glenoid rim using small absorbable plastic anchors.
Anatomy of the Shoulder Joint
The shoulder joint is made up of 3 bones: the shoulder blade (scapula), the humeral head and the collar-bone (clavicle).
Movements around the shoulder involve 3 separate articulations: the glenohumeral joint, the acromioclavicular joint and the scapulothoracic articulation. When the arm is raised, the majority of movement occur at the glenohumeral joint and the scapulothoracic articulation.
The glenohumeral joint is a ball and socket joint, comprising the socket (the glenoid) and the ball (the humeral head). Both surfaces of the joint are covered with an extremely smooth and rubbery cartilage (known as articular cartilage). The smooth surfaces create a frictionless articulation when lubricated with a small amount of joint fluid.
The glenoid is really a rather shallow socket. In fact, a dish is probably a more accurate description! This, however, is a design which is intended to allow the shoulder joint to have great range of movement. Unfortunately, the price of big range of movement is stability. You can probably image that a big ball sitting on a shallow dish will fall off very easily.
While that is true to a certain extent, the body has ways of preventing this from happening. A ring of cartilage attached to the rim of the glenoid helps to not only deepen the socket, but also serves as the attachment point of ligaments that help to hold the humeral head in place. This ring of cartilage is known as the labrum. The view of the glenoid seen end-on further demonstrates the labrum.
Note: Ligaments attaching the labrum and glenoid to the humeral head are not shown in order to allow readers to appreciate the importance of the labrum.
Frequently Asked Questions
What will the doctor do?
Will a shoulder with posterior instability become stable with time?
How long will I take to recover?
Will the posterior tear heal by itself?
What does posterior instability/ labral repair surgery entail?
What is the success rate of the surgery?
Will I be able to participate in sports after the surgery?
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