Shoulder pain from labral tears: are labral tears really causing the problem?

If you've been told you have a labral tear and that it's the cause of your shoulder pain and movement issues, there's something you need to know: Labral tears are not as important as your doctor thinks.

Labral tears don't have anything to do with pain - as near as we can tell.

For many years, the conventional medical wisdom has been this: if we can see something "torn" in your shoulder, that must be the reason you have pain. Based on MRIs and this belief, surgery has long been proposed as a way to solve shoulder pain that appears to be "caused" by labral tears.

If, in fact, the labral tears are causing people shoulder issues, we should be able to take someone off the street and, if we find a labral tear, that person should have pain. 

But the reality is much different.

People have labral tears and no shoulder pain.

One 2016 study looked at the prevalence of labral tears in the asymptomatic population. They looked at 53 adults who had no issues with their shoulder - no pain, and no history of surgery or injury to the shoulder. The average age of the adults was between 45 and 60 years old.

Two radiologists (blinded to the patients' histories) evaluated the MRIs and found superior labral tears in 55% and 72% of the patients respectively! That means more than half of these people had labral tears despite having no shoulder problems. Interestingly, in this study, there was no correlation between labral tears and age, sex, history of playing an overhead sport, imaging of the dominant or nondominant arm, or working a labor-intensive job.

That means more than half of these people had labral tears despite having no shoulder problems.

The paper concludes that a lesion on MRI may just be a sign of aging, without any consequence to the function of the shoulder. (Schwartzberg et al 2016).

Another study done in 2002 actually hinted at this reality (Miniaci 2002). In this study, they did MRIs on professional baseball pitchers without shoulder pain. They found that on MRI, 79% of the shoulders they examined had "abnormal" labrums. These abnormal labrums did not correlate with pain whatsoever (since all 28 of these pitchers were asymptomatic)!

It's clear that there is a very weak relationship between labral tears and shoulder pain - if there is any at all. 

If labral tears were a cause of shoulder pain, we would not find them in such high percentages in the asymptomatic population.

Do physical tests for labral tears matter?

There are a number of physical maneuvers that are believed to indicate when a labral tear exists and is causing your shoulder pain. Many of these physical tests have become a standard part of practice without any rigorous research and testing. Many doctors have assumed that these tests are accurate and helpful based on preliminary reports and beliefs.

In 2010, a systematic review of studies looked at a number of these physical tests to see how valid and useful these tests are. The paper, titled Physical examination tests are not valid for diagnosing SLAP tears: a review, is very clear about the usefulness of a number of tests (SLAP is an acronym for "superior labral tear from anterior to posterior").

The accuracy of Speed's and Yergason's tests for diagnosing a SLAP lesion was poor in the only methodologically robust study reviewed. The likelihood ratios for these tests could not rule in, or rule out, the presence of a SLAP lesion when compared with arthroscopic results. Assessments of numerous other tests could not be considered valid because of the serious shortcomings in the studies' methods.

Essentially, these physical tests do not provide any useful information about the presence of a labral tear, let alone the likelihood that a labral tear is causing your shoulder pain.

Conclusion

While it remains a possibility, a torn labrum does not seem to be a strong cause of shoulder pain. The evidence that labral tears cause shoulder pain is very weak. And the tests to determine whether a labral tear is the cause of your shoulder pain show little to no usefulness.

At the very best, we can say that labrum tears MIGHT cause pain, but the medical tools available to determine that don't seem to actually be able to give clear answers. Given that ambiguity, we believe it makes sense to at least temporarily set the labral tear perspective aside and work with muscles around the shoulder joint in a careful, gradual, and patient way to see if function can be restored and improved. 

This means teaching the muscles that affect the shoulder joint to build strength and coordination over time - something only dedicated training can accomplish! 

By working with muscles gradually and safely, we believe people can drastically improve their pain levels, confidence, and quality of life. 

Want to learn more about shoulder labral tears? Check out Part 1 of our two part blog series!