Why are shoulder labral tears important to talk about?
Shoulder pain is extremely common. A 2003 study in the Netherlands estimated that shoulder pain is the second most common complaint after lower back pain. Another 2011 study in the same country estimated that 3 out of 100 people goes to a general practitioner due to shoulder pain every year.
One of the causes of shoulder pain is believed to be shoulder labral tears. The most popular treatment for labral tears is surgery. As a matter of fact, the incidence of surgery for shoulder labral tears has been rising over the last decade.
But what does it mean to tell people they have shoulder labral tears?
What do doctors think it means?
What does it mean for how you approach shoulder pain?
And is surgery REALLY the best approach to treat shoulder labral tears?
Shoulder labral tears in a training context
We work with a lot of clients with shoulder issues. Our job as corrective exercise specialists is to help people move better and perform better in their athletic AND daily lives.
And we want to make sure what we do with our clients makes sense and won’t make shoulder problems worse.
So we’ve done our homework on shoulder pain, shoulder labral tears, and other shoulder joint pathologies.
Through this process, we learned a lot about the myths, misinformation, and plain deceptions around shoulder pain. And with time, experimentation, and experience, we’ve seen that you can take care of your shoulder labral tears in healthier ways than what the medical world currently offers.
First of all, what is a shoulder labral tear?
The labrum is a piece of cartilage found within certain joints – e.g. the hip and the shoulder.
In the shoulder, the labrum is between the head of the humerus and the scapula:
The labrum is believed to increase joint stability and serves as an anchor for ligaments and muscles. A shoulder labral tear is an injury to this piece of cartilage.
Doctors classify labral tears according to the sector of the labrum torn and if there’s pain or instability in the shoulder.
It’s believed that shoulder labrum tears are caused by direct trauma, overuse, or shoulder instability.
In the conventional medical theory, a shoulder labral tear leads to catching, clicking, and irreversible damage to the shoulder joint. It’s believed that this damage causes movement problems and eventual shoulder osteoarthritis.
In a training environment, we are trying to improve people’s range of motion, comfort, and overall movement competency. If the medical perspective is correct and the shoulder labral tear is a one-way ticket to joint degeneration, then less movement is the only prescription.
That’s a pretty disempowering perspective. It’s also one we think you shouldn’t take too seriously. In fact, we think people are better off ignoring that theory completely.
Because we’ve seen people with failed shoulder surgery regain full function with proper training.
Surgery may not work as promised. It can actually bring more problems than solutions – not to mention the cost in terms of time, money, and your emotional well-being.
We believe there’s a better long-term solution for shoulder pain than surgery.
A lot of what you’ve just read may seem controversial, especially if you’ve heard a lot of conventional textbook answers on shoulder labral tears. If you feel yourself getting agitated or angry, take a breath and settle in.
Keep your mind open as we take a deep look at shoulder pain, shoulder labral tears, and surgery for shoulder labral tears.
Do you even have a shoulder labral tear?
If you’re reading this, a doctor probably told you that you have a shoulder labral tear, so why bother even thinking about this?
Well, let’s take a look at the tools used to arrive at a shoulder labral tear diagnosis.
Can X-rays, MRI’s, MRA’s, and CT scans find shoulder labral tears?
X-rays are designed for bone tissue, not cartilage. So they aren’t helpful.
MRI’s, MRA (Magnetic Resonance Arthrography), and CT (Computed Tomography) scans are used instead.
Let’s look at how accurate MRI, MRA, and CT scans are for identifying shoulder labral tears.
A 2016 study looked at the accuracy of MRI diagnosis of labral tears. They had 127 patients who underwent shoulder surgery for labral tears. They compared the MRI findings before surgery to the arthroscopic findings.
MRI’s made a correct labral tear diagnosis 80% of the time. There were no false positives but there were several false negatives.
That means that if an MRI said you had a shoulder labral tear, you probably had one. That’s in contrast to hip labral tears, where MRIs have an extremely high false positive rate.
What about MRA? The process is like an MRI but with an injection of a contrast solution. This outlines the joint structure, and it’s believed to be more precise.
This 2012 study put MRA to the test.
They compared the MRA reports and the arthroscopic findings of 90 patients who underwent the same procedure for shoulder labral tears.
They found that the accuracy of MRA’s is actually lower than believed. Why?
Because MRA often missed labral tears.
83 out of 90 patients had a labrum tear identified in arthroscopy.
The MRA had identified only 65% of them. That means there were many false negatives. But there were no false positives.
So if MRA said you had a shoulder labral tear, you probably had one. But if you were told you didn’t have one, you might still have had one!
Now, the CT scan. The problem with this procedure is that CT scans can involve a powerful dose of X-ray radiation, comparable to 200 chest X-rays.
In any case, this 2008 study wanted to assess the accuracy of CT-arthrography scans (CT’s for joints) for diagnosing anterior labral tears of the shoulder.
They looked at the pre-operative CT-Arthrography records of 43 patients who underwent surgery for their shoulder labral tear and compared the CTA findings with the surgical findings.
The accuracy for diagnosing labral tears ranged from 88.8% to 91.6%, with a low risk of false positives.
So yes, MRI’s, MRAs, and CT scans are relatively good at finding labral tears!
If an MRI or MRA says you have a labral tear, you probably do. But if it says you don’t, you still might have a labral tear.
So if you’ve been told you have a shoulder labral tear, you probably have one.
But is that a reason to worry? Not quite.
Interestingly, what radiologists (the people reading and interpreting your medical images) and surgeons see aren’t the same. In other words, a radiologist might identify a labral tear on an MRI, but the surgeon might go into your shoulder and decide it’s not a significant tear anyway.
Wait, does that actually happen?
That’s what this 2014 study talks about.
They had 100 patients with shoulder labral tears on MRI. Those patients later underwent shoulder surgery for those labral tears.
But the records show something interesting:
The surgeon found that 18% of the SLAP tears on MRI were not relevant during the surgery.
And 18% of posterior labral tears were also determined to be irrelevant.
In other words, radiologists may diagnose lots of labral tears in the MRI’s. But then the surgeon opens you up, sees the tear, and decides it doesn’t need to be treated.
From the study:
"In our practice, labral tears are commonly seen and described on MR examination. High-resolution MR scanning allows for very sensitive detection of such tears. However, some of these tears might not be considered clinically significant by a surgeon. In particular, a high percentage of SLAP and posterior labral tears described on MR examination were described as fraying at arthroscopy. Most of these tears did not have surgical tacking performed."
Believe it or not, reading an MRI is not just a black and white, yes versus no practice. It comes down to who reads your MRI.
This 2015 study assessed the reliability of the opinion between two radiologists and an experienced shoulder surgeon.
Researchers did MRI's on 21 patients who underwent the same shoulder labral tear surgery.
The surgeon and the two radiologists had to assess whether the labrum was healed or re-torn after surgery – i.e. if the surgery was successful or not.
Easy answer right?
Well, only 43% of the MRI’s had 100% agreement across all interpretations. These professionals didn’t have the same opinion in more than half of the MRI’s.
In a real-life scenario, two healthcare professionals could evaluate the same MRI and arrive at different conclusions. How would you know who’s right? How would you know whose opinion to trust when considering shoulder surgery?
The bottom line here is that it’s impossible to know whether how one person interprets an MRI is accurate.
And it’s actually impossible to know with certainty whether the labral tear really is causing your pain.
Wait, what? That can’t be right, can it?
What about shoulder pain tests?
Sometimes doctors and therapists will say that physical tests can help determine whether your shoulder pain is from a labrum tear. The idea is that if you move the shoulder joint in specific ways, you’ll be able to definitively tell if someone has a labral tear.
Depending on the limitations or where the pain triggers, the professional can pinpoint the cause. Theoretically.
A systematic review in 2010 tested the reliability of physical tests for shoulder pathology. Researchers evaluated 36 studies about shoulder tests performed in patients with shoulder pain.
They included tests not only for shoulder labral tears but for shoulder impingement, scapular positioning, range of movement, and shoulder instability among others.
They gathered information from almost every test available to detect shoulder pathology.
The results of the tests for shoulder pain was problematic, to say the least. Most of the 36 studies indicated poor reliability for the tests.
The review concluded that physical tests can’t be used to diagnose shoulder pathology. They lack validity and reliability. They suggest that the shoulder physical tests should be abandoned.
Quoting the study:
“(...) Researchers need to start identifying clinical characteristics that have management and prognostic implications, and that clinicians should abandon the diagnostic pathological model which is based on tests that lack validity and reliability. (...) Using these procedures to make their associated diagnoses is an invalid and unreproducible process.”
Long story short: Shoulder pain tests are unreliable and don’t give any useful information - certainly not about whether you have a labral tear or not.
I know this is a bit shocking. Maybe we’re cherry-picking studies to prove our point?
Let’s take a look at two other studies for shoulder labrum tear tests. More specifically, SLAP tests.
In this 2018 systematic review, researchers wanted to see if the tests designed to diagnose SLAP tears could actually diagnose SLAP tears reliably.
They looked at 17 studies. Each study had patients with shoulder pain who underwent at least 1 clinical test for diagnosing SLAP. Then, each study compared the results of the test with findings in arthroscopy.
The idea is simple. If the test is positive for SLAP, the arthroscopic surgery should show a SLAP lesion.
Well, the results were disappointing. No single test was good enough to determine the presence of a SLAP lesion accurately. No particular test was statistically accurate in any of the studies.
And this isn’t the first time this happened. Another 2009 systematic review wanted to examine the clinical usefulness of SLAP tests. The goal was to determine if there’s enough evidence to keep using tests to diagnose a SLAP tear.
The authors analyzed 15 studies focused on the physical exam of SLAP tears.
Their conclusion: there aren’t good physical tests to effectively diagnose SLAP tears. They ended with a call to action:
“(...) We conclude that the current literature used as a resource for teaching in medical schools and continuing education lacks the validity necessary to be useful. There are no good physical examination tests that exist for effectively diagnosing a SLAP lesion. We would recommend that educational programs apply evidence-based medicine to their curriculum to avoid these weaknesses in the current body of literature.”
You have studies for years showing that physical tests for shoulder pathology and labral tears are inaccurate and unreliable.
But medical professionals keep using the same tests to “prove” your labral tear is the cause of your pain. The tests don’t prove anything. And research demonstrates that over and over again.
When you combine tests that are wildly inaccurate with MRI + MRA readings that are ambiguous, you have a situation ripe for error.
And we still haven’t looked at the biggest question about shoulder labral tears...
Do labral tears cause shoulder pain?
As near as we can tell, it’s unlikely that shoulder labral tears cause shoulder pain.
In a 2016 study, researchers took a sample of 53 adults from 45 to 60 years old and took MRI’s of their shoulders. None of the subjects had shoulder pain or any previous shoulder trauma. Two radiologists read the MRI’s.
One radiologist found shoulder labral tears in 55% of the population. The other found them in 72%.
Researchers didn’t find major differences regarding age, sex, type of job, or if the patient participated in overhead sports for 1 year.
So in a group of people with ZERO SHOULDER PAIN, 55% to 72% had shoulder labral tears..
In other words, what we call labral tears may just be the way a labrum is supposed to look! We’ve just misinterpreted it as “damage.”
Let’s be clear: they had shoulder labral tears. And no shoulder pain.
If labral tears cause shoulder pain, most of the people in that group should have had shoulder pain. But they didn’t.
The study concludes that shoulder labral tears might be a normal finding in asymptomatic middle-aged people!
In other words, what we call labral tears may just be the way a labrum is supposed to look! We’ve just misinterpreted it as “damage.”
This isn’t a new discovery. For example, a 2002 study evaluated MRI findings in both shoulders of 14 professional baseball pitchers. That’s a total of 28 shoulders evaluated.
Each pitcher had at least 1 year of professional experience. All athletes had asymptomatic shoulders and no history of previous shoulder injury, symptoms, or surgery.
Two radiologists experienced in interpreting shoulder MRI’s reviewed the images.
They found labrum “abnormalities” in 22 of the 28 shoulders. 10 of those shoulders had labrum tears. One pitcher had a SLAP tear in both shoulders!
22 “abnormal” labrum-shapes. 10 shoulder labral tears. Zero pitchers with shoulder pain.
There was no correlation between the labrum tears and shoulder pain. And these are people who are pushing their shoulders to the very edge of maximum performance.
Studies like these demonstrate that the presence of a labral tear has little (or nothing) to do with shoulder pain.
But do shoulder labral tears cause popping and snapping in the shoulder joint?
This is extremely common to hear from doctors. Yet, it’s unlikely that shoulder labral tears cause popping, snapping, and clicking sounds. The labrum itself is not stiff enough to catch on anything to make a loud clicking sound. It’s like a small cushion in your joint.
Imagine sitting on a pillow and trying to make a snapping sound by rubbing your butt on it. No matter how hard you rub, you won’t get a clicking or popping sound.
Here’s a visual breakdown:
If you’re experiencing popping and snapping in your shoulder, there’s probably nothing to worry about. It’s highly likely that tight muscles are rubbing against each other (or against some bony protuberance) and causing the noise.
And if that’s not enough to calm your fears, maybe this will. My son, when he was a newborn, would occasionally have popping and snapping noises in and around his shoulder when I was holding him.
His shoulders are fine.
Can’t shoulder injections show that a labral tear is causing your pain?
As we’ve seen, shoulder labral tears are very common. We know they are present in people WITH NO SHOULDER PAIN in HIGH numbers
We also know that physical tests for shoulder labral tears are useless.
MRI’s can show labral tears, but that doesn’t tell us if the labral tear is causing the shoulder pain.So, how do you determine if your shoulder pain is actually coming from a labral tear? How do you differentiate it from other pain sources?
Doctors will sometimes propose an anesthetic injection inside the joint. They believe this numbs the pain coming from labrum damage
If the labrum is the source of pain, the injection should resolve it. If the pain remains, the source is something else – i.e. the rotator cuff, bursitis, even pain radiating from the neck.
There’s just one problem. We haven’t found any study to back-up this belief. We simply can’t find a study that tests the accuracy of injections for diagnosing shoulder labral tears.
However, there is research on this with hip labral tears. And the available evidence shows that this type of injection doesn’t work for diagnosing hip labral tears.
Would injections for shoulder labrum tears be any different? Doubtful.
With ambiguous MRI readings, useless physical tests, and no evidence that injections tell us anything about the cause of shoulder pain, we’re left with no reliable way to determine whether shoulder pain comes from a shoulder labral tear.
All you have is a guess.
Based on a theory.
And the theory that shoulder labrum tears cause pain hasn’t been proven! The labral tears don’t seem to have a relationship to shoulder pain.
Whether you have a labral tear or not has no bearing on whether you have shoulder pain.
Whether you have a labral tear or not has no bearing on whether you have shoulder pain.
Do surgeries for shoulder labral tears work?
Before talking about the success rate of surgery for shoulder labral tears, let’s analyze the steps between shoulder pain and shoulder surgery:
- A history of a traumatic event on the shoulder.
- Shoulder pain.
- Positive physical tests (which we know are inaccurate).
- MRI that shows a shoulder labral tear (which we know are ambiguous).
- And, maybe, you did 6 weeks of conservative care. Or maybe not.
You are the perfect candidate for shoulder labral tear surgery.
We know that physical tests are unreliable and shoulder MRI’s shouldn't be relied on.
But only 6 weeks of conservative care? That’s a month and a half. That’s a very short amount of time to see real results. Not to mention the risk and complications after shoulder surgery.
Well, after this rather permissive set of criteria are met, the next question is…
What are the usual procedures for shoulder surgery?
If the surgeon doesn’t consider that the labral tear “healed”, the next step is usually surgery. The surgical options for shoulder labral tears are:
- Labral repair. Here, the surgeon reattaches the torn tissue. Sometimes the labrum is removed and reattached. If deemed necessary, the surgeon tightens the ligaments and the capsule too.
- Labral debridement. Here, the surgeon cuts off the torn pieces of the labrum.
- Biceps tenodesis. This is an option if the biceps tendon is affected too, e.g. a SLAP tear. The surgeon cuts the attachment of the biceps tendon to the labrum and reattaches it to the humerus.
The surgery can be open or through arthroscopy. The first involves opening the joint to access it easily. It's pretty gruesome. In the latter, the surgeon inserts a tiny camera to see the joint during the surgery. It’s less aggressive than open surgery.
Most studies about surgical procedures for shoulder labral tears focus on the process and outcomes of SLAP tears, as they’re the most frequent.
And the conclusion of this 2016 systematic review is that there’s not a clear answer for which surgical procedure is best for SLAP tears.
There isn’t a consensus on how to surgically approach shoulder labral tears.
Now, with all this uncertainty, the real concern is...
What’s the success rate for shoulder labrum surgery?
This 2013 systematic review wanted to analyze the outcomes of SLAP arthroscopy.
To do so, they did a 4-year follow-up of 179 patients who underwent the same SLAP surgery. Their results were disappointing:
- On average, patients had less range of motion (ROM). On average, flexion and external rotation both decreased by 5º and abduction decreased by 15º.
- 66 patients met the failure criteria.
- 50 underwent revision surgery.
From these results, we can tell that SLAP surgery doesn’t improve shoulder range of motion. It may actually worsen it. And 37% of the patients' surgeries "failed."
Not great results.
This 2017 randomized trial evaluated the outcomes of labral surgery versus sham surgery for SLAP tears.
A sham surgery is a fake surgery intervention. It mimics the initial incision and keeps the patient in the surgery room for the same time as a real surgery. It’s a clinical way to assess the placebo effect from surgeries.
They had a population of 118 patients with criteria for undergoing SLAP surgery:
- 40 underwent labral repair.
- 39 underwent biceps tenodesis.
- The remaining 39 had sham surgery.
Researchers did a 2-year follow-up.
Clearly you’d expect the REAL surgical interventions had better results than sham surgery.
Here were the results:
“There were no significant between-group differences at any follow-up in any outcome. (...) Postoperative stiffness occurred in five patients after labral repair and in four patients after tenodesis.”
So, SLAP surgery – whether it’s repair or tenodesis – has similar results as just opening the shoulder and doing NOTHING.
The placebo surgery worked just as well as the two real procedures.
But real surgeries also have REAL complications...
What are the complications from shoulder labrum surgeries?
This 2015 study reviews the complications after arthroscopic labral repair to treat shoulder instability.
The most common complications were...
Problems with anchors
Anchors have the risk of perforating the glenoid capsule – one of the many structures that stabilize the shoulder.
Anchors can also leave debris within the joint. A study mentioned in this review found intra-articular anchor debris in more than 50% of cases. This debris damages the joint.
They also found chondral damage in 70% of the patients. The more time after the surgery, the more chondral damage.
Translation: Rapid destruction of the cartilage cells. It results in a complete loss of cartilage. This leads to a progressive and severe loss of shoulder function.
This is apparently common in patients who had intra-articular pain pumps with a local anesthetic after the surgery.
This is cartilage damage due to wear and tear.
The rate of shoulder osteoarthritis after labral repair is 26% for arthroscopy and 33% for open surgery.
That's a 1 in 4 to 1 in 3 incidence following surgery for a shoulder labrum.
This is a severe loss of ROM and severe pain.
This is usually treated with physical therapy and conservative treatment. But if it fails, the patient goes to surgery. Again.
This is the most ironic possible complication.
Shoulder instability is one of the most frequent complications after labral repair to treat shoulder instability.
It can range from 2.9% to 13% depending on the various procedures.
So the question is: Would you undergo a shoulder labral tear surgery knowing that:
- It’s likely that you’ll lose range of motion?
- It has similar results as sham surgery?
- You could end up with debris in your joint?
- Your shoulder may still be as unstable as it was before?
“But aren’t there studies with high success rates for shoulder labrum surgery?”
Of course there are! Whether their results are reliable is another matter. Keep in mind that surgeons may have a different concept of “success” than a patient with shoulder pain.
I talk deeply about this in another post, but to sum it up:
This 2012 study looked at the results of SLAP repair after 5 years. They included 107 patients. They used the Rowe score to measure the results.
The average score was 62.8 preoperatively to 92.1 at follow-up. 13% of the patients still suffered from postoperative stiffness and pain despite these results.
Let’s take a quick look at the Rowe score. It’s designed to measure shoulder stability. However, there are two important flaws in this score:
- It has 4 versions. One patient could do each version and have completely different outcomes in each one. On top of that, most studies using the Rowe score don’t mention the version used.
- Here’s one version of the Rowe score in case you want to check. It has 3 sections with 4 choices each. If you play with it a bit, you’ll see that it’s fairly easy to have a high score with a subtle improvement.
Using the version of the link above, a 90 Rowe score can show that you still have limited mobility and discomfort, but your shoulder doesn’t subluxate.
The surgery could have fixed the shoulder stability, but at the cost of less range of motion and, still, mild pain.
And that’s considered a “positive” outcome.
This 2008 study wanted to measure the outcomes of SLAP surgery in 33 patients. They used the DASH score to evaluate the results.
This score evaluates the Disabilities of the Arm, Shoulder, and Hand (DASH). It has 30 questions related to activities to the daily living – i.e. write, make the bed, push a door. Each question has 5 options.
The more points, the worse the outcome.
Well, these patients scored an average of 10 points less after surgery.
If you play with the score a while – here’s the link – a 10 point reduction is not a gigantic improvement. You can see for yourself how easy it is to get a 10 point improvement.
To say you had "success" with a 10 point improvement is silly. You could get that same 10 points by waking up on the right side of the bed.
For many, a variation of 10 points could happen without surgery on a weekly basis!
Do surgeons believe surgery for shoulder labrum tears works? Sure.
Does it work sometimes based on some metrics? Sure.
But do the metrics align with your goals? And is the evidence strong that you’ll get what you want from shoulder surgery?
Not so sure...
If you have a shoulder labral tear, what should you do?
Let’s assume you have been told you have a shoulder labral tear. What should you do?
Before going further, don’t take this as medical advice. It’s coming from a very non-medical perspective. The ideas offered here are decidedly not medical but they are evidence-based.
If you’ve been told that a shoulder labral tear is causing your shoulder pain, think about these major questions:
- Is there any way to know that the labral tear is actually causing your shoulder pain? Based on the research – NO! Shoulder labral tears are common in people with no symptoms.
- What’s the likelihood that surgery will fully fix your shoulder pain? That’s tough to say, but there’s evidence that FAKE surgery is just as good as the real thing… which is to say that the real thing probably isn’t that good.
- What else could cause your shoulder pain? Movement problems are muscle problems. Muscle problems require retraining.
Look, a surgeon saying “the surgery guarantees to fix your shoulder pain” is well-intentioned and may truly have your best interests in mind.
But many well-intentioned surgeons strongly recommended spinal fusions to “cure” back pain for decades. Research eventually showed it was a WORSE option compared to conservative treatments like exercise and massage. But surgeons keep making billions of dollars a year performing unnecessary surgery that's been proven to be a worse choice than exercise.
Shoulder labral tears: what should you do?
We’ve worked with people with shoulder labral tears to avoid surgery. We’ve also worked with people after shoulder surgery failed to help.
We strongly encourage people to acknowledge their fears and anxieties around shoulder labral tears. But also remember there’s very little evidence that labral tears actually are the definitive cause of shoulder pain.
From what we’ve seen, repairing or removing the labrum is not the most important factor. The fact that the labrum may be torn doesn’t even seem to be marginally important.
We’ve seen that the game changer is training your shoulder muscles to work in balance. Gradually and carefully. Based on YOUR body and YOUR background.
That process requires time, learning, and patience. DON'T GET DISCOURAGED IF YOU DON'T SEE RESULTS QUICKLY.
It’s a highly individualized process and requires you to be fully engaged.
Here are some suggestions:
- Find a trainer, coach, or a physiotherapist who can coach you to move with good form in new ranges of motion. Please don’t jump into high-intensity interval training or some kind of boot camp/group class/Crossfit situation. This has to be customized for you.
- Identify areas that aren’t moving well and work to improve them.
- Learn how to stretch properly and appropriately for your body and your life.
- Identify muscles that are weak and build strength.
- Identify positions you find difficult and carefully work to make them more comfortable (by training the muscles there).
- Aim to improve on something every single day. Consistency is the most important part of this process.
Shoulder labral tears: Final words
Remember: just because a doctor believes something is true or says something is fact doesn’t actually mean it is.
Surgery sounds quite promising. Many people believe surgery will give them full function back, only to discover that retraining muscles is even more important after a long period of rest (and atrophy) after the surgery.
And there's another catch to be aware of.
Many people we’ve talked with have been told that they should never go back to high impact, high-intensity activities ever again after surgery. That’s not a great outcome for anyone who's active.
No more overhead weight lifting. No more pull ups. No more cartwheels. No more basketball. No more. No more. No more. Unless you are stubborn about retraining your shoulder.
Restoring shoulder mobility gradually and progressively can save you thousands of dollars and months to years of suffering.
And while the process is not a quick fix, it’s a solution that gets rid of pain naturally. It’s a process that expands your ability to enjoy all the activities that you love in life – even the high impact, high-intensity ones (once you’re ready!).