Shoulder Instability / Labral TearsÂ
Background
The shoulder has a wide range of motion, but that mobility also makes it vulnerable to instability. The labrum is a ring of cartilage around the shoulder socket that helps keep the ball of the upper arm centered. A fall, collision, or repeated overhead activity can injure the labrum and the surrounding ligaments.
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Labral tears are named for their location. A Bankart tear affects the front and lower part of the labrum and often occurs when the shoulder dislocates forward. A posterior labral tear affects the back of the socket. A SLAP tear involves the top of the labrum where the biceps tendon attaches. These injuries can cause different symptoms and require different treatments.
Symptoms
Patients may experience:
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A feeling that the shoulder slips, shifts, or could dislocate
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Pain during throwing, lifting, or pushing
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Deep shoulder pain with clicking, catching, or popping
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Weakness or loss of confidence in the shoulder
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Repeated dislocations or episodes of partial dislocation
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Difficulty sleeping on the affected shoulder
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A shoulder that feels unstable without fully dislocating still deserves evaluation, particularly if the episodes are recurring.
Diagnosis
Diagnosis begins with a discussion of how the symptoms started, any prior dislocations, and the positions that cause pain or instability. The examination assesses shoulder motion, strength, and stability in different directions.
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X-rays help evaluate the bones and identify changes associated with a dislocation. An MRI or MR arthrogram can provide more detail about the labrum and surrounding soft tissues. If the shoulder has dislocated repeatedly, a CT scan may be used to measure bone loss and help plan treatment.
Treament Options
Treatment depends on the location of the tear, the direction of instability, associated bone injury, and the patient’s activity goals.
Nonoperative Treatment
Physical therapy focuses on improving rotator cuff and shoulder blade strength, control, and stability. This may be appropriate for selected labral tears or a first episode of instability. Patients who continue to have pain or repeated episodes of slipping may benefit from a discussion about surgery.
Bankart Repair
When a shoulder dislocates forward, the labrum and ligaments at the front of the socket may tear away from the bone. A Bankart repair reattaches this tissue to the socket using small anchors. The goal is to restore stability and reduce the risk of another dislocation.
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The likelihood of success depends partly on the amount of bone loss and whether there is an associated injury to the ball of the shoulder. Substantial bone loss may require a different stabilization procedure, such as a Latarjet or other bone block procedure.
Remplissage
A forward dislocation can leave an indentation in the back of the upper arm bone called a Hill-Sachs lesion. If that indentation contributes to instability, a remplissage may be added to a Bankart repair. This secures tissue from the back of the shoulder into the indentation so it is less likely to catch on the edge of the socket. In appropriately selected patients, adding remplissage has been shown to reduce recurrent instability without reducing the likelihood of return to sport.
Posterior Labral Repair
A posterior labral tear can occur after an injury or from repeated force through the arm, such as during blocking, weightlifting, or pushing activities. It may cause deep pain or a sense that the shoulder shifts backward.
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When symptoms persist despite rehabilitation or the shoulder repeatedly slips, the torn labrum may be reattached to the back of the socket. Treatment also considers whether there is associated bone loss or another reason the shoulder is unstable.
SLAP Repair
A SLAP tear involves the top of the labrum and may affect the attachment of the biceps tendon. Many patients first try physical therapy focused on shoulder mechanics and strength.
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If symptoms persist, surgery may involve repairing the labrum or performing a biceps tenodesis, which moves the biceps tendon attachment away from the torn area. The choice depends on the patient’s age, tissue quality, symptoms, and sport or work demands. Overhead throwing athletes require particular attention to the demands of their sport.
Bone-Block Procedures
Repeated dislocations can wear away bone from the front edge of the shoulder socket, called the glenoid. When there is substantial bone loss, a Bankart repair alone may not provide reliable stability. A bone block procedure adds bone to the socket to restore its shape and help prevent the shoulder from slipping out again.
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Options include a Latarjet procedure, which moves a piece of bone from the shoulder blade, or a bone graft such as a distal tibial allograft. The choice depends on the amount of bone loss, the condition of the shoulder, and whether the patient has had prior stabilization surgery.
Return to Sport
Return to sport after shoulder stabilization is a gradual process. Patients first regain motion and strength, then progress through sport specific work such as throwing, lifting, or contact drills. Many athletes return to sporting activities around four to six months after surgery, although recovery varies by procedure and sport.
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Recent research on return to play after Bankart repair supports looking beyond the calendar. Before clearance, I assess shoulder motion, strength, stability, performance on functional tests, and the athlete’s confidence in the shoulder. Meeting these goals helps guide a safer return to competition and a decreased recurrence rate, particularly when the sport places repeated stress on the shoulder.