Shoulder Labral Tear Algorithm Rick Hill, Sarah Jarvis Mallory Mahoney, Madeline McCann Lauren Mulsow

Anatomy/ Biomechanics Glenohumeral joint Ball and Socket Joint Labrum Deepens glenoid Increases Stability https://www.google.com/search?q=glenoid+labrum&client=firefox-a&hs=iTb&rls=org.mozilla:en-US:official&source=lnms&tbm=isch&sa=X&ei=xiV1UauAGafP2QWIn4H4CQ&ved=0CAoQ_AUoAQ&biw=1525&bih=619#imgrc=yI7VaEG1zjuTaM%3A%3B1f0zuB-p1xsv9M%3Bhttp%253A%252F%252Fdc169.4shared.com%252Fimg%252FzwFqk3fW%252Fpreview_html_4359dc90.png%3Bhttp%253A%252F%252Fdc169.4shared.com%252Fimg%252FzwFqk3fW%252Fpreview.html%3B312%3B292

Injury SLAP lesion Bankart lesion Superior labral Inferior labral Anterior to Posterior Bankart lesion Inferior labral http://www.myerssportsmedicine.com/art/slap-lesion-bankart-tear.gif

Mechanism of Injury Macro Trauma Micro Trauma Fall on Out Stretched Hand Direct blow Sudden pull Micro Trauma Repetitive overuse injury

Differential Diagnosis Glenohumeral instability Rotator Cuff Pathology Shoulder impingement

Risk Factors Participation in Sports Trauma Micro-trauma secondary to shear force directed at the glenoid and labrum Trauma Force translating the humeral head relative to the glenoid Anterior / Posterior Shoulder Instability Increased risk secondary to increased translation of humeral head Glenoid Dysplasia A bone deficiency of the posteroinferior glenoid rim and hypertrophy of surrounding cartilage can increase risk of tear from shear forces

Symptoms Catching, clicking, locking, popping, grinding Decreased ROM Loss of strength Ache Pain with overhead activities Pain with axial loading Feeling of instability (dislocation/subluxation)

Instability (rule out) Impingement (rule out) RTC (rule out) History: Young OH athlete (throwing injury) compressive or distraction force on the shoulder fall onto outstretched hand or elbow w/GH jt adducted and extended “traumatic injury that involves substantial forces on the GH joint” Symptoms: catching, clicking, popping , locking, grinding deep shoulder pain pain w/OH activity pain w/axial loading sense of instability decreased ROM decreased MMT Instability (rule out) - Apprehension Test - Apprehension/Relocation Test Impingement (rule out) Hawkins-Kennedy Neer Horizontal Adduction Yocum RTC (rule out) Empty can Drop sign Painful arc ER Lag sign Labral (rule in): Biceps Load Test I Biceps Load Test II Internal Rotation Resistance Test Kim test Jerk test

Take Home Message When examining a patient with suspected labral tear it is important to understand the anatomy and biomechanics of the shoulder as well as associated risk factors and mechanisms of injury. Knowledge of this information, in combination with the patient profile will help to determine the direction to take upon objective exam of the patient. This algorithm can be used to test applicable hypotheses after the subjective exam and will help to guide a thorough yet efficient objective exam.

References Cleland, J.A., Koppenhaver, S. (2011). Netter’s Orthopaedic Clinical Examination: An Evidence-Based Approach. 2nd Ed. Philadelphia: Saunders – Elsevier. Dutton, M. (2004). The Shoulder Complex. Orthopaedic: Examination, evaluation, & intervention. (pp. 476). New York, NY:McGraw- Hill. Dutton, M. (2008). The Shoulder Complex. Orthopaedic examination, evaluation, and intervention (2nd ed., pp. 405-519). New York: McGraw-Hill Medical. Escobedo, E.M., Richardson, M.L., & Schulz, Y.B.E. (2007). Increased Risk of Posterior Glenoid Labrum Tears in Football Players. American Journal of Roentgenology, 188 (1), 193-197.  Guanche, C.A., Jones, D.C. (2003) “Clinical Testing for Tears of the Glenoid Labrum.” Arthroscopy: The Journal of Arthroscopic and Related Surgery, 19 (5), 517-523. Harper, K. W., Helms, C. A., Haystead, C. M., Higgins, L. D. (2005). Glenoid Dysplasia: Incidence and Association with Posterior Labral Tears as Evaluated on MRI. American Journal of Roentgenology, 184 (3), 984-988.   Luime, J.W., Verhangen, A.P., Miedema, H.S., Kuiper, J.I., Burdorf, A., Verhaar, J.A.N., Koes, B.W. (2004) “Does This Patient Have an Instability of the Shoulder or a Labrum Lesion?” Journal of the American Medical Association, 292 (16), 1989-1999. Munro, Wendy, and Raymond Healy. "The Validity and Accuracy of Clinical Tests Used to Detect Labral Pathology of the Shoulder – A Systematic Review." Manual Therapy14.2 (2009): 119-30. ScienceDirect. Web. 21 Apr. 2013.  Nam, E. K., & Snyder, S. J. (2003). Clinical Sports Medicine Update. The Diagnosis and Treatment of Superior Labrum, Anterior and Posterior (SLAP) Lesions. The American Journal of Sports Medicine, 31(5), 798-810. Retrieved April 17, 2013, from the PubMed database. NYU Langone Medical Center. (n.d.). NYU Langone Medical Center. Retrieved April 17, 2013, from http://www.med.nyu.edu/content?ChunkIID=432320#risk