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

2. Anatomy/ Biomechanics
Glenohumeral joint
Ball and Socket Joint
Labrum
Deepens glenoid
Increases Stability

3. Injury SLAP lesion Bankart lesion Superior labral Inferior labral
Anterior to Posterior
Bankart lesion
Inferior labral

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

5. Differential Diagnosis
Glenohumeral instability
Rotator Cuff Pathology
Shoulder impingement

6. 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

7. 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)

8. 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

9. 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.

10. 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 ). 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),  
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),
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),  
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),
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):  ScienceDirect. Web. 21 Apr  
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), Retrieved April 17, 2013, from the PubMed database.
NYU Langone Medical Center. (n.d.). NYU Langone Medical Center. Retrieved April 17, 2013, from