Doctors question effectiveness of shoulder labrum surgery
If you have questions about glenoid labrum surgery options, send them in by emailing
The shoulder’s broad range of motion leaves it susceptible to a broad range of injury. As with all joints, there are various stabilizing structures and one of the most important soft tissue stabilizing structures of the shoulder is the glenoid labrum. Because of this, athletes who depend on powerful shoulders and an excellent range of motion are particularly susceptible to injuries of the glenoid labrum, especially those with hypermobile shoulders.
Injuries to the glenoid labrum can be associated with and can cause instability, dislocation, and pain. When the labrum is torn or damaged, the shoulder is susceptible to recurrent dislocations, subluxation, as well as, clicking, catching, and locking secondary to partially attached fragments becoming entrapped between the articular surfaces.
Tears are the most common form of glenoid labral injury.
There are several different types of tears the labrum can sustain and these types are typically categorized based on the lesion location and/or arthroscopic appearance. In addition, many potential mechanisms of labral injury have been identified.
- Some of the most commonly reported labral injuries include Superior Labral Anterior to Posterior (SLAP) tear, flap tear, Bankart lesion, and degenerative lesions. Mechanisms of injury can include, but are not limited to compression, avulsion, traction, shear, and chronic degenerative changes.
The symptoms of a labral tear are very similar to symptoms resulting from injuries to other structures of the shoulder. Patients usually report pain with overhead activity and popping, locking, catching, or grinding with movement. Patients will also commonly report a feeling of instability and/or weakness with decreased range of motion. Glenoid labrum tears are especially significant because they are the most common lesion observed in recurrent shoulder dislocations.
A typical scenario in our office is a patient who has shoulder instability and received corticosteroid injections, which further weakened the cartilage and led to complete shoulder destruction and the eventual need for shoulder replacement.
Doctors question effectiveness of glenoid labrum surgery
In research headed by the University of Geneva and published in the medical journal Medicine, doctors wrote:
- “Despite the fact that surgery is commonly used to treat glenohumeral instability, there is no evidence that such treatment effectively corrects glenohumeral movement (instability).
- While surgical treatment for anterior instability limits the chance of dislocation, it does not seem to restore glenohumeral (movement) during functional range of motion.
- Such persistent microinstability may explain residual pain, apprehension, inability to return to activity and even emergence of dislocation arthropathy (joint instability that leads to chronic shoulder dislocation) that is seen in some patients. “(1)
The surgery may have made some patients more prone to instability and chronic shoulder dislocation.
Glenoid Shoulder labral tear tests and diagnosis
The glenoid is that area of the shoulder where the top of the upper arm bone (humeral head) fits into the shallow socket in the shoulder blade – that socket is the glenoid. As the upper arm bone head is usually much larger than the socket, soft tissue – the labrum surrounds the socket to help the head of the upper arm bone fit better. Just as important, especially to doctors who specialize in non-surgical joint stability the glenoid labrum acts as an attachment site for several ligaments.
Shoulder labral tears can be caused from a traumatic injury, such as a dislocation, fall onto an outstretched hand, or blunt force to the joint. If you suffer an injury with enough force to tear the labrum, it is highly likely that you will also tear or strain other tissues around the shoulder as well (i.e. ligaments or tendons that surround the joint). This is especially true of the biceps tendon that attaches directly to the labrum. Labral tears can also develop over time from repetitive motions, such as in throwing athletes or manual laborers.
In our office the diagnosis of glenoid labral tears begins with history and physical examination and not a rush for diagnostic imaging. Why do we sometimes give MRI or CT scans little credence? It is not our own philosophy, it has been documented in the research.
Doctors at the Virginia Commonwealth University-Medical College of Virginia wrote in the American Journal of Sports Medicine of the difficulty and diagnostic challenges of diagnosing a glenoid labral tear. They suggested that the diagnostic accuracy of individual tests in previous studies is very variable, which may be explained in part by the modest reliability of these tests. (The imaging scans are not that accurate). Doctors however, should look and listen to those things often found during a regular physical examination, the combination of popping or catching with the ability to reproduce a patient’s pain.(2)
In research separated by nine years, technologic advances in MRI and imaging tests still cannot provide reliable answers. In 2008 doctors at the Hospital of Special Surgery in New York wrote in the medical journal Clinics in Sports Medicine:
“Lesions of the superior labrum are complex and difficult to both diagnose and treat effectively. The clinical diagnosis is challenging due to the nonspecific history and physical examination. MRI has substantially improved our ability to detect SLAP tears, although experience is necessary to distinguish pathologic findings from normal anatomic variants.”(3)
The last sentence being the key, distinguishing between something that is actually causing pain and symptoms and something that was already there and no causing a problem. Typically a situation that leads to unnecessary surgery.
Now jump to 2017, let’s see how much the technologic improvements of the last decade have helped patients:
Doctors at Rush University Medical Center write in the same medical publication, Clinics in Sports Medicine
- It is imperative that the surgeon obtain as much information as possible from the physical examination (clinical evaluation) so as to avoid treatment of an incidental, truly asymptomatic lesions. No firm consensus exists as of yet on the most appropriate operative treatment for options for glenohumeral articular cartilage defects.(4)
Nine years later, still difficult to diagnose, difficult to recommend appropriate surgery.
So we begin to see the evidence that MRIs and arthrography have proven unreliable when diagnosing labral tears and injuries. Although arthroscopy can diagnose a labral tear, it is not the best treatment for it. In fact, as mentioned, controversy surrounds arthroscopic treatment for labral lesions since clear, evidence-based guidelines for surgical repair are lacking. As mentioned above the results of surgery are not shown to improve the condition of many patients.
Treating the whole shoulder, not simply the glenoid labrum tear may be the answer to faster recovery
During arthroscopic treatment, the damaged portion of the labrum may be removed or debrided, and/or the labrum may be reattached to the glenoid. Following surgery, patients wear a sling for four to six weeks and then proceed with exercises to regain motion and flexibility in the shoulder. Glenoid labrum tear surgery recovery time can then vary among patients.
Doctors at the Department of Orthopaedics, New England Baptist Hospital, Boston wrote in the medical journal Arthroscopy: studies have shown short-term success with shoulder arthroscopy but long-term results have been associated with continued pain, instability, and decreased function over time.(5)
Spanish doctors writing in the Journal of surgical orthopedic advances suggest to their fellow doctors that when treating the glenoid labral tear – it may be prudent to treat the entire labrum and not rely solely on the MRI interpretation and the isolated damage they may see.(6) Here we have surgeons acknowledging that to effectively treat the shoulder or any joint – you treat the whole joint, not just one area of damage. This is the basic tenet of comprehensive Prolotherapy. Treat the whole joint.
In another study, doctors writing in The Journal of bone and joint surgery found that arthroscopic extra-articular Bankart repairs (surgery to sew the joint capsule to the glenoid labrum) revealed an unexpectedly high number of patients with new episodes of instability.(8)
Conservative treatments and Prolotherapy for glenoid labral tears
Because of the influx of findings on common surgical procedures, some physicians choose to treat suspected labral tears with conservative treatments such as NSAIDS, physical therapy exercises and cortisone injections. Corticosteroid shots and anti-inflammatories address the joint swelling, so the symptoms appear better and people keep taking them, but these do not repair the joint instability. The joint instability without the “protection” of the joint swelling, which helps brace the joint, puts further pressure on such vital structures in the joint like the articular cartilage. Without resolution of the labral tear, ligament injury, or tendinopathy causing the shoulder instability.
It is the failure of these conservative treatments which lead to the epidemic of shoulder surgeries.
The problem with the arthroscopic treatment previously mentioned is that it involves removal of tissue. The glenoid labrum is the one of the most important soft tissue stabilizing structures of the shoulder. So when removed, the shoulder becomes less stable and more susceptible to further injury. An alternative to arthroscopy would be Prolotherapy, a regenerative injection technique that stimulates the healing of soft tissue. Prolotherapy injections aim to initiate or recreate the inflammatory stage of the healing process. It triggers a cascade of anabolic events and stimulates the new growth of cells. In short, it stimulates healing and indirectly rebuilds depleted tissues. The body will eventually overgrow bone to stabilize the joint. This is why long-term labral tears that are not treated lead to shoulder immobility and impingement.
Prolotherapy does not typically require time out of work. Prolotherapy accelerates the return to athletics.
In our recently published research Prolotherapy for Glenoid Labrum Tear, we talk about our experiences in treating patients with shoulder pain
In summary, we note that:
- Tears of the glenoid labrum are a common cause of shoulder instability and a frequent finding in patients with shoulder pain.
- Management of these patients typically involves an attempt to avoid surgery through conservative treatment, but these treatments are lacking at promoting labral healing.
- Regenerative injection therapies, including Prolotherapy, have shown promise in the treatment of several musculoskeletal disorders.
- Patients following Prolotherapy treatment reported highly significant improvements with respect to pain, stiffness, range of motion, crunching, exercise and need for medication.
Patient relief outcomes:
- In the 33 patients followed, the patients reported multiple symptoms, three categories of pain,
stiffness, range of motion, crunching, exercise limitation, etc.
- Patients reported complete relief of 69% of recorded symptoms that is best possible outcomes almost 70% of the time
- Thirty-two of the 33 patients in the study expressed satisfaction with treatment.
- Thirteen patients reported that surgery had been recommended by a previous physician, and all 13 reported that they no longer believed that they needed surgery.
“This research represents the first study of regenerative injection therapy for glenoid labral lesions. The results of the study were encouraging, as all patients with pain reported pain reduction and all patients with exercise impairment reported improved ability to exercise, in most cases resulting in a return to pre-injury levels.” 9
Labral tear treatment
Prolotherapy for glenoid labral tears involves multiple injections of dextrose-based solution to the various ligament and tendon attachments around the shoulder. As mentioned previously, those that suffer a labral tear often damage surrounding tissues in the process. Comprehensive Prolotherapy to all of the adjacent structures stimulates the immune system, through the natural inflammatory cascade, to repair the weakened tissues. It can be thought of like “spot welding” for an unstable shoulder joint.
Other Prolotherapy solutions
We can also use cellular Prolotherapy as a more aggressive approach to stimulate healing. Commonly, this involves the concentration of healing cells from the blood, known as Platelet Rich Plasma (PRP Prolotherapy). In our office, this combined approach of PRP and traditional dextrose Prolotherapy has shown great results as an alternative to surgery for labral tears in the shoulder. Because the labrum has such a poor blood supply on its own, PRP Prolotherapy is a way to bring healing cells directly to the labrum. Stem Cell therapy using bone marrow or adipose (fat) tissue may also be used in more complicated cases. These are then injected into the joint to heal musculoskeletal injuries. In addition to injecting dextrose solutions to the surrounding ligaments and tendons, cellular Prolotherapy works well for glenoid labral tear repair.
If you have questions about glenoid labrum surgery options, send them in by emailing
1 Lädermann A, Denard PJ, Tirefort J, Kolo FC, Chagué S, Cunningham G, Charbonnier C. Does surgery for instability of the shoulder truly stabilize the glenohumeral joint?: A prospective comparative cohort study. Medicine (Baltimore). 2016 Aug;95(31):e4369.
2 Walsworth MK, Doukas WC, Murphy KP, Mielcarek BJ, Michener LA: Reliability and diagnostic accuracy of history and physical examination for diagnosing glenoid labral tears. Am J Sports Med 2008; 36: 162-8.
3 Bedi, A., Allen, A.A. Superior labral lesions anterior to posterior—evaluation and arthroscopic management. Clinics in Sports Medicine. 2008;27:607-630.
4 Saltzman BM, Leroux T, Cole BJ. Management and Surgical Options for Articular Defects in the Shoulder. Clinics in Sports Medicine. 2017 Mar 11.
5 Katz, L.M., Hsu, S., Miller, S., Richmond, J.C., Khetia, E., Kohli, N., Curtis, S. Poor outcomes after SLAP repair: descriptive analysis and prognosis. The Journal of Arthroscopic and Related Surgery. 2009;25(8):849-855.
6 Ugorji JO, Pomeranz SJ. Spectrum of Injury to Posterior Glenoid Labral Complex With Emphasis on Diffuse Labral Tears. J Surg Orthop Adv. 2016 Spring;25(1):54-7
7 Levy YD, Williamson M, Flores-Hernandez C, D’Lima DD, Hoenecke HR Jr. Glenoid Rim Anatomy: Risk for Glenoid Vault Perforation During Labral Repair. Orthop J Sports Med. 2014 Nov 10;2(11):2325967114556257.
8 Kartus, C., Kartus, J., Matis, N., Forstner, R., Resch, H. Long-term independent evaluation after arthroscopic extra-articular Bankart repair with absorbable tacks. The Journal of Bone and Joint Surgery (American). 2007;89:1442-1448.
9 Hauser R et al. Prolotherapy: A Non-Invasive Approach to Lesions of the Glenoid Labrum; A Non-Controlled Questionnaire Based Study. The Open Rehabilitation Journal, 2013, 6, 69-76 [CMRS] [Google Scholar]