The Issue with MRI Findings

As previously mentioned, MRI results are poor predictors of pain and functionality. Healthcare professionals should prioritize treating the individual rather than solely focusing on imaging results.

Research consistently shows that asymptomatic individuals frequently exhibit tears on imaging studies. This is also evident in athletes; for example, rugby players and ballet dancers can have hip labral tears without experiencing pain or dysfunction.

Major League Baseball (MLB) players, including those in little leagues, may show MRI findings without any pain or performance issues. Notably, MRI results do not predict future injuries in MLB athletes.

Whether an MRI reveals a rotator cuff tear or a labral tear in the shoulder, surgery is often unnecessary. Let's first address rotator cuff issues for brevity.

Strength Matters!

While research is limited, existing studies suggest that surgery for rotator cuff tears can improve strength and muscle mass, particularly for medium to large tears.

Two studies compared physical therapy with surgical intervention for small to medium rotator cuff tears. Both approaches yielded significant improvements in patient-reported outcomes and strength, with no notable differences between the two. A 2021 study echoed these findings.

Five-year follow-ups indicated that while surgery produced higher strength and function scores than physical therapy, these differences were not deemed clinically significant. Both groups showed substantial improvement.

One study noted that 37% of rotator cuff tears treated with physical therapy increased in size by over 5 mm over five years, while no such progression was observed in patients who underwent surgery.

Another study reported that tear size increased in the physical therapy group after two years, whereas it decreased in the surgically repaired group. These results were statistically significant.

After an average of 8.8 years, patients who received conservative treatment showed muscle atrophy in 49% and fatty infiltration in 41% of cases.

Atrophy is a critical factor.

Another analysis indicated that about 23% of patients with rotator cuff repairs do not heal adequately. Factors linked to healing failure include lower bone density, older age, female gender, larger tears, increased fat in muscles, diabetes, shorter distances between the shoulder blade and upper arm bone, and additional procedures on the biceps muscle. However, only bone density, fat accumulation in the infraspinatus muscle, and the extent of tear retraction significantly affected healing outcomes.

What does this all imply?

Without consistent and appropriate resistance training, the shoulder cannot fully heal, regardless of surgical intervention.

The studies examining rotator cuff and labral tears often feature inadequate exercise programs, with low intensity and volume.

To build muscle and strength, regular resistance training is essential. Surgery does not promote muscle growth. While surgery may preserve muscle better than no intervention, it is not necessary for muscle maintenance.

Seek out a physical therapist proficient in exercise prescription. Your exercise regimen should include high-intensity workouts approaching failure, with over 12 sets per muscle group weekly.

To improve bone mineral density, incorporate upper extremity plyometrics, punching, and heavy lifting.

This data also applies to labral tears. If you develop a labral tear over time, rehabilitate it. Research supports non-operative management for non-traumatic labral tears.

As you may have guessed, there is one key variable that can alter your treatment approach.

Addressing Shoulder Dislocations

Traumatic shoulder injuries complicate matters. If you experience full-thickness rotator cuff tears with significant retraction or a large labral tear from a dislocation, the decision becomes more complex.

Again, consult orthopedic specialists and physical therapists. I am only sharing research and clinical insights, not medical advice.

For patients under 30, the risk of re-dislocating after non-operative treatment ranges from 70% to 90% (higher for overhead athletes), compared to about 25% with surgical intervention.

A major factor is the cause of the labral tear. If it develops gradually, similar to many rotator cuff tears, research indicates that non-operative treatments are not necessarily inferior to surgical options. However, if the tear results from a traumatic dislocation, the situation is more nuanced.

The primary objective should be to prevent future dislocations.

One study revealed that after two years, 54% of patients who did not have surgery experienced recurrent shoulder instability, while only 3% of those who underwent surgery faced issues. After eight years, 74% of the non-surgical group reported unsatisfactory outcomes according to the Oxford shoulder score, whereas 72% of the surgical group had good or excellent outcomes after ten years. The researchers concluded that surgery is preferable for active patients as it reduces the risk of recurrence.

Additionally, the more often a person experiences instability, the greater their likelihood of developing osteoarthritis, as repeated dislocations can stretch the joint capsule, injure surrounding ligaments, and potentially cause bone damage. Any surgery can accelerate arthritis progression, but recurrent dislocations likely cause more harm.

So, when would I recommend surgery to my patients?

Research identifies several factors increasing the risk of recurrent shoulder instability with non-operative treatment, including being younger than 30, leading an active lifestyle, losing over 20% of the glenoid surface, and having Hill–Sachs lesions.

Frequent shoulder dislocations can lead to additional rehabilitation time and potential damage to other shoulder structures, such as the rotator cuff and axillary nerve. Extra bone loss exacerbates instability and accelerates osteoarthritis development.

Your confidence in your shoulder may wane, leading to more apprehension and decreased physical activity. Reduced activity results in muscle, strength, mobility, and bone mineral density loss.

All of this is detrimental.

However, surgery is not without risks.

First, surgery carries inherent risks associated with anesthesia. The procedure itself is traumatic and can hasten the onset of osteoarthritis, with longer rehabilitation times and significant muscle loss due to immobilization.

The situation becomes more complex for athletes requiring a high range of shoulder mobility. Some volleyball players, baseball pitchers, and wrestlers may find that small labral tears enhance their mobility, providing a performance edge. If there’s no pain after rehabilitation and no recurrent dislocations, surgery may not be necessary.

Long-Term Follow-Up Data

One study tracked 40 patients under 30 for an average of 75 months after an initial traumatic shoulder dislocation. Patients were randomized to receive either immediate stabilization plus rehabilitation or immobilization followed by rehabilitation. Recurrent dislocations occurred in three surgical patients and nine in the traditional group (all within 24 months).

Despite the difference in dislocation rates, there were no differences in shoulder function between the two groups.

Other studies have shown that athletes can successfully return to sports following non-operative treatment.

In one study with an average follow-up of 3.1 years, 39 patients chose non-operative treatment; 20 opted for surgery within five years, leaving 19 who remained solely non-operative. All patients who successfully underwent non-operative treatment returned to sports, with 10 out of 15 overhead athletes regaining their pre-injury competitive level.

Keep in mind, this data pertains to the highest-risk group. For young, active patients, non-operative treatment can be effective.

This aligns with findings regarding long-term outcomes for rotator cuff and meniscus tears, where surgery often does not surpass non-surgical alternatives, even with suboptimal exercise programs.

Recommendations for Shoulder Exercise

I cringe whenever I review exercise protocols for non-operative groups. They often lack adequate intensity and volume, rendering them ineffective for building muscle mass or strength.

Many programs focus heavily on "scapula control" and feature an abundance of isometric exercises targeting only the rotator cuff muscles.

To protect the shoulder, it’s crucial to develop strength and muscle mass around the entire shoulder, including the pectorals and deltoids. The bench press and shoulder press are two of the most effective exercises for this purpose.

Strength should also be developed throughout the full range of motion, through exercises like pec flys or strict pull-ups (ensuring full range for every rep).

Incorporate dynamic strength training with movements like snatches and overhead squats, utilizing barbells and dumbbells for single-arm control.

Please avoid these exercises in the early stages of rehabilitation! The middle (pressing) and late-stage (snatch) exercises are often absent from research protocols.

Building muscle, strength, and power requires significant effort. It typically takes months to observe tangible muscle development beyond the initial recovery phase after an injury or surgery. Pain resolution is merely the beginning of rehabilitation.

A lack of pain does not equate to full recovery, nor does an MRI tear signify that you are broken.

Conclusions for Patients with Labral Tears

If you have a labral tear, should you proceed with surgery?

This article should not make that decision for you. Consult multiple orthopedic surgeons and physical therapists. I’m simply sharing research findings and my clinical interpretations.

In almost all scenarios, the evidence suggests attempting rehabilitation first.

Ensure your exercise program is appropriately designed. Commit to it for at least six months, incorporating high-intensity workouts that include heavy pressing and pulling. If you’re an overhead athlete, you’ll need a specific plan for returning to your sport (e.g., throwing or hitting).

Surgery may be necessary if recurrent shoulder dislocations occur.

If you engage in a rigorous rehabilitation program and aren’t participating in sports, the likelihood of recurrent dislocations is low.

For those without dislocations, the approach resembles that for other pathologies evident in imaging. Tears visible on MRIs do not inherently necessitate surgery. While surgery may be justified in certain cases, it should be viewed as a last resort.

I strongly encourage exploring non-operative options whenever possible. Just ensure that rehabilitation is given a genuine chance. A few low-intensity exercises will not suffice; building muscle and strength is essential for effective rehabilitation.

Pain and imaging results are poor indicators of health. Focus on becoming strong and resilient.

For more health and fitness insights, check out the Clinical Gap Podcast, where I release episodes weekly. For brief summaries of health and fitness research, subscribe here.