Learn more about how functional training can protect your shoulders.
If you’re experiencing shoulder pain, you may be wondering if you have a torn shoulder labrum. Read on for the science behind labral tear detection and diagnosis, and why functional training should be your first choice for managing pain and building the strength you need to maintain shoulder stability.
Shoulder pain is extremely common. A 2015 study found that up to 26 percent of the population is experiencing shoulder pain at any given time. By some estimates, shoulder pain is the second most common complaint after lower back pain. In fact, a 2011 study from the Netherlands estimated that 3 out of every 100 people go to a general practitioner due to shoulder pain every year.
Many orthopedic surgeons will tell you that shoulder labral tears are the cause of your shoulder pain, and prescribe surgery.
But I recommend taking a broader view on what might be causing your shoulder pain.
In this article, I’ll take a deep look at the research around shoulder discomfort, labral tears, when to consider surgery (hardly ever), and how functional training can help.
If you’re in shoulder pain, you’ll have a better sense of whether or not you might have a tear, and if you do, whether you should take action, and how.
Remember that in a functional training environment, you’re trying to improve your range of motion, comfort, and overall movement competency. If a doctor tells you that a labral tear is a one-way ticket to joint degeneration and that you should move less to avoid making things worse, that’s a pretty disempowering perspective. It’s also one I think you shouldn’t take too seriously. In fact, I think people are better off ignoring that perspective completely.
Why? Because we’ve seen people with failed shoulder surgery regain full function with proper training. More on that later. But first, what is a shoulder labral tear…
In the shoulder, the labrum is a piece of cartilage between the head of the humerus and the scapula:
An anatomy drawing of a shoulder labrum. Illustration by Biodigital.
A shoulder labral tear is an injury to this piece of cartilage, due to direct trauma, overuse, or instability.
Orthopedic surgeons will tell you that the labrum increases joint stability and serves as an anchor for ligaments and muscles.
Doctors classify labral tears according to the sector of the labrum that’s been torn and if there’s pain or instability in the shoulder.
There are several places and ways your shoulder labral could be torn: in the front of the shoulder (anterior tear), in the back (posterior tear), and commonly both, in a tear called superior labrum anterior posterior, meaning the tear runs from the upper part of the labrum to the back and the front. This is affectionately called a SLAP tear.
They may tell you a shoulder labral tear leads to catching, clicking, and irreversible damage to the shoulder joint, including movement problems and eventual shoulder osteoarthritis.
Well, to sum it up, with ambiguous MRI readings, useless physical tests, and no evidence that injections tell us anything about the cause of shoulder pain, we’re left with no reliable way to diagnose a shoulder labral tear. Read on for the research behind each of these methods.
X-rays are designed for bone tissue, not cartilage, so they aren’t helpful when trying to assess a labral tear. Magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and computed tomography (CT) scans are used instead.
Research has shown that MRI and MRA may actually miss some tears, but the more interesting research finding is the high degree of variability you find between how radiologists and surgeons interpret images and define damage.
Interestingly, what radiologists (the people reading and interpreting your medical images) and surgeons see aren’t the same. In other words, a radiologist might identify a labral tear via MRI, but the surgeon might go into your shoulder and decide it’s not a significant tear.
In this 2014 study, 100 patients with shoulder labral tears went through MRI. The patients later underwent shoulder surgery for those labral tears. The records reveal something interesting:
In other words, radiologists may diagnose lots of labral tears with MRI, but then the surgeon opens you up, sees the tear, and decides it doesn’t need to be treated.
Reading an MRI is not black and white. It comes down to who reads your MRI. This 2015 study assessed the reliability of the opinion between two radiologists and an experienced shoulder surgeon.
Researchers did MRI on 21 patients who underwent the same shoulder labral tear surgery. The surgeon and the two radiologists had to assess whether the labrum was healed or re-torn after surgery (i.e. if the surgery was successful or not). The three professionals only agreed on the MRI diagnosis 43 percent of the time. These professionals didn’t have the same opinion about more than half of the MRI.
The primary problem with CT scans is that they can involve a powerful dose of x-ray radiation, comparable to 200 x-rays.
In a 2009 study from Brigham and Women's Hospital in Boston, researchers estimated the potential risk of cancer from CT scans in 31,462 patients over 22 years. For the group as a whole, the increase in risk was slight — 0.7 percent above the overall lifetime risk of cancer in the United States, which is 42 percent. But for patients who had multiple CT scans, the increase in risk was higher, ranging from 2.7 percent to 12 percent. (In this group, 33 percent of the patients had received more than five CT scans; 5 percent had received more than 22 scans; and 1 percent had more than 38 scans.)
Do you think they'll share the same opinion? Photo by EVG Kowalievska on Pexels.
This means two healthcare professionals could evaluate the same MRI and arrive at different conclusions. How would you know whose opinion to trust when considering shoulder surgery? Unfortunately, it’s impossible to know if one person's interpretation of an MRI is accurate.
Furthermore, it’s actually impossible to know with certainty whether the labral tear really is causing your pain.
Sometimes doctors and therapists will say that physical tests, or moving your shoulder in specific ways and noticing how that triggers pain, can help determine whether you have a shoulder labral tear.
A 2010 systematic research review tested the reliability of physical tests for shoulder pathology. Researchers evaluated 36 studies about shoulder tests performed on patients with shoulder pain. They included tests not only for shoulder labral tears but for shoulder impingement, scapular positioning, range of movement, and shoulder instability, among other pathologies.
The 2010 review found that the reliability of physical tests for diagnosing shoulder pain was problematic, to say the least. The researchers concluded that physical tests can’t be used to diagnose shoulder pathology and suggested that physical tests be abandoned for figuring out shoulder pain.
Let’s take a look at two more studies about physical tests for shoulder labral tears:
In this 2018 systemic research review, researchers looked at 17 studies of people with shoulder pain. In each study, patients with shoulder pain were evaluated for labral tears through clinical tests, then evaluated for labral tears during arthroscopic surgery.
No single type of test was good enough to accurately determine the presence of a shoulder labral tear. No particular test was statistically accurate in any of the studies.
And this wasn’t the first time this happened. Another 2009 review wanted to examine the clinical usefulness of shoulder labral tear tests.
The authors analyzed 15 studies focused on the physical exam of shoulder labral tears, and concluded that there aren’t good physical tests to effectively diagnose SLAP tears.
Long story short: For decades, studies have shown that physical tests for shoulder pathology and labral tears are inaccurate and unreliable. However, medical professionals keep using the same tests to “prove” your labral tear is the cause of your pain. The tests don’t prove anything, and research demonstrates that over and over again.
Plus, when you combine tests that are wildly inaccurate with MRI and MRA readings that are ambiguous, you have a situation ripe for error.
As we’ve seen, shoulder labral tears are common. We know they’re present in people with no shoulder pain in high numbers. We also know that physical tests for shoulder labral tears are useless. MRI can show labral tears, but that doesn’t tell us if the labral tear is causing shoulder pain.
So, how do you determine if your shoulder pain is actually coming from a labral tear? How do you differentiate it from other pain sources?
Doctors will sometimes propose an anesthetic injection inside the joint. They believe this numbs the pain coming from labrum damage.
If the labrum is the source of pain, the injection should resolve it. If the pain remains, the source is something else ( e.g. the rotator cuff, bursitis, even pain radiating from the neck).
There’s just one problem. We haven’t found any study to back-up this belief. We simply can’t find a study that tests the accuracy of injections for diagnosing shoulder labral tears. However, there is research on this with hip labral tears. And… the available evidence shows that this type of injection doesn’t work for diagnosing hip labral tears.
Would injections for shoulder labral tears be any different? Doubtful.
With all of these methods, really, all you have is a guess based on a theory.
See this video on how to recover from a bad shoulder:
It’s extremely common to hear from doctors that any popping, snapping, and clicking in your shoulder might be a symptom of a labral tear. But the labrum itself is not stiff enough to catch on anything to make a loud clicking sound. It’s like a small cushion in your joint. Imagine sitting on a pillow and trying to make a snapping sound by rubbing your butt on it. No matter how hard you rub, you won’t get a clicking or popping sound.
Here’s a visual breakdown:
If you’re experiencing popping and snapping in your shoulder, there’s probably nothing to worry about. It’s highly likely that tight muscles are rubbing against each other (or against some bony protuberance) and causing the noise.
And if that’s not enough to calm your fears, maybe this will: My son, when he was a newborn, would occasionally have popping and snapping noises in and around his shoulder when I was holding him. His shoulders are fine.
When it comes to correlating shoulder pain to labral tears, remember that the theory that shoulder labral tears cause pain hasn’t been proven! Labral tears don’t seem to have a relationship to shoulder pain.
But more importantly, whether you have a labral tear or not has no bearing on whether you have shoulder pain.
In a 2016 study, researchers took a sample of 53 adults from 45 to 60 years old and took MRI of their shoulders. None of the subjects had shoulder pain or any previous shoulder trauma. Two radiologists read the MRI.
One radiologist found shoulder labral tears in 55 percent of the study subjects. The other found them in 72 percent. Researchers didn’t find major differences regarding age, sex, type of job, or patient participation in overhead sports.
So, in a group of people with zero shoulder pain, 55 percent to 72 percent had shoulder labral tears, depending on the radiologist interpreting the scans!
If labral tears cause shoulder pain, most of the people in that group should have had shoulder pain. But they didn’t. The study concludes that shoulder labral tears might be a normal finding in asymptomatic middle-aged people!
In other words, what we call labral tears may just be the way a labrum is supposed to look! We’ve just misinterpreted it as “damage.”
This isn’t a new discovery. For example, a 2002 study evaluated MRI findings in both shoulders of 14 professional baseball pitchers. That’s a total of 28 shoulders evaluated.
Now, THAT'S some shoulder range of motion. Photo by Pikrepo.
Each pitcher had at least one year of professional experience. All athletes had asymptomatic shoulders and no history of previous shoulder injury, symptoms, or surgery.
Two radiologists experienced in interpreting shoulder MRI reviewed the images. They found labrum “abnormalities” in 22 of the 28 shoulders. Ten of those shoulders had labral tears. One pitcher had a labral tear in both shoulders! Twenty-two “abnormal” labrum-shapes. Ten shoulder labral tears. Zero pitchers with shoulder pain.
These are people who are pushing their shoulders to the very edge of maximum performance.
Again, studies like these demonstrate that the presence of a labral tear has little (or nothing) to do with shoulder pain.
A 2019 review of the literature on SLAP tears and surgical summarizes everything you’ve read so far: Labral tears have no consistent correlation with pain, and the tests to diagnose them are ambiguous at best.
If you have shoulder pain and someone has told you that it’s coming from a labral tear, you may feel like your only option is surgery. After all, if something in your shoulder is torn, how could you possibly be able to do anything to fix it besides having surgery? You can’t possibly go in yourself to fix that tear!
But what are the odds of shoulder labrum surgery success?
While surgeons may suggest that shoulder surgery is often extremely successful, it’s important to look at the research. As with many orthopedic surgeries, initial reports of great success may not play out in the long run. In addition, what is considered success for a surgeon may not be the same for you as someone with shoulder pain.
Check out this video on whether or not labral tears should even be blamed for shoulder pain:
First of all, you should know that the research on surgery for shoulder labral tears doesn’t provide crystal clear answers for how to approach labral tears surgically. There is no obvious, clear answer about which surgical procedures do the best for specific shoulder problems.
A 2016 systematic review looked at 26 research articles on the surgical treatment of SLAP tears. The study was looking for “best practices” for surgery for shoulder labral tears based on overlap from the other studies.
The review found many studies did not include enough details on the actual repairs, criteria for determining if repairs were complete, and the actual details of post-operative rehabilitation.
There wasn’t enough information in these studies to be able to make meaningful comparisons and conclusions. If, for example, one surgical study performed a repair one way and another study reported it another way, the researchers couldn’t conclude whether one method was better than another.
So, how do you go from having shoulder pain to a doctor telling you you should get shoulder surgery?
It’s actually very easy. Most doctors follow guidelines similar to the ones below to determine if you are a good candidate for shoulder labral tear surgery:
That’s it. We know from the research that physical tests are unreliable and shoulder MRI shouldn't be relied on. But only six weeks of conservative care? That’s a month and a half. That’s a very short amount of time to see real results, especially before jumping into the potential risks and complications associated with shoulder surgery.
The surgical options for shoulder labral tears are:
The surgery can be open or through arthroscopy. The first involves opening the joint to access it easily. It's pretty gruesome. In the latter, the surgeon inserts a tiny camera to see the joint during the surgery. It’s less aggressive than open surgery.
Most studies about surgical procedures for shoulder labral tears focus on the process and outcomes of SLAP tears, as they’re the most frequent. The conclusion of this 2016 systematic research review is that there’s not a clear answer for which surgical procedure is best for SLAP tears. There isn’t a consensus on how to surgically approach shoulder labral tears.
This 2013 research review wanted to analyze the outcomes of SLAP arthroscopy. Researchers did a four-year follow-up with 179 patients who underwent the same SLAP surgery. Their results were disappointing:
From these results, we can tell that SLAP surgery doesn’t improve shoulder range of motion. It may actually worsen it, and a large percentage of surgeries failed. Not great results.
A 2015 analysis of diagnostic and therapeutic standards for SLAP tears, had some dismal conclusions about surgical treatment for shoulder labral tears: “In overhead athletes poor results after SLAP repair have been reported in more focused studies with persistent shoulder pain and long-term inability to return to previous level of sports.”
This 2017 randomized trial evaluated the outcomes of labral surgery versus placebo surgery for SLAP tears. A placebo surgery is a fake surgery intervention. It mimics the initial incision and keeps the patient in the surgery room for the same time as a real surgery. It’s a clinical way to assess the placebo effects from surgeries.
In the 2017 study, researchers worked with a population of 118 patients with criteria for undergoing SLAP surgery:
Researchers did a two-year follow-up. You would expect the real surgical interventions had better results than placebo surgery. However, SLAP surgery–whether repair or tenodesis–had similar results to placebo surgery, or opening the shoulder and doing nothing. The placebo surgery worked just as well as the two real procedures.
But real surgeries also have real complications.
This 2015 study reviews the complications after arthroscopic labral repair to treat shoulder instability. The most common complications were:
Problems with anchors
Anchors, or carbon-fiber structures inserted during surgery, have the risk of perforating the glenoid capsule–one of the many structures that stabilize the shoulder. Anchors can also leave debris within the joint. A study mentioned in this review found anchor debris in more than 50 percent of cases. This debris damages the joint. They also found chondral damage, or damage to cartilage, in 70 percent of the patients. The more time after the surgery, the more chondral damage.
Translation: Rapid destruction of the cartilage cells. It results in a complete loss of cartilage. This leads to a progressive and severe loss of shoulder function. This is apparently common in patients who had intra-articular pain pumps, or disposable medical devices implanted during arthroscopic surgery intended to deliver a local anesthetic after the surgery.
This is cartilage damage due to wear and tear. The rate of shoulder osteoarthritis after labral repair is 26 percent for arthroscopy and 33 percent for open surgery. That's an incidence of one in four for arthroscopy, and one in three for open surgery for a shoulder labrum.
This is a severe loss of range of motion, accompanied by severe pain. This is usually treated with physical therapy and conservative treatment. But if that fails, the patient goes to surgery, again.
This is the most ironic complication possible. Shoulder instability is one of the most frequent complications after labral repair to treat shoulder instability. Recurrent instability can range from 2.9 percent to 13 percent depending on the specific procedures.
So, would you undergo a shoulder labral tear surgery knowing that:
You might be saying, “But aren’t there studies with high success rates for shoulder labrum surgery?”
Of course there are! Whether their results are reliable is another matter. Keep in mind that surgeons may have a different concept of “success” than a patient with shoulder pain.
This 2012 study looked at the results of SLAP repair after five years. Thirteen percent of the patients still suffered from post-operative stiffness and pain.
The researchers looked at 107 patients, and they used the Rowe score (see below) to measure the results. The average score was 62.8 preoperatively and 92.1 at follow-up.
Using this version of assessment, a 90 Rowe score can show that you still have limited mobility and discomfort, but your shoulder doesn’t subluxate, or shift around and is slightly dislocated. The surgery could have improved shoulder stability, but at the cost of less range of motion and, still, mild pain. That’s considered a “positive” outcome.
The Rowe score designed to measure shoulder stability. However, there are two important flaws in this score:
This 2008 study wanted to measure the outcomes of SLAP surgery in 33 patients. They used the DASH score to evaluate the results. This score evaluates the Disabilities of the Arm, Shoulder, and Hand (DASH). It has 30 questions related to daily activities, including writing, making the bed, and pushing a door. Each question has five options. The more points, the worse the outcome.
Well, these patients scored an average of 10 points less after surgery. If you play with the score a while (here’s the link), a 10-point reduction is not a gigantic improvement. You can see for yourself how easy it is to get a 10-point improvement.
To say you had "success" with a 10-point improvement is silly. You could get that same 10 points by waking up on the right side of the bed.
For many, a variation of 10 points could happen without surgery!
Do surgeons believe surgery for shoulder labral tears actually works? Sure. Does it work sometimes based on some metrics? Sure. But do the metrics align with your goals? And is the evidence strong that you’ll get what you want from shoulder surgery?
I’ve done my homework on shoulder pain, shoulder labral tears, and other shoulder joint pathologies. Through this process, I’ve learned a lot about the myths, misinformation, and plain deceptions around shoulder pain. And with time, experimentation, and experience, I’ve seen that you can take care of your shoulder labral tears in healthier ways than what the medical world currently offers.
In some cases, surgery may not work as promised. It can actually cause more problems than solutions–not to mention the cost in terms of time, money, and your emotional well-being.
I believe there’s a better long-term solution for shoulder pain than surgery.
Before going further, don’t take this as medical advice. It’s coming from a very non-medical perspective. The ideas offered here are decidedly not medical but they are evidence-based. If you’ve been told that a shoulder labral tear is causing your shoulder pain, think about these major questions:
A surgeon who says “surgery guarantees to fix your shoulder pain” is well-intentioned and may truly have your best interest in mind. But research shows surgery is a worse option than conservative treatments like exercise and massage.
I’ve worked with people with shoulder labral tears to avoid surgery. I’ve also worked with people after shoulder surgery failed to help. And I strongly encourage people to acknowledge their fears and anxieties around shoulder labral tears. I also also encourage them to remember there’s very little evidence that labral tears actually are the definitive cause of shoulder pain.
I’ve seen that the game changer is training—gradually and carefully—your shoulder muscles to work in balance. Based on your body and your background, this process requires time, learning, and patience. It's not about silver bullets or quick results, rather it’s a highly individualized process that requires you to be fully engaged.
Here are some suggestions:
See this story of a failed shoulder labral tear surgery, with suggestions for ways to strengthen your shoulders and reduce the risk of injury:
Remember: just because a doctor believes something is true or says something is fact doesn’t actually mean it is.
Surgery sounds quite promising. Many people believe surgery will give them full function back, only to discover that retraining muscles is even more important after a long period of rest (and atrophy) after the surgery.
Many people I’ve talked with have been told that they should never go back to high impact, high-intensity activities ever again after surgery. That’s not a great outcome for anyone who's active.
No more overhead weight lifting. No more pull-ups. No more cartwheels. No more basketball.
Instead, you can experiment with functional training as an alternative to surgery, and restore shoulder mobility gradually and progressively so you save you thousands of dollars and months or years of suffering.
And while retraining muscles is not a quick fix, it’s a solution that gets rid of pain naturally. It’s a process that expands your ability to enjoy all the activities that you love in life—even the high impact, high-intensity ones (once you’re ready!).
As a trainer and movement coach, I am intensely interested in how people train the muscles that control movement to help people find range of motion and feel better It’s simple: Movement is ultimately what needs to be improved, so focus on the organs that help you move—your muscles!
By working with muscles gradually and safely, you can drastically improve your pain levels, confidence, and quality of life.
If you are experiencing hip pain, read my article on muscle dysfunction: ATM Theory: Your Joint Pain May Actually be Muscle Pain
Still not convinced? Why you DON’T Need Orthopedic Surgery for Joint Pain