LABRAL TEAR REHAB
Jim Dart, PTA
Perhaps one of the most difficult injuries to rehab properly and come back 100% and then some…Labral Tears. What is a Labram and Why is it so hard to rehab? Think of the labrum as a gasket for your shoulder. It’s a circular fibrocartligenous ring that fits around the socket of the shoulder. Its sole purpose is to make the joint socket deeper, making it more stable throughout all range of motions. The structure itself doesn’t get much blood flow to it – and isn’t inherently vascular so there is no way to repair itself. If its partially torn then the most conservative approach is to manage the pain
If a tear is great, and you wish to return to competitive physical activity then Surgery is the only option to return to 100%. If a tear is partial – it can be rehabbed by a conservative approach, and this means therapy to make the supporting musculature stronger and let the lagging parts that were previously untrained – support you once again.
Lets cut to the chase. Say you’ve got an injury, and it’s a clear cut diagnosed Labral Tear – not an impingement and not bursitis. How does the rehab start? Partial Labral Tears are a B*tch to rehab, especially if you don’t have knowledge. Usually a complete tear after surgery will take up to one year to bring you back to 90%, it is up to the compliance of the individual to really challenge for the next ten percent. I’ll start from square one, from the acute phase.
Usually an acute phase is within the first 48 hours, but for the Labrum its within the first 10 days. This is because of the avascular tissue. During this acute phase, the labrum is torn – exacerbated and inflamed. This inflammation gives way to a cascade effect which contributes to the end result which is functional disability.
Inflamed tissue in an enclosed space > Impingement > Pain > Instability > Guarding > Decrease Range of Motion
Acute Phase 1-12 Days
The key to this phase is to NOT re-exacerbate the tear. Let the body do its magic. You can help it with discharging the inflammatory foods from the diet, icing frequently (often under the arm pit since the cryogenic effect doesn’t have to combat nearly as many tendons and bones to reach the labrum), and using Fish oil for its anti-inflammatory effect. Your job in this phase is to keep the range of motion up outside the pain range, and to start doing some light isometrics, eccentric conditioning to the muscles OUTSIDE the pain range – meaning the range in which the labrum doesn’t impinge, pain, or the shoulder feel the least unstable.
With every movement you do you will want to squeeze your scaps together, as if you are arching under a bar – or setting up for a bench press. This will rotate the humerus into the glenoid socket and keep it fixed taking the pressure off of the labum. This is KEY. With every movement you must do this and strive to keep good form, this is how you properly retrain some untrained muscles while keeping the stimulus up during the rehab process.
The trick is to start from square one, do not immediately jump to trying to strengthen the muscles at the end range. You’re going to have to overhaul how the shoulder loads itself now because something that was once supported is not. Start with slight motions at the beginning of the ROM, fixing the scapula and really working the eccentric control
Slowly expand on this ROM with different angles & greater ranges in said motion for each rehab exercise you do. Manipulate the weights used as comfort and confidence grows. Do not rush this process. The Shoulder will feel awkward a tad and you may feel biceps pain from it compensating for the shoulder.
Blackburn Exercises & I’s – T’s – Y’s are paramount for preparing the scapular musculature, do these flat or on a slight inclined bench. Start with just Active ROM outside the pain range and move into it as you become more comfortable and heal up. Always challenge the scapula at different angles, different tempos and different weights. These can be done at the tail end of the Acute Phase, 3 sets of 10 each movement.
Once you are comfortable with the movement within the pain range – start changing the amplitude of the movement. Slow Eccentric <> Fast Concentric. Build on this with different angles, weights and exercises until the shoulder feels good enough to venture forth into the pain range.
Keeping the weighted movements outside the pain range you can now go into the pain range with light stretching and mobilizations. Mobilizations – or “Mobs” are used to either decrease Pain (Grade 1-2) or Increase ROM (Grades 3-4).
Grade 1 – Small/Slow Movements at the beginning of the ROM.
Grade 2 – Quick Movements in Midrange and up to the pain range.
Grade 3 – Quick Movements up to the pain range.
Grade 4 – Small Movements at the end of the ROM, into the pain range.
Sub Acute Phase 12-28 Days
Primarily using these mobilizations with minibands and therabands this will be the lion share of the rehab within the pain range for the next couple weeks. These challenge the tissue and joint capsule while working in the pain range sufficiently breaking up the adhesions. After the body has adapted to these mobs for a couple weeks then you can start working in light unilateral DB overheads, and Scaption Delt Raises (Flex the shoulder to 90 degrees and Abduct 30 degrees)
This will ensure that the supraspinatus and biceps tendons don’t impinge during the activity and will again fixate the humeral head in the shoulder socket, taking most of the torn labrum out of the equation.
The Sub Acute Phase should have these motions included: Mobs, Flexion, Extension, Scaption, Abduction, Circumduction & Closed Chain Movements such as Protraction Pushups and Wall Ball Circles.
Protraction, IR & ER. Essentially these are the ingredients for the shoulder rehab!
Phase 3 – 21 Days +
Slowly but surely, do not press the recovery its very much a gradual return to activity. I picked one exercise as a core exercise which I would gauge my recovery. I would start to work this exercise each Upperbody day and use every other week as a retest of sorts – every 2 weeks I would try and go a bit further and further with the weights I could use. The other exercises I would do would naturally compliment the core lift, in addition to the shoulder rehab movements you’ve now been doing for weeks now. It would pretty much look like a regular routine.
My core lift was Static Swiss Bar because it would rest a bit higher off my sternum – keeping the shoulder from approximating too much, but still be stabilized naturally by the movement. After the Swiss Bar Static Press I would do some complimentary Pressing with Dumbells on a flat and inclined position. Add in some rows and posterior delt exercises and call it a day. Don’t go overboard with the volume either; keep in mind with the shoulder stabilization and rehab exercises you do the shoulder will be worked enough. Strengthen the Pecs and biceps as they stabilize the shoulder joint. Remember to stretch them as well.
I would retest the core lift every other week until I was about at 90%+ of my past 1rm with that implement. From the Swiss bar I went to the barbell and by that time I was able to let it sit lower on the sternum because my shoulder had conditioned itself and stretched itself out enough. Once I was able to give an honest attempt at a 1rm with the barbell I then started to incorporate Push Presses and sparingly Split Jerks as they need the most stabilization. This process may take months. But you will find once you get into a rhythm with the rehab training you will gain in strength very quickly and make for a speedy comeback.
Once you are in the Phase 3 you can start adding in the more difficult and challenging Rehab movements. Some Videos below will give you some idea of what they should look like.
The most important thing is to keep the shoulder mobile! You are going to be within a pain range when you get to the later part of Phase 2 into Phase 3, but don’t worry this is merely challenging the joint capsule and surrounding musculature as well as break up any adhesions that maybe starting to deposit. Stretching, Icing, and RESTING in between upper body days is paramount. Don’t overdo the volume, and you must give your body time to not only adapt – but recover from injury!
Jim Dart, PTA
- DR. Heber, Murray. Rotator Cuff and The S.I.C.K. Scapula. http://www.elitesportstherapy.com/Rotator-Cuff-Injuries-and-the-S-I-C-K–Scapula. Accessed 11/6/2012
- Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: patho-anatomy and biomechanics. Arthroscopy. 2003 Apr;19(4):404-20
- NISMAT. Upper Body Strengthening Program. http://www.nismat.org/orthocor/programs/upper/upperex.html. Updated 03/08/2007. Accessed 11/6/2012.
- R.M. Boonstra Haarlem Holland. Scaption of the Shoulder Joint. http://glenohumeral.topcities.com/EnglFold/scaption.htm. Accessed 11/6/2012.
- Samayoa Priscilla. Study Blue. Regional Anatomy 1. http://www.studyblue.com/notes/note/n/regional-anatomy-1/deck/2983260. Accessed 11/6/2012