Shoulder Labral Tears Part 2: Does surgery work?

In this article, we're going to look at the statistics and studies on shoulder labral tear surgery to help you discern the risks involved. To learn all about shoulder labral tears check out part 1 of this blog series for more background information.

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!

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:

Is surgery for labral tears the obvious solution?

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 procedure does the best for specific shoulder problems.

A systematic review from 2016 looked at 26 research articles on the surgical treatment of SLAP lesions (superior labral tear from anterior to posterior). The study was looking for “best practices” for surgery for SLAP 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 postoperative 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 we can’t tell whether one method is better than the other.

From the abstract:

“These findings may be some of the factors responsible for the variability in treatment outcomes and suggest that efforts could be directed toward consistency in documenting and reporting surgical indications, surgical techniques, surgical endpoints, and efficacious rehabilitation programs” (Kibler 2016).

How do you go from shoulder pain to shoulder surgery?

It’s actually very easy. Here are the current guidelines for shoulder conditions. If you have: 

• A history of a traumatic event on the shoulder.
• Shoulder pain.
• Positive physical tests (which we know are inaccurate).
• MRI that shows a shoulder labral tear (which we know are ambiguous).
• And, maybe, you did 6 weeks of conservative care. Or maybe not.

You are the perfect candidate for shoulder labral tear surgery.

That’s it. We know from part one of this blog series that physical tests are unreliable and shoulder MRI’s shouldn't be relied on. But only 6 weeks of conservative care? That’s a month and a half. That’s a very short amount of time to see real results. Not to mention the risk and complications after shoulder surgery.

What are the usual procedures for shoulder surgery?

If the surgeon doesn’t consider that the labral tear “healed,” the next step is usually surgery. The surgical options for shoulder labral tears are:

• Labral repair. Here, the surgeon reattaches the torn tissue. Sometimes the labrum is removed and reattached. If deemed necessary, the surgeon tightens the ligaments and the capsule too.
• Labral debridement. Here, the surgeon cuts off the torn pieces of the labrum.
• Biceps tenodesis. This is an option if the biceps tendon is affected too, e.g. a SLAP tear. The surgeon cuts the attachment of the biceps tendon to the labrum and reattaches it to the humerus.

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 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.

What’s the success rate for shoulder labrum surgery?

This 2013 systematic review wanted to analyze the outcomes of SLAP arthroscopy. To do so, they did a 4-year follow-up of 179 patients who underwent the same SLAP surgery. Their results were disappointing:

• On average, patients had less range of motion (ROM). On average, flexion and external rotation both decreased by 5º and abduction decreased by 15º.
• 66 patients met the failure criteria.
• 50 underwent revision surgery.

From these results, we can tell that SLAP surgery doesn’t improve shoulder range of motion. It may actually worsen it, and 37% of the patients' surgeries "failed." Not great results. 

This 2017 randomized trial evaluated the outcomes of labral surgery versus sham surgery for SLAP tears. A sham 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 effect from surgeries.

They had a population of 118 patients with criteria for undergoing SLAP surgery:

• 40 underwent labral repair.
• 39 underwent biceps tenodesis.
• The remaining 39 had sham surgery.

Researchers did a 2-year follow-up. You would expect the REAL surgical interventions had better results than sham surgery. However, here were the results:

“There were no significant between-group differences at any follow-up in any outcome. (...) Postoperative stiffness occurred in five patients after labral repair and in four patients after tenodesis.”

​

SLAP surgery – whether it’s repair or tenodesis – has similar results as just 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...

What are the complications from shoulder labrum surgeries?

This 2015 study reviews the complications after arthroscopic labral repair to treat shoulder instability. The most common complications were:

Problems with anchors

Anchors 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 intra-articular anchor debris in more than 50% of cases. This debris damages the joint. They also found chondral damage in 70% of the patients. The more time after the surgery, the more chondral damage.

Chondrolysis

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 with a local anesthetic after the surgery.

Osteoarthritis

This is cartilage damage due to wear and tear. The rate of shoulder osteoarthritis after labral repair is 26% for arthroscopy and 33% for open surgery. That's an incidence of 1 in 4 for arthroscopy, and 1 in 3 for open surgery following surgery for a shoulder labrum.

Stiffness

This is a severe loss of ROM and severe pain. This is usually treated with physical therapy and conservative treatment. But if it fails, the patient goes to surgery. Again.

Recurrent instability

This is the most ironic possible complication. Shoulder instability is one of the most frequent complications after labral repair to treat shoulder instability.  It can range from 2.9% to 13% depending on the various procedures. 

So, would you undergo a shoulder labral tear surgery knowing that:

• It’s likely that you’ll lose range of motion?
• It has similar results as sham surgery?
• You could end up with debris in your joint?
• Your shoulder may still be as unstable as it was before?

“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. I talk deeply about this in another post, but to sum it up:

This 2012 study looked at the results of SLAP repair after 5 years. They included 107 patients, and they used the Rowe score to measure the results. The average score was 62.8 preoperatively to 92.1 at follow-up. 13% of the patients still suffered from postoperative stiffness and pain despite these results.

Let’s take a quick look at the Rowe score. It’s designed to measure shoulder stability. However, there are two important flaws in this score:

• It has 4 versions. One patient could do each version and have completely different outcomes in each one. On top of that, most studies using the Rowe score don’t mention the version used.
• Here’s one version of the Rowe score in case you want to check. It has 3 sections with 4 choices each. If you play with it a bit, you’ll see that it’s fairly easy to have a high score with a subtle improvement.

Using the version of the link above, a 90 Rowe score can show that you still have limited mobility and discomfort, but your shoulder doesn’t subluxate. The surgery could have fixed the shoulder stability, but at the cost of less range of motion and, still, mild pain. That’s considered a “positive” outcome.

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 activities to the daily living – i.e. write, make the bed, push a door. Each question has 5 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 on a weekly basis!

Do surgeons believe surgery for shoulder labrum tears 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?

Not so sure...  

If you have a shoulder labral tear, what should you do?

Let’s assume you have been told you have a shoulder labral tear. What should you do? Is shoulder surgery the right answer? Or something else? 

Surgery for a labrum tear is an option...

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:

• Is there any way to know that the labral tear is actually causing your shoulder pain? Based on the research – NO! Shoulder labral tears are common in people with no symptoms.
• What’s the likelihood that surgery will fully fix your shoulder pain? That’s tough to say, but there’s evidence that FAKE surgery is just as good as the real thing.
• What else could cause your shoulder pain? Movement problems are muscle problems. Muscle problems require retraining.

A surgeon saying “the surgery guarantees to fix your shoulder pain” is well-intentioned and may truly have your best interests in mind. Many well-intentioned surgeons strongly recommended spinal fusions to “cure” back pain for decades. Research eventually showed it was a WORSE option compared to conservative treatments like exercise and massage. But surgeons keep making billions of dollars a year performing unnecessary surgery that's been proven to be a worse choice than exercise.

What about non-surgical answers for shoulder labral tears?

We’ve worked with people with shoulder labral tears to avoid surgery. We’ve also worked with people after shoulder surgery failed to help. We strongly encourage people to acknowledge their fears and anxieties around shoulder labral tears. We also also encourage them to remember there’s very little evidence that labral tears actually are the definitive cause of shoulder pain.

From what we’ve seen, repairing or removing the labrum is not the most important factor. The fact that the labrum may be torn doesn’t even seem to be marginally important. We’ve seen that the game changer is training your shoulder muscles to work in balance. Gradually and carefully. Based on YOUR body and YOUR background. That process requires time, learning, and patience. It's not about silver bullets or quick results. It’s a highly individualized process and requires you to be fully engaged.

Here are some suggestions:

• Find a trainer, coach, or a physiotherapist who can coach you to move with good form in new ranges of motion. Please don’t jump into high-intensity interval training or some kind of boot camp/group class/Crossfit situation. This has to be customized for you.
• Identify areas that aren’t moving well and work to improve them.
• Learn how to stretch properly and appropriately for your body and your life. 
• Identify muscles that are weak and build strength.
• Identify positions you find difficult and carefully work to make them more comfortable (by training the muscles there).
• Aim to improve on something every single day. Consistency is the most important part of this process. 

The Summary on Surgery for Shoulder Labrum Tears

When looking at the research on surgery for labral tears of the shoulder, it's important to read the evidence closely. Long term studies show that surgery for shoulder labral tears are not simple "slam dunk" solutions.

Even the studies that support surgery for shoulder labral tears show a very modest benefit when you look closely at how success is being measured. And often success is measured using criteria that don't accurately account for people's desires to feel AND move better! 

One of the reasons why we encourage our clients to think outside the "orthopedic surgery" box is that these kinds of results and research appear to be quite common. This exact pattern has occurred already in medical history with back pain and back surgery and knee pain and knee surgery.

Research is now catching up to hip and shoulder issues.

As trainers and movement coaches, we are intensely interested in how people train the muscles that control movement to help people move and feel better (simple!). Movement is ultimately what needs to be improved - so focus on the organs that help you move - muscles!

By working with muscles gradually and safely, we believe people can drastically improve their pain levels, confidence, and quality of life.