Documentation:FIB book/Biomechanical Review of Shoulder and Labrum Injuries in Sport

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Introduction

A labrum is a ring of cartilage or soft tissue that surrounds the socket of a ball-and-socket joint. In the shoulder, the glenoid labrum stabilizes and cushions the glenohumeral joint, while keeping the humeral head in place. It does this by deepening the glenoid cavity and providing an attachment point for the shoulder capsule and ligaments[1]. Common Labrum injuries include Superior Labrum Anterior to Posterior (SLAP) tears, Bankart lesions, and Glenolabral Articular Disruption (GLAD) lesions, and typically result from acute trauma or repetitive mechanical stress[2]. An understanding of the biomechanics behind these injuries is essential to predict, prevent, protect, and diagnose these conditions in at-risk groups including athletes and labour workers. Long-term consequences of labral injuries include degenerative joint changes, increased risk of recurring dislocations, and early onset of osteoarthritis[3]. In professional athletes, career longevity may be significantly impacted, with studies indicating a high return-to-play rate following surgical repair, but with diminished performance levels over time[4]. This review aims to summarize and discuss the current biomechanical understanding of this injury, with a focus on more severe injuries caused by acute trauma.

Figure 1: Visualization of shoulder anatomy relevant to the Glenoid Labrum.

Injury Mechanisms

Acute Traumatic Injury Mechanisms:

  • SLAP (Superior Labrum Anterior to Posterior) Tears: Caused by excessive external rotation and abduction, leading to tensile and compressive forces in the superior labrum[1], or sudden axial loads causing humeral head displacement[5]. These modes are common in athletes performing overhead throwing motions, or when falling with an arm outstretched and/or to the side.
  • Bankart Lesions: This type of injury typically occurs during an anterior shoulder dislocation, where the anteroinferior labrum detaches from the glenoid rim during forced abduction and external rotation of the shoulder[6].
Figure 2: X-ray of Bankart Lesion injury after Glenohumeral dislocation
  • GLAD (Glenolabral Articular Disruption) Lesions: These lesions result from forced abduction in the presence of shear loading, and can also damage the articular cartilage in the shoulder[7].

Overuse Injury Mechanisms:

  • Cumulative stress on the labrum due to repetitive use or improper mechanics can lead to degenerative tearing and increased injury risk over time[8], especially in throwing athletes[9].

The most common forms of labrum injury resulting in medical intervention are SLAP tears and Bankart Lesions caused by acute trauma[10]. SLAP tears have been further classified into four primary types (Snyder et al, 1990) and six expanded classifications[3]:

  • Type I: Degenerative fraying of the superior labrum without actual detachment from the glenoid rim, Often due to age-related wear and tear rather than acute trauma. These injuries are typically not associated with significant shoulder instability.
  • Type II: A detachment of the superior labrum and biceps tendon from the glenoid, commonly caused by repetitive or acute stress in athletes performing overhead motions. This is the most common type of tear and typically requires surgical treatment. Further classifications of type II tears are:
    1. Type IIA: Anterior Detachment
    2. Type IIB: Posterior Detachment
    3. Type IIC: Combined anterior and posterior detachment
  • Type III: Described as a “bucket-handle” tear of the superior labrum, where a displaced fragment remains attached to the biceps tendon. Typically from acute trauma such as falling on an outstretched arm or a sudden axial pull on the shoulder. This can impact the mechanics of the joint and often requires surgical treatment.
  • Type IV: Also a “bucket-handle” type tear, but it extends into the biceps tendon due to trauma with higher loads. These injuries typically cause pain and dysfunction because of the involvement of the biceps tendon, but are less likely to require surgery.
  • Type V: A Labral tear extending into a Bankart Lesion, this is common in patients with anterior shoulder instability.
  • Type VI: An unstable labral flap tear involving the biceps tendon. In these injuries part of the labrum becomes mobile, causing additional shoulder instability.
  • Type VII: A superior labral tear that extends into the middle glenohumeral ligament, which affects all of the joint’s static stabilizers.
  • Types VIII-X: These classifications involve posterior labral extensions, tears on the circumference of the labrum, or complex detachments affecting multiple aspects of the glenoid. They are less common and can be caused by multiple complex mechanisms.

Experimental Research on Injury Loads and Thresholds

Studies from Hara et al. (1996)[11], Clavert et al. (2004)[12], Kuhn et al. (2003)[5], and Pradhan et al. (2001)[13] performed cadaveric experiments to quantify loads resulting in labrum injuries in different shoulder geometries. Demographic information on the specimens used in these experiments is consolidated below:

Table 1: Summary of specimen demographics for referenced studies.

Study Number of Specimens Cadaver Age Range (at t.o.d) Specimen Sex Preparation
M F
Hara et al. 15 55-88 9 6 Fresh Frozen
Clavert et al. 13 79.8 (mean) 7 6 Fresh Frozen
Kuhn et al. 20 55.4 ± 21 10 10 Unspecified
Pradhan et al. 13 53-82 (mean 64) Unspecified Fresh Frozen

Experiments from Hara et al. aimed to quantify the tensile strength of the labrum and shoulder capsule. Labrums and shoulder capsules were removed from the healthy specimens within 8 hours of death, and then frozen until the experiment. The specimens were then cut in radial sections 5mm wide, and tested using a strain gauge in a tensile test.

After performing tensile tests on all parts of a specimen, the mean force required to rupture the capsule and labrum complex is calculated over all 5mm sections of a sample, with the results shown below:

Age (yr) Sex Right (kg/5 mm) Left (kg/5 mm)
55 Male 5.54 ± 3.24 6.28 ± 2.05
62 Male 3.76 ± 1.17 3.69 ± 1.53
63 Male Not Measured 5.76 ± 1.12
65 Female 4.46 ± 0.72 5.72 ± 1.92
71 Female 4.77 ± 1.49 4.63 ± 1.77
73 Male Not Measured 4.82 ± 2.10
79 Male Not Measured 3.97 ± 1.37
82 Male 3.44 ± 1.13 3.96 ± 1.11
88 Female 3.18 ± 1.81 3.34 ± 1.55

Figure 3: Mean force necessary to cause rupture at all portions of the capsule and labral complex in the 15 shoulders.

The study from Clavert et al.[12] focused more on mechanisms that may cause labrum injury, instead of the mechanical properties of the tissue itself. This experiment simulated forward and backward falls with an outstretched arm, and used a mechanism that can simulate muscle forces. The results of this experiment showed a 100% incidence of type II SLAP lesions during forward falls (N=5), and 40% for backward falls (N=5). The authors suggest that “the role of shearing forces seems to be a major factor in the pathogenesis of these lesions, in association with predisposing anatomic factors.”[12].

The study by Kuhn et al.[5] focused on the load required to cause SLAP lesions. Specimens were loaded to simulate bicep tendon forces and shoulder loads during 100 cycles of a throwing motion. Two shoulder surgeons then blindly examined the specimens for presence of injury. Results indicated that SLAP lesions typically occurred at an average load of approximately 87 ± 31N, with the most frequent injury being type II SLAP lesions[5]. Authors concluded that tensile loading through the biceps tendon is particularly likely to cause SLAP tears.

Meanwhile, the study from Pradhan et al.[13] focused on Bankart lesions and shoulder cap injuries. They found that the mean force required to produce one of these lesions is approximately 237 ± 52N, and concluded that shoulder capsule deformation can lead to labrum (Bankart) lesions.

While these studies provide some information on injury loads and thresholds for the labrum, there is still a lack of comprehensive values to predict or model Labrum injuries in the mechanisms described in the previous section. For example, the study from Clavert et al. suggests that shearing forces are a major factor towards SLAP regions[12], but does not quantify this. The experiments from Hara et al. may provide the most direct values of tissue strength, but there are significant limitations to these results as will be discussed later. Quantifying injury loads and thresholds remains a valuable area for future experimental research.

Research Literature for Shoulder Injuries

The overarching theme in literature for shoulder and labrum injuries is that it is a difficult type of injury to study and analyze. The shoulder is a high-mobility joint that is stabilized by muscles which makes it difficult to understand the cause of different injuries to all the individual components [14].

Research Involving Throwing Sports

One of the areas that has a lot of research is throwing. Given the popularity of throwing sports such as softball, baseball, and football, there is a reasonable amount of research into the mechanics and biomechanics of throwing forces and injuries [14].

A paper published in 2020 analyzed the “windmill pitch” of softball players in the NCAA in the USA by comparing various studies that had conducted physical testing. The injury associated with this type of pitching is an overuse-related injury. They performed an analysis of the kinematics of the pitch by measuring torque, angular velocity, and force about the shoulder during all phases of the motion. The windmill pitch is divided into 4 phases: windup, stride, delivery, and follow through. Some examples of the findings of the maximum shoulder compressive forces were found to be 98% +/- 12% of body weight and 94% +/- 16% of body weight. They concluded that shoulder injuries are more common in pitchers than other players and occur at the beginning of the softball season, likely after time off. They also noted that the windmill pitch mechanisms put the biceps brachii, the glenoid labrum, and rotator cuff at risk of injury and that poor technique further enhances the risk of injury [14].

Another study analyzed the pitching changes in baseball players after they had undergone a SLAP tear repair. Thirteen college and professional athletes with previous SLAP tears were compared to 52 pitchers with no history of SLAP tears. During testing, participants wore a skin-tight suit and had reflective markers attached to them. Each participant threw 10 pitches and the speed was captured with a radar gun. Many cameras were used to record the pitch at a rate of 240 Hz and capture the location of the reflective markers over the pitching motion. Pitchers in the SLAP group were found to have much less external rotation than the control group. It was concluded that SLAP repairs compromise the pitcher’s ability to return to previous levels of performance [15].

Research Considering Impact to the Shoulder

Given the amount of research in the automotive industry, there exists literature that focuses on shoulder injuries during these types of impacts. Three studies from the early 2000s will be compared.

A study conducted in 2000 aimed to determine how lateral impacts cause injury to the shoulder. A pneumatic impacting ram was used to impact the shoulder at the glenohumeral joint of the cadavers. There were accelerometers placed in the shoulder to calculate the impact forces, along with other photographic instrumentation devices. They performed an initial impact with a 23kg pneumatic impacting ram at a constant velocity, and then checked for fracture. If no fracture occurred, they increased the impactor speed for the second impact to the opposite shoulder [16]. Another study aimed to determine the shoulder response in lateral sled tests. This study used unembalmed cadavers to perform side impact sled tests on a horizontal sled. At the end of the rails, the sled impacted a hydraulic snubber. Accelerometers were also chosen as a form of instrumentation and were mounted to many locations, notably the shoulder. High-speed cameras were used to capture the tests [17]. The third study also used cadavers to deliver impacts to the shoulder at different angles with an impacting plate. Accelerometers were used in a similar fashion to the first study along with photographic markers. The impacting plate was used at different speeds to obtain data for both injurious and non-injurious scenarios [18]. A table summarizing the comparison of the experimental set-up of the 3 studies can be found below.

Table 2 - Summary of Experimental Set-up for Impact Research on Shoulders

Study Number of Specimens Cadaver Age Range Specimen Sex Preparation Test Conducted Instrumentation
M F
Bolte et al. 11 40-84 6 5 Unembalmed fresh cadavers Pneumatic impacting ram Triaxial accelerometers, photographic target pins
Koh et al. 17 37-72 11 6 Unembalmed cadavers Side impact sled test Accelerometers and film
Compigne et al. 7 77-94 2 5 Unembalmed fresh cadavers Impacting plate Triaxial accelerometers, photographic markers and high-speed cameras

After the tests were conducted, the study from the year 2000 took MRIs of the cadavers and performed autopsies that focused on the shoulder. They identified the most common injury to be to the sternoclavicular joint. Furthermore, out of the total 22 impacts, half resulted in an AIS level 2 injury [16]. The second study from 2001 collected data such as shoulder height, forces, accelerations, and deflections to analyze their results. The most common injuries they observed were various AIS level 2 injuries such as acromioclavicular separation, acromion fracture, and clavicle fracture [17]. The last study from 2004 used the non-injurious impacts to the right shoulder to study shoulder kinematics. They found that the higher speed impacts to the left shoulder also produced mostly AIS level 2 injuries [18].

Research with High Density Data Collection

Another type of literature that exists regarding shoulder injuries is long-term data collection and grouped research. For example, a study was conducted in 1995 that analyzed 140 injuries to the superior glenoid labrum with the goal of determining the symptoms of the injury and the cause [19]. Another study from 2024 analyzed the location of 1763 surgically repaired labral tears over 23 years. The goal of this study was to determine what kind of labral tear was most common [10]. More in the realm of injury biomechanics, a study conducted in 2015 analyzed 142 patients with recurring shoulder problems and 21 cadavers subjected to a shoulder-testing device. The purpose of this study was to determine how effective the “Bankart repair” was in treating the Bankart lesion, an injury that was described in the introduction of this literature review. The 142 patients were analyzed with 3D CT scans and classified into groups based on their type of shoulder injury. The cadavers were fresh-frozen and had the shoulder partially dissected before testing. They subjected the dissected shoulders to varying levels of severity of Bankart lesions, and then proceeded to repair them using the Bankart repair. They used a custom shoulder-testing device that had 6 degrees of freedom to test the range of motion of the dissected cadaver shoulders. The general findings from this study were that the Bankart repair is not effective enough to restore stability in the shoulder joint [20].

Limitations of Existing Research

Studying the shoulder joint is a very difficult task due to its extreme mobility. While cadaveric testing conducted in studies like Hara et al. (1996)[11], Clavert et al. (2004)[12], Kuhn et al. (2003)[5], Pradhan et al. (2001)[13], and Mohr et al. (2024)[10] has the benefit of directly testing human labrums, there are several limitations to this study method. Firstly, when you remove the glenoid labrum from the shoulder itself in order to destructively test it with a simplified load case, it will not break the same as it would within an intact shoulder. Furthermore, it is impossible to replicate a realistic shoulder injury condition such as falling on an outstretched arm with the labrum removed. This makes it difficult to give meaning to the results of the tests, such as the mean force required to rupture the capsule and labral complex, as we can’t relate this to how hard someone would have to fall on an outstretched arm to cause a labral injury[11]. It is also difficult to justify comparing the results within a study to each other as each labrum is from a different person and the sample sizes are often quite small. The samples used in cadaveric testing are almost exclusively from older individuals (50+ years old) while most labrum injuries occur in younger athletic populations[3]. The mechanical properties of the labrum tissue taken from older, deceased donors differ significantly from young athletes. Furthermore, in much of the research that considers impact to the shoulder, it should be noted that an important limitation is that the types of test conducted do not accurately represent the injuries that may occur in real world automobile accidents. One can not predict the exact outcome from an isolated testing scenario[16].

Controversies and Future Directions in Labrum Injury Treatment

The topic of how to manage labrum injuries, such as SLAP tears and Bankart lesions, is still being debated in sports medicine and orthopedic research. One of the biggest questions is whether surgical or non-surgical treatment is better. Surgical treatment, specifically arthroscopic labral repair, is one of the most popular ones, but studies show that not all of the patients get the same outcomes [10]. Some research shows that conservative treatments, for example, physical therapy and rehabilitation programs, can give similar results, especially for older patients or patients who are not involved in competitive sports [1]. Patients who are active and engaged in competitive sports usually prefer the surgery because they want to regain full shoulder stability and function. The question which should be asked is what is the criteria to determine the optimal treatment method?

There is a disagreement about the long-term prognosis after surgical repair too. The rate of athletes returning to play is quite high but there is evidence showing that many of them experience diminished performance or recurrent instability over time [21]. The difference in patient outcomes shows us that it is needed to further research individual treatment plans based on factors like age, sport type, and injury severity.

It is possible to understand and observe labrum injury mechanisms by biomechanical modeling and cadaveric studies, but the options are limited when it comes to obtaining real-time live data coming from actual people. This can be done by using technologies such as wearable sensors or advanced imaging techniques, which can provide real-time analysis and data of shoulder mechanics [11]. This would help getting information on how to prevent these injuries and how to facilitate the rehabilitation protocols.

In the future, researchers should also focus on tissue engineering and regenerative medicine. The surgical repairs now usually rely on suturing the labrum back to the glenoid, but regenerative therapies, for example, stem cell treatments and biologic scaffolds give more alternatives which improve and help healing and reduce the risk of getting injured again [22].

While significant progress has been made in diagnosing and treating labrum injuries, ongoing debates regarding treatment efficacy, long-term outcomes, and emerging therapeutic options show us the need for deeper research. Improvements in personalized medicine, biomechanics, and regenerative approaches hold promise for improving patient care and optimizing recovery in both athletes and the general population.

More research using advanced imaging and wearable technology to attempt to capture the motion within the shoulder joint while in normal motion would greatly benefit our understanding of shoulder injury [11]. Currently the research focuses on cadaveric testing as taking in vivo measurements is significantly more difficult, but due to the mobility of the shoulder joint, cadaveric testing is not sufficient. While we would not want to injure a subject's shoulder, better understanding normal motion would help with injury prevention by identifying high injury risk shoulder motions or exposing early warning signs of degenerative labrum injuries. It would also be possible to develop better preventative physio training plans that reduce the risk of shoulder injury. It is clear in the research that surgical repair of labral tears is not always the best course, but apart from recommending surgery based on age, activity level, and shoulder instability, there is not a lot of research on what course of action is best for individual injuries [20]. More research should be done looking into using non-invasive imaging to determine the best course to recovery for labral injuries on a case-by-case basis. If we were better able to understand what specific injury conditions different recovery methods were best at treating, such as surgery, platelet-rich plasma or stem cell injections, or physiotherapy, patients would have a much better chance for a successful recovery.

References

  1. ↑ Jump up to: 1.0 1.1 1.2 Steinmetz RG, Guth JJ, Matava MJ, Brophy RH, Smith MV. Return to play following nonsurgical management of superior labrum anterior-posterior tears: a systematic review. J Shoulder Elbow Surg. 2022 Jun;31(6):1323-1333. doi: 10.1016/j.jse.2021.12.022. Epub 2022 Jan 19. PMID: 35063641.
  2. ↑ Tuite MJ, Pfirrmann CWA. Shoulder: Instability. 2021 Apr 13. In: Hodler J, Kubik-Huch RA, von Schulthess GK, editors. Musculoskeletal Diseases 2021-2024: Diagnostic Imaging [Internet]. Cham (CH): Springer; 2021. Chapter 1. Available from: https://www.ncbi.nlm.nih.gov/books/NBK570161/ doi: 10.1007/978-3-030-71281-5_1
  3. ↑ Jump up to: 3.0 3.1 3.2 Ochoa E Jr, Burkhart SS. Glenohumeral bone defects in the treatment of anterior shoulder instability. Instr Course Lect. 2009;58:323-36. PMID: 19385546.
  4. ↑ Return-to-sport and performance outcomes after isolated posterior labral repair in professional baseball players Paul, Ryan W. et al. Journal of Shoulder and Elbow Surgery, Volume 0, Issue 0
  5. ↑ Jump up to: 5.0 5.1 5.2 5.3 5.4 Kuhn JE, Lindholm SR, Huston LJ, Soslowsky LJ, Blasier RB. Failure of the biceps superior labral complex: a cadaveric biomechanical investigation comparing the late cocking and early deceleration positions of throwing. Arthroscopy. 2003 Apr;19(4):373-9. doi: 10.1053/jars.2003.50044. PMID: 12671620
  6. ↑ Jones KJ, Wiesel BB, Ganley TJ, Kelly JD. Biomechanics and pathology of shoulder instability. J Anat. 2020 Mar;236(3):458-472. doi: 10.1111/joa.13582.
  7. ↑ Miller RS, Harner CD. Glenoid labrum biomechanics and injury mechanisms in throwing athletes. In: Advances in Shoulder Surgery. Springer, New York, NY. 2014;12:247-265. doi: 10.1007/978-1-4939-1732-7_12
  8. ↑ Anderson MJ, Ho CP, Hawkins RJ. The recognition and treatment of superior labral (SLAP) lesions in the overhead athlete. Sports Health. 2013 Nov;5(6):477-486. PMID: 3811737.
  9. ↑ Brown SA, Wright JM, Patterson RM, Hawkins RJ. Computational modeling of glenohumeral stability: insights into labral function. Procedia Comput Sci. 2014;29:1486-1495. doi: 10.1016/j.procs.2014.05.325.
  10. ↑ Jump up to: 10.0 10.1 10.2 10.3 Mohr D, Nammour MA, Marcaccio SE, Arner JW, Bradley JP. Location of Shoulder Glenoid Labral Tears: A Study of 1763 Consecutive Patients. Am J Sports Med. 2024 Jul;52(8):2063-2070. doi: 10.1177/03635465241253835. Epub 2024 Jun 3. PMID: 38828637.
  11. ↑ Jump up to: 11.0 11.1 11.2 11.3 11.4 Smith CD, Masouros SD, Hill AM, Wallace AL, Amis AA, Bull AM. Tensile properties of the human glenoid labrum. J Anat. 2008 Jan;212(1):49-54. doi: 10.1111/j.1469-7580.2007.00832.x. Epub 2007 Nov 21. PMID: 18031481; PMCID: PMC2423387.
  12. ↑ Jump up to: 12.0 12.1 12.2 12.3 12.4 Clavert P, Bonnomet F, Kempf JF, Boutemy P, Braun M, Kahn JL. Contribution to the study of the pathogenesis of type II superior labrum anterior-posterior lesions: a cadaveric model of a fall on the outstretched hand. J Shoulder Elbow Surg. 2004 Jan-Feb;13(1):45-50. doi: 10.1016/j.jse.2003.09.008. PMID: 14735073
  13. ↑ Jump up to: 13.0 13.1 13.2 Pradhan RL, Itoi E, Hatakeyama Y, Urayama M, Sato K. Superior labral strain during the throwing motion. A cadaveric study. Am J Sports Med. 2001 Jul-Aug;29(4):488-92. doi: 10.1177/03635465010290041801. PMID: 11476391
  14. ↑ Jump up to: 14.0 14.1 14.2 Minetos, P. D., Trojan, J. D., Brown, S. M., & Mulcahey, M. K. (2020). Softball pitching mechanics and shoulder injuries: a narrative review. Sports Biomechanics, 22(6), 715–727. https://doi.org/10.1080/14763141.2020.1757142
  15. ↑ Laughlin WA, Fleisig GS, Scillia AJ, Aune KT, Cain EL, Dugas JR. Deficiencies in Pitching Biomechanics in Baseball Players With a History of Superior Labrum Anterior-Posterior Repair. The American Journal of Sports Medicine. 2014;42(12):2837-2841. doi:10.1177/0363546514552183
  16. ↑ Jump up to: 16.0 16.1 16.2 Bolte, J., and Hines, M., "Shoulder Response Characteristics and Injury Due to Lateral Glenohumeral Joint Impacts," SAE Technical Paper 2000-01-SC18, 2000, https://doi.org/10.4271/2000-01-SC18.
  17. ↑ Jump up to: 17.0 17.1 Koh, S., Cavanaugh, J., and Zhu, J., "Injury and Response of the Shoulder in Lateral Sled Tests," SAE Technical Paper 2001-22-0005, 2001, https://doi.org/10.4271/2001-22-0005.
  18. ↑ Jump up to: 18.0 18.1 Compigne, S., Caire, Y., Quesnel, T., and Verries, J., "Non-Injurious and Injurious Impact Response of the Human Shoulder Three-Dimensional Analysis of Kinematics and Determination of Injury Threshold," SAE Technical Paper 2004-22-0005, 2004, https://doi.org/10.4271/2004-22-0005.
  19. ↑ Snyder, S. J., Banas, M. P., & Karzel, R. P. (1990). An analysis of 140 injuries to the superior glenoid labrum. The American Journal of Sports Medicine, 18(4), 418–423. https://doi.org/10.1177/036354659001800406
  20. ↑ Jump up to: 20.0 20.1 Arciero RA, Parrino A, Bernhardson AS, et al. The Effect of a Combined Glenoid and Hill-Sachs Defect on Glenohumeral Stability: A Biomechanical Cadaveric Study Using 3-Dimensional Modeling of 142 Patients. The American Journal of Sports Medicine. 2015;43(6):1422-1429. doi:10.1177/0363546515574677
  21. ↑ Chang C, Weiss MF, Garcia GH. High return to play rate and diminished career longevity are present after shoulder instability in National Football League athletes. Arthrosc Sports Med Rehabil. 2023 Jan;5(1):e77-e85. doi: 10.1016/j.asmr.2023.00027.
  22. ↑ Patel NA, Lazarus MD, Smith KL. Quantitative assessment of glenoid labrum injury tolerance: implications for surgical repair. J Shoulder Elbow Surg. 2005;14(5):435-441. doi: 10.1016/j.jse.2005.04.015.


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