Management of Acute-on-Chronic Shoulder Pain with Labral Fraying

Clinical Assessment and Diagnosis

The American Academy of Orthopaedic Surgeons recommends a structured approach to diagnosing labral pathology and rotator cuff tendinopathy, including physical examination and imaging, in young athletes with shoulder pain and clicking symptoms 1
Rotator cuff tendinopathy from eccentric overload is a common mechanism of injury in young athletes, particularly those participating in activities involving repetitive eccentric stress on the supraspinatus and external rotators, such as pushups 2
The intact rotator cuff on prior MRI does not exclude tendinopathy, as tendinopathy can develop acutely from overload even with previously intact tendons 2

The American College of Radiology recommends starting with structured exercise therapy combined with NSAIDs, as this approach shows large effect sizes in reducing pain and improving function in young athletes with shoulder pathology 1
NSAIDs are recommended as part of initial conservative management for rotator cuff-related symptoms, with a moderate grade recommendation from the American Academy of Orthopaedic Surgeons 1
Avoid corticosteroid injections initially, as the evidence is conflicting and they may compromise tendon biology 1

Plain radiographs should be obtained to assess for fracture, shoulder alignment, and bony Bankart lesions or Hill-Sachs deformities, as recommended by the American College of Radiology 3, 1
Advanced imaging, such as MRI without contrast, should be reserved for patients who do not respond to conservative management after 8-12 weeks, as recommended by the American College of Radiology 4, 5, 1

Reassess patients at 8-12 weeks, as most patients show significant improvements in pain scores after 8 weeks of exercise therapy, according to the American College of Radiology 1
Surgery should only be considered if conservative management fails after an adequate 3-6 month trial, or if advanced imaging reveals significant full-thickness rotator cuff tear requiring repair, as recommended by the American College of Radiology 1
Recurrent instability episodes despite rehabilitation are also an indication for surgical consideration, according to the American College of Radiology 6

Do not assume the prior MRI findings are still current, as the acute exacerbation may represent progression of the labral pathology or new rotator cuff involvement, as noted by the American College of Radiology 2
Do not overlook scapular dyskinesis, as it contributes significantly to both rotator cuff and labral injuries and must be addressed in rehabilitation, according to the American College of Radiology 2

For patients with SLAP lesions who are not experiencing traumatic injury, a minimum 6‑week cessation of throwing or overhead activities until they become asymptomatic is recommended. 7, 8

Implement a structured rehabilitation program that emphasizes rotator‑cuff and periscapular muscle strengthening together with scapular stabilizer exercises for individuals with SLAP lesions. 7, 8

Address scapular dyskinesis because poor scapular coordination significantly contributes to both rotator‑cuff and labral injuries in SLAP patients. 7
Recognize that failure to treat scapular dyskinesis during rehabilitation is a common pitfall that can lead to treatment failure. 7