Difference between a Tear and Partial Labrum Tear

Tendinitis in itself can be very persistent and very painful. There is only one cure for it, rest. Which he should be doing at this time of year anyway. Really he would've benefited from a fall shut down to let him come back strong for spring and next summer.

A PT is not qualified to opine as to a labrum tear. So I would not let what a PT speculated about get me too tied up in knots. That being said, if the PT really thought your son had a labrum tear 6 months ago, he should've sent you to an orthopedist specializing in sports throwing injuries right then and there. And if he really thought there was a possible tear, telling your son to continue throwing rates as positively moronic. So I'm wondering if he was just listing possibilities 6 months ago and not really saying your son had a tear at that time.

The problem with labrums is that even with an MRI you can never really be sure without surgery, but you don't want to have the surgery (which is pretty intrusive itself) unless you're pretty sure it's needed. Some minor labrum tears can be bolstered with a conditioning regimen, others go so far that surgery is needed. Some inflammation signatures that look like labrum tears on an MRI are really just inflammation and not tears at all. You really need to see not just any orthopaedist, but one who has a depth of experience with throwing injuries. Interpreting an MRI is more of an art than a science.

FWIW the symptoms you describe sound more like severe tendinitis to me than a labrum issue. But I'm not a doctor, either. It's time to see the right people to assure that your son is doing the right things for himself and to give yourself a chance to get on a corrective course so that you can AVOID surgery if possible.

What I would guess happened is that your ortho put your son through some range of motion diagnostics and he heard some "crunching" or similar noise that can accompany a labrum tear. The key there is that while it is indicative of a tear it is not definitive and you may merely be dealing with an impingement or even just severe inflammation from laxity in the capsule, tendinitis or some combination. While all of these are serious and need attention, a lot of these situations call for nothing more than a break from throwing and dedication to a prescribed rehab and conditioning program.

So don't hit the panic button just yet, but do stop all throwing until someone who has the kind of resume you can have confidence in is doing the talking.

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The problem with labrums is that even with an MRI you can never really be sure without surgery, but you don't want to have the surgery (which is pretty intrusive itself) unless you're pretty sure it's needed. Some minor labrum tears can be bolstered with a conditioning regimen, others go so far that surgery is needed. Some inflammation signatures that look like labrum tears on an MRI are really just inflammation and not tears at all. You really need to see not just any orthopaedist, but one who has a depth of experience with throwing injuries. Interpreting an MRI is more of an art than a science.

I agree with much of what you're saying here Midlo.

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FWIW the symptoms you describe sound more like severe tendinitis to me than a labrum issue. But I'm not a doctor, either. It's time to see the right people to assure that your son is doing the right things for himself and to give yourself a chance to get on a corrective course so that you can AVOID surgery if possible.

The problem with labrums you mentioned once with not being able to truly know without going in. Another problem with labrums
is that labral tears and tendinitis of both the rotator cuff muscles (infraspinatus, supraspinatus, teres minor, and subscapularis) and also the long head of the biceps tendon. They all run through that small area so it's hard to differeniate sometimes.

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What I would guess happened is that your ortho put your son through some range of motion diagnostics and he heard some "crunching" or similar noise that can accompany a labrum tear. The key there is that while it is indicative of a tear it is not definitive and you may merely be dealing with an impingement or even just severe inflammation from laxity in the capsule, tendinitis or some combination.

"Crunching" would be what we call crepitus. That would be inflammation. I would hope a physician is not assessing this injury without subjectively/objectively ruling out a labral tear. There are several special tests that can be performed to better assess a labrum injury. They would be looking for catching and grinding rather than "crunching" really.


Obviously we cannot diagnose an injury over the internet. I would agree with Midlo to stop throwing now and get checked out.


Also, to answer your title question: The difference is simply the fibers that are torn. A partial tear is only some of the fibers while a full tear is the entire thing.

Thanks for the great info. Very helpful. As for the orthopedist, he is a local ortho specializing in sports injuries and considered to be a solid doctor. Due to a lack of testing (range-of-motion diagnostics/listening), we have opted for a second opinion. I felt that more extensive testing might have revealed more information. I also think the possibility of surgery warrants it.

He agreed with your comments about an MRI. He said it was tough to call on an MRI without contrast. I'll definitely push for that on the second opinion. He was very hesitant to suggest surgery on a patient this young (13) and preferred the PT at this time. He explained that he put little faith in an MRI and wasn't fully convinced that it was a partial-tear at his age and given his history.

As for the off-season, my son didn't play. He spent it lifting and in lessons (hitting/pitching) only. That is one of my largest reasons for concern. I want to eliminate the cause of the problem but cant pin-point it at the moment. I'm not sure that it wasn't the weight-lifting rather than the pitching. He's always had fairly good mechanics BUT has thrown his fair share of innings (has always been pitch counted though).

At any rate, we are discontinuing throwing for the holidays and will start PT early next week. After the holidays, we will see the Tallahassee Orthopedic Clinic, who I was told handles Florida State Univ's injuries. Hopefully the second opinion will reveal more or simply confirm what we already know at this point.

Again, thanks for the comments. Have a great holiday!

BK,
A couple of things.

Go see a Dr. that specializes in shoulders/elbows. As has been portrayed already, labrums are very, very tough to diagnose properly...even with MRI's with contrast. My son had three, two with contrast, two showed nothing, the third showed a tear. On top of that, a shoulder guy will give the best options for treatment planning.

Lifting can also be a source of aggravation of the shoulder. If it is tendinitis, complete rest is the Rx. This can be supplemented with NSaids (Naproxen, Ibuprofen, etc.) to reduce inflammation, and possibly even cortisone shots (although I have no idea about how cortisone is used in young people).

The term "tear" can also be misleading itself.

The labrum is a thick piece of cartilage or cartilage-like material. It is supposed to be affixed to bone at either end.

It can tear within itself, the way you think of a sheet of paper tearing.

It can also just detach from the bone, without suffering any damage to itself. That is also commonly referred to as a "tear".

In really bad cases, you see both things happening. Some extreme cases have the "fraying rope" issue where medically it's just hard to put the pieces back together.

There's no way your son could've continued throwing and lifting if he had that worst case scenario. The pain would be terrible and also the loss of function would be noticeable.

One thing you don't say is whether your son has seen a loss of velocity. That is also a sign of how severe an injury might be. If he had that, I would think you would've mentioned it. That makes me think you have reason to hope that things are not too bad for your son, and that maybe he has the pitcher's lament, laxity in the shoulder capsule. That is a rehab issue, not a surgical issue. Laxity is literally an overstretching of the shoulder capsule muscles, which is treated with throwing rest, toning exercises and then a forever conditioning program (which really all pitchers should be doing anyway, but they wait until they have an injury to find that out the hard way).

What bothers me is that you have missed 6 months of opportunity to shut down and then work the rehab program. I guess if he's not yet HS age, you aren't worried about HS tryouts yet (which start here in about 8 weeks), but you need to get on this NOW so that when his favorite time of year gets here he can hope to be healthy and ready to go without any second thoughts -- if it turns out it's just something he needs to rehab and not a surgical case. If he keeps trying to push through this without the proper approach, this problem could force him to lose an entire spring/summer season.

Why are 13 year olds lifting weights rigously anyway?
An MRI should be done to eliminate a tear. All throwing, even lessons come to a hault.
Do your homework on shoulder surgery for 13 year olds, you won't find too many doctors who will do it, even the best because shoulder surgery is very difficult to fully recover from, small tears can take care of themselves over time. If it was mine, no way am I going to put my 13 year old through major surgery. No more pitching.

I'm not sure if you’re concern is the lifting or that it is "rigorous." At any rate, we feel comfortable with lifting on a rigorous or regular schedule/program. We feel he is at an age that it is fairly safe. It's a low to mid-weight, high repetition program in conjunction with a good amount of plyometrics and band work.

As for surgery, we have discussed it and if necessary, will probably push for a post-season operation. Obviously, we would prefer another option such as PT but if it's necessary, I would prefer to fix it now. It's a difficult choice but I know he would be much happier playing the game later (High School) when it really matters and being at his best. I'm not saying he has a chance of going on (college) but if he does, we would like to afford him that opportunity. He has played at a high level for many years and put in a great amount of work. We would simply hate to see it go to waste if HE wants to move forward with it.

But trust me when I say we are much more inclined to choice an alternative to surgery. I'm certainly not gunning for that as an only solution and would like to avoid it if at all possible.

Continue to play and throw across the field if the pain is Tolerable !!!What in the h e l l is that kind of talk from a PT ? PAIN IS PAIN and not to be ignored or played with especially at 13 years of age---it could be the end of his arm as a baseball player

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Continue to play and throw across the field if the pain is Tolerable !!!What in the h e l l is that kind of talk from a PT ? PAIN IS PAIN and not to be ignored or played with especially at 13 years of age---it could be the end of his arm as a baseball player

I disagree. Pain is very subjective. I'm not saying go out and play no matter what, but playing "with pain" is not necessarily a dangerous thing. You have to differeniate between "pain," "soreness," and "aching" which isn't always easy.

I spent this past semester working with college women's gymnastics and the summer was spent in professional baseball. Many of those athletes play with "pain" every day. Some of them will have those types of aches and pains the rest of their lives. Yes, some of them were limited in what they could do, but they had to continue some part of practice. If we would have stopped them for any pain at all, not one of those gymnasts would have practiced!

At this age, arm pain needs to be taken seriously. Does that mean stop? Not always. But it needs to be addressed. As has been suggested to BK_Razorback, the player should stop throwing at this time and get evaluated by an orthopedic surgeon who has experience dealing with arm injuries.

BK,
I have heard that PT/trainer "you can keep playing and it won't cause further injury" information before.
Don't and I mean do not believe it unless and until you have a solid diagnosis based on the most sensitive medical testing that needs to be done.
If it can be proven the labrum is intact and you are dealing with impingement/bursitis, etc, it is a different issue in terms of playing and throwing, perhaps.
What seems a bit quizzical from your post is the location of the pain and the diagnosis of rotator cuff tendinitis. I believe you will find the pain from that condition is normally located on the back of the shoulder and especially occurs with deceleration during the throwing motion.
Our son was diagnosed with a labral tear based on a contrast MRI. Was told he could continue to play through his Milb season without causing more damage.

Our son followed the medical advice/trainer advice and played nearly an entire Milb season with a labral tear.
When the surgery was done, the assessment was there was a lot more damage than they thought. Now whether it was there and not detected on MRI or more damage occurred from following their advice and playing, well, they just "couldn't tell."
Does your son complain of any clicking in the shoulder during throwing?
Does he talk about the shoulder feeling loose or unstable during the throwing motion?
If you are getting him a second opinion, which is great I think, and going to FLA., I would urge you to consider having your son seen by James Andrews, MD.
Based on our experience, the "team doctor" stuff sounds good. It can end up being a very "hollow" sound both in terms of diagnostics and treatment.
If this were my son, knowing what I know now, I would want the very best sports doctor I can find, who is objective, a patient advocate, who knows shoulders, knows baseball players, and has a history of success in diagnosing labrum damage vs bursitis vs impingement vs some combination, who has the history of providing a plan to successfully prevent surgery, and has the best record of success in doing surgery, if it is needed.
As others have said, do your research. There is an April 2008 report from a Phillies team doctor. Shoulders are complicated. Knowing what I know now, and what our son experienced, I would not permit my son to play any baseball or do any stressful action(weight lifting) with that arm/shoulder until you and the doctors are clear on the diagnosis.
There may be doctors as good as James Andrews for shoulders. There are none better in terms of results.

Some interesting things that I found out about "team" doctors, they are the team doctors because they have provided a bid for business and won, usually at the lowest bid, this is common in college sports and in professional ball. I agree with infielddad, don't let that title fool you. If you would go to FL, go to Alabama, or find a doctor that specializes in shoulders, especially since ou seem to feel if a tear you want him to have surgery.

Personally, sounds more like a case of chronic tendinitous, and if so the issue should be WHY and WHAT is causing tendinitous. And all the questions asked by infielddad should be addressed and answered.

Your son is 13 years old. Your son is experienceing pain in his shoulder. Shut down the weightlifting. Shut down the throwing. Find out what is going on. Seriously dad shut him down and vigorously work to find out exactly what is going on with his arm. No way I would have my son working out with weights at 13. And certainly no way if he was having pain. As far as throwing. He ll no! No way. Find out what is going on.

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Originally posted by Coach_May: No way I would have my son working out with weights at 13.

Thank you CM for the comment, my feelings exactly.

Honestly, no offense to anyone, but I can understand why so many young players have issues these days.

First of all I would like to thank everyone for the great input. It’s amazing how much stress something of this nature can put on a young man. He knows coaches, players, and parents want him to play but is also aware of the long-term effects of playing injured.

Just to reiterate the issue in a more useable format and answer a couple previous questions, here’s the timeline of events:

1. 4 months ago and immediately following world series/end-of-season and starting football (he’s also a QB) experienced extreme pain in the top portion of the shoulder during the highest point (arm overhead) of his delivery. Could no longer handle any type of throwing/lifting. Could hear a grind in the joint.

2. Seen local orthopedist & had MRI. Was diagnosed with tendinitis of the rotator cuff and prescribed 6 weeks of therapy. No throwing/lifting.

3. Seen the PT. PT thought it sounded more like a torn labrum. Went through PT for the next 6 weeks. . Actually continued to take hitting lessons during this time with no pain. Again, not throwing/lifting during this period.

4. Returned to normal throwing activities after 6 weeks to include playing football and resuming pitching lessons. He had several lessons where he showed a marked increase in velocity from the season. Continued to strengthen shoulder with dumbbell and band workouts. He was very dedicated to this shoulder workout regime.

5. A month ago, started experiencing pain in the top portion of his shoulder joint. He has pinpointed the pain to be around the finish and at the point he begins to pronate. Not the same degree of pain but uncomfortable. Is hearing a popping in joint. He feels like his arm is allowed to extend forward too much during the finish.

6. Seen local orthopedist & had another MRI. MRI reported a partial thick tissue tear. Orthopedist had little faith in an MRI for tissue tears and even doubted it given my son’s history/age. Did not want to pursue surgery with a younger athlete. Prescribed PT again. Mentioned a mechanics adjustment. The only noticeable mechanical change that I noticed after the first injury was a slight drop in his arm slot. Went from high ¾ to low ¾.

7. After speaking to the PT, he still feels strongly about it being a tear. He said the PT will only help but it is “impossible to fix what is already broken.” He was ok with continuing to throw if the pain is within reason. Advised us to discontinue pitching/lifting at this time.

8. We are now scheduling a second opinion from an orthopedist that specializes in shoulder injuries at the Tallahassee Ortho Center.

Get the second opinion, let us know.

Cancelled Tallahassee Ortho Clinic appointment and my son is now seeing Dr. Andrews tomorrow. I think that was a good piece of advice.

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Originally posted by BK_Razorback:
Cancelled Tallahassee Ortho Clinic appointment and my son is now seeing Dr. Andrews tomorrow. I think that was a good piece of advice.

It's a good choice for one very important reason...peace of mind. Now you can rest assured that one of the opinions you have, comes from a knowledgeable and reputable source above reproach.

Good luck to Junior.

Diagnosis...little league shoulder. No tears. No throwing for 3 months.

Wow congrats Razor!! Thats some great news. Now make sure he does exactly what he is told to do. And take it slow when he does come back.

Can you fill us in with a slightly more technical description of "Little League shoulder"? Tendonitis? Inflammation?

I second that question.

I too would like to know what "little league" shoulder means just for future reference.

Any I'm VERY glad to hear that there is no major damage or surgery that needs to take place!

can you say..HAPPY NEW YEAR?! LOL

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Originally posted by 3FingeredGlove:
Can you fill us in with a slightly more technical description of "Little League shoulder"? Tendonitis? Inflammation?

little league shoulder = proximal humeral epiphysis

An inflammation of the growth plate in the shoulder. There have been extreme cases where it takes up to 2 years to heal and also cases where the growth plate cracks. Serious stuff if not dealt with correctly (rest and lots of ice). Not uncommon in athletes 12-16. Once the growth plate closes, no more LL Shoulder is possible.

Absolute rest is primary treatment plan. It's important to monitor the recovery and at the first sign of return, shut it down immediately to prevent permanent damage to the growth plate. It can be insidious and relentless in a small minority of cases.

WOW! 2 years to heal? This is even worse news than having to get TJ surgery.

Messing up growth plates on young players is never good.

Thanks for all the input and information. It was amazing to see how the 2 ortho's opinions of the problem differed.

The growth plate issue was very apparent after taking alook at an x-ray of BOTH shoulders and comparing them.

This was more than likely the issue 4 months ago and was simply misdiagnosed. Its unfortunate that he will be delayed starting his season but great to finally figure out the REAL issue and above all, no surgery to worry about.

The Andrews Institute was very good and worth the trip.

BK,
This is one poster who wants to commend you for being pro-active in attempting to understand what was going on in your son's shoulder, in appreciating it wouldn't "just go away" and in looking at his long term. It is also great that there was communication with your son so he could tell you when things were not right.
The shoulder and medical advice can present and amazing dichotomy.
Thanks for taking the time to post here, for being open to options some of us unfortunately learned through experience and for getting to the core issue, the treatment needed, and on a path to recovery. All our best for your son's recovery and future success back on the field when that occurs.
Nice work!

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Originally posted by BK_Razorback:
Thanks for all the input and information. It was amazing to see how the 2 ortho's opinions of the problem differed.

FWIW, my son visited his team doc (very good and well respected a year after a scope revealed nothing serious) who was perplexed with what might be causing his discomfort (no tears, etc). The option was to seek advice from a doctor who specializes in shoulders. So this is a good example of how opinions can differ and if surgery is ever an option without finding anything of serious nature on an MRI, especially for young players, seek opinions from those that know that body part like the back of their hand.

Hope that you follow Dr. Andrews advice, best of luck to your son.

JMO, remember for very young athletes everyone is different and parents have to pay attention to overworking their developing bodies.

Whew...3 months is over and my son is starting his throwing program. The X-ray is noticeably better but still shows a slight seperation of the growth plate. Doc says to play the middle infield and another month before pitching. Pitching will consist of 30-40 pitches per weekend. It's not much but probably enough to stay in some form of game readiness for next spring. We're keeping our fingers crossed and hoping the arm holds up for the season. It feels great at the moment.