Key Point
• Massage cannot repair cartilage injuries, but it can be an excellent adjunct treatment that can ease pain, help prevent further complications, and lead to overall treatment success.

It is common for clients to present with conditions outside the usual muscle-related injuries. We can often help clients with these conditions, but sometimes these problems require referral to another health-care provider. Let’s look at two cartilage injuries that fall into that category. Massage may play a beneficial role in pain management for both conditions. Yet, understanding these pathologies helps us better determine when an appropriate referral is warranted.

Glenoid Labrum Injury

The first of these cartilage injuries is called a glenoid labrum injury. As the name suggests, this problem affects the glenohumeral joint, frequently described as a ball-and-socket joint. However, the glenoid fossa (the socket) is quite shallow. The labrum helps make the socket deeper and aids in joint stability.
The fossa is surrounded by a rim of cartilage called the glenoid labrum. The labrum is composed of fibrocartilage, similar to that of the meniscus in the knee. It can be torn, chipped, or cracked, and blood supply is generally poor so it often takes a long time to heal when injured.
The glenoid labrum is fibrously connected to the glenoid fossa but also has other important soft-tissue attachments. Along the superior margin of the shoulder joint, the tendon from the long head of the biceps brachii attaches to the supraglenoid tubercle. However, it blends into the labrum before inserting into the bone (Image 1). As a result, very high tensile loads generated by the biceps brachii muscle are transmitted to the upper margin of the labrum.
When the biceps tendon experiences an immediate, strong pull, it lifts the outer rim of the labrum and can tear it away from the central portion. Often, these forces cause a tear in the superior portion of the labrum that runs from anterior to posterior (Image 2). This injury is frequently referred to as a SLAP lesion. SLAP stands for superior labrum anterior posterior, meaning the tear is in the superior portion of the labrum and running from anterior to posterior.
This injury often occurs with a sudden eccentric load on the biceps, such as catching something heavy or a sudden deceleration of the throwing arm. Because the biceps brachii works to decelerate the forceful elbow extension when you throw, it contracts suddenly to stop that motion. This injury is common in athletes like baseball players, whose sport requires a lot of throwing.
The SLAP lesion is difficult to identify with physical examination and generally requires high-tech diagnostic evaluation for accurate identification. However, certain clinical signs can indicate the likelihood of a labral injury. As noted above, an essential factor is a detailed history that suggests some high-force load in the shoulder. There may also be popping or clicking of the shoulder during various motions. Pain may accompany the clicking or popping but is not always present.
The second main labral injury type is a Bankart lesion or Bankart tear. This injury is a tear to the anterior and inferior portion of the labrum near where it blends with the inferior glenohumeral ligament (Image 3). This portion of the joint capsule and labral complex can also be stressed in repetitive overhead motions, such as throwing or serving a tennis ball. The Bankart lesion is also relatively common, along with shoulder dislocations.
Another common mechanism of labral injury is falling on an outstretched arm. A labral tear may occur from corresponding joint capsule damage, or the humeral head being thrust against the edge of the labrum. In some more traumatic cases, a chunk of bone gets pulled away when the inferior glenohumeral ligament and labrum pull away from the glenoid fossa. This injury is called a Bankart fracture and requires an arthroscopic surgical procedure to repair. If you are suspicious of a labral injury, the best protocol is to refer the client to an orthopedic physician so the injury may be diagnosed and the best possible treatment initiated (which may require surgery).
Other complications can develop as a result of labral tears. First, because of the poor innervation and circulation to the tissue, the tear may be significantly advanced before it causes enough pain to be recognized by the client.
Because the labrum is designed to hold the humeral head in position, a tear or disruption in the labral complex can lead to shoulder instability. Increased shoulder instability may predispose the person to dislocations or other shoulder pathologies, such as impingement or rotator cuff pathology.

Osteochondritis Dissecans

The second cartilage injury we’ll explore is something called osteochondritis dissecans (OCD). It can occur in several locations but is most common in the knee. Knee cartilage injuries commonly involve the lateral and medial menisci of the knee. However, OCD is different because it is associated with the articular cartilage at the tibiofemoral joint and not the meniscal fibrocartilage between the bones.
OCD is not a common condition. It is, however, something the massage practitioner should be aware of as a possible cause of knee pain. OCD is most often seen in younger patients, generally between 13 and 21 years old, and is present in males more often than females.
A layer of hyaline cartilage covers the tibia and femur on their ends, which reduces friction and wear at the joint. In OCD, a section of hyaline cartilage (and sometimes the underlying bone, called subchondral bone) separates from the remainder of the deeper bone. This separated fragment can float freely within the joint, causing locking, pain, clicking, or crepitus during movement.
The lateral side of the medial condyle of the femur is affected most commonly in OCD. During various knee motions, repetitive contact of the medial condyle against the tibial spine causes irritation (Image 4). The tibial spine is a slight ridge of bone on the tibial plateau where the anterior cruciate ligament attaches to the tibia.
It is unclear exactly how the process of cartilage degeneration and separation from the bone starts. There is some evidence that it occurs from previous trauma, repetitive impact loading, or abnormal ossification of the bone. In addition, it is thought that tensile forces of the cruciate ligament attachment may pull on the bone enough to weaken the osteochondral interface.
Most likely, it is due to multiple causes occurring at the same time. In some cases, avascular necrosis may develop and precede cartilage separation. Avascular necrosis is a process in which the blood supply to an area is decreased for some reason and results in local tissue damage and tissue death (necrosis).
There is evidence that a discoid meniscus can contribute to the development of OCD. A discoid meniscus refers to the shape of the meniscus of the knee. A normal medial meniscus is somewhat round when the individual is very young, and then it opens up into a “C” shape as the person ages. A discoid meniscus maintains much more of its round or “O” shape, affecting how the femoral condyle tracks with the meniscus. In some cases, MRI investigations have shown evidence of meniscal damage in patients with OCD.
OCD in the knee is easy to mistake for other knee problems. X-rays or MRIs are the most reliable tests for OCD. There are other signs and symptoms, however. With active or passive range of motion in the knee, clicking or crepitus may be evident with flexion or extension. Pain may occur along with the clicking movements if a loose piece of cartilage is floating in the knee. Pain will be described as deep within the knee joint.
Other knee complaints have similar symptoms and should be considered. Meniscal tears, internal ligament sprains, and injury to the coronary ligaments that hold the menisci in place may produce pain felt deep in the joint, similar to OCD. Chondromalacia patellae may also cause crepitus and grinding sensations during knee movements. Patellar tracking disorders and osteoarthritis are also likely to cause diffuse anterior knee pain like that of OCD. 
Most patients with osteochondritis dissecans are young. Conservative treatment with this population is often effective because they are skeletally immature, and activity modifications can reduce biomechanical stresses. With older patients, conservative treatment appears to be less effective, and there is a greater likelihood that surgery will be necessary.
Conservative treatment often includes patellar taping and exercises for the vastus medialis obliquus muscle. The primary goal is to improve knee joint biomechanics, which decreases aggravation of the osteochondral lesion.
Surgical procedures for OCD are primarily arthroscopic. That means there will be minimal irritation and a quicker recovery. Chondroplasty is the preferred procedure and involves removing the damaged cartilage. However, in some cases, there may still be pain and crepitus with movement. In addition, once cartilage is removed in an area, there is a greater chance that the individual will develop osteoarthritis later in life due to greater friction between the joint surfaces.

To Massage or Not?

The first question to answer when determining if massage is appropriate for any condition is whether it can cause an adverse effect. With labral tears, there is no indication that massage or any gentle range-of-motion activities performed within normal limits would cause a problem or worsen the condition.
The next question to consider is whether massage can help treat the injury. In the case of labral tears, they are too deep in the shoulder joint to be accessible with palpation. Also, the labrum is cartilage, so it doesn’t respond to soft-tissue treatment. However, as in many situations, these facts do not mean that massage is not beneficial.
Dysfunctional mechanics frequently accompany labral tears at the joint. Myofascial trigger points or other biomechanical imbalances may occur as the shoulder attempts to compensate for pain, instability, or loss of function associated with the injury. In many cases, massage can help restore biomechanical balance in the shoulder. Understanding labrum pathologies will help you ascertain when they might be occurring and aid in knowing when to make an appropriate referral.
It is not clear whether massage is of significant benefit for OCD. However, there does not appear to be anything in the etiology of OCD that suggests massage can be harmful or contraindicated, as long as it is performed within comfort limits. Local and specific massage applications to the knee joint may prove beneficial in helping reduce corresponding soft-tissue pain in the region. It is still unclear if massage would restore or improve adequate blood flow in the region. However, massage has general pain relief benefits outside of the specific condition treatment.
Time can be an essential factor in getting good results from treatment. The longer joint microtrauma persists, the greater the potential damage in the region. Therapists should refer clients exhibiting OCD signs to a physician as soon as possible so the condition can be appropriately evaluated and necessary treatment can begin. As noted, massage is not contraindicated for this problem and may reduce associated pain from the articular damage.
It is imperative we understand the limitations of what we do so we don’t give a client false hope about what massage can accomplish. Once conditions like these are diagnosed, massage is an excellent adjunct treatment that can help prevent further complications and lead to treatment success on a general level. 
Whitney Lowe is the developer and instructor of one of the profession’s most popular orthopedic massage training programs. His text and programs have been used by professionals and schools for almost 30 years. Learn more at academyofclinicalmassage.com.