(2b) The T2-weighted sagittal image confirms posterior displacement of the humeral head (arrow) relative to the glenoid (asterisk). . Look for excessive fluid in the subacromial bursa and for tears of the supraspinatus tendon. Edelson was the first to define the incidence of subtle forms of glenoid dysplasia by studying scapular specimens from several museum collections.15 Posteroinferior hypoplasia was defined as a dropping away of the normally flat plateau of the posterior part of the glenoid beginning 1.2 cm caudad to the scapular spine (Figure 17-7). Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. Examples include the reverse Bankart lesion, the POLPSA lesion, and the posterior GLAD lesion (sometimes referred to as a PLAD lesion) (Figs. 2011 Sep;27(9):1304-7. Numerous labral abnormalities may be encountered in patients with posterior glenohumeral instability. Figure 1. Bookshelf 15 Imaging of the patient in the ABER position can greatly increase the conspicuity of an ALPSA lesion, which can easily be overlooked on a routine MRI of the shoulder or on the standard axial sequence of an MRA. Operative findings were used as the gold standard for posterior labral tear extension. Notice rotator cuff muscles and look for atrophy. When the labrum gets damaged or torn, it puts the shoulder at increased risk for looseness and dislocation. It is, however, becoming more frequently recognized, particularly in athletes such as football players and weightlifters, in which posterior glenohumeral instability has achieved increased awareness.3 As McLaughlin stated in 19634, the clinical diagnosis is clear-cut and unmistakable, but only when the posterior subluxation is suspected. by Michael Zlatkin. nor be effaced against the humeral head, and intra-articular contrast can enhance visualization of the tear (3). Severe glenoid dysplasia or hypoplasia is a rare condition due to either brachial plexus birth palsy or a developmental abnormality with lack of stimulation of the inferior glenoid ossification center. 11). With increased advancements in CT and MRI, more subtle forms of glenoid dysplasia have been recognized. posteriorly directed force with the arm in a flexed, internally rotated and adducted position, patients with increased glenoid retroversion (~17) were 6x more likely to experience posterior instability compared to those with less glenoid retroversion (~7), helps generate cavity-compression effect of glenohumeral joint, anchors posterior inferior glenohumeral ligament (PIGHL, vague, nonspecific posterior shoulder pain, worsens with provocative activities that apply a posteriorly directed force to the shoulder, ex: pushing heavy doors, bench press, push-ups, arm positioned with shoulder forward flexed 90 and adducted, apply posteriorly directed force to shoulder through humerus, positive if patient experiences sense of instability or pain, grasp the proximal humerus and apply a posteriorly directed force, assess distance of translation and patient response, grade 2 = over edge of glenoid but spontaneously relocates, grade 3 = over edge of glenoid, does not spontaneously relocate, arm positioned with shoulder abducted 90 and fully internally rotated, axially load humerus while adducting the arm across the body, arm positioned with shoulder abducted 90 and forward flexed 45, apply posteriorly and inferiorly directed force to shoulder through humerus, posterior shoulder dislocations may be missed on AP radiographs alone, arthroscopic and open techniques may be used, suture anchor repair and capsulorrhaphy results in fewer recurrences and revisions than non-anchored repairs, return to previous level of function in overhead throwing athletes not as reproducible as other athletes, failure risk increases if adduction and internal rotation are not avoided in the acute postoperative period, posterior branch of the axillary nerve is at risk during arthroscopic stabilization, travels within 1 mm of the inferior shoulder capsule and glenoid rim, at risk during suture passage at the posterior inferior glenoid, can lead to anterior subluxation or coracoid impingement, Glenohumeral Joint Anatomy, Stabilizer, and Biomechanics, Traumatic Anterior Shoulder Instability (TUBS), Humeral Avulsion Glenohumeral Ligament (HAGL), Posterior Shoulder Instability & Dislocation, Multidirectional Shoulder Instability (MDI), Luxatio Erecta (Inferior Glenohumeral Joint Dislocation), Glenohumeral Internal Rotation Deficit (GIRD), Brachial Neuritis (Parsonage-Turner Syndrome), Glenohumeral Arthritis (Shoulder Arthritis), Shoulder Arthroscopy: Indications & Approach, Valgus Extension Overload (Pitcher's Elbow), Lateral Ulnar Collateral Ligament Injury (PLRI), Elbow Arthroscopy: Indications & Approach. 2009; 38(10):967-975. by Herold T, Bachthaler M, Hamer OW, et al. The labrum in the shoulder joint is a vital component that helps stabilize the humerus and shoulder blade during movement. When you have a excessive posterior force on an adducted arm the resultant is a posterior labral tear. Diagnosis . Hottya GA, Tirman PF, Bost FW, Montgomery WH, Wolf EM, Genant HK. A mid-substance tear of the posterior capsule is present with the medial component appearing lax and retracted (arrow). Burkhead WZ, Rockwood CA Treatment of instability of the shoulder with an exercise program. Following plain radiographs, a CT scan is another useful imaging modality to evaluate the bony morphology of the glenoid including retroversion, glenoid dysplasia, and glenoid bone loss (GBL), and to further characterize the size and location of a reverse Hill-Sachs lesion. CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum and Labral-Bicipital Complex. postulated that dislocations result in a 360 degree injury, with trauma to the anterior labrum, resulting in changes posteriorly, and vice versa. Glenoid labral tear. A 20-year-old college football offensive lineman undergoes arthroscopic right shoulder surgery for the injury shown in Figure A. Post-operatively he complains of burning pain in the region marked in yellow on Figure B. In type I there is no recess between the glenoid cartilage and the labrum. These are also called ganglion cysts of the shoulder. Non-surgical treatment tends to be most successful in patients with a history of atraumatic subluxations, whereas patients who experience an acute, traumatic posterior dislocation are much less likely to report successful outcomes from conservative therapy.19 Non-operative therapy focuses on strengthening the dynamic shoulder stabilizers and activity modification. AJR Am J Roentgenol. Also. Saupe N, White LM, Bleakney R, et al. Radiographics. . Labral repair or resection is performed. A Meta-Analysis of the Diagnostic Test Accuracy of MRA and MRI for the Detection of Glenoid Labral Injury. Patients with labral tears may present with a wide range of symptoms (depends on the injury type), which are often non-specific: Labral injuries can result from acute trauma (like shoulder dislocation or direct blow) or repetitive overuse. There was a posterior labrum tear. Look for HAGL-lesion (humeral avulsion of the glenohumeral ligament). In a 20 year-old football player following acute injury, a reverse Bankart lesion is present. Look for tears of the infraspinatus tendon. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthroscopic findings with arthroscopic correlation. Look for supraspinatus-impingement by AC-joint spurs or a thickened coracoacromial ligament. The supraspinatus tendon is the most important structure of the rotator cuff and subject to tendinopathy and tears. Detection of partial-thickness supraspinatus tendon tears: is a single direct MR arthrography series in ABER position as accurate as conventional MR arthrography? An area of capsular irregularity (arrow) is apparent as well. Look for impingement by the AC-joint. X-rays also demonstrate evidence of glenoid dysplasia (increased retroversion and hypoplasia), arthritic changes, and posterior humeral head subluxation or decentering of the humeral head. J Bone Joint Surg Am. Sensitivity was 66 %, and specificity was 77 %. Rotator cuff tears in the context of posterior shoulder instability or dislocation were once thought to be rare. Illustration by Biodigital. 2013 Sep 24;2013(9):CD009020. There are also newer treatments to consider that don't involve surgery. We hypothesize that this population will have fewer labral abnormalities than an athletic population. Despite multiple studies documenting a clear significant association between subtle glenoid dysplasia and posterior labral tears with associated posterior shoulder instability, there is little evidence demonstrating an association with worse outcomes following surgical intervention. The confirming test for a labral tear is an MRI preceded by an arthrogram. These tears include numerous variations designated by acronyms similar to those used for the more commonly seen anterior labral tears. The supraspinatus, infraspinatus and teres minor muscles and tendons are shown. A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. The biceps tendon is medially dislocated (short arrow). Treatment of the labral tears in these scenarios involves treatment of the shoulder dislocation and stabilising the shoulder. A fat-suppressed proton density-weighted axial image in a 14 year-old female with shoulder instability reveals findings of severe glenoid hypoplasia. even greater mobility of the os acromiale after surgery and worsening of the impingement (4). These are depicted in Figure 17-7. The authors found that specific acromial morphology on scapular-Y x-rays is significantly associated with the direction of glenohumeral instability. 10 A paralabral cyst indicates the presence of a labral tear. Arthroscopy. PT (only saw once) suspected labral tear, suggested I see an orthopedic surgeon & get an MRI. 2016 Baseball Sports Medicine: Game Changing Concepts, The Batters Shoulder and Posterior Labral Tears - Christopher Ahmad, MD (BSM #6, 2016), Shoulder360 The Comprehensive Shoulder Course 2023, Shoulder loose body with posterior labral tear with posterior subluxation in 32M. A recess more than 3-5 mm is always abnormal and should be regarded as a SLAP-tear. Non-contrast MRI had an accuracy of 85 %, sensitivity of 36 %, and a PPV of 13 %. MRI is not uncommonly the key to the diagnosis as patients may present with vague clinical findings that are not prospectively diagnosed, in part because of the relatively less common incidence and awareness of this entity. Between 2006 and 2008, 444 patients who had both shoulder arthroscopy and an MRI (non-contrast or MR arthrography) for shoulder pain at our institution prior to surgery were identified and included in the study. The anterior labrum and glenoid articular cartilage often demonstrate normal morphology one image superior to the . (OBQ12.268) Although x-ray findings are typically normal, they must be scrutinized to avoid errors of diagnosis such as missed posterior dislocations. When we assess the shoulder labrum there are 7 areas to look at which have some association with labral tears. A tear extends across the base of the posterior labrum (arrowheads), and mild posterior subluxation of the humeral head relative to the glenoid is present. Chang IY, Polster JM. Glenoid retroversion was significantly associated with the development of posterior shoulder instability (P < .001). Imaging signs of posterior glenohumeral instability. (B) Axillary radiograph of locked posterior glenohumeral dislocation. Both tests may . Study the labrum in the 3-6 o'clock position. The site is secure. There are a number of anatomical labral variants located between 11 and 3 o'clock, which can be mistaken for a SLAP tear: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Axial anatomy and checklist. Purpose: a pointed glenoid on axial imaging sequences is a normal-appearing glenoid without dysplasia, a lazy J has a rounded appearance of the posterior inferior glenoid, and a delta glenoid is a triangular osseous deficiency. De Maeseneer M, Van Roy F, Lenchik L et al. Not All SLAPs Are Created Equal: A Comparison of Patients with Planned and Incidental SLAP Repair Procedures. The posterior labrum is enlarged to replace the deficient glenoid rim. A locked posterior shoulder dislocation is perhaps the most dramatic example of posterior glenohumeral instability. It helps provide stability to the shoulder by . (10a) Ossification is seen along the posterior glenoid (arrows) in a professional baseball pitcher with a history of posterior instability. MR is the best imaging modality to examen patients with shoulder pain and instability. Usually it is an incidental finding and regarded as a normal variant. Clinical Relevance: . At this level also look for Bankart lesions. Posterior Labral Tear, Shoulder Soterios Gyftopoulos, MD, MSc ; Michael J. Tuite, MD To access 4,300 diagnoses written by the world's leading experts in radiology. After addressing the disease prevalence, HPI and PMH, the pre-test probability likelihood of long head bicep pathology was appointed. 3-T MRI of the shoulder: is MR arthrography necessary? 2016;36(6):1628-47. Unable to process the form. Fluid undermines a tear of the posterior glenoid labrum (arrow) in a 42 year-old male with persistent posterior shoulder pain. A posterior labral tear is referred to as a reverse Bankart lesion, or attenuation of the posterior capsulolabral complex, and commonly occurs due to repetitive microtrauma in athletes. A shoulder labral tear injury can cause symptoms such as pain, a catching or locking sensation, decreased range of motion and joint instability. In either case, the labrum can be torn off the bone. The thickened middle GHL should not be confused with a displaced labrum. In more advanced cases of glenoid dysplasia, hypertrophic changes of the labrum and hyaline cartilage are pronounced. Increased glenoid retroversion increases the risk of posterior shoulder instability by 6 times. Diagnosis can be made clinically with positive posterior labral provocative tests and confirmed with MRI studies of the shoulder. Notice the rotator cuff interval with coracohumeral ligament. (10b) A corresponding T2-weighted sagittal view in the same patient confirms the large ossification along the posteroinferior glenoid rim (arrows), compatible with a Bennett lesion. Which of the following is the next best step in management? 14). The glenoid cavity is the shallow socket of the scapula. At surgery, we put the labrum back in position against the bone. Unlike the anterior labrum, rarely do we have a posterior dislocation of the shoulder. Figure 17-1. A shoulder labral tear is an injury to this piece of cartilage, due to direct trauma, overuse, or instability. Notice red arrow indicating a small Perthes-lesion, which was not seen on the standard axial views. These images illustrate the differences between an sublabral recess and a SLAP-tear. A sublabral recess however is located at the site of the attachment of the biceps tendon at 12 o'clock and does not extend to the 1-3 o'clock position. Which of the images (Figures A-E) most likely corresponds to the patient's initial diagnosis? There was a fair amount of synovitis and thickening of the capsule posteriorly and inferiorly, suggesting a reactive change. 5). We have covered the tear itself and variants in earlier posts. Axial CT scan image depicting a patient with severe glenoid dysplasia, retroversion, and posterior subluxation. An axial image in a 53 year-old male following an acute traumatic posterior dislocation reveals tears of the posterior labrum (arrow) and posterior capsule (arrowhead). 2000 Jan;214(1):267-71 (14b) In a 39 year-old weightlifter with persistent posterior shoulder pain and instability, the axial image reveals the posterior capsule outlined by arthrographic fluid along both sides of the capsule, strongly suggestive of a capsular tear. The posterior labrum is stressed with an abducted arm and posterior force. There was no subscapularis or rotator cuff tear and no superior labrum tear. Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Cochrane Database Syst Rev. Apart from that, CT is superior to MR in assessing bony structures, so this modality is helpful in detecting co-existing small glenoid rim fractures. In shoulders with posterior instability, the acromion is situated higher and is oriented more horizontally in the sagittal plane than in normal shoulders and those with anterior instability. Methods: Between 2006 and 2008, 444 patients who had both shoulder arthroscopy and an MRI (non-contrast . 5 A type 1 capsule inserts on the labrum, a type 2 capsule inserts on the junction of the labrum and glenoid, and a type 3 capsule inserts more medially on the glenoid ().The typical posterior capsule inserts on the labrum, either at the labral tip or the . Other radiographic lesions that may be associated with posterior labral pathology and instability include the Bennett lesion, which is an extra-articular posterior ossification of the posterior inferior glenoid. Results: Fig. 6). MRI of the shoulder second edition 12) or at the humeral attachment (Fig. Notice the fibers of the inferior GHL. Labral tears, such as a SLAP tear that cause a paralabral cyst, can occur due to trauma (dislocation), repetitive movement . Diagnosis is made clinically with presence of increased anterior and posterior humeral translation, a sulcus sign, and overall increased . (A) Lightbulb sign demonstrating rounded appearance of the humeral head with a posterior glenohumeral dislocation. The findings are compatible with a posterior GLAD lesion (glenolabral articular disruption). Notice coracoclavicular ligament and short head of the biceps. 2005;184: 984-988. The following algorithm has been previously proposed 25. 2008 Aug; 24(8):921-9. Notice that the supraspinatus tendon is parallel to the axis of the muscle. Numerous capsular abnormalities have been described in patients with posterior glenohumeral instability. Posterior labral periosteal sleeve avulsion injury (POLPSA) in a 19 year-old football player following acute injury. 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. ALPSA lesions are . The posterior shoulder capsule plays a significant role in preventing posterior shoulder dislocation, particularly at the extremes of internal humeral rotation, the position in which most posterior dislocations occur. J Shoulder Elbow Surg. and transmitted securely. It is important to recognise these variants, because they can mimick a SLAP tear. Philadelphia, Pa: Lea & Blanchard; 1822, Pollock RG, Bigliani LU. It cushions the joint of the hip bone, preventing the bones from directly rubbing against each other. 2019 Dec 12;20(1):598. doi: 10.1186/s12891-019-2986-1. (OBQ11.152) J Bone Joint Surg Am 1993; 75:1175-1184. The diagnostic value of magnetic resonance arthrography of the shoulder in detection and grading of SLAP lesions: comparison with arthroscopic findings. A shoulder labral tear can occur due to repetitive overhead use, a lifting injury, a fall on the arm, a sudden pull on the arm, or having the arm twisted at the shoulder joint. First described by Andrews and colleagues in 1985, Snyder later classified lesions of the superior labrum into four types and coined the term SLAP tear (superior labral tear anterior-posterior). To make a tear in the labrum show up more clearly on the MRI, a dye may be injected into your shoulder before the scan is taken. Although increased glenoid retroversion is a risk factor for posterior shoulder instability, there is little evidence to support the claim that increasing glenoid retroversion is associated with worse outcomes following posterior labral repair.12 Hurley et al found that patients with symptomatic posterior instability and glenoid retroversion of greater than 9 degrees had higher recurrence rates after open soft-tissue procedures.13 Conversely, Bigliani and colleagues performed CT scans for 16 of 35 shoulders prior to an open posterior capsular shift and found the average retroversion was 6 degrees.14 Their surgical cohort had an 80% success rate but they did not attribute their failures to osseous anatomy. in Radiology in 2008 examined 36 patients following acute traumatic shoulder dislocation and revealed full-thickness tears in 19% of patients and partial or full-thickness tears in 42%.17As would be expected, subscapularis tears were most common, but tears were also identified in the supraspinatus and the infraspinatus. Accessibility The axillary radiograph is also helpful in the traumatic scenario for identifying a posterior glenoid rim fracture or a reverse Hill-Sachs lesion. When the If the patient is unable to abduct the arm, then a Velpeau view is an alternate orthogonal radiograph (Figure 17-4). where most labral tears are located. Imaging studies therefore are an important adjunct to the diagnosis and treatment of posterior shoulder instability. Notice that the biceps tendon is attached at the 12 o'clock position. Which of the listed structures augments the posterior-inferior glenohumeral ligament and is a static restraint to posterior translation of the humeral head on the glenoid when the shoulder is forward flexed, adducted, and internally rotated? It is seen in 11% of individuals. Also, although better visualized on MRA imaging, a hypertrophied posterior glenoid labrum is evident in patients with glenoid dysplasia (Figure 17-8). 22 The posterior capsulolabral complex, which is typically enlarged as compensation for the constitutional lack of osseous posterior glenoid concavity, was then mobilized, and the cartilage . Federal government websites often end in .gov or .mil. Having a structure when assessing a Shoulder MRI is very useful. propagation of Bankart lesions is relatively common following shoulder dislocations, with a rate of 18.5%. Broadly, clinical unidirectional . Locked posterior subluxation of the shoulder: diagnosis and treatment. Common symptoms of a SLAP tear include: dull or aching pain in the shoulder, especially while lifting over the head. Consecutive fat-suppressed proton density-weighted axial images at the mid glenoid in a football player with persistent shoulder pain reveals mild glenoid dysplasia, with a rounded contour of the posterior glenoid rim (arrows). 2019 Nov 7;19:199-202. doi: 10.1016/j.jor.2019.10.015. In previous studies, conventional MR sensitivity in detection of labral tears has ranged from 44% to 93% sensitivity compared with arthroscopy [1, 2].Two recent studies have assessed conventional MRI evaluation of the glenoid labrum using a 0.2-T extremity MR system. A hip (acetabular) labral tear is damage to cartilage and tissue in the hip socket. Careers. Surgical treatment: arthroscopic debridement . The shoulder, because of its wide range of motion, is anatomically predisposed to instability, but the vast majority of shoulder instability is anterior, with posterior instability estimated to affect 2-10% of unstable shoulders.1Although anterior shoulder dislocations have been recognized since the dawn of medicine, the first medical description of posterior shoulder dislocation did not occur until 1822.2In modern times, posterior shoulder instability is still a commonly missed diagnosis, in part due to a decreased index of suspicion for the entity among many physicians. However,patients with acute lesions often have joint effusion, which also distends the joint space, making the contrast administration unnecessary. Posterior ossification of the shoulder: the Bennett lesion. coracoacromial arch and coracoacromial ligament, glenohumeral ligaments - SGHL, MGHL, IGHL (anterior band). They may extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. Diagnostic criteria for both anterior and posterior labral tears present similarly. Pagnani MJ, Warren RF Stabilizers of the glenohumeral joint. The abduction external rotation (ABER) view is excellent for assessing the anteroinferior labrum at the 3-6 o'clock position, MRI. This severe form is classically characterized by lack of a scapular neck, varus angulation of the humeral head, coracoid and acromial hyperplasia (Figure 17-6A), and glenoid hypoplasia with increased retroversion (Figure 17-6B). The ball of the shoulder can dislocate toward the front of the shoulder (an anterior dislocation), or it can go out the back of the shoulder (called a posterior dislocation). Glenoid labrum (marked lig.) An example of this position is pushing open a door with a straight arm. In part III we will focus on impingement and rotator cuff tears. Normal anatomy. Of the 444 patients having an MRI and arthroscopy for shoulder pain, 121 had a SLAP diagnosis by MRI and 44 had a SLAP diagnosis by arthroscopy. Ferrari JD, Ferrari DA, Coumas J, Pappas AM. Utilizing the gle-noid clockface orientation on a sagittal image (Fig. Such injuries may be referred to as reverse HAGL (humeral avulsion of the glenohumeral ligament) or RHAGL lesions (Fig. Posterior labral tearing was apparent on contiguous images (not shown). Treatment may be nonoperative or operative depending on chronicity of symptoms, degree of instability, and patient activity demands. Biplanar radiographs should always be obtained when evaluating patients with suspected shoulder instability. Glenoid dysplasia, also referred to as glenoid hypoplasia and posterior glenoid rim deficiency, is now increasingly recognized as an anatomic variant that predisposes patients to posterior glenohumeral instability. 7-9). The labrum is the cartilage dish that sits between the ball and the socket configuration of the shoulder joint. Without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis. QID: . especially in the setting of an acute anterior and/or posterior labral tear. I don't have pain generally at all. Once thought to be a relatively rare entity, a study by Harper et al. 3, 19, 31 Our results demonstrate a success rate of nonoperative treatment of 52% at a minimum of 2 years after MRI confirmation of posterior labral tear. On MR arthrography it is customary to combine T1, T1 FS and T2 FS sequences for further assessment. . 13) of the posterior capsule. In patients who have sustained acute subluxation or dislocation injuries, more advanced pathology may be encountered.
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