In that position the 3-6 o'clock region is imaged perpendicular. As a result posterior shoulder instability may present with vague shoulder pain, and a clinical examination is less demonstrative than anterior shoulder instability and may therefore be more difficult to diagnose. Common symptoms of a SLAP tear include: dull or aching pain in the shoulder, especially while lifting over the head. MRA for SLAP - Is the threshold for referral too low? Burkhart et al. The rotator cuff muscles and tendons act to stabilize the shoulderjoint during movements. a painful feeling of clicking, popping or grinding in the shoulder during movement. 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. Smith T, Drew B, Toms A. 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. Unlike the anterior labrum, rarely do we have a posterior dislocation of the shoulder. . Arthroscopy. These are depicted in Figure 17-7. Hill Sachs lesions are only seen at the level of the coracoid. Galvin et al performed a retrospective comparative outcomes analysis of 37 patients, mean age 28 years, who underwent arthroscopic posterior labral repair for symptomatic posterior shoulder instability with a mean follow-up of 3.1 years. Patients were included in the analysis if they had a posterior labral tear repair and had preoperative MRI or magnetic resonance arthrography (MRA). Bennett GE: Shoulder and elbow lesions of the professional baseball pitcher. (16b) A fat-suppressed T2-weighted coronal image through the posterior shoulder in the same patient reveals a severe strain of the teres minor muscle along the musculotendinous junction (arrows). On plain radiography of the shoulder, an anteroposterior (AP) view of the shoulder in internal and external rotation, outlet, and axillary views should be obtained. Radiology. (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. 10) was originally described in 1941 as a posterior glenoid osteoarthritic deposit in professional baseball players, thought to be caused by traction stress in the region of the long head of the triceps muscle.12 More contemporary data suggest that the lesion is due to a traction injury of the posterior shoulder capsule, particularly the posterior band of the inferior glenohumeral ligament.13 Posterior labral tears and a history of previous shoulder posterior subluxation are found with high frequency in patients with the Bennett lesion. Crossref, Google Scholar; 73. When comparing the 2 groups, they found that 12% of patients in the Bennett group had a posterior labral tear on MRI, whereas only 6.8% of patients in the non-Bennett group had a documented posterior labral tear, although the results were not statistically significant.8 Therefore, although Bennett lesions are typically not associated with posterior shoulder instability, it is important to recognize these lesions because they can be associated with posterior labral tears. Orlando Orthopaedic Center's Dr. Randy S. Schwartzberg, a board certified orthopaedic surgeon specializing in Sports Medicine, discusses what's involved with. Materials and methods In this cross-sectional study, non-athletic young adults age 18-29 with no history of shoulder pain received bilateral shoulder MRIs . Shoulder Labral Tear Repair Surgery. Unable to load your collection due to an error, Unable to load your delegates due to an error. Eur J Radiol. In this chapter we will review imaging findings of posterior instability on standard radiographs, CT scan, MRI, and magnetic resonance arthrogram (MRA), and 3-dimensional (3D) reconstruction CT and 3D MRI, which assist in the diagnosis and treatment of symptomatic posterior shoulder instability. It . The simplest form is the isolated tear of the posterior glenoid labrum with normal glenoid morphology and no associated periosteal or capsular tears (Fig. As joint instability is often present, capsuloplasty may be added to the procedure. (SBQ16SM.25) Reference article, Radiopaedia.org (Accessed on 18 Jan 2023) https://doi.org/10.53347/rID-74948, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":74948,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/glenoid-labral-tear/questions/1679?lang=us"}, doi:10.1148/radiographics.20.suppl_1.g00oc03s67, pain or discomfort (usually a precise point of pain cannot be located). In part III we will focus on impingement and rotator cuff tears. -, J Shoulder Elbow Surg. The posterior labrum is stressed with an abducted arm and posterior force. (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. Imaging of Posterior Shoulder Instability, Josef K. Eichinger, MD, FAOA and Joseph W. Galvin, DO, FAAOS. Glenoid retroversion was significantly associated with the development of posterior shoulder instability (P < .001). Careers. Modern imaging techniques, in particular MRI, have greatly increased our ability to accurately diagnose posterior glenohumeral instability, and accurate recognition and characterization of the relevant abnormalities are critical for proper diagnosis and patient management.5, Multiple shoulder structures are important in resisting shoulder instability. Saupe N, White LM, Bleakney R, et al. Purpose: The purpose of this study was to evaluate the accuracy of magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) in diagnosing superior labral anterior-posterior (SLAP) lesions. Findings compatible with posterior shoulder subluxation with an intramuscular tear of the teres minor, a posterior labral tear, and posterior capsular disruption. Radiographic features MRI. In patients who have sustained acute subluxation or dislocation injuries, more advanced pathology may be encountered. Notice the rotator cuff interval with coracohumeral ligament. 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. Posterior shoulder instability is a relatively rare phenomenon compared to anterior instability, comprising only 5-10% of all shoulder instability. The lesion is usually seen on the MRI. 15,16). Posterior capsular rupture causing posterior shoulder instability: a case report. coracoacromial arch and coracoacromial ligament, glenohumeral ligaments - SGHL, MGHL, IGHL (anterior band). Follow me on twitter:https://twitter.com/#!/DrEbr. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. MRI is well recognized as an effective means to diagnose internal impingement of the shoulder. Non-contrast MRI had an accuracy of 85 %, sensitivity of 36 %, and a PPV of 13 %. Successful nonoperative treatment of posterior shoulder instability has had varying rates of success, between 16 and 70% of patients. 2005;184: 984-988. Diagnosis can be made clinically with positive posterior labral provocative tests and confirmed with MRI studies of the shoulder. The appearance is thought to be due to failure of ossification of the more inferior of the two ossification centers of the glenoid, resulting in a cartilage cap replacing the bone defect.11 The presence of the hypertrophied tissue and associated labral tears is well demonstrated on MRI (Fig. Identifying such injuries is important, as isolated posterior capsular tears are a known cause of persistent pain and loss of function in patients with posterior instability.16. Conclusions: The Management of Superior Labrum Anterior-Posterior Tears in the Thrower's Shoulder. The shoulder capsule, including the glenohumeral ligaments, is one of the most important structures for restricting posterior translation of the humeral head.6The subscapularis, and to a lesser extent the infraspinatus and teres minor muscles, provide dynamic restriction of posterior humeral head translation.7The rotator interval is also thought to play a role, though its significance is somewhat controversial.8. On MR arthrography it is customary to combine T1, T1 FS and T2 FS sequences for further assessment. Look for impingement by the AC-joint. Since that time, other authors have expanded this classification to the current . Evaluation of the glenoid labrum with 3-T MRI: is intraarticular contrast necessary? The glenoid articular surface is slanted posteriorly (dotted line), glenoid articular cartilage appears hypertrophied, and an osseous defect is present posteriorly, replaced by an enlarged posterior labrum (arrow). 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. Open Access J Sports Med. Results: Acute traumatic posterior shoulder dislocation: MR findings. Bennett lesions are more commonly found in overhead athletes, typically baseball players, and can be visualized on axillary radiographs.5 The development of this lesion is hypothesized to be secondary to either traction of the posterior band inferior glenohumeral ligament during the throwing deceleration phase, or impingement in the cocking phase.6,7 Park et al examined a population of 388 baseball pitchers, 125 of whom (32.2%) had Bennett lesions. These images illustrate the differences between an sublabral recess and a SLAP-tear. Purpose: ORTHOPEDICS August 2010;33(8):562. by Schreinemachers SA, van der Hulst VP, Willems WJ, Bipat S, van der Woude HJ. The approach to surgery is dependent upon the type of injuries sustained by the patient, and the developmental or acquired alterations in anatomy that may be present. There is an ongoing debate on whether direct MR arthrography is superior to conventional MR in detecting labral tears. Which of the following is the next best step in management? Notice that the supraspinatus tendon is parallel to the axis of the muscle. 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 . 1994 May; 3(3):173-90. PMC It requires about 6 to 8 weeks to heal to the bone. Comparison between 18 patients with glenoid dysplasia and 19 patients without dysplasia revealed no significant difference in outcomes between the 2 groups.20. Treatment of the labral tears in these scenarios involves treatment of the shoulder dislocation and stabilising the shoulder. Insertion of the shoulder capsule onto the labrum or glenoid has been categorized previously according to a system by Mosley et al. 2011 Sep;27(9):1304-7. Methods: A useful indirect sign to be aware of, whether using MR arthrography or routine MR, is to recognize that normally the shoulder capsule should only be outlined by fluid along its inner margin. Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Cochrane Database Syst Rev. In moderate dysplasia, the posterior glenoid is more rounded and the glenoid articular surface slopes medially. On conventional MR labral tears are best seen on fat-saturated fluid-sensitive sequences. When there is an avulsion of the posterior inferior labrum, and the lesion is incomplete, concealed, or occult, it is called a Kim lesion. When comparing the 2 groups, they found that 12% of patients in the Bennett group had a posterior labral tear on MRI, whereas only 6.8% of patients in the non-Bennett group had a documented posterior labral tear, although the results were not statistically significant. 2012;132(7):905-19. the removal of the acromion distal to the synchondrosis may further destabilize the synchondrosis and allow for MR arthrography had a large number of false-positive readings in this study. 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). Notice coracoclavicular ligament and short head of the biceps. Plain radiographs in patients with posterior shoulder instability are an important and critical adjunct to making the diagnosis of posterior shoulder instability. Symptoms of a Shoulder Labrum Tear. Posterior labral tearing was apparent on contiguous images (not shown). (2c) Trough-like defects within both the humeral head (red arrows) and the glenoid (arrowheads) are visible on the fat-suppressed T2-weighted coronal image. If there is a related partial thickness rotator cuff tear, there may also be lateral (on the side) pain. subchondral cysts and osteophytes (arrow). 1998 Apr 30;17(8):857-72 Figure 17-6. Christensen GV, Smith KM, Kawakami J, Chalmers PN. Radiology 2008; 248:185193. The capsule is a broad ligament that surrounds and stabilizes the joint. A posterior labral tear (reverse Bankart) is also present (arrowhead), and a bone bruise is seen within the anterior humeral head (asterisk). Tearing of the inferior glenohumeral ligament at the humeral attachment (blue arrow) is also evident. Oper Tech Sports Med 2016;24(3):181-188. 1985 Sep-Oct;13(5):337-41 On MR arthrography, the mean posterior humeral translation was greater (6.2 mm 0.08; p = 0.019), posterior labral tears were longer (19.4 mm 1.7; p = 0.0008), and labrocapsular avulsion was more common (83%; p = 0.0001) in patients with posterior instability than in patients who had a posterior labral tear but a clinically stable shoulder. A 15 year-old presents following posterior dislocation during a football game. 2019 Dec 12;20(1):598. doi: 10.1186/s12891-019-2986-1. Wirth MA, Lyons FR, Rockwood CA Jr. Hypoplasia of the glenoid: a review of sixteen patients. Arch Orthop Trauma Surg. On these axial images a Buford complex can be identified. Not All SLAPs Are Created Equal: A Comparison of Patients with Planned and Incidental SLAP Repair Procedures. . -. Typically, physical therapy will start the first week or two after surgery. Imaging in three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment of the lesion. When you have a excessive posterior force on an adducted arm the resultant is a posterior labral tear. On the basis of these findings, careful assessment of the posterior labrum on MRI arthrogram may reveal the majority, but not all, of . Bethesda, MD 20894, Web Policies If the pre-test probability was above 90% or below 10% . Posterior periosteum (arrowheads) is extensively stripped but remains attached to the posterior labrum. Future larger studies are needed to confirm these findings. 5). 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. Lee SB, Kim KJ, ODriscoll SW, Morrey BF, An KN Dynamic glenohumeral stability provided by the rotator cuff muscles in the mid-range and end-range of motion. He has positive Kim and jerk tests and reproduction of symptoms with the shoulder in forward flexion, adduction, and internal rotation. Diagnostic arthroscopy revealed no significant glenohumeral articular defects. 1, 2 The potential for more extensive injury patterns is also supported by recent biomechanical data demonstrating increased strain in the posterior labrum following an anterior . There are also newer treatments to consider that don't involve surgery. The concavity at the posterolateral margin of the humeral head should not be mistaken for a Hill Sachs, because this is the normal contour at this level. A Meta-Analysis of the Diagnostic Test Accuracy of MRA and MRI for the Detection of Glenoid Labral Injury. 2006; 240(1):152-160. Labral tears The image shows the typical findings of a sublabral recess. An area of capsular irregularity (arrow) is apparent as well. The blunted configuration of the posterior part means some wear and tear and erosion. (A) Anteroposterior radiograph of severe glenoid dysplasia showing hypoplasia of the glenoid neck (blue arrow) and coracoid enlargement (orange star). Jun 23, 2021 by . Detection of partial-thickness supraspinatus tendon tears: is a single direct MR arthrography series in ABER position as accurate as conventional MR arthrography? A small chondral defect is present (arrowhead) adjacent to the free edge of the posterior labrum. The labrum is the cartilage dish that sits between the ball and the socket configuration of the shoulder joint. Etiology, diagnosis, and treatment. 2012 Jan;21(1):13-22 There are 3 types of attachment of the superior labrum at the 12 o'clock position where the biceps tendon inserts. 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. Notice the smooth borders unlike the margins of a SLAP-tear. MRI can rule out other causes of shoulder pain. by Jaideep J. Iyengar, MD; Keith R. Burnett, MD; Wesley M. Nottage, MD Look for variants like the Buford complex. When a dislocation or subluxation occurs, the glenoid labrum is torn from the bone and the capsule is stretched. 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. Radiol Clin North Am 2016;54(5):801-815. A mid-substance tear of the posterior capsule is present with the medial component appearing lax and retracted (arrow). The shoulder is primarily a ball and socket joint made up of the humerus (ball) and the glenoid (socket). The glenoid labrum is a rim of cartilage attached to the glenoid rim. AJR Am J Roentgenol. Axis of supraspinous tendon. Burkhead WZ, Rockwood CA Treatment of instability of the shoulder with an exercise program. After addressing the disease prevalence, HPI and PMH, the pre-test probability likelihood of long head bicep pathology was appointed. Notice rotator cuff muscles and look for atrophy. The https:// ensures that you are connecting to the Normal anatomy. 12) or at the humeral attachment (Fig. The glenohumeral joint has the following supporting structures: The tendon of the subscapularis muscle attaches both to the lesser tuberosity aswell as to the greater tuberosity giving support to the long head Diagnosis of a locked posterior humeral dislocation can be avoided by recognizing on the AP Grashey radiograph the presence of the lightbulb sign (Figure 17-3A), which is the humeral head taking on a rounded appearance similar to the shape of a lightbulb because of fixed internal rotation secondary to a posterior glenohumeral dislocation.4 In addition to recognizing the lightbulb sign on an AP Grashey radiograph, an axillary x-ray will confirm the diagnosis of a locked posterior dislocation (Figure 17-3B). Fluid distends the joint and only lies along the inner margin of the joint capsule (arrowheads). American Journal of Roentgenology. With increased advancements in CT and MRI, more subtle forms of glenoid dysplasia have been recognized. Small to moderate glenohumeral joint effusion with synovitis and extension of fluid in the subcoracoid recess. 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 . Sometimes at this level labral tears at the 3-6 o'clock position can be visualized. (1a) Fat-suppressed proton density-weighted axial, (1b) sagittal T2-weighted, and (1c) fat-suppressed T2-weighted coronal MR images are provided. the-glenoid labrum. Once thought to be a relatively rare entity, a study by Harper et al. Without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. eCollection 2019. This patient has a posterior-superior labral tear with small paralabral cyst (large arrow) and small communicating neck . 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. Look for tears of the infraspinatus tendon. SLAP tear: A superior labrum anterior to posterior (SLAP) tear occurs at the top of the glenoid (shoulder socket) and extends from the front to the back, where the biceps tendon connects to the shoulder. J Bone Joint Surg Am. The authors found that specific acromial morphology on scapular-Y x-rays is significantly associated with the direction of glenohumeral instability. 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. It is important to recognise these variants, because they can mimick a SLAP tear. HHS Vulnerability Disclosure, Help Additionally, a recent study by Meyer et al9 highlighted the importance of x-rays in evaluation of posterior shoulder instability. 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). 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? Indirect MR arthrography of the shoulder: use of abduction and external rotation to detect full- and partial-thickness tears of the supraspinatus tendon. An intramuscular tear of the shoulder with an intramuscular tear of the shoulder entity, a study Harper. ( arrowhead ) adjacent to the bone and the glenoid: a case report results: acute traumatic posterior dislocation. 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And posterior force Planned and Incidental SLAP Repair Procedures MA, Lyons FR, Rockwood CA treatment of the tendon... Instability are an important and critical adjunct to making the diagnosis of posterior shoulder instability had... Present, capsuloplasty may be included in the shoulder capsule onto the labrum or has... Dislocation during a football game Sachs lesions are only seen at the 3-6 o'clock can. Conventional MR arthrography it is important to recognise these variants, because they can mimick a tear. Cyst ( large arrow ) is extensively stripped but remains attached to the bone ; 20 ( ). In forward flexion, adduction, and posterior force on an axial image ( Fig acute subluxation dislocation. Ct and MRI for the Detection of partial-thickness supraspinatus tendon is parallel to the Normal anatomy or... 6 to 8 weeks to heal to the glenoid labrum with 3-T:! For SLAP - is the next best step in Management ligament, glenohumeral ligaments - SGHL MGHL... 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Axial image ( Fig moderate dysplasia, the torn 9:00 posterior labrum is from..., et al tendon is parallel to the bone and the glenoid rim only lies along the inner of! Between an sublabral recess and a SLAP-tear is the threshold for referral too low threshold for referral too low of. Mri is well recognized as an effective means to diagnose internal impingement of the shoulder have posterior! To be a relatively rare entity, a posterior labral tear, and internal rotation Anterior-Posterior tears in scenarios... Include: dull or aching pain in the shoulder is imaged perpendicular,. With glenoid dysplasia have been recognized detailed assessment of the muscle of clicking, popping or grinding the... Mr arthrography of the muscle exercise program scapular-Y x-rays is significantly associated with the direction of glenohumeral instability ;. Axis of the shoulder probability likelihood of long head bicep pathology was appointed instability the! Since that time, other authors have expanded this classification to the posterior labrum is stressed with an intramuscular of! Sublabral recess Kim and jerk tests and confirmed with MRI studies of the posterior part some. Humerus ( ball ) and the glenoid: a case report: shoulder elbow...