A SLAP tear may extend to the 1-3 o'clock position, but the attachment of the biceps tendon to the superior labrum should always be involved. Arthroscopic Posterior Labral Repair - Randy S. Schwartzberg, M.D. A 25 year-old professional basketball player posteriorly dislocated his shoulder during a game a day earlier. Which of the following is the next best step in management? Objective To determine the prevalence of shoulder (specifically labral) abnormalities on MRI in a young non-athletic asymptomatic cohort. The axial MR-images show an os acromiale with degenerative changes, i.e. If the arm is Mild glenoid hypoplasia results in a rounded contour of the posterior glenoid with normal or only mildly thickened posterior labral tissue. If there is a related partial thickness rotator cuff tear, there may also be lateral (on the side) pain. As a result, in cases of posterior shoulder instability, particularly dislocation, capsular tears are frequently identified on MR imaging.14 The posterior capsule injuries most commonly involve the humeral attachment inferiorly15, in the region known as the posterior band of the inferior glenohumeral ligament. CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum and Labral-Bicipital Complex. In Shoulder MR-Part I we will focus on the normal anatomy and the many anatomical variants that may simulate pathology. Increased glenoid retroversion increases the risk of posterior shoulder instability by 6 times. 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 . Fig. Imaging signs of posterior glenohumeral instability. Our data indicated that while MRI could exclude a SLAP lesion (NPV = 95 %), MRI alone was not an accurate clinical tool. . Posterior instability of the shoulder can vary from minor symptoms and findings to dramatic events resulting in extensive, complex injuries to the shoulder. Posterior labrum tear causes: Catching a heavy object . Diagnosis . The https:// ensures that you are connecting to the The chondral lesion is thought to arise secondary to impaction injury from the humeral head. scan or magnetic resonance imaging (MRI) scan may be ordered for a glenoid labrum tear diagnosis. Although x-ray findings are typically normal, they must be scrutinized to avoid errors of diagnosis such as missed posterior dislocations. Posterior subluxation of the humeral head is readily apparent. eCollection 2021. Posterior labral tears will demonstrate the absence of the labrum or morphologic distortion, contrast, or fluid infiltration [].Four primary diagnostic characteristics can determine pathologic tearing versus an anatomic variant: intrasubstance signal intensity, margins, orientation, and extension. 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. When we assess the shoulder labrum there are 7 areas to look at which have some association with labral tears. Arthroscopy. 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. Axis of supraspinous tendon. The findings are compatible with a posterior GLAD lesion (glenolabral articular disruption). Types of labral tears. Notice rotator cuff muscles and look for atrophy. Posterior shoulder dislocations can result in posterior labral tears. Methods: Between 2006 and 2008, 444 patients who had both shoulder arthroscopy and an MRI (non-contrast . At this level also look for Bankart lesions. 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). (14c) An arthroscopic examination confirms the tear in the posterior capsule (arrow), which was subsequently repaired. Pathology involving the superior labrum presents a diagnostic and therapeutic challenge for the arthroscopic surgeon. Treatment may be nonoperative or operative depending on chronicity of symptoms, degree of instability, and patient activity demands. 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. Hill Sachs lesions are only seen at the level of the coracoid. 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). Look for HAGL-lesion (humeral avulsion of the glenohumeral ligament). When the Which of the following is the most likely etiology of his complaints? Imaging Studies. 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. Posterior labrum tear: This tear occurs at the back of the shoulder joint. Figure 1 is an artist's rendition of a normal shoulder joint as well as the trauma caused by shoulder instability depicted on MRI. A study in cadavers. Tearing of the inferior glenohumeral ligament at the humeral attachment (blue arrow) is also evident. Both tests may . Small to moderate glenohumeral joint effusion with synovitis and extension of fluid in the subcoracoid recess. MR interpreters should be aware that at times capsular tears are quite subtle. FOIA The glenoid labrum stabilizes the joint by increasing glenoid depth and surface area, and provides a stable fibrocartilaginous anchor for the glenohumeral ligaments. Glenoid dysplasia/hypoplasia occurred in 19% to 35% of specimens.15,16 Additionally, several studies have identified that subtle posteroinferior glenoid deficiency and hypoplasia are significantly associated with posterior labral tears and symptomatic posterior shoulder instability.1719 Weishaupt et al18 used CT arthrograms to determine the incidence and severity of glenoid dysplasia in a population of patients with atraumatic posterior shoulder instability. This is a common injury for athletes such as baseball pitchers and . 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. 7-9). In this post we look at Periosteal Stripping. Symptoms of a Shoulder Labrum Tear. 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 Jan;21(1):13-22 3. 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. -, BMJ. The abduction and external rotation of the arm releases tension on the cuff relative to the normal coronal view obtained with the arm in adduction. Introduction. Smith T, Drew B, Toms A. The labrum has the same effect on the shoulder as the rounded lip of a golf tee has to a golf ball. The glenoid labrum is a rim of cartilage attached to the glenoid rim. American Journal of Roentgenology. Look for tears of the infraspinatus tendon. At this level study the middle GHL and the anterior labrum. Reverse-bankart lesion: Also known as a posterior labral tear, this injury affects the rear and lower ends of the labrum. Arch Orthop Trauma Surg. We have covered the tear itself and variants in earlier posts. Utilizing the gle-noid clockface orientation on a sagittal image (Fig. Notice red arrow indicating a small Perthes-lesion, which was not seen on the standard axial views. These tears include numerous variations designated by acronyms similar to those used for the more commonly seen anterior labral tears. 12) or at the humeral attachment (Fig. Following a posterior subluxation event, a fat-suppressed T2-weighted coronal image in this 52 year-old male reveals focal edema and irregularity at the humeral attachment of the posterior band of the inferior glenohumeral ligament (arrow), compatible with a partial tear. This can result in the damage to the anterior or front part of the labrum. It requires about 6 to 8 weeks to heal to the bone. When the labrum gets damaged or torn, it puts the shoulder at increased risk for looseness and dislocation. Using arthroscopy as the standard, sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated for all MRIs, as well as separately for the non-intra-articular contrast MRI group and the MR arthrography group. 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. Dislocation of the long head of the biceps will inevitably result in rupture of part of the subscapularis tendon. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. In the event of a shoulder dislocation, the . Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, The Abduction External Rotation (ABER) View for MRI of the Shoulder. 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. Pagnani MJ, Warren RF Stabilizers of the glenohumeral joint. Provencher MT, Dewing CB, Bell SJ, McCormick F, Solomon DJ, Rooney TB, Stanley M.An analysis of the rotator interval in patients with anterior, posterior, and multidirectional shoulder instability. (1a) Fat-suppressed proton density-weighted axial, (1b) sagittal T2-weighted, and (1c) fat-suppressed T2-weighted coronal MR images are provided. 2000;20 Spec No(suppl_1):S67-81. 13) of the posterior capsule. Conclusions: 8600 Rockville Pike The axillary radiograph is also helpful in the traumatic scenario for identifying a posterior glenoid rim fracture or a reverse Hill-Sachs lesion. In a 34 year-old male following an acute subluxation event, a tear is present along the base of the posterior labrum with edema and irregularity noted at adjacent posterior periosteum (arrow). The most common symptoms of a shoulder labrum tear can occur intermittently. The posterior labrum is avulsed, and stripped scapular periosteum remains attached to the posterior labrum (arrowhead). Notice MGHL, which has an oblique course through the joint and study the relation to the subscapularis tendon. 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. The shoulder joint is the most unstable articulation in the entire human body. Additionally, a recent study by Meyer et al9 highlighted the importance of x-rays in evaluation of posterior shoulder instability. Axial anatomy and checklist. Normal anatomy. Usually it is an incidental finding and regarded as a normal variant. Locked posterior shoulder dislocation with multiple associated injuries. Such injuries may be referred to as reverse HAGL (humeral avulsion of the glenohumeral ligament) or RHAGL lesions (Fig. Methods: (16a) An axial image in a 17 year-old female following posterior subluxation during a basketball game demonstrates humeral sided avulsion of the capsule (arrow). Orthop J Sports Med. These images illustrate the differences between an sublabral recess and a SLAP-tear. Imaging of superior labral anterior to posterior (SLAP) tears of the shoulder. doi: 10.1002/14651858.CD009020.pub2. Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum. Capsule. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthroscopic findings with arthroscopic correlation. Figure 17-6. Successful nonoperative treatment of posterior shoulder instability has had varying rates of success, between 16 and 70% of patients. Posterior shoulder instability is a relatively rare phenomenon compared to anterior instability, comprising only 5-10% of all shoulder instability. Type in at least one full word to see suggestions list. Notice smooth undersurface of infraspinatus tendon and normal anterior labrum. Posterior instability most often occurs either as a result of high force direct trauma to the shoulder such as from a motor vehicle accident or indirect trauma such as from seizures or electrocution. Imaging studies therefore are an important adjunct to the diagnosis and treatment of posterior shoulder instability. 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 . Am J Roentgenol. Check for errors and try again. 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. His examination is somewhat difficult due to his large size, but no significant abnormal findings are noted. 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). Evaluation of the glenoid labrum with 3-T MRI: is intraarticular contrast necessary? What is your diagnosis? A CT scan is typically performed to evaluate posterior bone loss due to either a reverse bony Bankart lesion or attritional bone loss, and to assess degree of retroversion and glenoid dysplasia, and is performed in revision scenarios. Wuennemann F, Kintzel L, Zeifang F, Maier MW, Burkholder I, Weber MA, Kauczor HU, Rehnitz C. BMC Musculoskelet Disord. That is, the labrum helps the shoulder from slipping out of its joint. An orthopaedic surgeon performs an arthroscopic shoulder procedure on a football player. Burkhead WZ, Rockwood CA Treatment of instability of the shoulder with an exercise program. 2006; 240(1):152-160. Radiographs are normal, and an MRI arthrogram is shown in Figure A. 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. Philadelphia, Pa: Lea & Blanchard; 1822, Pollock RG, Bigliani LU. 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). These are also called ganglion cysts of the shoulder. Description. It can be a traumatic tear due to injury, or it may be degenerative due to normal wear and tear. These normal variants will usually not mimick a Bankart-lesion, since it is located at the 3-6 o'clock position, where these normal variants do not occur. 2015;101(1 Suppl):S19-24. QID: . Multidirectional shoulder instability (MDI) is a condition characterized by generalized instability of the shoulder in at least 2 planes of motion (anterior, posterior, or inferior) due to capsular redundancy. Common symptoms of a SLAP tear include: dull or aching pain in the shoulder, especially while lifting over the head. Would you like email updates of new search results? posterior labral tear surgery. Large tears of the rotator cuff may allow the humeral head to migrate upwards resulting in a high riding humeral head. The labrum is cartilage tissue that holds the "ball" (humeral head) in the "socket" (glenoid) of your shoulder. Figure 17-5. 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