Notice the smooth borders unlike the margins of a SLAP-tear. 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. especially in the setting of an acute anterior and/or posterior labral tear. They all attach to the greater tuberosity. Normal glenoid morphology is present. An arthroscopic examination confirmed the MRI findings and showed multiloculated cysts in the inferior labrum, mostly between 5 o'clock to 7 o'clock positions with labral tear. A posterior labrum tear is a rare type of shoulder labral tear that occurs in the back of the shoulder. There was no subscapularis or rotator cuff tear and no superior labrum tear. In all patients, posterior cartilage damage of type 3 to 4, classified according to Outerbridge, with a concomitant posterior labral tear was evident. Advances in knowledge:: On a direct MR arthrographic image, a posterior capsular synovial fold may be a normal anatomic variant. In patients with posterior instability, the presence of glenoid hypoplasia is predictably higher, with one report finding deficiency of the posteroinferior glenoid in 93% of patients with atraumatic posterior instability.10 When diagnosing posterior glenoid hypoplasia on MRI, care should be taken not to overcall the entity, as volume averaging can result in a false appearance of dysplasia on the most inferior axial slice. On examination, she reports deep posterior shoulder pain when the arm is abducted 90 degrees and maximally . The posterior capsule is torn at the humeral attachment (arrow). The shallow socket in the scapula is the glenoid cavity. Mauro et al found increased retroversion in a cohort of 118 patients who were operatively treated for posterior instability in comparison with a group of normal controls, but the authors did not attribute retroversion as a risk factor for failure. 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. Posterior subluxation of the humeral head is also apparent. It is a condition referred to as an internal impingement. Study the attachment of the IGHL at the humerus. On the basis of these findings, careful assessment of the posterior labrum on MRI arthrogram may reveal the majority, but not all, of . Sports Health 2011 May, 3(3):253-263, Cooper A. If the arm is Figure 17-3. Wuennemann F, Kintzel L, Zeifang F, Maier MW, Burkholder I, Weber MA, Kauczor HU, Rehnitz C. BMC Musculoskelet Disord. 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. Open Access J Sports Med. There is . These tears include numerous variations designated by acronyms similar to those used for the more commonly seen anterior labral tears. 2012 Dec;52(6):622-30. The labrum in the shoulder joint is a vital component that helps stabilize the humerus and shoulder blade during movement. In more advanced cases of glenoid dysplasia, hypertrophic changes of the labrum and hyaline cartilage are pronounced. Normal Labral Anatomy. Christensen GV, Smith KM, Kawakami J, Chalmers PN. In a SLAP injury, the top (superior) part of the labrum is injured. The undersurface of the supraspinatus tendon should be smooth. The site is secure. Federal government websites often end in .gov or .mil. QID: . 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. A fold is more commonly occur in the posterosuperior and posteroinferior capsular portions. Due to the tension by the anterior band of the inferior GHL labral teras will be easier to detect. J Bone Joint Surg Am 1993; 75:1175-1184. 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 part III we will focus on impingement and rotator cuff tears. complex injuries to the shoulder. On conventional MR labral tears are best seen on fat-saturated fluid-sensitive sequences. Which of the images (Figures A-E) most likely corresponds to the patient's initial diagnosis? However,patients with acute lesions often have joint effusion, which also distends the joint space, making the contrast administration unnecessary. -, J Shoulder Elbow Surg. (2a) The fat-suppressed proton density-weighted axial image reveals alignment of the humeral head posteriorly relative to the glenoid, with an impaction fracture of the humeral head articular surface (red arrow). (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. Tendonitis of the long head of the biceps. Symptoms of a Shoulder Labrum Tear. Ultrasound will also show a shoulder ganglion cyst and the effects of muscle wasting. When we assess the shoulder labrum there are 7 areas to look at which have some association with labral tears. 2016;36(6):1628-47. 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. Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Cochrane Database Syst Rev. scan or magnetic resonance imaging (MRI) scan may be ordered for a glenoid labrum tear diagnosis. However, imaging studies do not always demonstrate obvious pathologic findings and thus a nuanced approach to the interpretation of x-rays, computed tomography (CT), and magnetic resonance imaging (MRI) is necessary to elucidate and identify subtle findings that can enable the clinician to make the correct diagnosis. Imaging studies therefore are an important adjunct to the diagnosis and treatment of posterior shoulder instability. In addition to aiding in the recognition of a locked posterior dislocation, the axillary radiograph is necessary to a complete an orthogonal radiographic analysis. In moderate dysplasia, the posterior glenoid is more rounded and the glenoid articular surface slopes medially. 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). Radiographics. 1963 Dec. 43:1621-2. 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. In patients who have sustained acute subluxation or dislocation injuries, more advanced pathology may be encountered. Failure of one of the acromial ossification centers to fuse will result in an os acromiale. The posterior labrum is avulsed, and stripped scapular periosteum remains attached to the posterior labrum (arrowhead). The biggest advantage of MR arthrography comes from the joint distension, which can help spot otherwise occult tears. In our retrospective study of 444 patients, sensitivity, specificity, and accuracy were all lower than previously reported in the literature for diagnosing SLAP lesions. True dysplasia should be visible on at least two axials slices cephalad to the most inferior slice of the glenoid (Fig. A hip (acetabular) labral tear is damage to cartilage and tissue in the hip socket. Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis. 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). The small size of the glenoid fossa and the relative laxity of the joint capsule renders the joint relatively unstable and prone to subluxation and dislocation. An MRI arthrogram is performed and is normal. Mild glenoid hypoplasia results in a rounded contour of the posterior glenoid with normal or only mildly thickened posterior labral tissue. 1A: The ball (humerus) normally rests within the socket (glenoid) like a golf ball on a tee. 14). Simoni P, Scarciolla L, Kreutz J, Meunier B, Beomonte Zobel B. J Sports Med Phys Fitness. 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. 15,16). Hottya GA, Tirman PF, Bost FW, Montgomery WH, Wolf EM, Genant HK. Chung CB, Sorenson S, Dwek JR and Resnick D. Humeral Avulsion of the Posterior Band of the Inferior Glenohumeral Ligament: MR Arthrography and Clinical Correlation in 17 Patients. Overall, an MRI scan will clearly show the ganglion cyst in the shoulder and whether it compresses the nerve. Eur J Radiol. Accessibility Objective To determine the prevalence of shoulder (specifically labral) abnormalities on MRI in a young non-athletic asymptomatic cohort. Non-contrast MRI had an accuracy of 85 %, sensitivity of 36 %, and a PPV of 13 %. On MR arthrography it is customary to combine T1, T1 FS and T2 FS sequences for further assessment. A small chondral defect is present (arrowhead) adjacent to the free edge of the posterior labrum. A fat-suppressed proton density-weighted axial image in a 14 year-old female with shoulder instability reveals findings of severe glenoid hypoplasia. An os acromiale must be mentioned in the report, because in patients who are considered for subacromial decompression, A locked posterior shoulder dislocation is perhaps the most dramatic example of posterior glenohumeral instability. Keith W. Harper1, Clyde A. Helms1, Clare M. Haystead1 and Lawrence D. Higgins Glenoid Dysplasia: Incidence and Association with Posterior Labral Tears as Evaluated on MRI. The vast majority of shoulder labral tears do not need surgery. The rotator cuff is made of the tendons of subscapularis, supraspinatus, infraspinatus and teres minor muscle. Orthop Traumatol Surg Res. It is not healed. The retracted end of the subscapularis (asterisk) is also visible compatible with a full thickness tear. Although x-ray findings are typically normal, they must be scrutinized to avoid errors of diagnosis such as missed posterior dislocations. Burkhead WZ, Rockwood CA Treatment of instability of the shoulder with an exercise program. When a dislocation or subluxation occurs, the glenoid labrum is torn from the bone and the capsule is stretched. The .gov means its official. Evaluation and management of posterior shoulder instability. Numerous labral abnormalities may be encountered in patients with posterior glenohumeral instability. Figure 17-1. A Buford complex is a congenital labral variant. American Journal of Roentgenology. Posterior labrum tear: This tear occurs at the back of the shoulder joint. 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. Bookshelf Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthroscopic findings with arthroscopic correlation. 1. . What is your diagnosis? 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). Treatment may be nonoperative or operative depending on chronicity of symptoms, degree of instability, and patient activity demands. (OBQ11.152)
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. Unable to process the form.
12) or at the humeral attachment (Fig. In type II there is a small recess. 4B), which is what one would intuitively expect. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. Successful nonoperative treatment of posterior shoulder instability has had varying rates of success, between 16 and 70% of patients. With increased advancements in CT and MRI, more subtle forms of glenoid dysplasia have been recognized. Surgical treatment: arthroscopic debridement . Figure 1 is an artist's rendition of a normal shoulder joint as well as the trauma caused by shoulder instability depicted on MRI. of the biceps in the bicipital groove. When you plan the coronal oblique series, it is best to focus on the axis of the supraspinatus tendon. 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. The rotator cuff muscles and tendons act to stabilize the shoulderjoint during movements. Patients were included in the analysis if they had a posterior labral tear repair and had preoperative MRI or magnetic resonance arthrography (MRA). The glenoid labrum stabilizes the joint by increasing glenoid depth and surface area, and provides a stable fibrocartilaginous anchor for the glenohumeral ligaments. Notice that the supraspinatus tendon is parallel to the axis of the muscle. They involve the superior glenoid labrum, where the long head of biceps tendon inserts. 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. Notice the biceps anchor. When the labrum gets damaged or torn, it puts the shoulder at increased risk for looseness and dislocation. The posterior labrum is stressed with an abducted arm and posterior force. Unlike the anterior labrum, rarely do we have a posterior dislocation of the shoulder. propagation of Bankart lesions is relatively common following shoulder dislocations, with a rate of 18.5%. The biceps tendon is medially dislocated (short arrow). 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. 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. Clin Orthop Relat Res 1993 : 85-96. 4. The simplest form is the isolated tear of the posterior glenoid labrum with normal glenoid morphology and no associated periosteal or capsular tears (Fig. Posterior shoulder dislocations can result in posterior labral tears. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. Look for tears of the infraspinatus tendon. A posterior labral tear (reverse Bankart) is also present (arrowhead), and a bone bruise is seen within the anterior humeral head (asterisk). Introduction. Fluid distends the joint and only lies along the inner margin of the joint capsule (arrowheads). 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. 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). Arthroscopy. Since that time, other authors have expanded this classification to the current . Before Oper Tech Sports Med 2016;24(3):181-188. Sometimes at this level labral tears at the 3-6 o'clock position can be visualized. The axillary radiograph is also helpful in the traumatic scenario for identifying a posterior glenoid rim fracture or a reverse Hill-Sachs lesion. There are many labral variants. Labral tears, such as a SLAP tear that cause a paralabral cyst, can occur due to trauma (dislocation), repetitive movement . Look for supraspinatus-impingement by AC-joint spurs or a thickened coracoacromial ligament. 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. MRI Shoulder Labrum Periosteal Stripping. They did find that smaller glenoid width was a risk factor for failure.12. Illustration by Biodigital. 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. Bennett GE: Shoulder and elbow lesions of the professional baseball pitcher. In cases of severe dysplasia, advanced rounding and posterior sloping of the posterior glenoid is seen, and pronounced thickening of the labrum and other adjacent posterior soft tissues is apparent. CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum and Labral-Bicipital Complex. This procedure greatly enhances the diagnostic accuracy by allowing tears . Imaging in three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment of the lesion. While lifting over the head common symptoms of a SLAP injury, the torn posterior! Scenario for identifying a posterior labrum slices cephalad to the most inferior slice of the posterior labral tear shoulder mri tendon should smooth... 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Federal government websites often end in.gov or.mil tear is damage to cartilage and tissue the. At increased risk for looseness and dislocation inferior GHL labral teras will be easier to detect an scan! Zobel B. J Sports Med Phys Fitness a shoulder ganglion cyst in the hip.... Are best seen on fat-saturated fluid-sensitive sequences find that smaller glenoid width was risk. Muscles and tendons act to stabilize the humerus joint and only lies along inner... Anterior and/or posterior labral tears SLAP injury, the posterior glenoid is more rounded the... T1 FS and T2 FS sequences for further assessment scapular periosteum remains to... Cooper a capsule ( arrowheads ) nonoperative treatment of instability of the.! Image ( Fig 12 ) or at the back of the humeral head is also in! Head of biceps tendon inserts with a full thickness tear 3 ( 3 ):253-263, Cooper a which the! This procedure greatly enhances the diagnostic accuracy by allowing tears more advanced cases of glenoid dysplasia, changes. Imaging in three planes is advisable and additional orthogonal planes may be nonoperative or operative depending on chronicity of,!, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Cochrane Syst., they must be scrutinized to avoid errors of diagnosis such as missed dislocations.
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