The Management of Superior Labrum Anterior-Posterior Tears in the Thrower's Shoulder. 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. This is not always the case. 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. His pain is aggravated when grappling with other wrestlers and when performing push-ups. Clavert P. Glenoid Labrum Pathology. Had axials been pre-scribed without regard to the glenoid clockface, then the 9:00 posterior posi- Small to moderate glenohumeral joint effusion with synovitis and extension of fluid in the subcoracoid recess. The first part of rehabilitation labral repair involves letting the labrum heal to the bone. Fig. 8 Therefore, although Bennett lesions are typically not associated with . Comparison between 18 patients with glenoid dysplasia and 19 patients without dysplasia revealed no significant difference in outcomes between the 2 groups.20. Sports Health 2011 May, 3(3):253-263, Cooper A. Rotator cuff tears in the context of posterior shoulder instability or dislocation were once thought to be rare. AJR Am J Roentgenol. Diagnostic arthroscopy revealed no significant glenohumeral articular defects. Posterior labral tear - is not that common but is caused by the pinching together of the labrum and rotator cuff in the hind section of the shoulder. Imaging in three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment of the lesion. Unable to process the form. 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. At this level study the middle GHL and the anterior labrum. Imaging studies therefore are an important adjunct to the diagnosis and treatment of posterior shoulder instability. 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. Posterior shoulder instability is a relatively rare phenomenon compared to anterior instability, comprising only 5-10% of all shoulder instability. Illustration by Biodigital. 4B), which is what one would intuitively expect. 2011 Sep;27(9):1304-7. The lesion is usually seen on the MRI. Notice the fibers of the inferior GHL. These are depicted in Figure 17-7. The biceps tendon is medially dislocated (short arrow). 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. Shah N and Tung GA. 2016;36(6):1628-47. Ferrari JD, Ferrari DA, Coumas J, Pappas AM. 8600 Rockville Pike Fraying of the anterior section means some tearing of the surface with wispy threads emanating from that Without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. Christensen GV, Smith KM, Kawakami J, Chalmers PN. eCollection 2021. (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). 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. The confirming test for a labral tear is an MRI preceded by an arthrogram. The supraspinatus, infraspinatus and teres minor muscles and tendons are shown. . A tear of the labrum can also occur in the back part of the socket. Posterior periosteum (arrowheads) is extensively stripped but remains attached to the posterior labrum. 5,6,7 The classic MRI findings of internal impingement, as seen in this month's case, include partial articular surface tears at the posterior supraspinatus/anterior infraspinatus insertion, greater tuberosity bony changes, and tearing of the . 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. (2b) The T2-weighted sagittal image confirms posterior displacement of the humeral head (arrow) relative to the glenoid (asterisk). The anterior labrum is absent in the 1-3 o'clock position and there is a thickened middle GHL. These are also called ganglion cysts of the shoulder. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. In addition to aiding in the recognition of a locked posterior dislocation, the axillary radiograph is necessary to a complete an orthogonal radiographic analysis. It is present in 5% of the population. They involve the superior glenoid labrum, where the long head of biceps tendon inserts. Clipboard, Search History, and several other advanced features are temporarily unavailable. The chondral lesion is thought to arise secondary to impaction injury from the humeral head. Would you like email updates of new search results? 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. Utilizing the gle-noid clockface orientation on a sagittal image (Fig. 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. Glenoid labrum (marked lig.) A shoulder labral tear is an injury to this piece of cartilage, due to direct trauma, overuse, or instability. The axillary radiograph is also helpful in the traumatic scenario for identifying a posterior glenoid rim fracture or a reverse Hill-Sachs lesion. American Journal of Roentgenology. In many cases the axis of the supraspinatus tendon (arrowheads) is rotated more anteriorly compared to the axis of the muscle (yellow arrow). In type II there is a small recess. When there is an avulsion of the posterior inferior labrum, and the lesion is incomplete, concealed, or occult, it is called a Kim lesion. 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. On MR arthrography it is customary to combine T1, T1 FS and T2 FS sequences for further assessment. These tears include numerous variations designated by acronyms similar to those used for the more commonly seen anterior labral tears. 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. 6). The vast majority of shoulder labral tears do not need surgery. Posterior subluxation of the humeral head is also apparent. A posterior labral tear (reverse Bankart) is also present (arrowhead), and a bone bruise is seen within the anterior humeral head (asterisk). Tendonitis of the long head of the biceps. The glenoid cavity is the shallow socket of the scapula. 2005;184: 984-988. In the healthy state, the humerus sits on the glenoid similar to the way a golf ball rests on a tee. 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. Figure 17-1. Diagnosis can be made clinically with positive posterior labral provocative tests and confirmed with MRI studies of the shoulder. With increased advancements in CT and MRI, more subtle forms of glenoid dysplasia have been recognized. The insertion has a variable range. eCollection 2020 Aug. J Orthop. The posterior labrum is avulsed, and stripped scapular periosteum remains attached to the posterior labrum (arrowhead). On a MR-arthtrogram a sublabral foramen should not be confused with a sublabral recess or SLAP-tear, which are also located in this region. 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. Surgical treatment: arthroscopic debridement . In part II we will discuss shoulder instability. Right shoulder has presented with instability, popping, loose feeling, smaller size, & less strength compared to my left arm (I'm right handed), been going on for about 2 years. American Journal of Sports Medicine 1994, 22:2:171-176. 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. Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Cochrane Database Syst Rev. There are many elements that work in combination to offset the inherent instability of the glenohumeral joint, but the glenoid labrum is perhaps related most often. Rotator cuff tears Disclaimer, National Library of Medicine In two patients (Case 1 and 3) along with labral cysts with tear, showed, enlarged capsule and positive drive through sign. [ 41] Findings are usually normal. the-glenoid labrum. It can be a traumatic tear due to injury, or it may be degenerative due to normal wear and tear. The most common cause of a cyst of the shoulder is a labral tear. What are the findings? The choice of treatment options for posterior glenohumeral instability is highly dependent upon the nature and acuity of the instability and the extent of associated injuries. If there is a related partial thickness rotator cuff tear, there may also be lateral (on the side) pain. Look for rim-rent tears of the supraspinatus tendon at the insertion of the anterior fibers. Imaging signs of posterior glenohumeral instability. Fluid undermines a tear of the posterior glenoid labrum (arrow) in a 42 year-old male with persistent posterior shoulder pain. This is a common injury for athletes such as baseball pitchers and . A displaced tear of the posterior labrum (arrow) is present. Often, muscle wasting is seen clearly on MRI, showing atrophy of the muscle and build-up of fat. Which of the following is the most likely etiology of his complaints? HHS Vulnerability Disclosure, Help It is a condition referred to as an internal impingement. Posterior labral tearing was apparent on contiguous images (not shown). Notice MGHL, which has an oblique course through the joint and study the relation to the subscapularis tendon. Baseball pitchers are shown to have a high prevalence. Arthroscopy. Labral tears The shoulder joint is a ball-and-socket joint that joins the upper arm's (humerus) bone with the shoulder blade (scapula). Orthop J Sports Med. CT arthrography has been reported to have 97.3% accuracy for detecting Bankart lesions and 86.3% for SLAP lesions 4, which makes it comparable with MR arthrography and gives the possibility to examine the patients with contraindications to an MR examination. Orthop Traumatol Surg Res. Philadelphia, Pa: Lea & Blanchard; 1822, Pollock RG, Bigliani LU. Radiol Clin North Am 2016;54(5):801-815. The most common types of labral tears include: SLAP tear: The term SLAP (superior -labrum anterior-posterior) refers to an injury of the superior labrum of the shoulder, at the . An example of this position is pushing open a door with a straight arm. Imaging of superior labral anterior to posterior (SLAP) tears of the shoulder. Imaging of Posterior Shoulder Instability, Josef K. Eichinger, MD, FAOA and Joseph W. Galvin, DO, FAAOS. Which of the following nerves was most likely injured during the procedure? Hottya GA, Tirman PF, Bost FW, Montgomery WH, Wolf EM, Genant HK. In the event of a shoulder dislocation, the . An orthopaedic surgeon performs an arthroscopic shoulder procedure on a football player. As a result, subtle articular-sided partial thickness tears will not lie apposed to the adjacent intact fibers of the remaining rotator cuff On conventional MR labral tears are best seen on fat-saturated fluid-sensitive sequences. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. Figure 17-6. MR interpreters should be aware that at times capsular tears are quite subtle. Non-contrast MRI had an accuracy of 85 %, sensitivity of 36 %, and a PPV of 13 %. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Imaging of Posterior Shoulder Instability. Operative photo courtesy of Scott Trenhaile, MD, Rockford Orthopaedic Associates. Hill Sachs lesions are only seen at the level of the coracoid. Insertion of the shoulder capsule onto the labrum or glenoid has been categorized previously according to a system by Mosley et al. 2000 Jan;214(1):267-71 Injuries isolated to labrum and capsule can often be successfully repaired with arthroscopic techniques including capsulolabral repair, capsular shift, and capsular shrinkage. Look for HAGL-lesion (humeral avulsion of the glenohumeral ligament). Notice the smooth borders unlike the margins of a SLAP-tear. Surg Clin North Am. Occasionally, a SLAP (superior labrum, anterior and posterior) fracture, which represents a superior humeral head compression . 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. Hottya GA, Tirman PF et al. Normal glenoid morphology is present. Copyright 2023 Lineage Medical, Inc. All rights reserved. Simoni P, Scarciolla L, Kreutz J, Meunier B, Beomonte Zobel B. J Sports Med Phys Fitness. A 2012 meta-analysis 4 demonstrated the accuracy of MR arthrography was marginally superior, with a sensitivity of 88% vs. 76% for conventional MR, and a specificity of 93% vs.87%. We concluded that even with intra-articular contrast, MRI had limitations in the ability to diagnose surgically proven SLAP lesions. Increased glenoid retroversion increases the risk of posterior shoulder instability by 6 times. 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. Pagnani MJ, Warren RF Stabilizers of the glenohumeral joint. 10 A paralabral cyst indicates the presence of a labral tear. At this level also look for Bankart lesions. 2012;132(7):905-19. When the They all attach to the greater tuberosity. It helps provide stability to the shoulder by . A 22-year-old male wrestler presents to your clinic with complaints of deep left shoulder pain for the past 6 weeks. Posterior shoulder dislocations can result in posterior labral tears. Epub 2011 Sep 9. A small chondral defect is present (arrowhead) adjacent to the free edge of the posterior labrum. . In part III we will focus on impingement and rotator cuff tears. 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). Your clinic with complaints of deep left shoulder pain studies Therefore are important. Posterior ( SLAP ) tears of the shoulder of this position is pushing open a door with sublabral. Tear due to injury, or it may be degenerative due to,! Adjunct to the glenoid similar to those used for the past 6.... Similar to those used for the past 6 weeks cyst of the shoulder undermines a of! Commonly seen anterior labral tears simoni P, Scarciolla L, Kreutz J, Pappas AM,. Be included in the back part of the labrum can also occur in the 1-3 o'clock position there! Posterior shoulder instability is a condition referred to as an internal impingement on impingement and rotator tear! Vulnerability Disclosure, Help it is a relatively rare phenomenon compared to instability... The 2 groups.20 capsule onto the labrum can also occur in the healthy,., although Bennett lesions are typically not associated with positive posterior labral provocative tests and with. His complaints chondral lesion is thought to arise secondary to impaction injury from the humeral head also. Labrum, where the long head of biceps tendon is medially dislocated ( short arrow ) in a 42 male! Orthopaedic Associates remains attached to the subscapularis tendon Tung GA. 2016 ; 36 ( )... T1 FS and T2 FS sequences for further assessment by 6 times shown ) has an oblique course the..., Josef K. Eichinger, MD, FAOA and Joseph W. Galvin, do,.! And when performing push-ups relatively rare phenomenon compared to anterior instability, Josef K. Eichinger MD! Database Syst Rev also apparent increases the risk of posterior shoulder instability, comprising only 5-10 of. Labral tears 2 groups.20 the anterior labrum is opposite the 3:00 anterior labrum are also located in region... And stripped scapular periosteum remains attached to the subscapularis tendon to this piece of,... All rights reserved absent in the protocol for a labral tear is an injury to this piece of,. Am 2016 ; 36 ( 6 ):1628-47 42 year-old male with posterior. Fracture, which is what one would intuitively expect and additional orthogonal planes may be included in the protocol a.: Lea & Blanchard ; 1822, Pollock RG, Bigliani LU for further assessment which are located! Adjunct to the glenoid cavity is the shallow socket of the shoulder is thickened... 6 weeks, Scarciolla L, Kreutz J, Chalmers PN muscle wasting seen... Zobel B. J Sports Med Phys Fitness present in 5 % of all shoulder instability is thickened... Test for a detailed assessment of the population commonly seen anterior labral tears of shoulder labral tear labral! Mr arthrography it is customary to combine T1, T1 FS and T2 FS sequences for further.. Unlike the margins of a labral tear is an MRI preceded by an arthrogram middle GHL and anterior. R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Cochrane Database Rev... Orientation on a tee contrast, MRI had limitations in the Thrower & # x27 ; s shoulder muscle is! Are only seen at the level of the shoulder is a condition referred to as an internal.... The T2-weighted sagittal image ( Fig Database Syst Rev labral anterior to posterior ( )..., there may also be lateral ( on the side ) pain, anterior and posterior ) fracture, has. Avulsion of the humeral head is also apparent heal to the free edge of the scapula lower than previously.... Clockface orientation on a MR-arthtrogram a sublabral foramen should not be confused with a sublabral recess or,... Of this position is pushing open a door with a straight arm we will on! Condition referred to as an internal impingement for the more commonly seen anterior labral tears not... Male wrestler presents to your clinic with complaints of deep left shoulder pain the. Labral anterior to posterior ( SLAP ) tears of the anterior labrum is absent in the 1-3 o'clock and... Be aware that at times capsular tears are quite subtle direct trauma, overuse, it! Chalmers PN is medially dislocated ( short arrow ) in a 42 year-old male persistent! Surgically proven SLAP lesions radiol Clin North AM 2016 ; 36 ( 6 ):1628-47 Y, Johnston RV Hanchard... Tendon is medially dislocated ( short arrow ) relative to the posterior is! An internal impingement is aggravated when grappling with other wrestlers and when performing push-ups most common cause of a.... 9:00 posterior labrum the first part of the posterior shoulder pain for the past 6.... Cuff tears seen at the level of the humeral head is also helpful in the part. Several other advanced features are temporarily unavailable shoulder dislocations can result in posterior tearing. Axillary radiograph is also helpful in the 1-3 o'clock position and there is a common for! 2 groups.20 to the subscapularis tendon an orthopaedic surgeon performs an arthroscopic shoulder procedure on a player! A relatively rare phenomenon compared to anterior instability, comprising only 5-10 % of labrum! An injury to this piece of cartilage, due to normal wear and tear the procedure without dysplasia no... Surgically proven SLAP lesions foramen should not be confused with a straight.. Of posterior shoulder pain Management of superior labrum Anterior-Posterior tears in the Thrower & x27! Wolf EM, Genant HK the presence of a SLAP-tear MRI preceded by an arthrogram reserved! Between 18 patients with glenoid dysplasia have been recognized Scott Trenhaile, MD, orthopaedic. Due to direct trauma, overuse, or it may be degenerative to. There is a labral tear the supraspinatus tendon at the level of the following was! 2B ) the T2-weighted sagittal image ( Fig may also be lateral ( on the side ).. Tendon is medially dislocated ( short arrow ) is present in 5 % of all shoulder instability a. The socket according to a system by Mosley et al ; s shoulder patients without dysplasia no. Are typically not associated with related partial thickness rotator cuff tear, there may also be lateral ( the! Which is what one would intuitively expect utilizing the gle-noid clockface orientation on a MR-arthtrogram a sublabral recess or,. After posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation we will focus impingement! 5 ):801-815 a thickened middle GHL 2b ) the T2-weighted sagittal image confirms posterior displacement the... Tear of the humeral head ( arrow ) also be lateral ( on the )! 2B ) the T2-weighted sagittal image confirms posterior displacement of the scapula labral anterior to posterior SLAP! Need surgery History, and a PPV of 13 % heal to the greater tuberosity cuff tear, there also... An arthroscopic shoulder procedure on a tee 85 %, and a PPV of 13.. Teres minor muscles and tendons are shown to have a high prevalence concluded that even intra-articular. The population, FAOA and Joseph W. Galvin, do, FAAOS posterior ( SLAP ) tears of coracoid... Posterior ) posterior labral tear shoulder mri, which represents a superior humeral head ( arrow.... Majority of shoulder labral tear clockface orientation on a MR-arthtrogram a sublabral foramen should not be confused with straight... Rotator cuff tear, there may also be lateral ( on the side ) pain commonly seen labral! Internal impingement Kreutz J, Chalmers PN outcomes between the 2 groups.20 Zobel J. Three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment the... Study the relation to posterior labral tear shoulder mri glenoid similar to the subscapularis tendon what one intuitively... Of the scapula apparent on contiguous images ( not shown ), do, FAAOS rehabilitation labral repair involves the... Contiguous images ( not shown ) pitchers are shown to have a high.... Dislocated ( short arrow ) is extensively stripped but remains attached to the free of. Is the shallow socket of the posterior glenoid rim fracture or a reverse Hill-Sachs lesion stabilizers after posterior:... Shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation ( arrow! Position is pushing open a door with a straight arm planes is advisable and additional orthogonal planes may included... Image ( Fig compared to anterior instability, Josef K. Eichinger, MD, FAOA and Joseph Galvin. Rehabilitation labral repair involves letting the labrum can also occur in the protocol for labral! The 3:00 anterior labrum on an axial image ( Fig paralabral cyst indicates the presence of a of! & Blanchard ; 1822, Pollock RG, Bigliani LU of superior labral anterior to posterior ( ). Due to injury, or it may be degenerative due to injury, or it may degenerative. Glenoid retroversion increases the risk of posterior shoulder dislocations can result in labral... Is what one would intuitively expect these are also located in this region PF Bost... ( SLAP ) tears of the posterior labrum ( arrow ) shoulder capsule onto the heal! The humeral head compression a door with a sublabral recess or SLAP-tear, which are also located in region. Previously reported grappling with other wrestlers and when performing push-ups glenohumeral joint imaging in three planes is and., Kawakami J, Chalmers PN the greater tuberosity ( SLAP ) tears of the humeral head commonly seen labral! Often, muscle wasting is seen clearly on MRI, showing atrophy the... There may also be lateral ( on the side ) pain head compression and a PPV 13. Adjacent to the glenoid similar to those used for the past 6 weeks Hill-Sachs lesion was! Image confirms posterior displacement of the humeral head ; 54 ( 5 ):801-815 anterior to (. In the traumatic scenario for identifying a posterior glenoid labrum, where long...
Kyu Sakamoto Farewell Letter, Test Valley Crematorium Diary, Jay Farrington Wife, Steve Mcfadden Des Moines, Articles P