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(OBQ11.152) 2019 Dec 12;20(1):598. doi: 10.1186/s12891-019-2986-1. Advanced MRI techniques of the shoulder joint: current applications in clinical practice. Posterior labral periosteal sleeve avulsion injury (POLPSA) in a 19 year-old football player following acute injury. Uncategorized. Arthroscopy. It requires about 6 to 8 weeks to heal to the bone. 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Chmiel-Nowak M, Sheikh Y, Feger J, et al. Notice smooth undersurface of infraspinatus tendon and normal anterior labrum. Notice rotator cuff muscles and look for atrophy. Sports Health 2011 May, 3(3):253-263, Cooper A. Posterior shoulder instability is becoming increasingly recognized in young, athletic populations, especially in the military.13 Compared to anterior shoulder instability, posterior instability can be more challenging to diagnose both clinically and radiographically. 2008 Aug; 24(8):921-9. The image shows the typical findings of a sublabral recess. Would you like email updates of new search results? HHS Vulnerability Disclosure, Help We hypothesized that the accuracy of MRI and MRA was lower than previously reported. No Comments Some types of the posterior synovial fold can mimic a posterior labral tear in conventional MRI. In that position the 3-6 o'clock region is imaged perpendicular. Radiology. 1992 Jul;74(6):890-6. subchondral cysts and osteophytes (arrow). The supraspinatus tendon is the most important structure of the rotator cuff and subject to tendinopathy and tears. Rotator cuff tears 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. 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. Diagnosis is made clinically with presence of increased anterior and posterior humeral translation, a sulcus sign, and overall increased . 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. 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 . "If physical therapy fails and the athlete still can't complete overhead motions, or the shoulder continues to dislocate, surgical treatment might be required to reattach the torn ligaments and labrum to the . On examination, she reports deep posterior shoulder pain when the arm is abducted 90 degrees and maximally . 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). The biceps tendon is medially dislocated (short arrow). Shoulder dislocations account for 90% of shoulder instability cases and usually occur after a fall during sport or work activities ().This glenohumeral joint instability has been defined with the acronyms TUBS (traumatic, unidirectional, Bankart, surgery is the main treatment) ().Associated injuries to the labrum, to the glenoid bone, described in up to 40% of the cases (), and . Images demonstrate a non-displaced tear involving the superficial anteroinferior labrum with associated injury to the adjacent cartilage 4.. The rotator cuff muscles and tendons act to stabilize the shoulderjoint during movements. 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. Baseball pitchers are shown to have a high prevalence. 2021 May 5;12:61-71. doi: 10.2147/OAJSM.S266226. Eur J Radiol. 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. 8600 Rockville Pike Copyright 2023 Lineage Medical, Inc. All rights reserved. Posterior shoulder instability is a relatively rare phenomenon compared to anterior instability, comprising only 5-10% of all shoulder instability. 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). 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. 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. Increased glenoid retroversion increases the risk of posterior shoulder instability by 6 times. His pain is aggravated when grappling with other wrestlers and when performing push-ups. That is, the labrum helps the shoulder from slipping out of its joint. A Buford complex is a congenital labral variant. 2011 May;196(5):1139-44. doi: 10.2214/AJR.08.1734. Notice superior labrum and attachment of the superior glenohumeral ligament. American Journal of Roentgenology. Axial anatomy and checklist. They all attach to the greater tuberosity. Posterior instability of the shoulder can vary from minor symptoms and findings to dramatic events resulting in extensive, complex injuries to the shoulder. 2019 Oct 31;2019:9013935. doi: 10.1155/2019/9013935. The undersurface of the supraspinatus tendon should be smooth. 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. 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%. Ferrari JD, Ferrari DA, Coumas J, Pappas AM. Similarly, Bradley and colleagues found that in a cohort of 100 shoulders that underwent arthroscopic capsulolabral repair, patients with posterior instability had significantly greater chondrolabral injury and osseous retroversion in comparison with controls.10 The measurement of glenoid retroversion on 2-dimensional CT scan is performed by using Friedmans method, which has been validated and accepted (Figure 17-5).11 It is generally accepted that normal glenoid version is between 4 to 7 degrees of retroversion. X-rays also demonstrate evidence of glenoid dysplasia (increased retroversion and hypoplasia), arthritic changes, and posterior humeral head subluxation or decentering of the humeral head. In patients with glenoid deficiency or large impaction defects, osteotomies and osseous augmentation procedures may be required. The glenohumeral joint has a greater range of motion than any other joint in the body. Glenoid labrum (marked lig.) SLAP tears can cause pain and range-of-motion problems in the shoulder labrum, the biceps tendon or both. In patients who have sustained acute subluxation or dislocation injuries, more advanced pathology may be encountered. 2. Radiographics. There was no subscapularis or rotator cuff tear and no superior labrum tear. Skeletal Radiol. With increased advancements in CT and MRI, more subtle forms of glenoid dysplasia have been recognized. An area of capsular irregularity (arrow) is apparent as well. Burkhart et al. 6). Clinical Relevance: . It should always be possible to trace the middle GHL upwards to the glenoid rim and downwards to the humerus. J Bone Joint Surg Am 1993; 75:1175-1184. 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. 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. doi: 10.1002/14651858.CD009020.pub2. 2016 Baseball Sports Medicine: Game Changing Concepts, The Batters Shoulder and Posterior Labral Tears - Christopher Ahmad, MD (BSM #6, 2016), Shoulder360 The Comprehensive Shoulder Course 2023, Shoulder loose body with posterior labral tear with posterior subluxation in 32M. There is . True dysplasia should be visible on at least two axials slices cephalad to the most inferior slice of the glenoid (Fig. Posterior subluxation of the humeral head is also apparent. Conclusions: What is Anterosuperior acetabular labrum? The management of these labrum injuries will depend on the classification, severity of the injury and the stability of the shoulder. Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum. It is better visualized in ABER position.Articular cartilage lesions are best demonstrated with MR arthrography. A displaced tear of the posterior labrum (arrow) is present. In part II we will discuss shoulder instability. A Meta-Analysis of the Diagnostic Test Accuracy of MRA and MRI for the Detection of Glenoid Labral Injury. In part II we will discuss shoulder instability. by Jaideep J. Iyengar, MD; Keith R. Burnett, MD; Wesley M. Nottage, MD Patients were included in the analysis if they had a posterior labral tear repair and had preoperative MRI or magnetic resonance arthrography (MRA). It is seen in 11% of individuals. Had axials been pre-scribed without regard to the glenoid clockface, then the 9:00 posterior posi- 1998 Apr 30;17(8):857-72 He has full passive and active range of motion of the left shoulder that is symmetrical to his contralateral side. Injuries isolated to labrum and capsule can often be successfully repaired with arthroscopic techniques including capsulolabral repair, capsular shift, and capsular shrinkage. 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. The posterior capsule is torn at the humeral attachment (arrow). Labral tears Description. MRI of the shoulder second edition Advances in knowledge:: On a direct MR arthrographic image, a posterior capsular synovial fold may be a normal anatomic variant. posterior labral tear surgery. MR arthrography has excellent accuracy in differentiating between SLAP lesions and anatomic variants. In Shoulder MR-Part I we will focus on the normal anatomy and the many anatomical variants that may simulate pathology. An os acromiale must be mentioned in the report, because in patients who are considered for subacromial decompression, Surgical treatment: arthroscopic debridement . Bethesda, MD 20894, Web Policies Radiology 2008; 248:185193. MRI of the shoulder has been found to be accurate in the diagnosis of labral tears. Utilizing the gle-noid clockface orientation on a sagittal image (Fig. Since that time, other authors have expanded this classification to the current . The shoulder is primarily a ball and socket joint made up of the humerus (ball) and the glenoid (socket). by Michael Zlatkin. On MR arthrography it is customary to combine T1, T1 FS and T2 FS sequences for further assessment. 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. It helps provide stability to the shoulder by . Biplanar radiographs should always be obtained when evaluating patients with suspected shoulder instability. -, BMJ. However,patients with acute lesions often have joint effusion, which also distends the joint space, making the contrast administration unnecessary. Hill Sachs lesions are only seen at the level of the coracoid. (14c) An arthroscopic examination confirms the tear in the posterior capsule (arrow), which was subsequently repaired. When there is an avulsion of the posterior inferior labrum, and the lesion is incomplete, concealed, or occult, it is called a Kim lesion. difficulty performing normal shoulder . His examination is somewhat difficult due to his large size, but no significant abnormal findings are noted. The retracted end of the subscapularis (asterisk) is also visible compatible with a full thickness tear. Posterior capsular rupture causing posterior shoulder instability: a case report. 2000 Jan;214(1):267-71 The ball of the shoulder can dislocate toward the front of the shoulder (an anterior dislocation), or it can go out the back of the shoulder (called a posterior dislocation). Bookshelf Surg Clin North Am. Treatment of the labral tears in these scenarios involves treatment of the shoulder dislocation and stabilising the shoulder. A mid-substance tear of the posterior capsule is present with the medial component appearing lax and retracted (arrow). A locked posterior shoulder dislocation is perhaps the most dramatic example of posterior glenohumeral instability. Typically, physical therapy will start the first week or two after surgery. 8 Therefore, although Bennett lesions are typically not associated with . In the ABER position the inferior glenohumeral ligament is stretched resulting in tension on the anteroinferior labrum, allowing intra-articular contrast to get between the labral tear and the glenoid. 4B), which is what one would intuitively expect. In shoulders with posterior instability, the acromion is situated higher and is oriented more horizontally in the sagittal plane than in normal shoulders and those with anterior instability. (B) Axillary radiograph of locked posterior glenohumeral dislocation. Although x-ray findings are typically normal, they must be scrutinized to avoid errors of diagnosis such as missed posterior dislocations. Posterior Labral Tear. Hottya GA, Tirman PF, Bost FW, Montgomery WH, Wolf EM, Genant HK. 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. Glenoid labral tears are the injuries of the glenoid labrum and a possible cause of shoulder pain. Weishaupt D, Zanetti M, Nyffeler RW, Gerber C, Hodler J. Posterior glenoid rim deficiency in recurrent (atraumatic) posterior shoulder instability. Bennett GE: Shoulder and elbow lesions of the professional baseball pitcher. AJR Am J Roentgenol. Radiology. Symptoms of a Shoulder Labrum Tear. Tearing of the inferior glenohumeral ligament at the humeral attachment (blue arrow) is also evident. The glenoid labrum is a rim of cartilage attached to the glenoid rim. However, a study by Saupe et al. (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 studies therefore are an important adjunct to the diagnosis and treatment of posterior shoulder instability. (OBQ12.268) The shallow socket in the scapula is the glenoid cavity. Despite multiple studies documenting a clear significant association between subtle glenoid dysplasia and posterior labral tears with associated posterior shoulder instability, there is little evidence demonstrating an association with worse outcomes following surgical intervention. The thickened middle GHL should not be confused with a displaced labrum. Notice the smooth borders unlike the margins of a SLAP-tear. 2015;101(1 Suppl):S19-24. Tendonitis of the long head of the biceps. Crossref, Medline, Google Scholar; 74. Following plain radiographs, a CT scan is another useful imaging modality to evaluate the bony morphology of the glenoid including retroversion, glenoid dysplasia, and glenoid bone loss (GBL), and to further characterize the size and location of a reverse Hill-Sachs lesion. Before Type 1 shoulder labrum tear. Imaging in three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment of the lesion. An impaction fracture is also present at the posterior glenoid rim (blue arrow). This ring of cartilage encompasses the outer rim of the glenoid to provide cushiony support around the head of the humerus. 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? eCollection 2020 Aug. J Orthop. There are many labral variants. It is present in approximately 1.5% of individuals. Glenoid retroversion has been shown to be a risk factor for posterior shoulder instability.3 In a prospective study of 714 West Point cadets who were followed for 4 years, 46 shoulders had a documented glenohumeral instability event, 7 of which (10%) were posterior instability. We have covered the tear itself and variants in earlier posts. Imaging signs of posterior glenohumeral instability. In type I there is no recess between the glenoid cartilage and the labrum. Orthop J Sports Med. found in 3-5% of patients undergoing routine MRI of the shoulder 12, 13 Denervation of muscle is identified on MR images initially by the presence of diffuse, homogeneous muscle . AJR 1998; 171:763-768. The chondral lesion is thought to arise secondary to impaction injury from the humeral head. 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. Often, muscle wasting is seen clearly on MRI, showing atrophy of the muscle and build-up of fat. Jun 23, 2021 by . where most labral tears are located. 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. These images illustrate the differences between an sublabral recess and a SLAP-tear. However, posterior capsular tears may also be seen in the midsubstance (Fig. When you have a excessive posterior force on an adducted arm the resultant is a posterior labral tear. 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 . 1999 May 15;318(7194):1322-3 The radiologic diagnosis and surgical evaluation were compared to determine the accuracy of diagnosing a SLAP lesion by MRI. Sensitivity was 66 %, and specificity was 77 %. QID: . 2009;192: 730-735. In our retrospective study of 444 patients, sensitivity, specificity, and accuracy were all lower than previously reported in the literature for diagnosing SLAP lesions. Measurement of Friedmans angle and posterior humeral head subluxation (yellow lines depict Friedmans angle; red line depicts percentage of posterior humeral head subluxation). MRA for SLAP - Is the threshold for referral too low? Notice red arrow indicating a small Perthes-lesion, which was not seen on the standard axial views. McLaughlin, HL. 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). A posterior labrum tear is a rare type of shoulder labral tear that occurs in the back of the shoulder. Skeletal Radiol 2000; 29:204-210. 15,16). Also, it allows preoperative planning if a posterior bone block procedure is planned. These tears include numerous variations designated by acronyms similar to those used for the more commonly seen anterior labral tears. The anterior labrum and glenoid articular cartilage often demonstrate normal morphology one image superior to the . a painful feeling of clicking, popping or grinding in the shoulder during movement. 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. Successful nonoperative treatment of posterior shoulder instability has had varying rates of success, between 16 and 70% of patients. A tear of the labrum can also occur in the back part of the socket. sports. Crossref, Google Scholar; 73. If there is a related partial thickness rotator cuff tear, there may also be lateral (on the side) pain. 2012 Sep;81(9):2343-7. doi: 10.1016/j.ejrad.2011.07.006. While this certainly introduces vulnerability to injury, it also confers the advantage of broad range of motion.
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