2012;132(7):905-19. 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. A displaced tear of the posteroinferior labrum is present, with a torn piece of periosteum (arrow) remaining attached to the posterior labrum. An orthopaedic surgeon performs an arthroscopic shoulder procedure on a football player. We hypothesize that this population will have fewer labral abnormalities than an athletic population. eCollection 2020 May-Jun. If the pre-test probability was above 90% or below 10% . In a SLAP injury, the top (superior) part of the labrum is injured. The chondral lesion is thought to arise secondary to impaction injury from the humeral head. 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? Radiol Clin North Am 2016;54(5):801-815. 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. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. MeSH This is a common injury for athletes such as baseball pitchers and . Chang IY, Polster JM. Type 1 shoulder labrum tear. Additionally, a recent study by Meyer et al9 highlighted the importance of x-rays in evaluation of posterior shoulder instability. At this level study the middle GHL and the anterior labrum. A tear of the labrum can also occur in the back part of the socket. A posterior labrum tear is a rare type of shoulder labral tear that occurs in the back of the shoulder. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. The term SLAP stands for Superior Labrum Anterior and Posterior. 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 shoulder labral tear can occur due to repetitive overhead use, a lifting injury, a fall on the arm, a sudden pull on the arm, or having the arm twisted at the shoulder joint. The labrum has the same effect on the shoulder as the rounded lip of a golf tee has to a golf ball. As joint instability is often present, capsuloplasty may be added to the procedure. Normal Labral Anatomy. 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). There is . Often, muscle wasting is seen clearly on MRI, showing atrophy of the muscle and build-up of fat. It helps provide stability to the shoulder by . Notice red arrow indicating a small Perthes-lesion, which was not seen on the standard axial views. These shoulder MRI findings in middle-aged populations emphasize the need for supporting clinical judgment when making treatment decisions for this patient population. Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis. These are depicted in Figure 17-7. 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. Oper Tech Sports Med 2016;24(3):181-188. Unlike the anterior labrum, rarely do we have a posterior dislocation of the shoulder. Which of the following is the most likely etiology of his complaints? 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%. It is seen in 11% of individuals. In that position the 3-6 o'clock region is imaged perpendicular. The anterosuperior labrum is absent in the 1-3 o'clock position and the middle glenohumeral ligament is usually thickened. 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. Normal anatomy. (B) Axillary radiograph of locked posterior glenohumeral dislocation. 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). His examination is somewhat difficult due to his large size, but no significant abnormal findings are noted. Surg Clin North Am. Study the attachment of the IGHL at the humerus. 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 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. When the It is a condition referred to as an internal impingement. Plain radiographs in patients with posterior shoulder instability are an important and critical adjunct to making the diagnosis of posterior shoulder instability. 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. The https:// ensures that you are connecting to the It can be a traumatic tear due to injury, or it may be degenerative due to normal wear and tear. There was a posterior labrum tear. 1998 Apr 30;17(8):857-72 Methods MR arthrograms of 97 patients with isolated posterior glenoid labral tears by arthroscopy and those of 96 age and gender-matched controls with intact posterior labra were reviewed by two blinded . On MR an os acromiale is best seen on the superior axial images. The labrum is the cartilage dish that sits between the ball and the socket configuration of the shoulder joint. (1a) Fat-suppressed proton density-weighted axial, (1b) sagittal T2-weighted, and (1c) fat-suppressed T2-weighted coronal MR images are provided. An os acromiale must be mentioned in the report, because in patients who are considered for subacromial decompression, Figure 1 is an artist's rendition of a normal shoulder joint as well as the trauma caused by shoulder instability depicted on MRI. 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. Diagnosis can be made clinically with positive posterior labral provocative tests and confirmed with MRI studies of the shoulder. Rotator cuff tears in the context of posterior shoulder instability or dislocation were once thought to be rare. 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. In two patients (Case 1 and 3) along with labral cysts with tear, showed, enlarged capsule and positive drive through sign. Postoperatively, there are strict instructions to avoid adduction and internal rotation of the operative shoulder. Imaging of Posterior Shoulder Instability, Josef K. Eichinger, MD, FAOA and Joseph W. Galvin, DO, FAAOS. A 22-year-old male wrestler presents to your clinic with complaints of deep left shoulder pain for the past 6 weeks. True anteroposterior or Grashey x-ray. 1. 8600 Rockville Pike A sublabral foramen or sublabral hole is an unattached anterosuperior labrum at the 1-3 o'clock position. J Bone Joint Surg Am 1993; 75:1175-1184. Look for excessive fluid in the subacromial bursa and for tears of the supraspinatus tendon. A hip (acetabular) labral tear is damage to cartilage and tissue in the hip socket. The .gov means its official. The capsule is a broad ligament that surrounds and stabilizes the joint. official website and that any information you provide is encrypted Insertion of the shoulder capsule onto the labrum or glenoid has been categorized previously according to a system by Mosley et al. 2. (14a) Normal capsular appearance on an axial fat-suppressed T1-weighted MR arthrographic image. Methods: Indirect MR arthrography of the shoulder: use of abduction and external rotation to detect full- and partial-thickness tears of the supraspinatus tendon. It cushions the joint of the hip bone, preventing the bones from directly rubbing against each other. In part III we will focus on impingement and rotator cuff tears. In part III we will focus on impingement and rotator cuff tears. Radiographics. Shah N and Tung GA. -, BMJ. Sensitivity was 66 %, and specificity was 77 %. Also, although better visualized on MRA imaging, a hypertrophied posterior glenoid labrum is evident in patients with glenoid dysplasia (Figure 17-8). The simplest form is the isolated tear of the posterior glenoid labrum with normal glenoid morphology and no associated periosteal or capsular tears (Fig. Common symptoms of a SLAP tear include: dull or aching pain in the shoulder, especially while lifting over the head. 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. Description. Without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. In Shoulder MR-Part I we will focus on the normal anatomy and the many anatomical variants that may simulate pathology. The glenoid cavity is the shallow socket of the scapula. Objective The purpose of this study is to evaluate the accuracy of MR arthrography in detecting isolated posterior glenoid labral injuries using arthroscopy as the reference standard. Christensen GV, Smith KM, Kawakami J, Chalmers PN. Please enable it to take advantage of the complete set of features! Had axials been pre-scribed without regard to the glenoid clockface, then the 9:00 posterior posi- 5). There are also newer treatments to consider that don't involve surgery. Arthroscopy. Overall, an MRI scan will clearly show the ganglion cyst in the shoulder and whether it compresses the nerve. 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. Which of the images (Figures A-E) most likely corresponds to the patient's initial diagnosis? As a result, subtle articular-sided partial thickness tears will not lie apposed to the adjacent intact fibers of the remaining rotator cuff 10 A paralabral cyst indicates the presence of a labral tear. However, a study by Saupe et al. If the arm is Purpose: 1994 May; 3(3):173-90. There was a fair amount of synovitis and thickening of the capsule posteriorly and inferiorly, suggesting a reactive change. On MR arthrography it is customary to combine T1, T1 FS and T2 FS sequences for further assessment. Background:The literature demonstrates a high prevalence of asymptomatic knee and hip findings on magnetic resonance imaging (MRI) in athletes. Dr. Ebraheim's educational animated video describes posterior labral tear - posterior shoulder instability. Figure 17-1. Clin Orthop Relat Res 1993 : 85-96. . Eur J Radiol. 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 there is an avulsion of the posterior inferior labrum, and the lesion is incomplete, concealed, or occult, it is called a Kim lesion. (B) Axillary radiograph demonstrating severe glenoid dysplasia with hypoplasia of the posterior glenoid and severe retroversion. At this level also look for Bankart lesions. Since that time, other authors have expanded this classification to the current . 2021 May 5;12:61-71. doi: 10.2147/OAJSM.S266226. 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. Figure 17-3. The retracted end of the subscapularis (asterisk) is also visible compatible with a full thickness tear. 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. His pain is aggravated when grappling with other wrestlers and when performing push-ups. . If there is a related partial thickness rotator cuff tear, there may also be lateral (on the side) pain. Numerous labral abnormalities may be encountered in patients with posterior glenohumeral instability. Pathomechanics and Magnetic Resonance Imaging of the Thrower's Shoulder. PMC This sublabral recess can be difficult to distinguish from a SLAP-tear or a sublabral foramen. 4B), which is what one would intuitively expect. With increased advancements in CT and MRI, more subtle forms of glenoid dysplasia have been recognized. Normal glenoid morphology is present. Radiographics. Posterior labral periosteal sleeve avulsion injury (POLPSA) in a 19 year-old football player following acute injury. Biplanar radiographs should always be obtained when evaluating patients with suspected shoulder instability. There are 3 types of attachment of the superior labrum at the 12 o'clock position where the biceps tendon inserts. These images illustrate the differences between an sublabral recess and a SLAP-tear. (OBQ12.268) A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. Symptoms of a Shoulder Labrum Tear. Hottya GA, Tirman PF, Bost FW, Montgomery WH, Wolf EM, Genant HK. Orthop Traumatol Surg Res. 1A: The ball (humerus) normally rests within the socket (glenoid) like a golf ball on a tee. Look for rim-rent tears of the supraspinatus tendon at the insertion of the anterior fibers. 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. J Bone Joint Surg Am. 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 . On MR arthrography it is customary to combine T1, T1 FS and T2 FS sequences for further assessment. I don't have pain generally at all. Articular cartilage is maintained. The labrum is a thick fibrous ring that surrounds the glenoid. Advances in knowledge:: On a direct MR arthrographic image, a posterior capsular synovial fold may be a normal anatomic variant. 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. (SBQ16SM.25) Dougherty MC, Kulenkamp JE, Boyajian H, Koh JL, Lee MJ, Shi LL. 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