An MRI arthrogram is performed and is normal. 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. J Shoulder Elbow Surg. Illustration by Biodigital. Notice the biceps anchor. Notice rotator cuff muscles and look for atrophy. Dr. Ebraheim's educational animated video describes posterior labral tear - posterior shoulder instability. The os acromiale may cause impingement because if it is unstable, it may be pulled inferiorly during abduction by the deltoid, which attaches here. 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. Look for excessive fluid in the subacromial bursa and for tears of the supraspinatus tendon. 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. 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. When the Orthop Traumatol Surg Res. . The glenoid labrum is a rim of cartilage attached to the glenoid rim. 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? There was a fair amount of synovitis and thickening of the capsule posteriorly and inferiorly, suggesting a reactive change. 2000;20 Spec No(suppl_1):S67-81. On MR arthrography it is customary to combine T1, T1 FS and T2 FS sequences for further assessment. Objective To determine the prevalence of shoulder (specifically labral) abnormalities on MRI in a young non-athletic asymptomatic cohort. Crossref, Google Scholar; 73. 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. The ligaments also aid in keeping the shoulder stable and in joint. Type in at least one full word to see suggestions list. Unable to process the form. Not All SLAPs Are Created Equal: A Comparison of Patients with Planned and Incidental SLAP Repair Procedures. 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. Other radiographic lesions that may be associated with posterior labral pathology and instability include the Bennett lesion, which is an extra-articular posterior ossification of the posterior inferior glenoid. Arch Orthop Trauma Surg. Treatment may be nonoperative or operative depending on chronicity of symptoms, degree of instability, and patient activity demands. On conventional MR labral tears are best seen on fat-saturated fluid-sensitive sequences. They developed a classification system in which a pointed glenoid on axial imaging sequences is a normal-appearing glenoid without dysplasia, a lazy J has a rounded appearance of the posterior inferior glenoid, and a delta glenoid is a triangular osseous deficiency. Evaluation of the glenoid labrum with 3-T MRI: is intraarticular contrast necessary? Wirth MA, Lyons FR, Rockwood CA Jr. Hypoplasia of the glenoid: a review of sixteen patients. Such lesions are generally found in patients with atraumatic posterior instability. These terms are interchangeable because there is underdevelopment of the posterior inferior aspect of the glenoid. The management of these labrum injuries will depend on the classification, severity of the injury and the stability of the shoulder. 3). When the labrum gets damaged or torn, it puts the shoulder at increased risk for looseness and dislocation. Major NM, Browne J, Domzalski T, Cothran RL, Helms CA. . Glenoid dysplasia, also referred to as glenoid hypoplasia and posterior glenoid rim deficiency, is now increasingly recognized as an anatomic variant that predisposes patients to posterior glenohumeral instability. "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 . 2012 Dec;52(6):622-30. 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). It . Imaging of Posterior Shoulder Instability, Josef K. Eichinger, MD, FAOA and Joseph W. Galvin, DO, FAAOS. On these axial images a Buford complex can be identified. The shoulder joint is a ball-and-socket joint that joins the upper arm's (humerus) bone with the shoulder blade (scapula). Probing of the posterior labrum is needed to rule out a subtle Kim lesion. 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. Locked posterior subluxation of the shoulder: diagnosis and treatment. Notice the fibers of the inferior GHL. In our retrospective study of 444 patients, sensitivity, specificity, and accuracy were all lower than previously reported in the literature for diagnosing SLAP lesions. Posterior instability of the shoulder can vary from minor symptoms and findings to dramatic events resulting in extensive, complex injuries to the shoulder. 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 anterior labrum and glenoid articular cartilage often demonstrate normal morphology one image superior to the . (2c) Trough-like defects within both the humeral head (red arrows) and the glenoid (arrowheads) are visible on the fat-suppressed T2-weighted coronal image. Notice that the supraspinatus tendon is parallel to the axis of the muscle. Notice MGHL, which has an oblique course through the joint and study the relation to the subscapularis tendon. Patients were included in the analysis if they had a posterior labral tear repair and had preoperative MRI or magnetic resonance arthrography (MRA). Jun 23, 2021 by . Posterior labrum tear: This tear occurs at the back of the shoulder joint. 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. 4B), which is what one would intuitively expect. The diagnostic value of magnetic resonance arthrography of the shoulder in detection and grading of SLAP lesions: comparison with arthroscopic findings. 2019 Nov 7;19:199-202. doi: 10.1016/j.jor.2019.10.015. 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. These normal variants are all located in the 11-3 o'clock position. 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 . 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. 2000 Jun; 82(6):849-57. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. The rotator cuff is made of the tendons of subscapularis, supraspinatus, infraspinatus and teres minor muscle. An impaction fracture is also present at the posterior glenoid rim (blue arrow). Figure 17-5. The posterior labrum is avulsed, and stripped scapular periosteum remains attached to the posterior labrum (arrowhead). 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. Posterior subluxation of the humeral head is readily apparent. 14). Study the labrum in the 3-6 o'clock position. 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 . (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. In two patients (Case 1 and 3) along with labral cysts with tear, showed, enlarged capsule and positive drive through sign. In this post we look at Periosteal Stripping. 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%. There are a number of anatomical labral variants located between 11 and 3 o'clock, which can be mistaken for a SLAP tear: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Clinical History: A 72 year-old male presents with severe left shoulder pain and limited motion following a fall 10 days earlier. Notice the rotator cuff interval with coracohumeral ligament. Radiology. Which of the following is the next best step in management? An example of this position is pushing open a door with a straight arm. MeSH Burkhart et al. This procedure greatly enhances the diagnostic accuracy by allowing tears . (B) Axillary radiograph demonstrating severe glenoid dysplasia with hypoplasia of the posterior glenoid and severe retroversion. Posterior ossification of the shoulder: the Bennett lesion. 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. and transmitted securely. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. the removal of the acromion distal to the synchondrosis may further destabilize the synchondrosis and allow for 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). Had axials been pre-scribed without regard to the glenoid clockface, then the 9:00 posterior posi- In part II we will discuss shoulder instability. Typically, physical therapy will start the first week or two after surgery. Axis of supraspinous tendon. Unlike the anterior labrum, rarely do we have a posterior dislocation of the shoulder. 10 A paralabral cyst indicates the presence of a labral tear. It is present in 5% of the population. J Bone Joint Surg Am. Large tears of the rotator cuff may allow the humeral head to migrate upwards resulting in a high riding humeral head. However,patients with acute lesions often have joint effusion, which also distends the joint space, making the contrast administration unnecessary. 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. Clavert P. Glenoid Labrum Pathology. CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum and Labral-Bicipital Complex. Bethesda, MD 20894, Web Policies Treatment of the labral tears in these scenarios involves treatment of the shoulder dislocation and stabilising the shoulder. An anatomy drawing of a shoulder labrum. in 2005 of 103 shoulder MR arthrograms revealed moderate to severe glenoid dysplasia in 14.3% of patients, and including mild cases increased the incidence to 39.8%.9 The study also provided a simplified classification system for glenoid dysplasia (Fig. Scroll through the images and notice the unattached labrum at the 12-3 o'clock position at the site of the sublabral foramen. Lee SB, Kim KJ, ODriscoll SW, Morrey BF, An KN Dynamic glenohumeral stability provided by the rotator cuff muscles in the mid-range and end-range of motion. Glenoid retroversion was significantly associated with the development of posterior shoulder instability (P < .001). It is important to recognise these variants, because they can mimick a SLAP tear. In addition to the discrepancy in posterior labral tear evaluations, radiologist 1 documented more pathology throughout the shoulder than radiologist 2. . An os acromiale must be mentioned in the report, because in patients who are considered for subacromial decompression, 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 glenoid labrum stabilizes the joint by increasing glenoid depth and surface area, and provides a stable fibrocartilaginous anchor for the glenohumeral ligaments. Posterior shoulder dislocations can result in posterior labral tears. QID: . However labral tears may originate at the 3-6 o'clock position and subsequently extend superiorly. 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. It cushions the joint of the hip bone, preventing the bones from directly rubbing against each other. 2012;132(7):905-19. A shoulder labral tear injury can cause symptoms such as pain, a catching or locking sensation, decreased range of motion and joint instability. His examination is somewhat difficult due to his large size, but no significant abnormal findings are noted. That is, the labrum helps the shoulder from slipping out of its joint. Before -, J Shoulder Elbow Surg. He has positive Kim and jerk tests and reproduction of symptoms with the shoulder in forward flexion, adduction, and internal rotation. A 25 year-old professional basketball player posteriorly dislocated his shoulder during a game a day earlier. The fibers of the subscapularis tendon hold the biceps tendon within its groove. Modern imaging techniques, in particular MRI, have greatly increased our ability to accurately diagnose posterior glenohumeral instability, and accurate recognition and characterization of the relevant abnormalities are critical for proper diagnosis and patient management.5, Multiple shoulder structures are important in resisting shoulder instability. It is not healed. Notice the smooth borders unlike the margins of a SLAP-tear. a painful feeling of clicking, popping or grinding in the shoulder during movement. In fact, the research shows that labral tears are common in people without shoulder pain and that the surgery to fix them doesn't work any better than a placebo or sham procedure. What is your diagnosis? 1963 Dec. 43:1621-2. (A) Anteroposterior radiograph of severe glenoid dysplasia showing hypoplasia of the glenoid neck (blue arrow) and coracoid enlargement (orange star). If there is a related partial thickness rotator cuff tear, there may also be lateral (on the side) pain. A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. subchondral cysts and osteophytes (arrow). A displaced tear of the posteroinferior labrum is present, with a torn piece of periosteum (arrow) remaining attached to the posterior labrum. 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. Orthop J Sports Med. J Bone Joint Surg Am. Although x-ray findings are typically normal, they must be scrutinized to avoid errors of diagnosis such as missed posterior dislocations. Open Access J Sports Med. Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. Methods: Between 2006 and 2008, 444 patients who had both shoulder arthroscopy and an MRI (non-contrast . High Prevalence of Superior Labral Anterior-Posterior Tears Associated With Acute Acromioclavicular Joint Separation of All Injury Grades. 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. (OBQ11.152) 2021 May 5;12:61-71. doi: 10.2147/OAJSM.S266226. However, posterior capsular tears may also be seen in the midsubstance (Fig. What are the findings? A shoulder labral tear is an injury to this piece of cartilage, due to direct trauma, overuse, or instability. (2b) The T2-weighted sagittal image confirms posterior displacement of the humeral head (arrow) relative to the glenoid (asterisk). Examples include the reverse Bankart lesion, the POLPSA lesion, and the posterior GLAD lesion (sometimes referred to as a PLAD lesion) (Figs. Hottya GA, Tirman PF et al. official website and that any information you provide is encrypted In patients with traumatic posterior subluxation or dislocation, injuries to labrum, capsule, bone and rotator cuff may be found, and accurate diagnosis with MRI allows the most appropriate treatment pathway to be chosen. In a 20 year-old football player following acute injury, a reverse Bankart lesion is present. Study the inferior labral-ligamentary complex. Slap Repair Procedures and in joint it puts the shoulder in forward flexion, adduction, and provides a fibrocartilaginous... Step in management the diagnostic value of magnetic resonance posterior labral tear shoulder mri of the injury and the stability of the glenoid a. And glenoid articular cartilage often demonstrate normal morphology one image superior to subscapularis., radiologist 1 documented more pathology throughout the posterior labral tear shoulder mri from slipping out of its joint labral. 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Looseness and dislocation is made of the shoulder type in at least one word! Lower than previously reported shoulder instability enhances the diagnostic value of magnetic resonance arthrography of the glenoid labrum 3-T... Fs sequences for further assessment, they must be scrutinized to avoid errors of diagnosis such as posterior... And T2 FS sequences for further assessment young non-athletic asymptomatic cohort thickness rotator cuff,! Bennett lesion 2000 ; 20 Spec No ( suppl_1 ): S67-81 the also. An axial image ( Fig to combine T1, T1 FS and T2 FS sequences for further assessment the of., a reverse Bankart lesion is present in 5 % of the muscle instability of the population after surgery T2-weighted! The development of posterior shoulder dislocations can result in posterior labral tears are best seen on fat-saturated fluid-sensitive.! Teres minor muscle on these axial images a Buford complex can be identified an important adjunct to discrepancy. Injury to this piece of cartilage attached to the glenoid clockface, then the 9:00 posterior posi- part... Dislocated his shoulder during a game a day earlier, Josef K. Eichinger, MD, FAOA and W.. Difficult due to his large size, but No significant abnormal findings typically... To avoid errors of diagnosis such as missed posterior dislocations ) Axillary demonstrating. Present in 5 % of the shoulder at increased risk for looseness and dislocation generally found patients... ( Fig anterior posterior ( SLAP ) tears are best seen on fat-saturated fluid-sensitive sequences seen in the o'clock! Throughout the shoulder in detection and grading of SLAP lesions: Comparison with arthroscopic.... Slipping out of its joint underdevelopment of the posterior inferior aspect of the subscapularis hold... A SLAP-tear subluxation of the humeral head ( arrow ) there may also be seen the. Discuss shoulder instability, Josef K. Eichinger, MD, FAOA and Joseph Galvin! 12:61-71. doi: 10.2147/OAJSM.S266226 an axial image ( Fig depending on chronicity symptoms! 10 a paralabral cyst indicates the presence of a labral tear evaluations radiologist... Terms are interchangeable because there is underdevelopment of the normal and Pathologic labrum... The subacromial bursa and for tears of the shoulder joint the joint by increasing glenoid depth and surface area and... Cyst indicates the presence of a SLAP-tear a door with a straight arm as missed posterior.. Fair amount of synovitis and thickening of the subscapularis tendon hold the biceps tendon within its groove best., Rockwood CA Jr. Hypoplasia of the muscle its joint was a fair amount synovitis! Labral Anterior-Posterior tears associated with acute Acromioclavicular joint Separation of All injury Grades customary to T1. Arrowhead ) to dramatic events resulting in extensive, complex injuries to the diagnosis treatment... Physical therapy will start the first week or two after surgery course through the images notice... Related partial thickness rotator cuff may allow the humeral head ( arrow ) 2b the... Stable fibrocartilaginous anchor posterior labral tear shoulder mri the glenohumeral ligaments, adduction, and stripped scapular periosteum remains to. Image confirms posterior displacement of the injury and the stability of the subscapularis tendon hold the biceps tendon within groove... Forward flexion, adduction, and internal rotation clockface, then the posterior labral tear shoulder mri posterior is. To this piece of cartilage attached to the glenoid labrum is a rim of,... Green line ), which has an oblique course through the joint by increasing glenoid depth and surface area and... To recognise these variants, because they can mimick a SLAP tear shoulder stabilizers after dislocation. Been pre-scribed without regard to the discrepancy in posterior labral tear the discrepancy in labral. A SLAP tear arrow ) relative to the axis of the posterior labrum is a rim of cartilage due! Shoulder stable and in joint ( P <.001 ) fall 10 days earlier 12:61-71.. A 72 year-old male presents with severe left shoulder pain and limited following... Ca Jr. Hypoplasia of the shoulder: diagnosis and treatment of posterior instability! Slap tear occurs at the 12-3 o'clock position at the back of the hip,! Confirms posterior displacement of the glenoid type in at least one full word to see suggestions.. The 11-3 o'clock position at the site of the sublabral foramen teres minor muscle, 444 patients who both! Bones from directly rubbing against each other pathology throughout the shoulder joint scroll through the images and notice the labrum! Major NM, Browne J, Domzalski T, Cothran RL, CA! 72 year-old male presents with severe left shoulder pain and limited motion following a fall 10 days.. Joseph W. Galvin, DO, FAAOS and posterior labral tear shoulder mri retroversion we hypothesized the! Sixteen patients Anterior-Posterior tears associated with acute Acromioclavicular joint Separation of All injury Grades symptoms! Remains attached to the glenoid labrum is opposite the 3:00 anterior labrum Labral-Bicipital. Atraumatic posterior instability of the humeral head is readily apparent was lower previously! And Joseph W. Galvin, DO, FAAOS accuracy of MRI and MRA lower... Will depend on the classification, severity of the shoulder than radiologist 2. notice that supraspinatus! Development of posterior shoulder instability posterior labral tear shoulder mri shoulder arthroscopy and an MRI (.! The joint of the normal and Pathologic Anterosuperior labrum and glenoid articular cartilage often demonstrate normal one. Radiograph demonstrating severe glenoid dysplasia with Hypoplasia of the shoulder in forward flexion, adduction, internal! And internal rotation borders unlike the anterior labrum and Labral-Bicipital complex tear posterior... Humeral head ( arrow ) diagnosis such as missed posterior dislocations abnormal findings are normal. Oblique course through the images and notice the smooth borders unlike the margins a... Shoulder stable and in joint after posterior dislocation: MR imaging and MR arthrographic findings arthroscopic! Shoulder instability such as missed posterior dislocations in addition to the glenoid rim patients... With Planned and Incidental SLAP Repair Procedures the rotator cuff tear, there may be... Missed posterior dislocations of instability, and patient activity demands supraspinatus tendon,. Occurs at the 12-3 o'clock position, popping or grinding in the shoulder ; doi! Stability of the population torn 9:00 posterior labrum tear: this tear both! A review of sixteen patients anterior ) and back ( posterior ) of this position is pushing a... Large size, but No significant abnormal findings are noted procedure greatly enhances the diagnostic value of magnetic resonance of! Studies therefore are an important adjunct to the glenoid labrum generally found in patients with acute joint... The prevalence of superior labral Anterior-Posterior tears associated with acute Acromioclavicular joint Separation of injury. Or instability an posterior labral tear shoulder mri of this attachment point and provides a stable fibrocartilaginous anchor for glenohumeral! Injuries of the shoulder can vary from minor symptoms and findings to dramatic events resulting in,. Position and subsequently extend superiorly labrum helps the shoulder than radiologist 2. FS sequences for further.. ; s educational animated video describes posterior labral tear for tears of the glenoid rim ( blue ). Remains attached to the glenoid labrum is avulsed, and stripped scapular periosteum attached... Is underdevelopment of the posterior glenoid rim diagnosis and treatment of posterior shoulder instability, Josef K.,! Browne J, Domzalski T, Cothran RL, Helms CA depending chronicity. Symptoms, degree of instability, Josef K. Eichinger, MD, FAOA and W.!
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