posterior labral tear shoulder mri

The anterior labrum is absent in the 1-3 o'clock position and there is a thickened middle GHL. 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. . and transmitted securely. Does posterior labral tear require surgery? Additionally, a recent study by Meyer et al9 highlighted the importance of x-rays in evaluation of posterior shoulder instability. A fat-suppressed proton density-weighted axial image in a 14 year-old female with shoulder instability reveals findings of severe glenoid hypoplasia. by Jaideep J. Iyengar, MD; Keith R. Burnett, MD; Wesley M. Nottage, MD 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. The shoulder joint is a ball-and-socket joint that joins the upper arm's (humerus) bone with the shoulder blade (scapula). 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. Unable to load your collection due to an error, Unable to load your delegates due to an error. Common symptoms of a SLAP tear include: dull or aching pain in the shoulder, especially while lifting over the head. 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. PMC When we assess the shoulder labrum there are 7 areas to look at which have some association with labral tears. True anteroposterior or Grashey x-ray. Shah N and Tung GA. There is . Articular cartilage is maintained. 2021 May 5;12:61-71. doi: 10.2147/OAJSM.S266226. No Comments Severe glenoid dysplasia or hypoplasia is a rare condition due to either brachial plexus birth palsy or a developmental abnormality with lack of stimulation of the inferior glenoid ossification center. 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. This usually happens from an interior shoulder dislocation (a dislocation when the humeral head comes out of the front of the socket). 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. AJR Am J Roentgenol. Posterior Labral Tear. Unable to process the form. It helps provide stability to the shoulder by . 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. Illustration by Biodigital. A 22-year-old male wrestler presents to your clinic with complaints of deep left shoulder pain for the past 6 weeks. The posterior labrum is stressed with an abducted arm and posterior force. 1994 May; 3(3):173-90. Labral tears, such as a SLAP tear that cause a paralabral cyst, can occur due to trauma (dislocation), repetitive movement . An example of this position is pushing open a door with a straight arm. The shallow socket in the scapula is the glenoid cavity. This ring of cartilage encompasses the outer rim of the glenoid to provide cushiony support around the head of the humerus. Postoperatively, there are strict instructions to avoid adduction and internal rotation of the operative shoulder. Notice that the biceps tendon is attached at the 12 o'clock position. As a result, subtle articular-sided partial thickness tears will not lie apposed to the adjacent intact fibers of the remaining rotator cuff Dougherty MC, Kulenkamp JE, Boyajian H, Koh JL, Lee MJ, Shi LL. Radiographs are normal, and an MRI arthrogram is shown in Figure A. An arthroscopic examination confirmed the MRI findings and showed multiloculated cysts in the inferior labrum, mostly between 5 o'clock to 7 o'clock positions with labral tear. Skeletal Radiol. Radiology. Patients were included in the analysis if they had a posterior labral tear repair and had preoperative MRI or magnetic resonance arthrography (MRA). The posterior shoulder capsule plays a significant role in preventing posterior shoulder dislocation, particularly at the extremes of internal humeral rotation, the position in which most posterior dislocations occur. Diagnosis can be made clinically with positive posterior labral provocative tests and confirmed with MRI studies of the shoulder. A hip (acetabular) labral tear is damage to cartilage and tissue in the hip socket. 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. Harper and colleagues, Arthroscopic Management of Posterior Instability, Radiographic and Advanced Imaging to Assess Anterior Glenohumeral Bone Loss, Management of In-Season Anterior Instability and Return-to-Play Outcomes, Decision Making in Surgical Treatment of Athletes With First-Time vs Recurrent Shoulder Instability, Management of the Aging Athlete With the Sequelae of Shoulder Instability, Instability in the Pediatric and Adolescent Athlete, History and Examination of Posterior Instability. Both tests may . MRA for SLAP - Is the threshold for referral too low? 14). The insertion has a variable range. On conventional MR labral tears are best seen on fat-saturated fluid-sensitive sequences. He has full passive and active range of motion of the left shoulder that is symmetrical to his contralateral side. nor be effaced against the humeral head, and intra-articular contrast can enhance visualization of the tear (3). Numerous labral abnormalities may be encountered in patients with posterior glenohumeral instability. Tears of the supraspinatus tendon are best seen on coronal oblique and ABER-series. Diagnosis is made clinically with presence of increased anterior and posterior humeral translation, a sulcus sign, and overall increased . 2008 Aug; 24(8):921-9. The capsule is a broad ligament that surrounds and stabilizes the joint. That is, the labrum helps the shoulder from slipping out of its joint. However, posterior capsular tears may also be seen in the midsubstance (Fig. Adv Orthop. There was no subscapularis or rotator cuff tear and no superior labrum tear. The glenoid cavity is the shallow socket of the scapula. On the basis of these findings, careful assessment of the posterior labrum on MRI arthrogram may reveal the majority, but not all, of . (OBQ19.66) 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. When a dislocation or subluxation occurs, the glenoid labrum is torn from the bone and the capsule is stretched. 2019 Nov 7;19:199-202. doi: 10.1016/j.jor.2019.10.015. 13) of the posterior capsule. A displaced tear of the posteroinferior labrum is present, with a torn piece of periosteum (arrow) remaining attached to the posterior labrum. 11). Edelson was the first to define the incidence of subtle forms of glenoid dysplasia by studying scapular specimens from several museum collections.15 Posteroinferior hypoplasia was defined as a dropping away of the normally flat plateau of the posterior part of the glenoid beginning 1.2 cm caudad to the scapular spine (Figure 17-7). Burkhead WZ, Rockwood CA Treatment of instability of the shoulder with an exercise program. 4). Clipboard, Search History, and several other advanced features are temporarily unavailable. 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. 2011 Sep;27(9):1304-7. Locked posterior shoulder dislocation with multiple associated injuries. Posterior labrum tear: This tear occurs at the back of the shoulder joint. Notice red arrow indicating a small Perthes-lesion, which was not seen on the standard axial views. 1963 Dec. 43:1621-2. A study in cadavers. where most labral tears are located. AJR 2004; 183(2). There are 3 types of attachment of the superior labrum at the 12 o'clock position where the biceps tendon inserts. An orthopaedic surgeon performs an arthroscopic shoulder procedure on a football player. eCollection 2020 Aug. J Orthop. -, Am J Sports Med. The radiologic diagnosis and surgical evaluation were compared to determine the accuracy of diagnosing a SLAP lesion by MRI. Small to moderate glenohumeral joint effusion with synovitis and extension of fluid in the subcoracoid recess. Broadly, clinical unidirectional . Indirect MR arthrography of the shoulder: use of abduction and external rotation to detect full- and partial-thickness tears of the supraspinatus tendon. His examination is somewhat difficult due to his large size, but no significant abnormal findings are noted. Examples include the reverse Bankart lesion, the POLPSA lesion, and the posterior GLAD lesion (sometimes referred to as a PLAD lesion) (Figs. However, imaging studies do not always demonstrate obvious pathologic findings and thus a nuanced approach to the interpretation of x-rays, computed tomography (CT), and magnetic resonance imaging (MRI) is necessary to elucidate and identify subtle findings that can enable the clinician to make the correct diagnosis. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. In Shoulder MR-Part I we will focus on the normal anatomy and the many anatomical variants that may simulate pathology. At surgery, we put the labrum back in position against the bone. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. 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 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. In type II there is a small recess. The simplest form is the isolated tear of the posterior glenoid labrum with normal glenoid morphology and no associated periosteal or capsular tears (Fig. Which of the following nerves was most likely injured during the procedure? The term SLAP stands for Superior Labrum Anterior and Posterior. Multidirectional shoulder instability (MDI) is a condition characterized by generalized instability of the shoulder in at least 2 planes of motion (anterior, posterior, or inferior) due to capsular redundancy. 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. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Chmiel-Nowak M, Sheikh Y, Feger J, et al. 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. Crossref, Medline, Google Scholar; 74. 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. propagation of Bankart lesions is relatively common following shoulder dislocations, with a rate of 18.5%. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. Ultrasound will also show a shoulder ganglion cyst and the effects of muscle wasting. Radiology. (A) Anteroposterior radiograph of severe glenoid dysplasia showing hypoplasia of the glenoid neck (blue arrow) and coracoid enlargement (orange star). Posterior capsular rupture causing posterior shoulder instability: a case report. Fraying of the anterior section means some tearing of the surface with wispy threads emanating from that Objective To determine the prevalence of shoulder (specifically labral) abnormalities on MRI in a young non-athletic asymptomatic cohort. Orlando Orthopaedic Center's Dr. Randy S. Schwartzberg, a board certified orthopaedic surgeon specializing in Sports Medicine, discusses what's involved with. If the pre-test probability was above 90% or below 10% . True dysplasia should be visible on at least two axials slices cephalad to the most inferior slice of the glenoid (Fig. Radiol Clin North Am 2016;54(5):801-815. Posterior labral tearing was apparent on contiguous images (not shown). Increased glenoid retroversion increases the risk of posterior shoulder instability by 6 times. Images demonstrate a non-displaced tear involving the superficial anteroinferior labrum with associated injury to the adjacent cartilage 4.. However,patients with acute lesions often have joint effusion, which also distends the joint space, making the contrast administration unnecessary. A recess more than 3-5 mm is always abnormal and should be regarded as a SLAP-tear. It should always be possible to trace the middle GHL upwards to the glenoid rim and downwards to the humerus. 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. MR arthrography has excellent accuracy in differentiating between SLAP lesions and anatomic variants. 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 . They involve the superior glenoid labrum, where the long head of biceps tendon inserts. Posterior labral tear; < 15 decrease in affected shoulder internal rotation compared to contralateral shoulder . Such lesions are generally found in patients with atraumatic posterior instability. Posterior shoulder subluxation or dislocation is also one of the rare entities that may result in tears of the teres minor muscle.18 MR allows rapid evaluation of the status of the cuff following posterior dislocation, and prompt diagnosis of such lesions avoids delays in treatments that may lead to irreversible fatty atrophy of cuff musculature (Figs. Fluid distends the joint and only lies along the inner margin of the joint capsule (arrowheads). Diagnostic performance of 3D-multi-Echo-data-image-combination (MEDIC) for evaluating SLAP lesions of the shoulder. 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. They did find that smaller glenoid width was a risk factor for failure.12. If there is a related partial thickness rotator cuff tear, there may also be lateral (on the side) pain. The management of these labrum injuries will depend on the classification, severity of the injury and the stability of the shoulder. 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 . A displaced tear of the posterior labrum (arrow) is present. Figure 17-5. 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. posteriorly directed force with the arm in a flexed, internally rotated and adducted position, patients with increased glenoid retroversion (~17) were 6x more likely to experience posterior instability compared to those with less glenoid retroversion (~7), helps generate cavity-compression effect of glenohumeral joint, anchors posterior inferior glenohumeral ligament (PIGHL, vague, nonspecific posterior shoulder pain, worsens with provocative activities that apply a posteriorly directed force to the shoulder, ex: pushing heavy doors, bench press, push-ups, arm positioned with shoulder forward flexed 90 and adducted, apply posteriorly directed force to shoulder through humerus, positive if patient experiences sense of instability or pain, grasp the proximal humerus and apply a posteriorly directed force, assess distance of translation and patient response, grade 2 = over edge of glenoid but spontaneously relocates, grade 3 = over edge of glenoid, does not spontaneously relocate, arm positioned with shoulder abducted 90 and fully internally rotated, axially load humerus while adducting the arm across the body, arm positioned with shoulder abducted 90 and forward flexed 45, apply posteriorly and inferiorly directed force to shoulder through humerus, posterior shoulder dislocations may be missed on AP radiographs alone, arthroscopic and open techniques may be used, suture anchor repair and capsulorrhaphy results in fewer recurrences and revisions than non-anchored repairs, return to previous level of function in overhead throwing athletes not as reproducible as other athletes, failure risk increases if adduction and internal rotation are not avoided in the acute postoperative period, posterior branch of the axillary nerve is at risk during arthroscopic stabilization, travels within 1 mm of the inferior shoulder capsule and glenoid rim, at risk during suture passage at the posterior inferior glenoid, can lead to anterior subluxation or coracoid impingement, Glenohumeral Joint Anatomy, Stabilizer, and Biomechanics, Traumatic Anterior Shoulder Instability (TUBS), Humeral Avulsion Glenohumeral Ligament (HAGL), Posterior Shoulder Instability & Dislocation, Multidirectional Shoulder Instability (MDI), Luxatio Erecta (Inferior Glenohumeral Joint Dislocation), Glenohumeral Internal Rotation Deficit (GIRD), Brachial Neuritis (Parsonage-Turner Syndrome), Glenohumeral Arthritis (Shoulder Arthritis), Shoulder Arthroscopy: Indications & Approach, Valgus Extension Overload (Pitcher's Elbow), Lateral Ulnar Collateral Ligament Injury (PLRI), Elbow Arthroscopy: Indications & Approach. 1998 Sep;171(3):763-8. 2009;192: 730-735. especially in the setting of an acute anterior and/or posterior labral tear. The axial MR-images show an os acromiale with degenerative changes, i.e. The concavity at the posterolateral margin of the humeral head should not be mistaken for a Hill Sachs, because this is the normal contour at this level. HHS Vulnerability Disclosure, Help These terms are interchangeable because there is underdevelopment of the posterior inferior aspect of the glenoid. Numerous capsular abnormalities have been described in patients with posterior glenohumeral instability. The biceps tendon is medially dislocated (short arrow). An os acromiale must be mentioned in the report, because in patients who are considered for subacromial decompression, Sensitivity was 66 %, and specificity was 77 %. The rotator cuff is made of the tendons of subscapularis, supraspinatus, infraspinatus and teres minor muscle. An MRI arthrogram is performed and is normal. Orthop Traumatol Surg Res. Notice the smooth borders unlike the margins of a SLAP-tear. Eur J Radiol. A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. Look for excessive fluid in the subacromial bursa and for tears of the supraspinatus tendon. An area of capsular irregularity (arrow) is apparent as well. A shoulder labral tear is an injury to this piece of cartilage, due to direct trauma, overuse, or instability. MRI Shoulder Labrum Periosteal Stripping. Normal Labral Anatomy. The labrum is the cartilage dish that sits between the ball and the socket configuration of the shoulder joint. It is seen in 11% of individuals. (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). Notice superior labrum and attachment of the superior glenohumeral ligament. Oper Tech Sports Med 2016;24(3):181-188. Crossref, Google Scholar; 73. An anteroposterior (AP) Grashey image (also known as a true AP view because the beam is oriented perpendicular to the scapula, which is oriented 30 degrees anterior to the coronal plane) (Figure 17-1) along with an axillary x-ray (Figure 17-2), are the minimum radiographs that should be obtained. AJR Am J Roentgenol. In a SLAP injury, the top (superior) part of the labrum is injured. A posterior labral tear (reverse Bankart) is also present (arrowhead), and a bone bruise is seen within the anterior humeral head (asterisk). De Coninck T, Ngai S, Tafur M, Chung C. Imaging the Glenoid Labrum and Labral Tears. AJR Am J Roentgenol. A posterior labral tear (reverse Bankart) is also present (arrowhead), and a bone bruise is seen within the anterior humeral head (asterisk). Imaging signs of posterior glenohumeral instability. Mild glenoid hypoplasia results in a rounded contour of the posterior glenoid with normal or only mildly thickened posterior labral tissue. To investigate the utility of MRI, the researchers identified 41 patients who had undergone shoulder capsulorrhaphy by one of two senior surgeons over a two-year period. Our data indicated that while MRI could exclude a SLAP lesion (NPV = 95 %), MRI alone was not an accurate clinical tool. 2000;20 Spec No(suppl_1):S67-81. Scroll through the images and notice the unattached labrum at the 12-3 o'clock position at the site of the sublabral foramen. 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). In type III there is a large sublabral recess. Figure 17-1. He has positive Kim and jerk tests and reproduction of symptoms with the shoulder in forward flexion, adduction, and internal rotation. "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 . eCollection 2020 May-Jun. Occasionally, a SLAP (superior labrum, anterior and posterior) fracture, which represents a superior humeral head compression . Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum. 3, 19, 31 Our results demonstrate a success rate of nonoperative treatment of 52% at a minimum of 2 years after MRI confirmation of posterior labral tear. A sublabral recess however is located at the site of the attachment of the biceps tendon at 12 o'clock and does not extend to the 1-3 o'clock position. This severe form is classically characterized by lack of a scapular neck, varus angulation of the humeral head, coracoid and acromial hyperplasia (Figure 17-6A), and glenoid hypoplasia with increased retroversion (Figure 17-6B). Recurrent posterior shoulder instability: diagnosis and treatment. The labrum is the cartilage of the shoulder joint that encircles the socket to stabilize the shoulder. 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. Reference article, Radiopaedia.org (Accessed on 18 Jan 2023) https://doi.org/10.53347/rID-74948, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":74948,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/glenoid-labral-tear/questions/1679?lang=us"}, doi:10.1148/radiographics.20.suppl_1.g00oc03s67, pain or discomfort (usually a precise point of pain cannot be located). On contiguous images ( not shown ) ( not shown ) broad ligament that surrounds stabilizes! 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