posterior labral tear shoulder mri

High Prevalence of Superior Labral Anterior-Posterior Tears Associated With Acute Acromioclavicular Joint Separation of All Injury Grades. 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. Study the cartilage. Probing of the posterior labrum is needed to rule out a subtle Kim lesion. It is present in approximately 1.5% of individuals. It requires about 6 to 8 weeks to heal to the bone. Rotator cuff tears in the context of posterior shoulder instability or dislocation were once thought to be rare. The authors found that specific acromial morphology on scapular-Y x-rays is significantly associated with the direction of glenohumeral instability. A shoulder labral tear is an injury to this piece of cartilage, due to direct trauma, overuse, or instability. Non-contrast MRI had an accuracy of 85 %, sensitivity of 36 %, and a PPV of 13 %. sports. Tearing of the inferior glenohumeral ligament at the humeral attachment (blue arrow) is also evident. Hottya GA, Tirman PF, Bost FW, Montgomery WH, Wolf EM, Genant HK. Open Access J Sports Med. where most labral tears are located. 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. MR arthrography had a large number of false-positive readings in this study. Radiology. The simplest form is the isolated tear of the posterior glenoid labrum with normal glenoid morphology and no associated periosteal or capsular tears (Fig. In order to cover an array of clinical scenarios, we used a pretest probability range of 20-80% at 20% increments according to the likelihood of pathology. . -, J Shoulder Elbow Surg. Mild glenoid hypoplasia results in a rounded contour of the posterior glenoid with normal or only mildly thickened posterior labral tissue. 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. Notice that the biceps tendon is attached at the 12 o'clock position. Having a structure when assessing a Shoulder MRI is very useful. Look for tears of the infraspinatus tendon. Type in at least one full word to see suggestions list. Results: The insertion has a variable range. Fraying of the anterior section means some tearing of the surface with wispy threads emanating from that Numerous labral abnormalities may be encountered in patients with posterior glenohumeral instability. With increased advancements in CT and MRI, more subtle forms of glenoid dysplasia have been recognized. 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. Notice rotator cuff muscles and look for atrophy. The glenoid cavity is the shallow socket of the scapula. Posterior labral tear; < 15 decrease in affected shoulder internal rotation compared to contralateral shoulder . 1998 Sep;171(3):763-8. Radiology 2008; 248:185193. (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. (10a) Ossification is seen along the posterior glenoid (arrows) in a professional baseball pitcher with a history of posterior instability. 5,6,7 The classic MRI findings of internal impingement, as seen in this month's case, include partial articular surface tears at the posterior supraspinatus/anterior infraspinatus insertion, greater tuberosity bony changes, and tearing of the . 1998 Apr 30;17(8):857-72 Comparison between 18 patients with glenoid dysplasia and 19 patients without dysplasia revealed no significant difference in outcomes between the 2 groups.20. Bookshelf Axial anatomy and checklist. The findings are compatible with a posterior GLAD lesion (glenolabral articular disruption). AJR Am J Roentgenol. government site. Careers. In type II there is a small recess. I don't have pain generally at all. 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. 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. Background:The literature demonstrates a high prevalence of asymptomatic knee and hip findings on magnetic resonance imaging (MRI) in athletes. It is not healed. 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. ALPSA lesions are . Dislocation of the long head of the biceps will inevitably result in rupture of part of the subscapularis tendon. There was no subscapularis or rotator cuff tear and no superior labrum tear. Posterior shoulder instability is a relatively rare phenomenon compared to anterior instability, comprising only 5-10% of all shoulder instability. Orlando Orthopaedic Center's Dr. Randy S. Schwartzberg, a board certified orthopaedic surgeon specializing in Sports Medicine, discusses what's involved with. Objective To determine the prevalence of shoulder (specifically labral) abnormalities on MRI in a young non-athletic asymptomatic cohort. If the patient is unable to abduct the arm, then a Velpeau view is an alternate orthogonal radiograph (Figure 17-4). The anterior labrum and glenoid articular cartilage often demonstrate normal morphology one image superior to the . 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 . What is your diagnosis? Etiology, diagnosis, and treatment. 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. American Journal of Roentgenology. Simoni P, Scarciolla L, Kreutz J, Meunier B, Beomonte Zobel B. J Sports Med Phys Fitness. . Increased glenoid retroversion increases the risk of posterior shoulder instability by 6 times. 2019 Dec 12;20(1):598. doi: 10.1186/s12891-019-2986-1. They may extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. 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. We hypothesize that this population will have fewer labral abnormalities than an athletic population. Clinical History: A 72 year-old male presents with severe left shoulder pain and limited motion following a fall 10 days earlier. (B) Axillary radiograph of locked posterior glenohumeral dislocation. MRI of the shoulder second edition They did find that smaller glenoid width was a risk factor for failure.12. It can be a traumatic tear due to injury, or it may be degenerative due to normal wear and tear. Look for supraspinatus-impingement by AC-joint spurs or a thickened coracoacromial ligament. Evaluation and management of posterior shoulder instability. 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 axillary radiograph is also helpful in the traumatic scenario for identifying a posterior glenoid rim fracture or a reverse Hill-Sachs lesion. 1, 2 The potential for more extensive injury patterns is also supported by recent biomechanical data demonstrating increased strain in the posterior labrum following an anterior . The diagnostic value of magnetic resonance arthrography of the shoulder in detection and grading of SLAP lesions: comparison with arthroscopic findings. 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. (A) Anteroposterior radiograph of severe glenoid dysplasia showing hypoplasia of the glenoid neck (blue arrow) and coracoid enlargement (orange star). Purpose: (16a) An axial image in a 17 year-old female following posterior subluxation during a basketball game demonstrates humeral sided avulsion of the capsule (arrow). -, BMJ. A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. (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. Common symptoms of a SLAP tear include: dull or aching pain in the shoulder, especially while lifting over the head. 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. The labrum is the cartilage of the shoulder joint that encircles the socket to stabilize the shoulder. 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. These are depicted in Figure 17-7. Which of the following is the most likely etiology of his complaints? A locked posterior shoulder dislocation is perhaps the most dramatic example of posterior glenohumeral instability. 2. MR is the best imaging modality to examen patients with shoulder pain and instability. Surgery may be required if the tear gets worse or does not improve after physical therapy. The https:// ensures that you are connecting to the (1a) Fat-suppressed proton density-weighted axial, (1b) sagittal T2-weighted, and (1c) fat-suppressed T2-weighted coronal MR images are provided. 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. sharing sensitive information, make sure youre on a federal PMC by Michael Zlatkin. Look for excessive fluid in the subacromial bursa and for tears of the supraspinatus tendon. J Bone Joint Surg Am. Eur J Radiol. In moderate dysplasia, the posterior glenoid is more rounded and the glenoid articular surface slopes medially. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. In addition to aiding in the recognition of a locked posterior dislocation, the axillary radiograph is necessary to a complete an orthogonal radiographic analysis. 2012 Jan;21(1):13-22 4. Which of the following nerves was most likely injured during the procedure? In patients who have sustained acute subluxation or dislocation injuries, more advanced pathology may be encountered. Clin Orthop Relat Res 1993 : 85-96. 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. Orthop J Sports Med. MRI. Notice the rotator cuff interval with coracohumeral ligament. An anatomy drawing of a shoulder labrum. Which of the images (Figures A-E) most likely corresponds to the patient's initial diagnosis? Occasionally, a SLAP (superior labrum, anterior and posterior) fracture, which represents a superior humeral head compression . Federal government websites often end in .gov or .mil. When we assess the shoulder labrum there are 7 areas to look at which have some association with labral tears. In our retrospective study of 444 patients, sensitivity, specificity, and accuracy were all lower than previously reported in the literature for diagnosing SLAP lesions. a painful feeling of clicking, popping or grinding in the shoulder during movement. It helps provide stability to the shoulder by . 1A: The ball (humerus) normally rests within the socket (glenoid) like a golf ball on a tee. Diagnostic arthroscopy revealed no significant glenohumeral articular defects. Examples include the reverse Bankart lesion, the POLPSA lesion, and the posterior GLAD lesion (sometimes referred to as a PLAD lesion) (Figs. 10 A paralabral cyst indicates the presence of a labral tear. Provencher MT, Dewing CB, Bell SJ, McCormick F, Solomon DJ, Rooney TB, Stanley M.An analysis of the rotator interval in patients with anterior, posterior, and multidirectional shoulder instability. 2015;101(1 Suppl):S19-24. Notice red arrow indicating a small Perthes-lesion, which was not seen on the standard axial views. A Buford complex is a congenital labral variant. The labrum is cartilage tissue that holds the "ball" (humeral head) in the "socket" (glenoid) of your shoulder. The posterior labrum is stressed with an abducted arm and posterior force. Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum. Utilizing the gle-noid clockface orientation on a sagittal image (Fig. A Meta-Analysis of the Diagnostic Test Accuracy of MRA and MRI for the Detection of Glenoid Labral Injury. On plain radiography of the shoulder, an anteroposterior (AP) view of the shoulder in internal and external rotation, outlet, and axillary views should be obtained. The management of these labrum injuries will depend on the classification, severity of the injury and the stability of the shoulder. He has full passive and active range of motion of the left shoulder that is symmetrical to his contralateral side. 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. Notice coracoclavicular ligament and short head of the biceps. While this certainly introduces vulnerability to injury, it also confers the advantage of broad range of motion. At surgery, we put the labrum back in position against the bone. 1992 Jul;74(6):890-6. If the arm is Radiographics. Broadly, clinical unidirectional . In Shoulder MR-Part I we will focus on the normal anatomy and the many anatomical variants that may simulate pathology. Hill Sachs lesions are only seen at the level of the coracoid. There are many labral variants. 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. Normal anatomy. The labrum is a band of tough cartilage and connective tissue that lines the rim of the hip socket, or acetabulum. . A recess more than 3-5 mm is always abnormal and should be regarded as a SLAP-tear. Posterior ossification of the shoulder: the Bennett lesion. Patients often do not experience frank posterior dislocation events such as that with anterior shoulder instability and more commonly develop attritional lesions. It is important to recognise these variants, because they can mimick a SLAP tear. The site is secure. 2019 Nov 7;19:199-202. doi: 10.1016/j.jor.2019.10.015. Glenoid labrum (marked lig.) Often, muscle wasting is seen clearly on MRI, showing atrophy of the muscle and build-up of fat. Chung CB, Sorenson S, Dwek JR and Resnick D. Humeral Avulsion of the Posterior Band of the Inferior Glenohumeral Ligament: MR Arthrography and Clinical Correlation in 17 Patients. Burkhart et al. 13) of the posterior capsule. 2021 May 5;12:61-71. doi: 10.2147/OAJSM.S266226. Pathomechanics and Magnetic Resonance Imaging of the Thrower's Shoulder. The first part of rehabilitation labral repair involves letting the labrum heal to the bone. In patients with glenoid deficiency or large impaction defects, osteotomies and osseous augmentation procedures may be required. Failure of one of the acromial ossification centers to fuse will result in an os acromiale. 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). . An MRI arthrogram is performed and is normal. 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. A displaced tear of the posterior labrum (arrow) is present. A normal glenoid labrum has a laterally pointing edge and normal posterior labral morphology. The capsule is a broad ligament that surrounds and stabilizes the joint. Before 6). difficulty performing normal shoulder . MRA for SLAP - Is the threshold for referral too low? Harper and colleagues17 similarly developed a classification scheme with normal, mild, moderate, and severe glenoid dysplasia. 2009;192: 730-735. Tendonitis of the long head of the biceps. The labrum is the cartilage dish that sits between the ball and the socket configuration of the shoulder joint. 2013 Sep 24;2013(9):CD009020. Hottya GA, Tirman PF et al. Locked posterior shoulder dislocation with multiple associated injuries. There are 3 types of attachment of the superior labrum at the 12 o'clock position where the biceps tendon inserts. 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). 2005;184: 984-988. J Am Med Assoc 117: 510-514, 1941. The abduction external rotation (ABER) view is excellent for assessing the anteroinferior labrum at the 3-6 o'clock position, Check for errors and try again. In part II we will discuss shoulder instability. 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. 11). However, a study by Saupe et al. 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. Notice that the supraspinatus tendon is parallel to the axis of the muscle. 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. An area of capsular irregularity (arrow) is apparent as well. The glenohumeral joint has the following supporting structures: The tendon of the subscapularis muscle attaches both to the lesser tuberosity aswell as to the greater tuberosity giving support to the long head Successful nonoperative treatment of posterior shoulder instability has had varying rates of success, between 16 and 70% of patients. 2016;36(6):1628-47. Figure 17-6. 3. Epub 2011 Sep 9. Figure 17-1. On examination, she reports deep posterior shoulder pain when the arm is abducted 90 degrees and maximally . Imaging signs of posterior glenohumeral instability. MR arthrography has excellent accuracy in differentiating between SLAP lesions and anatomic variants. Skeletal Radiol. An impaction fracture is also present at the posterior glenoid rim (blue arrow). Pathology involving the superior labrum presents a diagnostic and therapeutic challenge for the arthroscopic surgeon. Since that time, other authors have expanded this classification to the current . This top area is also where the biceps tendon attaches to the labrum. The biceps tendon is medially dislocated (short arrow). No Comments 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. 15 Imaging of the patient in the ABER position can greatly increase the conspicuity of an ALPSA lesion, which can easily be overlooked on a routine MRI of the shoulder or on the standard axial sequence of an MRA. Axis of supraspinous tendon. Posterior Labral Tear. MRI is well recognized as an effective means to diagnose internal impingement of the shoulder. 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). The shoulder, because of its wide range of motion, is anatomically predisposed to instability, but the vast majority of shoulder instability is anterior, with posterior instability estimated to affect 2-10% of unstable shoulders.1Although anterior shoulder dislocations have been recognized since the dawn of medicine, the first medical description of posterior shoulder dislocation did not occur until 1822.2In modern times, posterior shoulder instability is still a commonly missed diagnosis, in part due to a decreased index of suspicion for the entity among many physicians. 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. J Shoulder Elbow Surg. The posterior labrum is avulsed, and stripped scapular periosteum remains attached to the posterior labrum (arrowhead). Both tests may . 2000 Jun; 82(6):849-57. Surgical treatment: arthroscopic debridement . On MR an os acromiale is best seen on the superior axial images. Without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. Images in the ABER position are obtained in an axial way 45 degrees off the coronal plane (figure). (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. Does posterior labral tear require surgery? 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.
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