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. The shoulder joint is the most unstable articulation in the entire human body. Successful nonoperative treatment of posterior shoulder instability has had varying rates of success, between 16 and 70% of patients. The insertion has a variable range. 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 . Notice the biceps anchor. As joint instability is often present, capsuloplasty may be added to the procedure. 2012 Jan;21(1):13-22 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. The chondral lesion is thought to arise secondary to impaction injury from the humeral head. (OBQ19.66) 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. especially in the setting of an acute anterior and/or posterior labral tear. 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. Clin Orthop Relat Res 1993 : 85-96. 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. 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. Injury can also lead to a cyst that painfully compresses nerves in the shoulder. The biceps looked stable. Check for errors and try again. AJR 1998; 171:763-768. Wuennemann F, Kintzel L, Zeifang F, Maier MW, Burkholder I, Weber MA, Kauczor HU, Rehnitz C. BMC Musculoskelet Disord. The axial MR-images show an os acromiale with degenerative changes, i.e. Does posterior labral tear require surgery? Biplanar radiographs should always be obtained when evaluating patients with suspected shoulder instability. Also. Mauro et al found increased retroversion in a cohort of 118 patients who were operatively treated for posterior instability in comparison with a group of normal controls, but the authors did not attribute retroversion as a risk factor for failure. Images in the ABER position are obtained in an axial way 45 degrees off the coronal plane (figure). Evaluation of the glenoid labrum with 3-T MRI: is intraarticular contrast necessary? The fibers of the subscapularis tendon hold the biceps tendon within its groove. Orthop J Sports Med. The shoulder capsule, including the glenohumeral ligaments, is one of the most important structures for restricting posterior translation of the humeral head.6The subscapularis, and to a lesser extent the infraspinatus and teres minor muscles, provide dynamic restriction of posterior humeral head translation.7The rotator interval is also thought to play a role, though its significance is somewhat controversial.8. There are many elements that work in combination to offset the inherent instability of the glenohumeral joint, but the glenoid labrum is perhaps related most often. 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. Sensitivity was 66 %, and specificity was 77 %. Ultrasound will also show a shoulder ganglion cyst and the effects of muscle wasting. The glenoid labrum is a rim of cartilage attached to the glenoid rim. The glenoid articular surface is slanted posteriorly (dotted line), glenoid articular cartilage appears hypertrophied, and an osseous defect is present posteriorly, replaced by an enlarged posterior labrum (arrow). Broadly, clinical unidirectional . Notice that the supraspinatus tendon is parallel to the axis of the muscle. In addition to the discrepancy in posterior labral tear evaluations, radiologist 1 documented more pathology throughout the shoulder than radiologist 2. . It is present in approximately 1.5% of individuals. In type III there is a large sublabral recess. MRI of the shoulder second edition It can be a traumatic tear due to injury, or it may be degenerative due to normal wear and tear. 2000;20 Spec No(suppl_1):S67-81. When the labrum gets damaged or torn, it puts the shoulder at increased risk for looseness and dislocation. doi: 10.1002/14651858.CD009020.pub2. Wirth MA, Lyons FR, Rockwood CA Jr. Hypoplasia of the glenoid: a review of sixteen patients. It is a condition referred to as an internal impingement. 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. Fluid distends the joint and only lies along the inner margin of the joint capsule (arrowheads). by Jaideep J. Iyengar, MD; Keith R. Burnett, MD; Wesley M. Nottage, MD Which of the following is the most likely etiology of his complaints? J Bone Joint Surg Am. Also, it allows preoperative planning if a posterior bone block procedure is planned. Clinical Relevance: . 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. 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. 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. Once thought to be a relatively rare entity, a study by Harper et al. Scroll through the images and notice the unattached labrum at the 12-3 o'clock position at the site of the sublabral foramen. In patients with glenoid deficiency or large impaction defects, osteotomies and osseous augmentation procedures may be required. Some types of the posterior synovial fold can mimic a posterior labral tear in conventional MRI. HHS Vulnerability Disclosure, Help official website and that any information you provide is encrypted Detection of partial-thickness supraspinatus tendon tears: is a single direct MR arthrography series in ABER position as accurate as conventional MR arthrography? Fraying of the anterior section means some tearing of the surface with wispy threads emanating from that Having a structure when assessing a Shoulder MRI is very useful. 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. A Buford complex is a congenital labral variant. Our data indicated that while MRI could exclude a SLAP lesion (NPV = 95 %), MRI alone was not an accurate clinical tool. These normal variants are all located in the 11-3 o'clock position. The shoulder joint is a ball and socket joint that connects the bone of the upper arm (humerus) with the shoulder blade (scapula). Advanced MRI techniques of the shoulder joint: current applications in clinical practice. Oper Tech Sports Med 2016;24(3):181-188. Patients often do not experience frank posterior dislocation events such as that with anterior shoulder instability and more commonly develop attritional lesions. (10a) Ossification is seen along the posterior glenoid (arrows) in a professional baseball pitcher with a history of posterior instability. However, a study by Saupe et al. Weishaupt D, Zanetti M, Nyffeler RW, Gerber C, Hodler J. Posterior glenoid rim deficiency in recurrent (atraumatic) posterior shoulder instability. Measurement of Friedmans angle and posterior humeral head subluxation (yellow lines depict Friedmans angle; red line depicts percentage of posterior humeral head subluxation). 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. (14a) Normal capsular appearance on an axial fat-suppressed T1-weighted MR arthrographic image. They may extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. On conventional MR labral tears are best seen on fat-saturated fluid-sensitive sequences. It is present in 5% of the population. (16b) A fat-suppressed T2-weighted coronal image through the posterior shoulder in the same patient reveals a severe strain of the teres minor muscle along the musculotendinous junction (arrows). subchondral cysts and osteophytes (arrow). It cushions the joint of the hip bone, preventing the bones from directly rubbing against each other. Imaging of superior labral anterior to posterior (SLAP) tears of the shoulder. In part II we will discuss shoulder instability. 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 . Shah AA, Butler RB, Fowler R, Higgins LD. Normal glenoid morphology is present. 1. 2008 Aug; 24(8):921-9. Posterior ossification of the shoulder: the Bennett lesion. At this level study the middle GHL and the anterior labrum. 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 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). 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. These are depicted in Figure 17-7. 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). When we assess the shoulder labrum there are 7 areas to look at which have some association with labral tears. Type in at least one full word to see suggestions list. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthroscopic findings with arthroscopic correlation. Capsule. The labrum in the shoulder joint is a vital component that helps stabilize the humerus and shoulder blade during movement. Operative photo courtesy of Scott Trenhaile, MD, Rockford Orthopaedic Associates. A posterior labrum tear is a rare type of shoulder labral tear that occurs in the back of the shoulder. Axis of supraspinous tendon. What is Anterosuperior acetabular labrum? Bethesda, MD 20894, Web Policies Sports Health 2011 May, 3(3):253-263, Cooper A. 8600 Rockville Pike The glenohumeral joint has a greater range of motion than any other joint in the body. McLaughlin, HL. Ferrari JD, Ferrari DA, Coumas J, Pappas AM. Simoni P, Scarciolla L, Kreutz J, Meunier B, Beomonte Zobel B. J Sports Med Phys Fitness. Unlike the anterior labrum, rarely do we have a posterior dislocation of the shoulder. In type I there is no recess between the glenoid cartilage and the labrum. Mild glenoid hypoplasia results in a rounded contour of the posterior glenoid with normal or only mildly thickened posterior labral tissue. No Comments Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. 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. 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