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Glenoid Labrum Lesions
From WikiSM
(Redirected from Glenoid Labral Tears)
Other Names
- Labral Tear
- Glenoid Labral Tear
- Superior Labrum Anterior Posterior (SLAP) tear
Background
- This page currently refers to all lesions of the Glenoid Labrum
- Including:
- Superior Labrum Anterior Posterior (SLAP) tear
- Andrew's Lesion
- Anterior Labral Tear
- Posterior Labral Tear
- Antero-inferior Labral Tear
- Postero-inferior Labral Tear
- Inferior Tear
History
Epidemiology
- SLAP Tear
- Accounts for 80-90% of labral pathology (need citation)
- Anterior-inferior (Bankart)
- Most common (need citation, conflicts with statement about SLAP tear)
- Posterior
- Rare, seen on only 2-6% of arthroscopies[1]
Pathophysiology
- Pathology can an be divided into 6 glenoid sectors per Synder[2]
Pathoanatomy
- Glenoid Labrum
- Fibrocartilage of the shoulder joint
- Runs along the outer rim of the glenoid
- Provides up to 10% of glenohumeral stability[3]
- Other structures
- Continguous with the insertion of the long head of the Biceps Brachii onto the supraglenoid tubercle
- Glenohumeral Ligaments
SLAP Tear
- SLAP: Superior Labrum from Anterior to Posterior
- Accounts for 80-90% of labral pathology
- Can be challenging to diagnosis due to concomitant shoulder pathology
- 88% of patients with arthroscopy confirmed SLAP tear have other intra-articular lesions[4]
Pathophysiology
- Due to tightness of posterior-inferior glenohumeral ligament, shifting GH contact posteriorly, increases shearing forces
Etiology
- Can be acute or insidious
- Occurs in throwing and overhead athletes in dominant shoulder
Associated Injuries
- Glenohumeral Internal Rotation Deficit
- Internal Impingement
- Rotator Cuff Tear
- Instability
- Scapular Dyskinesis
Andrew's Lesion
- Pure superior labrum detachment without extension into biceps footplate
- Mainly found in throwers
Anterior Labral Tear
- Pure anterior labral tear
- Associated with middle glenohumeral ligament tear
- Rare
- Location: Sector 2
Posterior Labral Tear
- Rare, less common than anterior tear
- Sector 6 labral injury
Pathophysiology
- Due to posteriorly directed force
- Sometimes referred to as a reverse bankart
Etiology
- Weightlifting (bench press), football linemen (blocking), swimmers, gymnasts, wrestlers
Associated Injuries
- Kim Lesion: Incomplete avulsion of posterior inferior labrum
Antero-inferior Labral Tear
- Associated injuries
- Acute or chronic anterior Shoulder Instability
- Injuries to the Glenohumeral Ligament Complex
- Perthe's Lesion: Antero-inferior labral detachment
- Gleno-labral Articular Disrupotion (GLAD)
- Bankart Lesion
- ALPSA lesion: Anterior Labroligamentous Periosteal Sleeve Avulsion
- Sector 3, 4
Postero-inferior Labral Tear
- Sectors 5, 6
Inferior Labral Tear
- Sector 4 (between 4 o'clock and 8 o'clock position)
- Poorly described in the literature with case reports and series only[5]
Pathophysiology
- In case series, dislocation does not appear to be associated
- Suspect repetitive microtrauma[6]
Etiology
- Unclear in limited case series
- Patients endorse pain, not instability
Associated Injuries
Risk Factors
- General
- Labral dysplasia (buferd complex)
- Scapular hyperlaxity
- Scapular Dyskinesis
- Posterior
- Weightlifting (bench press)
- Football lineman (blocking)
- Swimmers, gymnasts, wrestlers
- SLAP
- Glenohumeral Internal Rotation Deficit
Differential Diagnosis
- Fractures
- Proximal Humerus Fracture
- Humeral Shaft Fracture
- Clavicle Fracture
- Scapula Fracture
- First Rib Fracture (traumatic or atraumatic)
- Dislocations & Separations
- Arthropathies
- Muscle & Tendon Injuries
- Rotator Cuff
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatrics
- Coracoid Avulsion Fracture
- Humeral Head Epiphysiolysis (Little League Shoulder)
Clinical Features
- History
- Patients will typically report pain, instability
- May have a history of shoulder injury or dislocation
- Pain will be vague, non specific
- May endorse clicking or popping
- Throwers may endorse a loss of throwing velocity, ball control or changes to mechanics
- Physical: Physical Exam Shoulder
- Important to perform a thorough shoulder examination
- The labrum in general is best tested with provocative testing
- Special Tests
- Jobe Relocation Test: Supine with abducted, externally rotated shoulder and a posterior force
- Internal Rotation Resistance Test: Arm abducted to 90°, internally and externally rotate against resistance
- Crank Test: Hyper-abducted shoulder, axial load on humerus with internal and external rotation
- OBriens Test: Shoulder flex to 90°, upward force against resistance in supination and pronation
- Apprehension Test: Flexes elbow to 90°, abduct shoulder to 90°, slowly externally rotate shoulder
- Load and Shift Test: Arm slightly abducted, apply anterior-posterior force to humeral head assessing translation
- Clunk Test: fully abduct arm then apply anterior force
- Anterior Slide Test: Place patients hand on hip, apply anterior force along axis of humerus
- New Pain Provocation Test: Arm abducted, elbow flexed to 90°, supinate and pronate forearm
- Posterior-inferior
- SLAP Lesion (not specific)
- Passive Compression Test: Arm abducted to 30°, externally rotated, axial load into joint with extension
- Dynamic Labral Shear Test: Externally rotate arm and abduct to 90°, bring form 90-120° to reproduce symptoms
- Compression Rotation Test: Shoulder and elbow flexed to 90°, apply compressive force, rotate humerus
- Inferior
- Sulcus Sign: Place axial traction on affected limb with arm resting at side
- Posterior
- Posterior Apprehension Test: Apply a posterior force through flexed, adducted shoulder
- Biceps
- Speeds Test: Shoulder flex to 90°, upward force against resistance in supination and pronation
- Biceps Load Test: Resisted flexion with arm abducted to 90°, maximal external rotation
- Biceps Load Test II: Resisted flexion with arm abducted to 120°, maximal external rotation
- Yergasons Test: Elbow flexed to 90°, forearm pronated, attempt to supinate against resistance
Evaluation

Coronal T2-weighted fat-suppressed MRI shows superior labral tear and overlying paralabral cyst (arrow) and a low grade intrasubstance tear of supraspinatus tendon (arrowhead)[7]
Radiographs
- Start with Standard Radiographs Shoulder
- Often normal
- Useful for excluding other causes of shoulder pain
- Posterior: may see glenoid retroversion, posterior glenoid erosion
CT
- Arthrography[8]
- Sensitivity: 94-98%
- Specificity: 73-88%
- Advantage over MRI in evaluating bone
MRI
- Arthrography
- Sensitivity: 82-89%
- Specificity: 91-98%
- Arthrography may not be necessary if magnet is 3T or larger[9]
- SLAP: T2 signal intensity between superior labrum, lateral to glenoid rim, posterior to biceps
Classification
SLAP Tear
- Type I: degenerative lesion, fraying of the labrum
- Type II: Labrum, long head of biceps torn
- Type III: Bucket handle detachment of superior aspect
- Type IV: Type III lesion extending into the biceps brachii
- Type V: Type II tear with anterior shoulder instability
- Type VI: Large labral flap without detachment of biceps
- Type VII: Type II tear with affected middle, inferior glenohumeral ligament tear
- Type VIII: Type II tear involving cartilage adjacent to biceps footplate
Management
Nonoperative
- Posterior
- First line treatment
- Activity Modification
- NSAIDS
- Physical Therapy
- SLAP
- First line treatment
- Address GIRD if present, stretch posterior capsule
- Activity Modification
- NSAIDS
- Physical Therapy
- Similar outcomes to surgical management for pain, function and QOL. However, return to overhead sports was inferior[10]
Operative
- Posterior
- Indications: Failure of conservative management
- Technique: Posterior labral repair, capsulorrphaphy
- SLAP
- Indications: Failure of conservative management
- Technique: arthroscopic debridement, possible repair of labrum, biceps tenotomy or tenodesis
Rehab and Return to Play
Rehabilitation
- SLAP Lesion[11]
- Weeks 1-4: passive and active flexion, avoid extremes of motion and biceps exercises
- Weeks 4-6: progress to active ROM, isometric resistance training
- Week 6-12: Functional exercise, light strength training
- Weeks 12+: Advance strength and ROM, sport specific activities
Return to Play
- SLAP: Typically around 6 months
Complications
- Axillary Nerve Palsy
- Overtightenting of the capsule
- Stiffness
- Inability to return to same level of competition
- Suprascapular Nerve Injury
- Failed repair with persistant symptoms
See Also
- Internal
- External
- Sports Medicine Review Shoulder Pain: https://www.sportsmedreview.com/by-joint/shoulder/
References
- ↑ Bisson LJ. Thermal capsulorrhaphy for isolated posterior instability of the glenohumeral joint without labral detachment. Am J Sports Med. 2005;33:1898–904.
- ↑ Snyder, Stephen J., et al. "SLAP lesions of the shoulder." Arthroscopy 6.4 (1990): 274-279.
- ↑ Halder AM, Kuhl SG, Zobitz ME, et al. Effects of the glenoid labrum and glenohumeral abduction on stability of the shoulder joint through concavity-compression: an in vitro study. J Bone Joint Surg Am 2001;83:1062–9.
- ↑ Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. J Bone Joint Surg Am 2003;85-A:66–71.
- ↑ Irion V, Cheah M, Jones GL, Bishop JY. The isolated inferior glenohumeral labrum injury, anterior to posterior (the ILAP): A case series. Int J Shoulder Surg. 2015;9(1):13–19. doi:10.4103/0973-6042.150218
- ↑ Moon, Chang-Yun, Jong-Hun Ji, and Sung-Jae Kim. "Multidirectional instability accompanying an inferior labral cyst." Clinics in orthopedic surgery 2.2 (2010): 121-124.
- ↑ Murakami, Akira M., et al. "The epidemiology of MRI detected shoulder injuries in athletes participating in the Rio de Janeiro 2016 Summer Olympics." BMC musculoskeletal disorders 19.1 (2018): 1-7.
- ↑ Chloros, George D., et al. "Imaging of glenoid labrum lesions." Clinics in sports medicine 32.3 (2013): 361-390.
- ↑ Major, Nancy M., et al. "Evaluation of the glenoid labrum with 3-T MRI: is intraarticular contrast necessary?." American Journal of Roentgenology 196.5 (2011): 1139-1144.
- ↑ Edwards, Sara L., et al. "Nonoperative treatment of superior labrum anterior posterior tears: improvements in pain, function, and quality of life." The American journal of sports medicine 38.7 (2010): 1456-1461.
- ↑ https://www.orthobullets.com/shoulder-and-elbow/3053/slap-lesion
Created by:
John Kiel on 11 March 2020 13:19:45
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Last edited:
4 October 2022 12:01:47
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