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Glenoid Labrum Lesions

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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

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


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


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
  • Posterior
    • Weightlifting (bench press)
    • Football lineman (blocking)
    • Swimmers, gymnasts, wrestlers
  • SLAP
    • Glenohumeral Internal Rotation Deficit

Differential Diagnosis


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
    • Kim Test: Arm abducted to 90°, apply axial load and elevate arm cranial and anterior
    • Jerk Test: Arm abducted to 90°, internally rotated with axial load and arm is abducted anteriorly in same plane
  • SLAP Lesion (not specific)
  • Inferior
    • Sulcus Sign: Place axial traction on affected limb with arm resting at side
  • Posterior
  • 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
  • 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


See Also


References


  1. Bisson LJ. Thermal capsulorrhaphy for isolated posterior instability of the glenohumeral joint without labral detachment. Am J Sports Med. 2005;33:1898–904.
  2. Snyder, Stephen J., et al. "SLAP lesions of the shoulder." Arthroscopy 6.4 (1990): 274-279.
  3. 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.
  4. 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.
  5. 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
  6. 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.
  7. 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.
  8. Chloros, George D., et al. "Imaging of glenoid labrum lesions." Clinics in sports medicine 32.3 (2013): 361-390.
  9. 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.
  10. 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.
  11. https://www.orthobullets.com/shoulder-and-elbow/3053/slap-lesion
Created by:
John Kiel on 11 March 2020 13:19:45
Authors:
Last edited:
13 April 2022 11:07:45
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