Shoulder: Instability

1
Michael J. Tuite and Christian W. A. Pfirrmann

Glenohumeral instability may be unidirectional (anterior

Learning Objectives instability or posterior instability) or multidirectional.
• To know the types of glenohumeral instability and Multidirectional instability is affecting a minority of patients.
anatomic factors for the development of glenohu- The classification in traumatic instability and atraumatic
meral instability. instability is important from an imaging perspective. Both
• To understand the concept of the glenoid track and instabilities are characterized by recurrent dislocations of the
the engaging Hill-Sachs lesion. glenohumeral joint. However, in traumatic instabilities,
• To understand the MR appearance of SLAP tears, structural changes such as labral, ligamentous, and bony
overhead thrower labral tears, and the labral tears lesions are highly prevalent. In atraumatic instabilities the
associated with spinoglenoid notch cysts. glenohumeral joint may not exhibit any injuries [2].
• To understand how to distinguish labral tears from
normal labral variants.
Key Point
• In atraumatic instabilities the glenohumeral joint
1.1 Glenohumeral Instability may be normal at imaging.

Glenohumeral instability is the inability to keep the humeral

head centered in the glenoid fossa. Glenohumeral instability can
The labrum, the ligaments, and the bony structures con-
be classified according to etiology and direction of instability.
tribute to the stability of the glenohumeral joint. Usually, the
Glenohumeral instability can be classified into static insta-
labrum receives the highest attention at imaging. However,
bilities, dynamic instabilities, and voluntary dislocation [1].
the glenoid labrum only contributes about 10% to the stabil-
Static instability is associated with significant structural
ity glenohumeral joint. Therefore, it is important to also
alteration of the shoulder, for example, large rotator cuff
include the glenohumeral ligaments and the bony structures
tears or a glenoid dysplasia with consecutive static decenter-
into a comprehensive imaging assessment.
ing of the humeral head.
Dynamic instability is the classic form of instability, com-
monly caused by trauma, and is usually associated with inju-
1.2 Anterior Instability
ries to the labrum, to the glenohumeral ligaments, and often
with fractures of the glenoid rim. Dynamic instability may
1.2.1 Labral Lesions in Anterior Instability
also be associated with general hyperlaxity.
Bankart lesion: The “Bankart lesion” was described by A. S.
Blundell Bankart in the British Medical Journal in 1923 [3].
M. J. Tuite (*)
Department of Radiology, University of Wisconsin, The Bankart lesion consists of a tear of the anteroinferior
Madison, WI, USA labrum. The labrum and the periosteum are completely
e-mail: [email protected] detached. Therefore, the labrum seems to float distant to the
C. W. A. Pfirrmann glenoid rim when viewed at arthroscopy or on transverse
MRI—Medical Radiological Institute, Zurich, Zurich, Switzerland MRI sections (Fig. 1.1).
e-mail: [email protected]

© The Author(s) 2021 1

J. Hodler et al. (eds.), Musculoskeletal Diseases 2021–2024, IDKD Springer Series,
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2 M. J. Tuite and C. W. A. Pfirrmann

Fig. 1.1 Bankart lesion Fig. 1.3 ALPSA lesion

Axial fluid sensitive fat-saturated MR arthrography image shows a Axial fluid sensitive fat-saturated MR arthrography image shows an
Bankart lesion (red arrow) consisting of a tear of the antero-inferior ALPSA lesion (red arrow). The detached labrum is medially displaced
labrum. The labrum and the periosteum are completely detached. and scarred to the glenoid neck
Therefore, the labrum seems to float distant to the glenoid rim

Fig. 1.4 GLAD lesion

Fig. 1.2 Perthes lesion Axial fluid sensitive fat-saturated MR arthrography image shows a
Axial fluid sensitive fat-saturated MR arthrography image shows the GLAD lesion. A portion of the anterior inferior glenoid articular carti-
anteroinferior labrum (red arrow) detached from the edge of the glenoid lage is avulsed associated with a partial labral tear. The labrum is not
but still attached to the intact periosteum detached or dislocated

Perthes lesion: The Perthes lesion was described some GLAD lesion: GLAD stands for “glenolabral articular
years earlier than the Bankart lesion in 1906 [4]. The antero- disruption” and was also described by Neviaser in 1993 [6].
inferior labrum is detached from the edge of the glenoid but The GLAD lesion consists of an anteroinferior glenoid artic-
still attached to the intact periosteum. Often the labrum may ular cartilage injury associated with a partial labral tear. The
be almost normally positioned at imaging. However, func- labrum is not detached or dislocated. Patients with GLAD
tionally the labrum no longer adds to the stability glenohu- lesions usually have a stable glenohumeral joint and present
meral joint (Fig. 1.2). with anterior shoulder pain (Fig. 1.4).
ALPSA lesion: In 1993 Neviaser [5] described the anterior
labro-ligamentous periosteal sleeve avulsion (ALPSA)
lesion as a cause for anterior instability of the shoulder. In 1.2.2 Ligament Lesions in Anterior Instability
the ALPSA lesion, the periosteum between the labrum and
glenoid remains intact. The detached labrum displaces medi- One of the most important stabilizers for the glenohumeral
ally and inferiorly. The labrum and the periosteum heal on joint is the inferior glenohumeral ligament (IGHL). The
the scapular neck (Fig. 1.3). IGHL connects the glenoid to the humerus and has the shape
1 Shoulder: Instability 3

of a hammock with a strong anterior and posterior bundle. Therefore, the size, location, and relation to the glenoid need
Two distinct patterns of the attachment of the IGHL to the to be addressed.
glenoid are described [7]. In most joints (80%) the IGHL Some types of Hill-Sachs are at risk for an engaging
attaches directly to the labrum with some fibers extending lesion and need to be treated: risk factors are a large and wide
onto the glenoid neck. Less commonly (20%) the IGHL Hill-Sachs lesion, a medially located Hill-Sachs lesion, or a
attaches only to the glenoid neck. Therefore, a detachment of Hill-Sachs lesion with an oblique orientation on neutral posi-
the glenoid labrum is a detachment of the IGHL in most tion of the humerus. Cases with an engaging Hill-Sachs
cases. Most frequently the failure of the IGHL is on the gle- lesion present with a large bony defect of the glenoid at the
noid side. Failure on the humeral side is termed “humeral same time (bipolar lesion).
avulsion of glenohumeral ligament” or HAGL lesion. HAGL
lesions may be difficult to be diagnosed at arthroscopy. The 1.2.3.3 G lenoid Track Theory, On-Track and
J sign (the axillary recess is normally U-shaped—conversion Off-­Track Lesions
to a J shape is called the J sign) and axillary fluid extravasa- In the abduction and external rotation (ABER) position of
tion at MR arthrography are suggestive of a HAGL lesion. the shoulder, patients with glenohumeral instability experi-
However, a false-positive diagnosis of HAGL lesions is not ence subluxation and apprehension. Apprehension is the fear
uncommon at MRI [8]. Fluid extravasation at MR arthrogra- of imminent dislocation of a patient anterior instability with
phy may occur with an intact IGHL or also in a mid-­substance when placing the arm in an ABER position.
tear of the IGHL. The “glenoid track” is the contact area of the glenoid sur-
face onto the posterosuperior humeral head in the ABER
position (Fig. 1.5).
Key Point The contact area between the glenoid and the humeral
• The inferior glenohumeral ligament attaches directly head, e.g., the “glenoid track,” measures approximately 84%
to the labrum in most joints. Therefore, a detach- of the glenoid transverse diameter, whereas reminder of gle-
ment of the glenoid labrum is a detachment of the noid (16%) contacts with the medial margin of the rotator
IGHL in most cases. cuff footprint [10].

• On-track: Hill-Sachs lesion remains within the glenoid

track.
1.2.3 Bony Lesions in Anterior Instability • Off-track: Hill-Sachs lesion extends past the glenoid track
medially and is therefore at risk for engaging.
1.2.3.1 Glenoid
A bony defect of the glenoid rim is probably the most impor-
tant factor for the development of an unstable glenohumeral Key Point
joint. Bony defects of the glenoid that are more than half of • Reasons for the “off-track” lesion are a large Hill-­
the maximal AP diameter of the glenoid in length lead to a Sachs lesion, a medially located Hill-Sachs lesion,
significant loss of dislocation resistance. This may not be and/or a bony defect of the glenoid rim.
compensated for by a Bankart repair or labral reconstruction
alone. A bony procedure such as a Latarjet procedure or bone
grafting procedure to augment the anterior glenoid rim is
often necessary. 1.3 Posterior Instability
A bony defect can be congenital, can be a result of a gle-
noid rim fracture, or can be the result of the chronic instabil- 1.3.1 Labral Lesions in Posterior Instability
ity. Repetitive anterior subluxations of the humeral head lead
to glenoid bone loss without the presence of a fragment at the Posterior instability of the glenohumeral joint is common in
glenoid rim. young active patients. Posterior instability of the glenohumeral
joint is most prevalent in young men, for example, the military
1.2.3.2 Humerus population. Posterior instability of the glenohumeral joint is
In 1940 Harold A. Hill and Maurice D. Sachs described the often caused by repetitive microtrauma. Repetitive pushups,
grooved defect of the humeral head in the journal Radiology. pullups, or heavy weightlifting (bench press) may promote
The presence of a Hill-Sachs lesion confirms the diagnosis of posterior instability of the glenohumeral joint. Also, in swim-
anterior instability of the glenohumeral joint. The prevalence ming and golf which puts stress on the posterior capsule, pos-
of Hill-Sachs lesion that needs to be treated is about 7% [9]. terior instability of the glenohumeral joint may be seen.
4 M. J. Tuite and C. W. A. Pfirrmann

Fig. 1.5 Glenoid track theory, on-track situation, and off-track situation lesion extends past glenoid track medially, and the Hill-Sachs lesion
The “glenoid track” is the contact area of the glenoid surface onto is engaging (c). Off-track situation: the bony defect of the glenoid
the humeral head in the ABER position (a). On-track situation: the rim narrows the glenoid track humeral head. Hill-Sachs lesion
Hill-­Sachs lesion remains within the glenoid track, and the Hill- extends past glenoid track medially, and the Hill-Sachs lesion is
Sachs lesion is not engaging (b). Off-track situation: the Hill-Sachs engaging (d)

Key Points
Anatomic risk factors for posterior instability of the
glenohumeral joint include:

• Increased glenoid retroversion.

• Increased humeral head retroversion.
• Posterior glenoid dysplasia (brachial plexus birth
palsy).

The Kim lesion, named after the author who first described
this lesion, represents a posteroinferior labrum avulsion [11].
Often the labral lesion is concealed. Adjacent a marginal
chondrolabral junction, lesion caused by repetitive posterior Fig. 1.6 Kim’s lesion
subluxations of the humeral head is observed (Fig. 1.6). Axial fluid sensitive fat-saturated MR arthrography image shows a pos-
Kim’s triad includes: teroinferior labrum avulsion lesion (red arrow)

• Concealed posteroinferior labral tear. copy of 5–38% [12]. Although SLAP tears are often painful,
• Marginal chondral lesion. smaller tears can be asymptomatic and identified inciden-
• Retroversion of the glenoid. tally at surgery or on a shoulder MR scan done for other
reasons. SLAP tears can occur acutely after a fall on an out-
stretched hand or from either acute or repetitive biceps trac-
1.4 Labral Tears Without Overt Instability tion on the superior labrum. The SLAP tears in overhead
throwing athletes will be discussed further in the next section
1.4.1  uperior Labrum Anterior-Posterior
S on Overhead Thrower Injuries.
(SLAP) Tears SLAP tears can have a variety of tear orientations, so are
often subdivided into several types. A type 1 SLAP tear refers to
SLAP tears are superior labral tears that occur in the region a frayed free edge of the superior labrum and is a common find-
of the biceps anchor. SLAP tears are one of the more com- ing in older individuals. Type 1 SLAP tears are usually degen-
mon tears of the glenoid labrum, with a prevalence at arthros- erative or from overuse and may be minimal or asymptomatic.
1 Shoulder: Instability 5

The higher-type SLAP tears are longitudinal tears of the ear increased signal being irregular, extending across the
superior labrum, and these tears may require surgery to alle- entire labrum on an oblique coronal image, curving later-
viate symptoms. The most common higher-type SLAP tear is ally, there being two increased signal lines (a recess that is
a type 2 SLAP tear, which is a partial-thickness longitudinal more medial, and the tear which is located more laterally,
tear of the superior labrum. These tears can have either a also called the “double oreo” sign), or signal width > 2 mm
stable or unstable biceps anchor depending on their size and on MR or 3 mm at MR arthrography. High signal at the
specific site of involvement. Distinguishing a stable from an labral-chondral junction posterior to the biceps anchor has
unstable type 2 SLAP tear can be difficult on MR images, been proposed as a possible MR sign of a SLAP tear; how-
but in general larger tears at the base of the labrum that ever several studies have found that at MR arthrography a
weaken the biceps anchor are more unstable. normal superior recess can extend posterior to the biceps in
The anterior to posterior length of type 2 SLAP tears var- up to 90% of individuals.
ies in different individuals. Some have subcategorized type 2
SLAP tears as 2A (anterosuperior), 2B (posterosuperior), or
2C (involving the entire superior labrum from anterior to
Key Point
posterior). The posterosuperior type 2B SLAP tears are
• For SLAP tears the linear increased signal usually
sometimes seen in overhead throwing athletes and in patients
curves laterally, in distinction from a normal labral
with a spinoglenoid notch paralabral cyst, both discussed in
variant superior sublabral recess which curves
a later section.
medially.
A type 3 SLAP tear is a full-thickness tear resulting in a
bucket handle torn labral segment. Type 3 SLAP tears tend to
have a stable biceps anchor. A type 4 SLAP tear extends into
the biceps tendon. There are currently some 12 types of 1.4.2 Overhead Thrower Labrocapsular
SLAP tears described, and the type 5 and above tears mainly Injuries
involve extension to other parts of the labrum or adjacent
structures. Overhead throwing athletes can develop an overuse injury
SLAP tears appear on MR images as linear increased sig- of the shoulder that includes a superior labral tear. There are
nal extending to an articular surface of the labrum between two related etiologies that have been described for why
the 11:00 and 1:00 position of the glenoid rim [13] (Fig. 1.7). labral tears occur in these athletes, glenohumeral internal
Because some patients have a superior recess normal variant rotation deficit (GIRD) and internal impingement. GIRD
in this region of the labrum, there are several MR signs that results from thickening and fibrosis of the posterior band
have been proposed to help distinguish a SLAP tear from a inferior glenohumeral ligament and capsule and results
normal recess. The findings of a SLAP tear include the lin- from repetitive traction during the deceleration phase of

Fig. 1.7 Superior labrum

anterior–posterior (SLAP)
tear
Two consecutive oblique coronal
fat-suppressed T2-weighted
images show irregular, laterally
curving high signal (arrow) in the
superior labrum
6 M. J. Tuite and C. W. A. Pfirrmann

throwing. Internal impingement presents as pain in the late tears can be small, they are often better seen on MR arthrog-
cocking phase of throwing with decreased throwing veloc- raphy with abduction and external rotation (ABER) images.
ity. Internal impingement is felt to be a shoulder microinsta- There are several other lesions of the labrocapsular com-
bility condition due to a posterosuperior shift of the humeral plex that can be seen in throwing athletes. Patients with
head contact point with the glenoid due to GIRD, a stretched GIRD can have focal thickening of the posterior band infe-
anterior capsule, and muscle fatigue that allows increased rior glenohumeral ligament near the labral insertion, with
contact of the under surface of the rotator cuff with the pos- loss of the normal labrocapsular recess in this region. These
terosuperior labrum [14]. athletes can also have an exostosis in this region, the Bennett
There are two main mechanisms that are believed to lead lesion, which is felt to result from repetitive traction leading
to labral injury in patients with GIRD and internal impinge- to ossification of the posterior band inferior glenohumeral
ment. The first is repetitive forceful contact between the ligament at the glenoid insertion. Throwers often develop a
greater tuberosity and the posterosuperior glenoid rim during chronically stretched anterior capsule which allows the
abduction and external rotation, which causes fraying or increased external rotation in the late cocking phase of the
tears of the posterosuperior labrum. The other is longitudinal throwing motion that is associated with increased throwing
twisting of the long head biceps tendon at full external rota- velocity, although this can be difficult to diagnose on MR
tion of the humerus, which twists the biceps anchor resulting images. They can also develop tears of the anterior capsule
in a “peel-back” SLAP tear. The biceps muscle also contracts due to tensile overload; these tears are more common in
late in the throwing motion during deceleration so as to slow older overhead throwing athletes where the capsule has
the extension of the elbow, and this applies repetitive traction become less pliable.
forces on the superior labrum and may exacerbate tears. There are several additional findings in the shoulder asso-
The posterosuperior labral tears with internal impinge- ciated with internal impingement. The most important is an
ment appear similar on MR to SLAP tears from other mecha- articular surface partial thickness cuff tear of the posterior
nisms. Overhead throwers can develop free edge fraying in supraspinatus or anterior infraspinatus tendon (Fig. 1.8).
the posterosuperior labrum, which other than their distinc- Another common finding in throwers is prominent posterior
tive posterosuperior location appear similar to other type 1 humeral head cysts. These have been sometimes called a
SLAP tears on MR with blunting and irregularity of the free “pseudo Hill-Sachs” lesion, but they occur more posterior
edge. The other common SLAP tear in overhead throwers is than a true posterolateral Hill-Sachs lesion. A partial tear of
a type 2B SLAP tear which will appear as irregular laterally the inferior subscapularis muscle-tendon junction has also
curved high signal (Fig. 1.8). Other throwers may have a been described in throwing athletes.
smaller focal tear of the posterosuperior labrum that does not
extend to the 12:00 position of the glenoid. Because these
1.4.3  pinoglenoid Notch Cyst
S
and Posterosuperior Labral Tear

Shoulder paralabral cysts are pseudocysts that result from a

labrocapsular tear that allows joint fluid to extravasate into
the paralabral soft tissues. Paralabral cysts can occur at any
point around the glenoid rim, but are most common adjacent
to the posterosuperior region of the glenoid rim. The postero-
superior location is common because cysts can form here
easily in the fat plane between the supraspinatus and infra-
spinatus muscles lateral to the scapular spine, an area known
as the spinoglenoid notch.
The labral tears associated with spinoglenoid notch para-
labral cysts can be type 2B SLAP tears (superior labral tears
that extend posteriorly) or focal posterosuperior labral tears.
Focal tears in the posterosuperior labrum can occur after
acute trauma such as a fall on an outstretched hand or from
repetitive trauma. Labral tears in this region are not uncom-
Fig. 1.8 Overhead thrower labral tear mon in overhead throwers, but most are not associated with
Oblique coronal fat-suppressed T1-weighted MR arthrogram image in a paralabral cyst in this group of athletes.
a 21-year-old baseball pitcher who has pain with throwing shows a tear
of the posterosuperior labrum (arrows). There is also an articular sur- Spinoglenoid notch paralabral cysts are symptomatic
face partial thickness rotator cuff tear (arrowhead) because they often compress the suprascapular nerve, which
1 Shoulder: Instability 7

symptoms are usually external rotation weakness from

a
denervation of the infraspinatus muscle; large cysts that
extend superiorly into the suprascapular notch can also
involve the motor branch to the supraspinatus muscle caus-
ing arm abduction weakness.
On MR, paralabral cysts appear as a well-defined T2
high signal mass medial and adjacent to the posterosupe-
rior labrum (Fig. 1.9) [15, 16]. On MR arthrography, there
is variable filling of the cyst with intraarticular contrast.
Although 85% of cysts are associated with a labral tear, the
tear often partially heals so that fluid in the glenohumeral
joint and the paralabral cyst may not have a bidirectional
communication.
The infraspinatus muscle may appear normal on MR even
if the patient is experiencing pain, possibly due to nerve
impingement affecting the sensory fibers more than the
motor fibers. Other spinoglenoid notch cysts will have asso-
ciated increased T2 signal in the infraspinatus muscle,
termed denervation edema. If the cyst is left untreated, the
patient may develop fat replacement and atrophy of the mus-
b cle. If a cyst is large and extends up to the suprascapular
notch region, there may also be T2 high signal in the supra-
spinatus muscle. Again, if the cyst is long-standing, there
may be fat replacement atrophy of both the infraspinatus and
supraspinatus muscles.

1.5 Normal Labral Variants

One of the difficulties with accurately diagnosing labral tears

on MR imaging is the normal labral variants, which can
sometimes appear similar to tears. The most common loca-
tion for the labral variants is from 11:00 posterosuperiorly to
the 3:00 anteriorly on the glenoid rim. The labral variants are
mainly sections of the labrum that are partially or completely
unattached to the glenoid rim.
The most common labral variant is a superior sublabral
recess, which is a partially unattached superior labrum
between 11:00 and 1:00 that is seen in 74% of people [17].
Fig. 1.9 Spinoglenoid notch cyst
The recess formed by the partially unattached superior
(a) Oblique sagittal T1-weighted and (b) oblique sagittal fat-suppressed labrum occurs at the articular surface of the labral-chondral
T2-weighted images show a paralabral cyst in the spinoglenoid notch junction; the peripheral superomedial margin of the superior
(arrows) and denervation edema (arrowheads) within the caudal portion labrum remains adherent to the glenoid rim. Some have clas-
of the infraspinatus muscle
sified the attachment of the superior labrum to the glenoid
rim into one of three “biceps-labral complexes”: type 1
courses through the fat plane between the supraspinatus and (entire medial base of the labrum adherent to the glenoid
infraspinatus muscles. The suprascapular nerve contains sen- rim), type 2 (superior recess ≤2 mm), or type 3 (superior
sory fibers that supply the posterior joint capsule and acro- recess >2 mm) [18]. On MR images, a superior sublabral
mioclavicular joint and motor fibers that innervate the recess will appear as smooth medially curving linear high
infraspinatus and supraspinatus muscles. The most common signal at the labral-chondral junction which does not extend
presentation of a spinoglenoid notch paralabral cyst is pain, outward across the entire base of the labrum.
and half the patients who are symptomatic will have only The next most common location for labral variants is in
pain due to the sensory fibers being primarily affected. Motor the anterosuperior (1:00–3:00) labrum between the origins
8 M. J. Tuite and C. W. A. Pfirrmann

of the middle and inferior glenohumeral ligaments. There are

three labral variants that can occur in the anterosuperior a
labrum. One is a sublabral foramen, where the labrum is
focally unattached to the glenoid rim, and is present in
10–15% of individuals [19]. The second is a Buford complex
where the anterosuperior portion of the labrum is absent and
there is a thick, cord-like middle glenohumeral ligament, and
this is seen in 1–2% of individuals. The third is an anterosu-
perior sublabral recess where the labrum is only attached to
the glenoid rim at its outer margin, similar to a superior sub-
labral recess. There is an increased association of these
anterosuperior labral variants with the more common supe-
rior sublabral recess.
The sublabral foramen and anterosuperior recess will appear
on MR images as high signal between the labrum and glenoid
rim. The Buford complex appears on MR images as a segment
of the anterosuperior glenoid rim where no labrum is visible,
although the patient also has a thick middle glenohumeral liga-
ment which may lie against the glenoid rim and mimic the
unattached labrum of a sublabral foramen (Fig. 1.10).

b
Key Point
• On MR, increased signal between the labrum and
glenoid rim isolated to the anterosuperior labrum is
more likely to be a sublabral foramen normal vari-
ant than to be a tear.

Although less common than in the 11:00–3:00 region, a

shallow recess at the inner labral-chondral junction can also
occur at other regions around the glenoid rim [20]. These
smooth, less than 2 mm deep recesses should not be con-
fused with a labral tear.
There is controversy whether these labral variants are
congenital or developmental such as from prior post-­
traumatic detachment. For the superior recess, De Palma Fig. 1.10 Buford complex normal labral variant
found these recesses were more prevalent with increasing (a) Axial T1-weighted and (b) oblique sagittal fat-suppressed T2-weighted
images show an absent anterosuperior labrum (arrow) and a thick, cord-
age and therefore believed they were an acquired lesion pos- like middle glenohumeral ligament (arrowheads), known as a Buford
sibly from chronic repetitive traction [21]. Tena-Arregui complex
et al. found that a superior recess was not present in still-born
fetal specimens and came to the same conclusion but did osuperior labrum to insert directly onto the supraglenoid
observe that 10% of fetuses had a sublabral foramen, a simi- tubercle in some individuals. This pitfall should not be mis-
lar prevalence to adults [22]. It may be that some variants are taken for a biceps-labral junction tear.
congenital and others acquired. In any case, most believe that
a superior recess or an anterosuperior labral variant is an
incidental finding and if “repaired” at surgery will only 1.6 Concluding Remarks
worsen symptoms.
Finally, there is a finding on oblique coronal MR images MR is the best modality for imaging the glenoid labrum and
called a “pseudoSLAP,” where T2 high signal fluid is pres- instability, but even with high-quality images, accurately
ent between the long head biceps tendon and the anterior-­ diagnosing pathology can be challenging. Learning the var-
superior labrum on oblique coronal images. This occurs ied MR appearances of labral tears and injuries to the capsule
because the long head biceps tendon can pass over the anter- is important to help confirm the clinical findings and guide
1 Shoulder: Instability 9

presurgical planning. Recognizing labral tears above the 9. Kurokawa D, Yamamoto N, Nagamoto H, Omori Y, Tanaka M,
midpoint of the glenoid, and distinguishing them from the Sano H, Itoi E. The prevalence of a large Hill-Sachs lesion that
needs to be treated. J Shoulder Elb Surg. 2013;22(9):1285–9.
normal labral variants, is important in identifying several of 10. Gyftopoulos S, Yemin A, Beltran L, Babb J, Bencardino J. Engaging
the causes of shoulder pain. Hill-Sachs lesion: is there an association between this lesion and
findings on MRI? Am J Roentgenol. 2013;201(4):W633–8.
11. Kim SH, Ha KI, Yoo JC, Noh KC. Kim’s lesion: an incomplete
and concealed avulsion of the posteroinferior labrum in poste-
Take Home Messages rior or multidirectional posteroinferior instability of the shoulder.
• The classification in traumatic instability and atrau- Arthroscopy. 2004;20(7):712–20.
matic instability is very important because the 12. Mohana-Borges A, Chung C, Resnick D. Superior labral anteropos-
terior tear: classification and diagnosis on MRI and MR arthrogra-
examination in a patient with an atraumatic instabil-
phy. AJR. 2003;181:1449–62.
ity of the glenohumeral joint may be normal. 13. Symanski JS, Subhas N, Babb J, Nicholson J, Gyftopoulos
• All structures (labrum, ligament, bone) contributing S. Diagnosis of superior labrum anterior-to-posterior tears by using
to glenohumeral instability must be addressed. MR imaging and MR arthrography: a systematic review and meta-­
analysis. Radiology. 2017;285(1):101–13.
• The increased signal on MR seen in SLAP tears is
14. Lin DJ, Wong TT, Kazam JK. Shoulder injuries in the overhead-­
often irregular, directed cranially or curves laterally, throwing athlete: epidemiology, mechanisms of injury, and imaging
and extends into the superior labrum. findings. Radiology. 2018;286(2):370–87. https://doi.org/10.1148/
• The increased signal on MR of a normal variant radiol.2017170481.
15. Tung GA, Entzian D, Stern JB, et al. MR imaging and MR
superior sublabral recess is smooth, curves medi-
arthrography of paraglenoid labral cysts. Am J Roentgenol.
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