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A 27-year-old male bodybuilder presents to the office with vague, deep shoulder pain and weakness with his bench press. His examination is somewhat difficult due to his large size, but no significant abnormal findings are noted. Radiographs are normal, and an MRI arthrogram is shown in Figure A. Which of the following is the most likely etiology of his complaints?
Pectoralis major rupture
Supraspinatus partial thickness tear
Tendonitis of the long head of the biceps
Posterior labral tear
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The clinical presentation and MRI are consistent with a Posterior labral tear.
Posterior labral tears are commonly seen in individuals that have repeated posteriorly-directed stress across their glenohumeral joint (football linemen, bodybuilders). These patients will often present with ill-described pain deep in their shoulder joint, along with decreases in shoulder strength. Focused shoulder examinations, such as the Jahnke Jerk Test or Push-pull test, can elicit pain from posterior labral tears; however, the sensitivity and specificity of these tests remain under question.
Mair et al. reviewed the outcome of posterior labral injuries in nine athletes who underwent arthroscopic repair with a bioabsorbable tack after failure of conservative management; all were able to return to contact sports. They note that posteriorly applied forces can result in a shear-type vector that can cause posterior labral tears without capsular injury.
Bradley et al. reviewed 91 athletes with unidirectional recurrent posterior shoulder instability that were treated with an arthroscopic posterior capsulolabral reconstruction. They found that significant improvements in stability, pain, and function at a mean of 27 months postoperatively. Eighty-nine percent of the patients were able to return to their sport.
Figure A shows an axial MRI arthrogram of the shoulder with a posterior labral tear and an associated paralabral cyst. Illustration A is another axial shoulder MRI arthrogram cut showing a posterior labral tear (red arrow) and an associated paralabral cyst (yellow arrows).
Answer 1-4: The MRI does not show evidence of injury to his pectoralis major, supraspinatus tendon, superior labrum, or long head of his biceps.
Mair SD, Zarzour RH, Speer KP.
Am J Sports Med. 1998 Nov-Dec;26(6):753-8. PMID: 9850774 (Link to Abstract)
Bradley JP, Baker CL, Kline AJ, Armfield DR, Chhabra A
Am J Sports Med. 2006 Jul;34(7):1061-71. PMID: 16567458 (Link to Abstract)
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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. Which of the following nerves was most likely injured during the procedure?
The posterior branch of the axillary nerve travels within 1mm of the inferior capsule of the glenohumeral joint and can be injured with suture passing devices during posterior-inferior labral repairs. The superior-lateral brachial cutaneous nerve and the nerve to the teres minor always arise from the posterior branch. Injury can lead to teres minor weakness on external rotation and sensory symptoms in the lateral arm in the region marked by yellow in Figure B.
Figure A shows an axial image of the shoulder with a posterior-inferior labral tear off of the glenoid with a small fragment of bone.
Ball et al traced the course of the axillary nerve in cadaveric shoulders and noted that the posterior branch of the axillary nerve has an intimate association with the inferior aspects of the glenoid and shoulder joint capsule, which may place it at particular risk during capsular plication or thermal shrinkage procedures.
Esmail et al used intraoperative nerve monitoring to identify axillary nerve position, capsule thickness, and provide real-time identification of impending nerve injury and function during shoulder thermal capsulorrhaphy. The use of intraoperative nerve monitoring altered the heat application technique in 4 of 11 patients and may have prevented nerve injury.
Illustration A shows the sensory distribution of the axillary nerve. Illustration B shows an arthroscopic image (viewing from anterior while in the lateral decubitus position) following repair of this posterior-inferior labral tear.
Ball CM, Steger T, Galatz LM, Yamaguchi K
J Bone Joint Surg Am. 2003 Aug;85-A(8):1497-501. PMID: 12925629 (Link to Abstract)
Esmail AN, Getz CL, Schwartz DM, Wierzbowski L, Ramsey ML, Williams GR
Arthroscopy. 2005 Jun;21(6):665-71. PMID: 15944620 (Link to Abstract)
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HPI - 32 yr old male with hx of "shoulder dislocation" when in high school during football. Not aware if posterior or anterior. Was scheduled to have surgery back then but choose not to. Did well for many years but recently started to develop locking and catching and occational shoulder pains, otherwise very functional.
Options for this patient?
Arthroscopic video demonstrating probing a Kim lesion. Kim lesions are an incom...
Arthroscopic shoulder posterior labral repair for instability