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Updated: Jun 5 2023

Posterior Labral Tear

  • summary
    • A posterior labral tear is referred to as a reverse Bankart lesion, or attenuation of the posterior capsulolabral complex, and commonly occurs due to repetitive microtrauma in athletes.  
    • Diagnosis can be made clinically with positive posterior labral provocative tests and confirmed with MRI studies of the shoulder. 
    • Treatment may be nonoperative or operative depending on chronicity of symptoms, degree of instability, and patient activity demands. 
  • Epidemiology
    • Demographics
      • athletes
        • weightlifters (bench press)
        • football linemen (blocking)
        • swimmers
        • gymnasts
        • wrestlers
  • Etiology
    • Pathophysiology
      • repetitive microtrauma to the posterior capsulolabral complex
        • most common mechanism
        • posteriorly directed force with the arm in a flexed, internally rotated and adducted position
      • glenoid retroversion
        • patients with increased glenoid retroversion (~17°) were 6x more likely to experience posterior instability compared to those with less glenoid retroversion (~7°)
    • Associated injuries
      • Kim lesion
        • an incomplete and sometimes concealed avulsion of posteroinferior labrum
  • Anatomy
    • Posterior labrum
      • function
        • helps generate cavity-compression effect of glenohumeral joint
        • creates 50% of the glenoid socket depth
        • provides posterior stability
      • anatomy
        • composed of fibrocartilagenous tissue
        • anchors posterior inferior glenohumeral ligament (PIGHL)
    • Glenohumeral joint anatomy
  • Presentation
    • Symptoms
      • vague, nonspecific posterior shoulder pain is the most common symptoms
        • worsens with provocative activities that apply a posteriorly directed force to the shoulder
          • ex: pushing heavy doors, bench press, push-ups
      • clicking or popping in the shoulder with range of motion
      • sense of instability
        • less common
      • pain during throwing
        • late cocking phase
    • Physical exam
      • posterior joint line tenderness
      • provocative tests
        • posterior apprehension test
          • arm positioned with shoulder forward flexed 90° and adducted
          • apply anterior support to scapula
          • apply posteriorly directed force to shoulder through humerus
          • positive if patient experiences sense of instability or pain
        • posterior load and shift test
          • patient rests arm at their side
          • grasp the proximal humerus and apply a posteriorly directed force
          • assess distance of translation and patient response
            • grade 0 = no translation
            • grade 1 = to edge of glenoid
            • grade 2 = over edge of glenoid but spontaneously relocates
            • grade 3 = over edge of glenoid, does not spontaneously relocate
        • jerk test
          • arm positioned with shoulder abducted 90° and fully internally rotated
          • axially load humerus while adducting the arm across the body
          • clunk indicates subluxation of the humeral head off the posterior glenoid
            • highly sensitive and specific for a posterior labral tear
        • kim test
          • arm positioned with shoulder abducted 90° and forward flexed 45°
          • apply posteriorly and inferiorly directed force to shoulder through humerus
          • positive if patient experiences pain
            • highly sensitive and specific for posteroinferior labral tear
  • Imaging
    • Radiographs
      • recommended views
        • true AP, scapular Y and axillary views
          • axillary view required to ensure glenohumeral joint reduction
            • posterior shoulder dislocations may be missed on AP radiographs alone
      • findings
        • often normal
        • in chronic cases axillary view may show
          • glenoid retroversion or
          • posterior glenoid erosion
    • MRI
      • indications
        • diagnostic study of choice
      • technique
        • intra-articular contrast increases sensitivity for labral pathology
  • Treatment
    • Nonoperative
      • activity modification, NSAIDs, PT
        • indications
          • first line of treatment
        • technique
          • rotator cuff and deltoid strengthening
          • periscapular stabilization
    • Operative
      • posterior labral repair, capsulorrhaphy
        • indications
          • extensive nonoperative management fails
        • technique
          • arthroscopic and open techniques may be used
            • arthroscopic preferred to open given the extensive posterior surgical dissection required
              • more reliable return to play
          • suture anchor repair and capsulorrhaphy results in fewer recurrences and revisions than non-anchored repairs
          • probing of posterior labrum is required to rule out a subtle Kim lesion
        • outcomes
          • generally good
          • 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
  • Complications
    • Axillary nerve palsy
      • 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
    • Overtightening of posterior capsule
      • can lead to anterior subluxation or coracoid impingement
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