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Introduction
  • Definition
    • commonly referred to as a reverse Bankart lesion, or attenuation of the posterior capsulolabral complex
  • Epidemiology
    • athletes
      • weightlifters (bench press)
      • football linemen (blocking)
      • swimmers
      • gymnasts
  • 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
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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(OBQ12.268) 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? Review Topic

QID: 4628
FIGURES:
1

Pectoralis major rupture

25%

(657/2660)

2

Supraspinatus partial thickness tear

1%

(36/2660)

3

SLAP lesion

9%

(231/2660)

4

Tendonitis of the long head of the biceps

2%

(53/2660)

5

Posterior labral tear

63%

(1671/2660)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ11.152) 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? Review Topic

QID: 3575
FIGURES:
1

Radial

1%

(12/2381)

2

Upper subscapular

0%

(4/2381)

3

Lower subscapular

1%

(28/2381)

4

Suprascapular

1%

(13/2381)

5

Axillary

97%

(2315/2381)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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