Review Question - QID 216802

The patient is presenting with a posterior labral tear. Following operative management, the repair can be compromised with excessive shoulder flexion, adduction, and internal rotation and should be minimized or avoided in the immediate postoperative period.

Posterior labral tears often manifest as insidious onset shoulder pain and lead to posterior shoulder instability. The classic manifestation is shoulder pain that is reproduced with shoulder flexion, adduction, and internal rotation with axial load. This is often seen in football offensive linemen and weightlifters who bench press heavy weight. Surgical treatment includes arthroscopic or open labral repair. Following operative management, excessive shoulder flexion, adduction, and internal rotation can damage the labral repair and should be avoided in the immediate post-operative period.

Millett et al. reviewed the diagnosis and treatment of recurrent posterior dislocations. The authors stated nonoperative treatment is often effective, but surgical intervention targeting the salient aspects of instability may be required in refractory cases. They concluded arthroscopic repair of the caspsulolabral pathology to be the preferred treatment for surgical cases.

Hawkins et al. evaluated glenohumeral joint translation in anesthetized patients. They reported patients with anterior instability demonstrated 29% anterior translation, 21% posterior translation, and 49% inferior translation compared to 17%, 26%, and 29% translation for normal shoulders, respectively. The authors concluded clinically assessing the position of the humeral head relative to the glenoid rim is the most practical method for determining humeral head translation.

Kido et al. performed a cadaveric study determining the role of the deltoid on dynamic shoulder stability. They reported muscle contraction of the three heads of the deltoid significantly reduced glenohumeral translation in anterior capsule vented and Bankart lesion models. The authors concluded the deltoid muscle acts as a dynamic stabilizer of the glenohumeral joint with the shoulder in abduction and external rotation.

Lee and An performed a biomechanical study of the dynamic stability of the glenohumeral joint offered by the deltoid muscle. They reported the middle and posterior heads of the deltoid provide the greatest compressive forces and fewer shear forces than the anterior head. They concluded repair of the glenoid labrum functions to enhance the compressive forces generated by the deltoid.

Figure A is an axial T2 MRI of the left shoulder with a posterior labral tear.

Incorrect answers
Answer 1: Biceps tenodesis performed for SLAP tears or biceps tendonitis would incorporate a period of no active elbow motion in the postoperative protocol.
Answer 3: Repair of anterior labral tears and HAGL lesions can be disrupted with shoulder abduction and external rotation.
Answer 4: Range of motion as tolerated without restrictions can potentially place the patient in an injurious position with respect to the repair.
Answer 5: Passive shoulder range of motion for a minimum of 6 weeks is the typical postoperative protocol for rotator cuff repairs.