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Figure B
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Figure C
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Figure D
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Figure E
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Figure F
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This patient's history and examination is suggestive of a posterior labral injury (Figure B). Posterior shoulder instability and dislocations are less common than anterior shoulder instability and dislocations but are much more commonly missed. Microtrauma (posterior instability) may lead to a labral tear, incomplete labral avulsion, or erosion of the posterior labrum. It may also lead to gradual stretching of the capsule and patulous posterior capsule. This type of posterior instability is common in lineman, weight lifters, and overhead athletes. Diagnosis is made radiographically in the setting of acute dislocations. Chronic or subtle instability can be diagnosed with the presence of positive posterior instability provocative tests and confirmed with MRI studies showing posterior labral pathology. Treatment may be nonoperative or operative depending on the chronicity of symptoms, recurrence of instability, and the severity of labrum and/or glenoid defects. Bradley et al. reviewed the different patterns of posterior shoulder instability. They reported that in the athletic population, recurrent posterior subluxations are far more common than recurrent or locked posterior dislocations. They concluded that conservative and operative management of posterior instability should be individualized to meet the demands of its diverse patient population, ranging from post-traumatic instability in contact athletes to recurrent posterior subluxations in overhead athletes. Provencher et al. reviewed the diagnosis and management of posterior instability. They reported that posterior instability is often difficult to diagnose as symptoms may be vague and patients may describe pain with a bench press, push-ups, or a decrease in athletic performance. They concluded that physical exam findings, such as the Jerk maneuver, can re-create the instability episode and may aid in the diagnosis. Figure A depicts the Kim test which is performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45 forward flexion while simultaneously applying axial load on the elbow & posterior-inferior force on the upper humerus. Figure C depicts a SLAP tear. Figure D depicts a Bankart lesion. Figure E depicts a subscapularis tear. Figure F depicts a supraspinatus tear and a SLAP tear. Illustration A is an MRI image showing the posterior labral tear. Illustration B depicts the Jerk maneuver for posterior shoulder instability. Incorrect Answers: Answer 2: A SLAP tear would be best evaluated with maneuvers such as biceps provocation tests (ie. Speed's test, Yergason's test, Kim biceps load test), active compression test (O'Brien's test), crank test, dynamic labral shear test, and Kibler anterior slide test Answer 3: A Bankart lesion would be best evaluated with maneuvers such as apprehension sign, relocation sign, and relocation sign Answer 4: A subscapularis tear would be best evaluated with maneuvers such as excessive passive ER, belly press, lift-off, and IR lag sign Answer 5: A supraspinatus tear would be best evaluated with maneuvers such as drop arm test, and pain with Jobe test
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