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Anterosuperior Labral Tear Without Biceps Anchor Involvement: A Subtle Isolated Cause of a Painful Shoulder
Anterosuperior Labral Tear Without Biceps Anchor Involvement: A Subtle Isolated Cause of a Painful Shoulder Raffaele Garofalo, M.D., Nicole Pouliart, M.D., Ph.D., Enzo Vinci, M.D., Giorgio Franceschi, M.D., Roberto Aldegheri, M.D., and Alessandro Castagna, M.D.
Purpose: The purposes of this study were to determine common clinical symptoms related to an anterosuperior labral tear without biceps anchor involvement and to establish the outcome of arthroscopic management of this injury. Methods: In our database of arthroscopic procedures we identified 23 patients with an isolated anterosuperior labral tear. The mean age at the time of surgery was 38.3 ⫾ 6.8 years (range, 18 to 59 years). The preoperative clinical diagnosis varied, but an anterosuperior labral isolated lesion was not detected before surgery. The diagnosis of anterosuperior labral tear was made arthroscopically, and the lesion was fixed with a suture anchor technique, by use of 1 single bioabsorbable anchor. Patients were reviewed after a minimum of 2.5 years of follow-up. Clinical outcome was evaluated with the Rowe score, American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale score. Results: History, clinical examination, and preoperative imaging usually failed to indicate the presence of an isolated anterosuperior labral tear as the cause of shoulder pain in our patients. Repair of the labral lesions yielded good to excellent results with normalization of the range of motion and a significant improvement in shoulder scores (Rowe, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale). Conclusions: Isolated tears of the anterosuperior labrum represent a subtle cause of shoulder pain and dysfunction. The lesion is very difficult to diagnose clinically. Arthroscopic repair is a reliable procedure providing a good outcome in terms of pain relief, patient satisfaction, and shoulder scores. Level of Evidence: Level IV, therapeutic case series.
S
ince its original description by Snyder et al.,1 the SLAP lesion or tear of the superior labrum of the glenohumeral joint has been well recognized as a cause of shoulder pain and dysfunction particularly with overhead activities, because the long head of the biceps becomes unstable in these positions.
From the Orthopedic Unit, F. Miulli Hospital, Acquaviva delle Fonti (R.G.), Bari, Italy; Department of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel (N.P.), Brussels, Belgium; Shoulder Unit, Humanitas Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (E.V., A.C.), Milan, Italy; and Orthopedic Unit, University of Padova (G.F., R.A.), Padova, Italy. The authors report no conflict of interest. Received November 29, 2009; accepted May 27, 2010. Address correspondence and reprint requests to Raffaele Garofalo, M.D., Via Padova 13, 70029 Santeramo in Colle, Bari, Italy. E-mail: [email protected] © 2011 by the Arthroscopy Association of North America 0749-8063/9712/$36.00 doi:10.1016/j.arthro.2010.05.022
A lesion of the anterosuperior labrum without involvement of the biceps anchor appears to be a more rare and probably under-recognized pathologic entity. Furthermore, the normal anatomic variations of the labrum in this area make the diagnosis very difficult. Pathology of the labral complex above the equator of the shoulder has been described as a degenerative lesion without glenohumeral joint instability,2 as a tear of the anterosuperior labrum associated with partial tearing of the supraspinatus tendon (SLAC lesion),3 or as a tear associated with posterior shoulder instability.4 The pathogenesis of these individual lesions may be different and is probably related to a combination of factors. Under-diagnosis may also be related to the fact that these lesions can often only be appreciated by complete and careful arthroscopic inspection and probing.5 Clinical symptoms and signs of this specific lesion are not well established, and this factor makes the preoperative diagnosis very difficult, especially
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 1 (January), 2011: pp 17-23
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when we realize that there often are associated lesions that can complicate and confound the clinical pattern. The purposes of this study were (1) to identify a common clinical pattern to improve the understanding of this lesion and (2) to evaluate the clinical outcome of a series of patients with an isolated anterosuperior labral tear without biceps anchor involvement treated with arthroscopic repair using a suture anchor technique. Our hypothesis was that an anterosuperior labral tear can be an isolated cause of shoulder pain and discomfort and that an arthroscopic repair can be expected to improve symptoms. METHODS All data—from patient history to clinical examination and from conservative treatment to surgery, as well as results from additional investigations and shoulder scores—for each patient who is seen in our clinic, from the first outpatient visit to the last follow-up visit, are recorded in a standardized way in a database. This includes the data for 3,252 patients who underwent an arthroscopic procedure at our institution between January 2004 and October 2007. Initially, the arthroscopic records in the database were scrupulously perused by 2 of the authors to identify all cases with involvement of the anterosuperior labrum. From these procedures, those that showed an anterosuperior labral tear were selected. Finally, the operative notes and recorded intraoperative videos of these patients were reviewed to exclude patients with associated lesions. This allowed us to identify only those patients who presented with isolated anterosuperior labral tears and in whom an isolated anterosuperior labral repair was done. We identified 23 patients with an isolated anterosuperior labral tear, which was diagnosed by inspection and probing. In these patients there were no signs of synovitis, other capsuloligamentous lesions, associated rotator cuff lesions, or lesions of the biceps tendon or pulley. A type II SLAP tear was excluded by showing that the biceps anchor could not be lifted to expose subchondral bone. Subacromial pathology was also excluded by a routine bursal examination. The flowchart in Fig 1 details the selection procedure. All 23 patients were successfully contacted and agreed to return for clinical follow-up at a minimum of 2.5 years after surgery. Data from the clinical history and preoperative clinical evaluation, as well as the intraoperative findings, including operative notes and videos of every procedure, were analyzed (Table 1).
FIGURE 1. biceps.)
Flowchart of case selection. (LHB, long head of
There were 11 male and 12 female patients. The mean age at the time of surgery was 38.3 ⫾ 6.8 years (range, 18 to 59 years). The injured shoulder was the dominant side in 15 cases. The mean duration of symptoms before presentation to our clinic was 3.5 ⫾ 4.5 months. Preoperative and postoperative evaluation consisted of a patient-based questionnaire and physical examination. Clinical assessment consisted of measurement of glenohumeral range of motion (ROM) with a goniometer, as well as shoulder-specific examination. The Rowe rating score,6 Simple Shoulder Test as originally as reported by Rockwood and Matsen,7 and American Shoulder and Elbow Surgeons score8 were assessed. Pain was recorded by use of a visual analog scale, where a score of 0 points indicates no pain and a score of 10 points indicates the worst possible pain. All patients underwent evaluation with preoperative radiographs (anteroposterior, axillary, and arch views) and magnetic resonance imaging by use of coronal and axial views with T1 and T2 fat suppression sequences that failed to show any specific lesion in all cases. Surgery had been performed by a single surgeon with the same assistants in all cases after failure of conservative treatment of at least 4 months’ duration, consisting of activity modification and anti-inflammatory medication, as well as physical therapy and an exercise regimen.
ANTEROSUPERIOR LABRAL TEAR TABLE 1.
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Summary of Preoperative Clinical Data Clinical Examination
Patient No.
Age (yr)
1
43
Fall onto shoulder
⫹
2 3
50 47
Insidious pain Insidious pain
4 5
45 45
6 7
Clinical History
Load and Shift
O’Brien
Preoperative Diagnosis
⫹
⫹
⫹
⫹ ⫹
⫹
Insidious pain Motor vehicle accident
⫹
⫹
18 38
Motor vehicle accident Motor vehicle accident
⫹ ⫹
⫹
8
41
Motor vehicle accident
⫹
⫹
9
58
Motor vehicle accident
⫹
10
59
Motor vehicle accident
⫹
⫹
11
54
Motor vehicle accident
⫹
⫹
12
26
Motor vehicle accident
⫹
⫹
13
22
Motor vehicle accident
⫹
14
31
Motor vehicle accident
⫹
15 16
27 34
Motor vehicle accident Overhead sport
⫹
17
26
Overhead sport
18 19 20 21
30 31 37 31
Overhead Overhead Overhead Overhead
22 23
45 44
Overhead work Overhead work
Subacromial impingement and biceps instability Subacromial impingement Subacromial impingement and SLAP lesion Subacromial impingement Instability of long head of biceps Internal impingement Painful microinstability shoulder Painful microinstability shoulder Post-traumatic painful shoulder Post-traumatic painful shoulder Post-traumatic painful shoulder Post-traumatic painful shoulder Post-traumatic painful shoulder Post-traumatic painful shoulder SLAP lesion Painful microinstability shoulder Partial superior rotator cuff tear SLAP lesion SLAP lesion Superior cuff tear Superior rotator cuff tear and SLAP lesion Partial superior cuff tear Subacromial impingement
sport sport sport sport
Castagna
Impingement
Whipple
⫹ ⫹ ⫹ ⫹
⫹ ⫹
⫹
⫹ ⫹
⫹ ⫹
⫹
Arthroscopy was performed with the patient in the lateral decubitus position. Routine anterosuperior and posterolateral portals were established to inspect the joint and address the lesions found. Because the anterosuperior labrum was deemed unstable because of the tear, it was reinserted after abrasion by use of a bioabsorbable 2.9-mm anchor with two No. 2 nonabsorbable polyester sutures (Figs 2 and 3). This repair allowed for reinsertion of the middle glenohumeral ligament. No attempt was made to close the rotator interval. Seven patients were identified as having a sublabral foramen or Buford complex; in these specific cases, because smooth borders were seen, no
⫹
⫹ ⫹
⫹ ⫹ ⫹
⫹ ⫹ ⫹
⫹
⫹
⫹
repair was attempted at this level. However, the anterosuperior insertion of this complex at the level of the anterosuperior glenoid was disrupted with signs of fraying and tearing, and the superior attachment was then repaired while the smooth area was left untouched. A standard postoperative rehabilitation protocol for labral repair was implemented. In particular, the arm was immobilized in an Ultrasling II (DJO, Vista, CA) with 15° of abduction and slight internal rotation so as to avoid retropulsion. After 10 days, passive movements of forward elevation and pendulum exercises were allowed. Formal supervised physical therapy
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FIGURE 2. Intra-articular arthroscopic view of a right shoulder showing a tear of the anterosuperior labrum with detachment.
consisted of gradual resumption of passive and activeassisted ROM of the shoulder, and progressive muscular strengthening was started at 4 weeks postoperatively when use of the arm sling was discontinued. Patients were reviewed by a single physician at a mean follow-up of 42.3 months (range, 30 to 60 months) using the evaluation parameters mentioned previously. In addition, to evaluate patient satisfaction, they were asked whether they would undergo the same procedure. All statistical analyses were performed by a biostatistician with S-Plus, version 7.0 (Enterprise Developer, Geneve, Switzerland). The Student t test or Wilcoxon test was used to evaluate preoperative and postoperative values of the scores, with a significance threshold set at the standard P value of .05.
parable to the contralateral arm. Because of high pain scores and limited ROM with a restriction in strength as indicated by the patients, probably because of pain, shoulder scores were low, even though most patients did not have instability. The load-and-shift test in the apprehension position was considered positive in 16 patients (70%). In particular, there was pain in 6 patients, increased translation in 7 patients, and a click in the remaining 3 patients. In 12 patients (52%) the O’Brien test elicited a positive response. The Whipple test, specifically used to evaluate the anterior supraspinatus tendon, was slightly positive in 9 patients (39%). The subacromial impingement test was positive in 7 patients (30%). In 6 patients (26%) an apprehensionand-relocation test performed with the arm in 45° of abduction and external rotation (Castagna test) was considered positive because of posterior pain during this maneuver. The preoperative diagnoses were varied, but an anterosuperior labral tear as the cause of shoulder pain and discomfort was not suspected. Data at final follow-up At the time of final follow-up, the level of pain (visual analog scale score) improved significantly (P ⬍ .05) in all patients (Table 2). In particular, 11 patients had no pain at all, 8 patients reported occasional pain at a level of 1 to 2, and 4 patients reported a pain level of 1 to 3. In 13 of 23 patients (56%), the preoperative night pain had even disappeared immediately in the first week after surgery. Nine patients
RESULTS Preoperative data Before surgery, all patients complained of shoulder pain aggravated by overhead activities. Night pain was present in all 23 patients. Ten patients complained of a popping sensation. Almost half of the patients mentioned a history of a motor vehicle accident and a third were involved in overhead sports or work, whereas the others had a variety of precipitating factors (Table 1). Clinical examination showed a limitation in active and passive shoulder elevation because of pain, although internal rotation in adduction remained com-
FIGURE 3. Intra-articular arthroscopic view of a right shoulder from a posterior portal showing repair of the anterosuperior labral tear with double-loaded suture and a bioabsorbable anchor.
ANTEROSUPERIOR LABRAL TEAR TABLE 2.
Preoperative and Final Follow-Up Scores
VAS score Forward elevation (°) External rotation in abduction (°) Abduction (°) Internal rotation Thigh Buttock Sacrum T12 T7 Rowe score ASES score SST score
Preoperative
Final Follow-Up
P Value
7.4 ⫾ 1.8 87.3 ⫾ 8.0
1.1 ⫾ 1.2 175.4 ⫾ 18.3
⬍ .05 ⬍ .05
55.1 ⫾ 6.7 75.0 ⫾ 25.1
85.1 ⫾ 4.9 154.9 ⫾ 40.1
⬍ .05 ⬍ .05 ⬎ .05
0 0 2 9 12 42.3 ⫾ 14.6 30.2 ⫾ 17.4 9.08 ⫾ 3.1
0 0 0 5 18 97.6 ⫾ 8.3 89.7 ⫾ 11 1.17 ⫾ 2.3
⬍ .05 ⬍ .05 ⬍ .05
NOTE. Data are expressed as mean ⫾ SD or No. of patients (N ⫽ 23). The data regarding motion refer to active ROM. Abbreviations: VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeon; SST, Simple Shoulder Test; T, thoracic vertebra.
reported a gradual decrease of shoulder pain, whereas a painful postoperative capsulitis developed in one patient with a good evolution only after 8 months. No other complications were observed. All patients declared that they would be willing to undergo the same procedure. A complete resolution of subjective symptoms such as popping was documented, and all patients were able to resume overhead and sports activities. All preoperatively positive clinical tests (subacromial impingement test, Whipple test, O’Brien test, and apprehension-and-relocation test at 45° of abduction and external rotation) were negative at the final follow-up evaluation. No significant differences were observed in passive and active ROM compared with the unaffected arm. More specifically, no limitation in external rotation as compared with the uninjured side was noted. By final follow-up, all scores displayed a statistically significant improvement (P ⬍ .05). DISCUSSION In this study we found that an arthroscopic repair of an isolated tear of the anterosuperior labrum without involvement of other structures in the shoulder joint including the biceps anchor can be expected to improve symptoms. This rare pathology, with an incidence of not even 1% in symptomatic shoulders undergoing arthroscopy at our institution, causes pain
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especially at night, with an active and passive limitation of ROM due to this pain as a common presentation. Clinically, it can simulate the findings of other painful conditions of the shoulder, and often, the diagnosis is only made at arthroscopy. Although many articles describe labral degeneration and fraying without frank tears in the anterosuperior quadrant or lesions also involving the biceps anchor,1,9-15 few deal with tears of the anterosuperior labrum not extending to the biceps anchor.2,4,16,17 A sharp increase in interest in lesions in this area was seen in the 1990s, but few articles have been published since 2000. The first description of a labral tear specifically located in the anterosuperior quadrant of the glenoid extending into the origin of the long head of the biceps was reported by Andrews et al.18 in a group of overhead throwing athletes. Snyder et al.1 identified a more extensive injury involving the superior labrum not only anteriorly but also posteriorly and called it a SLAP lesion. Their subdivision into 4 different types was expanded by Maffet et al.19 Burkhart and Morgan15 described the peel-back mechanism as a possible cause. All these descriptions always included lesions to the insertion of the long head of the biceps at the level of the glenoid rim. Labral tears above the equator without involvement of the biceps anchor form a more complex and controversial topic. Apparently, this lesion was not thought to be significant for many years and by many surgeons. This attitude may have 2 explanations. On the one hand, the normal anatomic variation of the labrum in this region, such as a sublabral hole, a cord-like middle glenohumeral ligament, or a Buford complex, as well as the tendency for degenerative changes from as early as the second or third decade,10 makes a firm diagnosis of pathology and subsequent management very difficult. On the other hand, anterosuperior lesions of the labrum rarely seem to be accompanied by capsuloligamentous lesions and are usually encountered in patients with stable shoulders, and they are therefore often thought not to contribute to clinical instability. Most of the described patients with isolated anterosuperior lesions reported painful shoulders, regularly associated with clicking or locking without subluxation or dislocation.9-14,16-22 Our study indicates that the diagnostic problem is related to the absence of reproducible clinical signs. In not a single patient in this study was an anterosuperior labral tear suspected as the diagnosis preoperatively. That previous articles on anterosuperior labral le-
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sions did not report associated signs of instability may be related to a lack of testing in the adequate direction. Anterosuperior instability is related to the superior and middle glenohumeral ligaments and will not be discerned by standard testing in the apprehension position of 90° of abduction and external rotation. A load-and-shift test or apprehension-and-relocation test in 90° of abduction with neutral rotation and slight retropulsion may be more contributive. Recently, Castagna et al.23 described an apprehension-and-relocation test performed with the arm at 45° of abduction with external rotation as a sign of minor shoulder instability correlated with pathology of the anterosuperior labrum, particularly at the level of the middle glenohumeral ligament. This test was positive in 6 of our patients. Savoie et al.3 found that the load-andshift test allowed for earlier diagnosis of anterosuperior injuries associated with instability. This test was found to be positive in 70% of patients in our series. Because of pain during testing, any load-and-shift maneuver may, however, be difficult to perform correctly or could be misinterpreted as false-negative. Rose et al.2 were convinced that only a positive O’Brien test is suggestive for anterosuperior labral lesions because 87% of their patients had this. Only 52% of our patients had a positive O’Brien test. The relevance of other clinical tests in relation to anterosuperior labral lesions has not been well reported, especially because many patients also had associated lesions. Interestingly, in our study the impingement test and the Jobe test were often positive. This may be explained by secondary impingement. Several mechanisms may be responsible for this type of injury. In accordance with Savoie et al.,3 we may suppose that an anterosuperior subluxation event occurred during trauma in 12 of our patients (a motor vehicle accident in 11 and a fall onto the side of the shoulder in 1). In 8 of our patients with a history of overhead sports or work activities, a chronic traction or attrition injury may have occurred because of repetitive stress on the anterosuperior structures with secondary subacromial or internal impingement.23-25 In these cases the anterosuperior labral tear may represent minor shoulder instability related to slightly increased anterosuperior translation of the humeral head in relation to the glenoid.23 On the other hand, the arm does not necessarily have to be in the overhead position for this capsuloligamentous area to be under stress. The superior glenohumeral ligament limits anterior and inferior translation of the humeral head during shoulder flexion and, to a lesser degree, during abduction. The
middle glenohumeral ligament limits external rotation in abduction as well as inferior translation of the humeral head. Both structures may also come under tension when the arm is in abduction with retropulsion.26-30 Therefore stress in the upper part of the labrum may also occur in lower grades of abduction with external rotation and/or retropulsion. These positions of the arm occur during many activities of daily living, such as reaching backward. This hypothesis may explain why some patients not involved in overhead activities or without a preceding trauma may have this injury. Three of our patients had an insidious onset of symptoms without any history of trauma or microtrauma. Few experimental studies have addressed isolated labral tears.25,31,32 These studies show that minor increases in anterior translation during straight anterior testing may occur with isolated anterosuperior labral tears but that significant increases occur in anterior translation up to subluxation (possibly resulting in instability in a clinical setting) when the labral tear is associated with a lesion of the superior and/or middle glenohumeral ligament. Because of the small sample size and its retrospective retrieval, the study has some limitations. Although patients for this study were identified retrospectively from a database, all preoperative and postoperative data were collected prospectively in the standardized database. Nevertheless, some cases of isolated tears may have been miscataloged, or in contrast, associated lesions may have been overlooked when data were entered into the database or when the intraoperative videos were recorded. Therefore the 23 cases that were selected for this series may not represent the true number of isolated tears in our arthroscopic cohort. In addition, all tears were treated by repair. Therefore this study cannot determine what the results for other forms of treatment, for example, debridement or simply leaving the lesion untreated, would be. Ideally, a prospective study with control groups should be conducted. Because of the low incidence, however, such a study may not attain sufficient power. CONCLUSIONS Isolated tears of the anterosuperior labrum represent a subtle cause of shoulder pain and dysfunction. The lesion is very difficult to diagnose clinically. Arthroscopic repair with a suture anchor technique is a reliable procedure providing a good outcome in terms of pain relief, patient satisfaction, and shoulder scores.
ANTEROSUPERIOR LABRAL TEAR REFERENCES 1. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6:274-279. 2. Rose T, Hepp P, Korner J, Josten C, Lill H. Anterosuperior labrum lesions of the shoulder joint: Pathogenesis, arthroscopic treatment, and results. Knee Surg Sports Traumatol Arthrosc 2002;10:316-320. 3. Savoie FH III, Field LD, Atchinson S. Anterior superior instability with rotator cuff tearing: SLAC lesion. Orthop Clin North Am 2001;32:457-461, ix. 4. Savoie FH III, Holt MS, Field LD, Ramsey JR. Arthroscopic management of posterior instability: Evolution of technique and results. Arthroscopy 2008;24:389-396. 5. Diercks RL. Anterosuperior labrum lesions of the shoulder joint: Pathogenesis, arthroscopic treatment, and results. Knee Surg Sports Traumatol Arthrosc 2003;11:200; author reply 201 (Letter). 6. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: A long-term end-result study. J Bone Joint Surg Am 1978;60: 1-16. 7. Rockwood CA Jr, Matsen FA III. The Shoulder. Philadelphia: Saunders, 2000. 8. King GJ, Richards RR, Zuckerman JD, et al. A standardized method for assessment of elbow function. Research Committee, American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg 1999;8:351-354. 9. Ogilvie-Harris DJ, Wiley AM. Arthroscopic surgery of the shoulder. A general appraisal. J Bone Joint Surg Br 1986;68: 201-207. 10. Kohn D. The clinical relevance of glenoid labrum lesions. Arthroscopy 1987;3:223-230. 11. Glasgow SG, Bruce RA, Yacobucci GN, Torg JS. Arthroscopic resection of glenoid labral tears in the athlete: A report of 29 cases. Arthroscopy 1992;8:48-54. 12. Altchek DW, Warren RF, Wickiewicz TL, Ortiz G. Arthroscopic labral debridement. A three-year follow-up study. Am J Sports Med 1992;20:702-706. 13. Payne LZ, Jokl P. The results of arthroscopic debridement of glenoid labral tears based on tear location. Arthroscopy 1993; 9:560-565. 14. Terry GC, Friedman SJ, Uhl TL. Arthroscopically treated tears of the glenoid labrum. Factors influencing outcome. Am J Sports Med 1994;22:504-512. 15. Burkhart SS, Morgan CD. The peel-back mechanism: Its role in producing and extending posterior type II SLAP lesions and its
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30. 31. 32.
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effect on SLAP repair rehabilitation. Arthroscopy 1998; 14:637-640. Tomlinson RJ Jr, Glousman RE. Arthroscopic debridement of glenoid labral tears in athletes. Arthroscopy 1995;11:42-51. Savoie FH III, Papendik L, Field LD, Jobe C. Straight anterior instability: Lesions of the middle glenohumeral ligament. Arthroscopy 2001;17:229-235. Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985;13:337-341. Maffet MW, Gartsman GM, Moseley B. Superior labrumbiceps tendon complex lesions of the shoulder. Am J Sports Med 1995;23:93-98. Andrews JR, Kupferman SP, Dillman CJ. Labral tears in throwing and racquet sports. Clin Sports Med 1991;10:901911. Martin DR, Garth WP Jr. Results of arthroscopic debridement of glenoid labral tears. Am J Sports Med 1995;23:447-451. Gartsman GM, Hammerman SM. Superior labrum, anterior and posterior lesions. When and how to treat them. Clin Sports Med 2000;19:115-124. Castagna A, Nordenson U, Garofalo R, Karlsson J. Minor shoulder instability. Arthroscopy 2007;23:211-215. Warner JJ, Deng XH, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685. Field LD, Savoie FH III. Anterosuperior instability and rotator interval. Oper Tech Sports Med 1997;5:257-263. Pagnani MJ, Warren RF. Stabilizers of the glenohumeral joint. J Shoulder Elbow Surg 1994;3:173-190. Speer KP. Anatomy and pathomechanics of shoulder instability. Clin Sports Med 1995;14:751-760. Pouliart N, Somers K, Eid S, Gagey O. Variations in the superior capsuloligamentous complex and description of a new ligament. J Shoulder Elbow Surg 2007;16:821-836. Pouliart N, Somers K, Gagey O. Arthroscopic glenohumeral folds and microscopic glenohumeral ligaments: The fasciculus obliquus is the missing link. J Shoulder Elbow Surg 2008;17: 418-430. Di Giacomo G, Pouliart N, Costantini A, Vita AD. Functional Anatomy of the Shoulder. Berlin: Springer-Verlag, 2008. Pouliart N, Gagey O. The effect of isolated labrum resection on shoulder stability. Knee Surg Sports Traumatol Arthrosc 2006;14:301-308. Pouliart N, Marmor S, Gagey O. Simulated capsulolabral lesion in cadavers: Dislocation does not result from a Bankart lesion only. Arthroscopy 2006;22:748-754.
Purpose: The purposes of this study were to determine common clinical symptoms related to an anterosuperior labral tear without biceps anchor involvement and to establish the outcome of arthroscopic management of this injury. Methods: In our database of arthroscopic procedures we identified 23 patients with an isolated anterosuperior labral tear. The mean age at the time of surgery was 38.3 ⫾ 6.8 years (range, 18 to 59 years). The preoperative clinical diagnosis varied, but an anterosuperior labral isolated lesion was not detected before surgery. The diagnosis of anterosuperior labral tear was made arthroscopically, and the lesion was fixed with a suture anchor technique, by use of 1 single bioabsorbable anchor. Patients were reviewed after a minimum of 2.5 years of follow-up. Clinical outcome was evaluated with the Rowe score, American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale score. Results: History, clinical examination, and preoperative imaging usually failed to indicate the presence of an isolated anterosuperior labral tear as the cause of shoulder pain in our patients. Repair of the labral lesions yielded good to excellent results with normalization of the range of motion and a significant improvement in shoulder scores (Rowe, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale). Conclusions: Isolated tears of the anterosuperior labrum represent a subtle cause of shoulder pain and dysfunction. The lesion is very difficult to diagnose clinically. Arthroscopic repair is a reliable procedure providing a good outcome in terms of pain relief, patient satisfaction, and shoulder scores. Level of Evidence: Level IV, therapeutic case series.
S
ince its original description by Snyder et al.,1 the SLAP lesion or tear of the superior labrum of the glenohumeral joint has been well recognized as a cause of shoulder pain and dysfunction particularly with overhead activities, because the long head of the biceps becomes unstable in these positions.
From the Orthopedic Unit, F. Miulli Hospital, Acquaviva delle Fonti (R.G.), Bari, Italy; Department of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel (N.P.), Brussels, Belgium; Shoulder Unit, Humanitas Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) (E.V., A.C.), Milan, Italy; and Orthopedic Unit, University of Padova (G.F., R.A.), Padova, Italy. The authors report no conflict of interest. Received November 29, 2009; accepted May 27, 2010. Address correspondence and reprint requests to Raffaele Garofalo, M.D., Via Padova 13, 70029 Santeramo in Colle, Bari, Italy. E-mail: [email protected] © 2011 by the Arthroscopy Association of North America 0749-8063/9712/$36.00 doi:10.1016/j.arthro.2010.05.022
A lesion of the anterosuperior labrum without involvement of the biceps anchor appears to be a more rare and probably under-recognized pathologic entity. Furthermore, the normal anatomic variations of the labrum in this area make the diagnosis very difficult. Pathology of the labral complex above the equator of the shoulder has been described as a degenerative lesion without glenohumeral joint instability,2 as a tear of the anterosuperior labrum associated with partial tearing of the supraspinatus tendon (SLAC lesion),3 or as a tear associated with posterior shoulder instability.4 The pathogenesis of these individual lesions may be different and is probably related to a combination of factors. Under-diagnosis may also be related to the fact that these lesions can often only be appreciated by complete and careful arthroscopic inspection and probing.5 Clinical symptoms and signs of this specific lesion are not well established, and this factor makes the preoperative diagnosis very difficult, especially
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 1 (January), 2011: pp 17-23
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when we realize that there often are associated lesions that can complicate and confound the clinical pattern. The purposes of this study were (1) to identify a common clinical pattern to improve the understanding of this lesion and (2) to evaluate the clinical outcome of a series of patients with an isolated anterosuperior labral tear without biceps anchor involvement treated with arthroscopic repair using a suture anchor technique. Our hypothesis was that an anterosuperior labral tear can be an isolated cause of shoulder pain and discomfort and that an arthroscopic repair can be expected to improve symptoms. METHODS All data—from patient history to clinical examination and from conservative treatment to surgery, as well as results from additional investigations and shoulder scores—for each patient who is seen in our clinic, from the first outpatient visit to the last follow-up visit, are recorded in a standardized way in a database. This includes the data for 3,252 patients who underwent an arthroscopic procedure at our institution between January 2004 and October 2007. Initially, the arthroscopic records in the database were scrupulously perused by 2 of the authors to identify all cases with involvement of the anterosuperior labrum. From these procedures, those that showed an anterosuperior labral tear were selected. Finally, the operative notes and recorded intraoperative videos of these patients were reviewed to exclude patients with associated lesions. This allowed us to identify only those patients who presented with isolated anterosuperior labral tears and in whom an isolated anterosuperior labral repair was done. We identified 23 patients with an isolated anterosuperior labral tear, which was diagnosed by inspection and probing. In these patients there were no signs of synovitis, other capsuloligamentous lesions, associated rotator cuff lesions, or lesions of the biceps tendon or pulley. A type II SLAP tear was excluded by showing that the biceps anchor could not be lifted to expose subchondral bone. Subacromial pathology was also excluded by a routine bursal examination. The flowchart in Fig 1 details the selection procedure. All 23 patients were successfully contacted and agreed to return for clinical follow-up at a minimum of 2.5 years after surgery. Data from the clinical history and preoperative clinical evaluation, as well as the intraoperative findings, including operative notes and videos of every procedure, were analyzed (Table 1).
FIGURE 1. biceps.)
Flowchart of case selection. (LHB, long head of
There were 11 male and 12 female patients. The mean age at the time of surgery was 38.3 ⫾ 6.8 years (range, 18 to 59 years). The injured shoulder was the dominant side in 15 cases. The mean duration of symptoms before presentation to our clinic was 3.5 ⫾ 4.5 months. Preoperative and postoperative evaluation consisted of a patient-based questionnaire and physical examination. Clinical assessment consisted of measurement of glenohumeral range of motion (ROM) with a goniometer, as well as shoulder-specific examination. The Rowe rating score,6 Simple Shoulder Test as originally as reported by Rockwood and Matsen,7 and American Shoulder and Elbow Surgeons score8 were assessed. Pain was recorded by use of a visual analog scale, where a score of 0 points indicates no pain and a score of 10 points indicates the worst possible pain. All patients underwent evaluation with preoperative radiographs (anteroposterior, axillary, and arch views) and magnetic resonance imaging by use of coronal and axial views with T1 and T2 fat suppression sequences that failed to show any specific lesion in all cases. Surgery had been performed by a single surgeon with the same assistants in all cases after failure of conservative treatment of at least 4 months’ duration, consisting of activity modification and anti-inflammatory medication, as well as physical therapy and an exercise regimen.
ANTEROSUPERIOR LABRAL TEAR TABLE 1.
19
Summary of Preoperative Clinical Data Clinical Examination
Patient No.
Age (yr)
1
43
Fall onto shoulder
⫹
2 3
50 47
Insidious pain Insidious pain
4 5
45 45
6 7
Clinical History
Load and Shift
O’Brien
Preoperative Diagnosis
⫹
⫹
⫹
⫹ ⫹
⫹
Insidious pain Motor vehicle accident
⫹
⫹
18 38
Motor vehicle accident Motor vehicle accident
⫹ ⫹
⫹
8
41
Motor vehicle accident
⫹
⫹
9
58
Motor vehicle accident
⫹
10
59
Motor vehicle accident
⫹
⫹
11
54
Motor vehicle accident
⫹
⫹
12
26
Motor vehicle accident
⫹
⫹
13
22
Motor vehicle accident
⫹
14
31
Motor vehicle accident
⫹
15 16
27 34
Motor vehicle accident Overhead sport
⫹
17
26
Overhead sport
18 19 20 21
30 31 37 31
Overhead Overhead Overhead Overhead
22 23
45 44
Overhead work Overhead work
Subacromial impingement and biceps instability Subacromial impingement Subacromial impingement and SLAP lesion Subacromial impingement Instability of long head of biceps Internal impingement Painful microinstability shoulder Painful microinstability shoulder Post-traumatic painful shoulder Post-traumatic painful shoulder Post-traumatic painful shoulder Post-traumatic painful shoulder Post-traumatic painful shoulder Post-traumatic painful shoulder SLAP lesion Painful microinstability shoulder Partial superior rotator cuff tear SLAP lesion SLAP lesion Superior cuff tear Superior rotator cuff tear and SLAP lesion Partial superior cuff tear Subacromial impingement
sport sport sport sport
Castagna
Impingement
Whipple
⫹ ⫹ ⫹ ⫹
⫹ ⫹
⫹
⫹ ⫹
⫹ ⫹
⫹
Arthroscopy was performed with the patient in the lateral decubitus position. Routine anterosuperior and posterolateral portals were established to inspect the joint and address the lesions found. Because the anterosuperior labrum was deemed unstable because of the tear, it was reinserted after abrasion by use of a bioabsorbable 2.9-mm anchor with two No. 2 nonabsorbable polyester sutures (Figs 2 and 3). This repair allowed for reinsertion of the middle glenohumeral ligament. No attempt was made to close the rotator interval. Seven patients were identified as having a sublabral foramen or Buford complex; in these specific cases, because smooth borders were seen, no
⫹
⫹ ⫹
⫹ ⫹ ⫹
⫹ ⫹ ⫹
⫹
⫹
⫹
repair was attempted at this level. However, the anterosuperior insertion of this complex at the level of the anterosuperior glenoid was disrupted with signs of fraying and tearing, and the superior attachment was then repaired while the smooth area was left untouched. A standard postoperative rehabilitation protocol for labral repair was implemented. In particular, the arm was immobilized in an Ultrasling II (DJO, Vista, CA) with 15° of abduction and slight internal rotation so as to avoid retropulsion. After 10 days, passive movements of forward elevation and pendulum exercises were allowed. Formal supervised physical therapy
20
R. GAROFALO ET AL.
FIGURE 2. Intra-articular arthroscopic view of a right shoulder showing a tear of the anterosuperior labrum with detachment.
consisted of gradual resumption of passive and activeassisted ROM of the shoulder, and progressive muscular strengthening was started at 4 weeks postoperatively when use of the arm sling was discontinued. Patients were reviewed by a single physician at a mean follow-up of 42.3 months (range, 30 to 60 months) using the evaluation parameters mentioned previously. In addition, to evaluate patient satisfaction, they were asked whether they would undergo the same procedure. All statistical analyses were performed by a biostatistician with S-Plus, version 7.0 (Enterprise Developer, Geneve, Switzerland). The Student t test or Wilcoxon test was used to evaluate preoperative and postoperative values of the scores, with a significance threshold set at the standard P value of .05.
parable to the contralateral arm. Because of high pain scores and limited ROM with a restriction in strength as indicated by the patients, probably because of pain, shoulder scores were low, even though most patients did not have instability. The load-and-shift test in the apprehension position was considered positive in 16 patients (70%). In particular, there was pain in 6 patients, increased translation in 7 patients, and a click in the remaining 3 patients. In 12 patients (52%) the O’Brien test elicited a positive response. The Whipple test, specifically used to evaluate the anterior supraspinatus tendon, was slightly positive in 9 patients (39%). The subacromial impingement test was positive in 7 patients (30%). In 6 patients (26%) an apprehensionand-relocation test performed with the arm in 45° of abduction and external rotation (Castagna test) was considered positive because of posterior pain during this maneuver. The preoperative diagnoses were varied, but an anterosuperior labral tear as the cause of shoulder pain and discomfort was not suspected. Data at final follow-up At the time of final follow-up, the level of pain (visual analog scale score) improved significantly (P ⬍ .05) in all patients (Table 2). In particular, 11 patients had no pain at all, 8 patients reported occasional pain at a level of 1 to 2, and 4 patients reported a pain level of 1 to 3. In 13 of 23 patients (56%), the preoperative night pain had even disappeared immediately in the first week after surgery. Nine patients
RESULTS Preoperative data Before surgery, all patients complained of shoulder pain aggravated by overhead activities. Night pain was present in all 23 patients. Ten patients complained of a popping sensation. Almost half of the patients mentioned a history of a motor vehicle accident and a third were involved in overhead sports or work, whereas the others had a variety of precipitating factors (Table 1). Clinical examination showed a limitation in active and passive shoulder elevation because of pain, although internal rotation in adduction remained com-
FIGURE 3. Intra-articular arthroscopic view of a right shoulder from a posterior portal showing repair of the anterosuperior labral tear with double-loaded suture and a bioabsorbable anchor.
ANTEROSUPERIOR LABRAL TEAR TABLE 2.
Preoperative and Final Follow-Up Scores
VAS score Forward elevation (°) External rotation in abduction (°) Abduction (°) Internal rotation Thigh Buttock Sacrum T12 T7 Rowe score ASES score SST score
Preoperative
Final Follow-Up
P Value
7.4 ⫾ 1.8 87.3 ⫾ 8.0
1.1 ⫾ 1.2 175.4 ⫾ 18.3
⬍ .05 ⬍ .05
55.1 ⫾ 6.7 75.0 ⫾ 25.1
85.1 ⫾ 4.9 154.9 ⫾ 40.1
⬍ .05 ⬍ .05 ⬎ .05
0 0 2 9 12 42.3 ⫾ 14.6 30.2 ⫾ 17.4 9.08 ⫾ 3.1
0 0 0 5 18 97.6 ⫾ 8.3 89.7 ⫾ 11 1.17 ⫾ 2.3
⬍ .05 ⬍ .05 ⬍ .05
NOTE. Data are expressed as mean ⫾ SD or No. of patients (N ⫽ 23). The data regarding motion refer to active ROM. Abbreviations: VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeon; SST, Simple Shoulder Test; T, thoracic vertebra.
reported a gradual decrease of shoulder pain, whereas a painful postoperative capsulitis developed in one patient with a good evolution only after 8 months. No other complications were observed. All patients declared that they would be willing to undergo the same procedure. A complete resolution of subjective symptoms such as popping was documented, and all patients were able to resume overhead and sports activities. All preoperatively positive clinical tests (subacromial impingement test, Whipple test, O’Brien test, and apprehension-and-relocation test at 45° of abduction and external rotation) were negative at the final follow-up evaluation. No significant differences were observed in passive and active ROM compared with the unaffected arm. More specifically, no limitation in external rotation as compared with the uninjured side was noted. By final follow-up, all scores displayed a statistically significant improvement (P ⬍ .05). DISCUSSION In this study we found that an arthroscopic repair of an isolated tear of the anterosuperior labrum without involvement of other structures in the shoulder joint including the biceps anchor can be expected to improve symptoms. This rare pathology, with an incidence of not even 1% in symptomatic shoulders undergoing arthroscopy at our institution, causes pain
21
especially at night, with an active and passive limitation of ROM due to this pain as a common presentation. Clinically, it can simulate the findings of other painful conditions of the shoulder, and often, the diagnosis is only made at arthroscopy. Although many articles describe labral degeneration and fraying without frank tears in the anterosuperior quadrant or lesions also involving the biceps anchor,1,9-15 few deal with tears of the anterosuperior labrum not extending to the biceps anchor.2,4,16,17 A sharp increase in interest in lesions in this area was seen in the 1990s, but few articles have been published since 2000. The first description of a labral tear specifically located in the anterosuperior quadrant of the glenoid extending into the origin of the long head of the biceps was reported by Andrews et al.18 in a group of overhead throwing athletes. Snyder et al.1 identified a more extensive injury involving the superior labrum not only anteriorly but also posteriorly and called it a SLAP lesion. Their subdivision into 4 different types was expanded by Maffet et al.19 Burkhart and Morgan15 described the peel-back mechanism as a possible cause. All these descriptions always included lesions to the insertion of the long head of the biceps at the level of the glenoid rim. Labral tears above the equator without involvement of the biceps anchor form a more complex and controversial topic. Apparently, this lesion was not thought to be significant for many years and by many surgeons. This attitude may have 2 explanations. On the one hand, the normal anatomic variation of the labrum in this region, such as a sublabral hole, a cord-like middle glenohumeral ligament, or a Buford complex, as well as the tendency for degenerative changes from as early as the second or third decade,10 makes a firm diagnosis of pathology and subsequent management very difficult. On the other hand, anterosuperior lesions of the labrum rarely seem to be accompanied by capsuloligamentous lesions and are usually encountered in patients with stable shoulders, and they are therefore often thought not to contribute to clinical instability. Most of the described patients with isolated anterosuperior lesions reported painful shoulders, regularly associated with clicking or locking without subluxation or dislocation.9-14,16-22 Our study indicates that the diagnostic problem is related to the absence of reproducible clinical signs. In not a single patient in this study was an anterosuperior labral tear suspected as the diagnosis preoperatively. That previous articles on anterosuperior labral le-
22
R. GAROFALO ET AL.
sions did not report associated signs of instability may be related to a lack of testing in the adequate direction. Anterosuperior instability is related to the superior and middle glenohumeral ligaments and will not be discerned by standard testing in the apprehension position of 90° of abduction and external rotation. A load-and-shift test or apprehension-and-relocation test in 90° of abduction with neutral rotation and slight retropulsion may be more contributive. Recently, Castagna et al.23 described an apprehension-and-relocation test performed with the arm at 45° of abduction with external rotation as a sign of minor shoulder instability correlated with pathology of the anterosuperior labrum, particularly at the level of the middle glenohumeral ligament. This test was positive in 6 of our patients. Savoie et al.3 found that the load-andshift test allowed for earlier diagnosis of anterosuperior injuries associated with instability. This test was found to be positive in 70% of patients in our series. Because of pain during testing, any load-and-shift maneuver may, however, be difficult to perform correctly or could be misinterpreted as false-negative. Rose et al.2 were convinced that only a positive O’Brien test is suggestive for anterosuperior labral lesions because 87% of their patients had this. Only 52% of our patients had a positive O’Brien test. The relevance of other clinical tests in relation to anterosuperior labral lesions has not been well reported, especially because many patients also had associated lesions. Interestingly, in our study the impingement test and the Jobe test were often positive. This may be explained by secondary impingement. Several mechanisms may be responsible for this type of injury. In accordance with Savoie et al.,3 we may suppose that an anterosuperior subluxation event occurred during trauma in 12 of our patients (a motor vehicle accident in 11 and a fall onto the side of the shoulder in 1). In 8 of our patients with a history of overhead sports or work activities, a chronic traction or attrition injury may have occurred because of repetitive stress on the anterosuperior structures with secondary subacromial or internal impingement.23-25 In these cases the anterosuperior labral tear may represent minor shoulder instability related to slightly increased anterosuperior translation of the humeral head in relation to the glenoid.23 On the other hand, the arm does not necessarily have to be in the overhead position for this capsuloligamentous area to be under stress. The superior glenohumeral ligament limits anterior and inferior translation of the humeral head during shoulder flexion and, to a lesser degree, during abduction. The
middle glenohumeral ligament limits external rotation in abduction as well as inferior translation of the humeral head. Both structures may also come under tension when the arm is in abduction with retropulsion.26-30 Therefore stress in the upper part of the labrum may also occur in lower grades of abduction with external rotation and/or retropulsion. These positions of the arm occur during many activities of daily living, such as reaching backward. This hypothesis may explain why some patients not involved in overhead activities or without a preceding trauma may have this injury. Three of our patients had an insidious onset of symptoms without any history of trauma or microtrauma. Few experimental studies have addressed isolated labral tears.25,31,32 These studies show that minor increases in anterior translation during straight anterior testing may occur with isolated anterosuperior labral tears but that significant increases occur in anterior translation up to subluxation (possibly resulting in instability in a clinical setting) when the labral tear is associated with a lesion of the superior and/or middle glenohumeral ligament. Because of the small sample size and its retrospective retrieval, the study has some limitations. Although patients for this study were identified retrospectively from a database, all preoperative and postoperative data were collected prospectively in the standardized database. Nevertheless, some cases of isolated tears may have been miscataloged, or in contrast, associated lesions may have been overlooked when data were entered into the database or when the intraoperative videos were recorded. Therefore the 23 cases that were selected for this series may not represent the true number of isolated tears in our arthroscopic cohort. In addition, all tears were treated by repair. Therefore this study cannot determine what the results for other forms of treatment, for example, debridement or simply leaving the lesion untreated, would be. Ideally, a prospective study with control groups should be conducted. Because of the low incidence, however, such a study may not attain sufficient power. CONCLUSIONS Isolated tears of the anterosuperior labrum represent a subtle cause of shoulder pain and dysfunction. The lesion is very difficult to diagnose clinically. Arthroscopic repair with a suture anchor technique is a reliable procedure providing a good outcome in terms of pain relief, patient satisfaction, and shoulder scores.
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