Imaging of shoulder instability

Abstract

The shoulder enjoys the widest range of motion of all the joints in the human body, therefore requires a delicate balance between stability and motility. The glenohumeral joint is inclined to fall into two main instability categories: macro and micro. Macroinstability can be traumatic or atraumatic, with anterior or posterior dislocation of the humeral head. Microinstability falls within the broader section of acquired instability in overstressed shoulder caused by repeated joint stress. Anterior traumatic instability is the most frequent entity and a relatively common injury in young and athletic population. While shoulder instability is a clinical diagnosis, imaging impacts the patient management by detailing the extent of injury, such as capsulo-labral-ligamentous tears, fracture, and/or dislocation, describing the predisposing anatomic conditions and guide the therapetic choice. The aim of this comprehensive review is to cover the imaging findings of shoulder instability by different imaging techniques.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Fig. 20
Fig. 21
Fig. 22

References

  1. 1.

    Jaggi A, Noorani A, Malone A, Cowan J, Lambert S, Bayley I. Muscle activation patterns in patients with recurrent shoulder instability. Int J Shoulder Surg. 2012;6(4):101–7.

    PubMed  PubMed Central  Google Scholar 

  2. 2.

    Pastor MF, Smith T, Struck M, Wellmann M. Stability versus mobility of the shoulder. Biomechanical aspects in athletes. Orthopade. 2014;43(3):209–14.

    CAS  PubMed  Google Scholar 

  3. 3.

    Gerber C, Nyffeler RW. Classification of glenohumeral joint instability. Clin Orthop Relat Res. 2002;400:65–76.

    Google Scholar 

  4. 4.

    Myers JB, Oyama S. Sensorimotor factors affecting outcome following shoulder injury. Clin Sports Med. 2008;27(3):481–90 x.

    PubMed  Google Scholar 

  5. 5.

    Matsen FA 3rd, Harryman DT 2nd, Sidles JA. Mechanics of glenohumeral instability. Clin Sports Med. 1991;10(4):783–8.

  6. 6.

    Seeger LL, Gold RH, Bassett LW. Shoulder instability: evaluation with MR imaging. Radiology. 1988;168(3):695–7.

    CAS  PubMed  Google Scholar 

  7. 7.

    Jacobson JA. Shoulder US: anatomy, technique, and scanning pitfalls. Radiology. 2011;260(1):6–16.

    PubMed  Google Scholar 

  8. 8.

    Flannigan B, Kursunoglu-Brahme S, Snyder S, Karzel R, Del Pizzo W, Resnick D. MR arthrography of the shoulder: comparison with conventional MR imaging. AJR Am J Roentgenol. 1990;155(4):829–32.

    CAS  PubMed  Google Scholar 

  9. 9.

    Steinbach LS. MRI of shoulder instability. Eur J Radiol. 2008;68(1):57–71.

    PubMed  Google Scholar 

  10. 10.

    Tirman PF, Smith ED, Stoller DW, Fritz RC. Shoulder imaging in athletes. Semin Musculoskelet Radiol. 2004;8(1):29–40.

    PubMed  Google Scholar 

  11. 11.

    Kadi R, Milants A, Shahabpour M. Shoulder anatomy and normal variants. J Belg Soc Radiol. 2017;101(Suppl 2):3.

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Williams MM, Snyder SJ. A sublabral foramen must not be confused with a Bankart lesion. Arthroscopy. 1994;10(5):586.

    CAS  PubMed  Google Scholar 

  13. 13.

    Mohana-Borges AV, Chung CB, Resnick D. Superior labral anteroposterior tear: classification and diagnosis on MRI and MR arthrography. AJR Am J Roentgenol. 2003;181(6):1449–62.

    PubMed  Google Scholar 

  14. 14.

    Reinold MM, Curtis AS. Microinstability of the shoulder in the overhead athlete. Int J Sports Phys Ther. 2013;8(5):601–16.

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Chan KK, Muldoon KA, Yeh L, Boutin R, Pedowitz R, Skaf A, et al. Superior labral anteroposterior lesions: MR arthrography with arm traction. AJR Am J Roentgenol. 1999;173(4):1117–22.

    CAS  PubMed  Google Scholar 

  16. 16.

    Thomas SC, Matsen FA 3rd. An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior glenohumeral instability. J Bone Joint Surg Am. 1989;71(4):506–13.

  17. 17.

    Schneeberger AG, Hersche O, Gerber C. The unstable shoulder. Classification and therapy. Unfallchirurg. 1998;101(3):226–31.

    CAS  PubMed  Google Scholar 

  18. 18.

    Farrar NG, Malal JJ, Fischer J, Waseem M. An overview of shoulder instability and its management. Open Orthop J. 2013;7:338–46.

    PubMed  PubMed Central  Google Scholar 

  19. 19.

    Winge S, Thomsen NO, Jensen CH, Klareskov B. Shoulder instability. Ugeskr Laeger. 1998;160(25):3707–13.

    CAS  PubMed  Google Scholar 

  20. 20.

    Sudkamp NP, Granrath M, Hoffmann R, Haas NP. Instability of the shoulder joint in the athlete. Chirurg. 1994;65(11):901–9.

    CAS  PubMed  Google Scholar 

  21. 21.

    Ly JQ, Beall DP, Sanders TG. MR imaging of glenohumeral instability. AJR Am J Roentgenol. 2003;181(1):203–13.

    PubMed  Google Scholar 

  22. 22.

    Wischer TK, Bredella MA, Genant HK, Stoller DW, Bost FW, Tirman PF. Perthes lesion (a variant of the Bankart lesion): MR imaging and MR arthrographic findings with surgical correlation. AJR Am J Roentgenol. 2002;178(1):233–7.

    PubMed  Google Scholar 

  23. 23.

    Bernhardson AS, Bailey JR, Solomon DJ, Stanley M, Provencher MT. Glenoid bone loss in the setting of an anterior labroligamentous periosteal sleeve avulsion tear. Am J Sports Med. 2014;42(9):2136–40.

    PubMed  Google Scholar 

  24. 24.

    Amrami KK, Sperling JW, Bartholmai BJ, Sundaram M. Radiologic case study. Glenolabral articular disruption (GLAD) lesion. Orthopedics. 2002;25(1):29 95–6.

    PubMed  Google Scholar 

  25. 25.

    Bozzo A, Oitment C, Thornley P, Yan J, Habib A, Hoppe DJ, et al. Humeral avulsion of the glenohumeral ligament: indications for surgical treatment and outcomes-a systematic review. Orthop J Sports Med. 2017;5(8):2325967117723329.

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    Kwak SM, Brown RR, Trudell D, Resnick D. Glenohumeral joint: comparison of shoulder positions at MR arthrography. Radiology. 1998;208(2):375–80.

    CAS  PubMed  Google Scholar 

  27. 27.

    Wolf EM, Arianjan A. Hill-Sachs remplissage, an arthroscopic solution for the enganging Hill-Sachs lesion: 2-10-year follow-up and incidence of recurence. J shoulder Elb Surg. 2014;23 (6):814–20

  28. 28.

    Horst K, Von Harten R, Weber C, Andruszkow H, Pfeifer R, Dienstknecht T, et al. Assessment of coincidence and defect sizes in Bankart and Hill-Sachs lesions after anterior shoulder dislocation: a radiological study. Br J Radiol. 2014;87(1034):20130673.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Rashid MS, Crichton J, Butt U, Akimau PI, Charalambous CP. Arthroscopic “Remplissage” for shoulder instability: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016;24(2):578–84.

    PubMed  Google Scholar 

  30. 30.

    Maio M, Sarmento M, Moura N, Cartucho A. How to measure a Hill-Sachs lesion: a systematic review. EFORT Open Rev. 2019;4(4):151–7.

    PubMed  PubMed Central  Google Scholar 

  31. 31.

    Yamamoto N, Itoi E, Abe H, Minagawa H, Seki N, Shimada Y, et al. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. J Shoulder Elb Surg. 2007;16(5):649–56.

    Google Scholar 

  32. 32.

    Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy. 2014;30(1):90–8.

    PubMed  Google Scholar 

  33. 33.

    Itoi E. ‘On-track’ and ‘off-track’ shoulder lesions. EFORT Open Rev. 2017;2(8):343–51.

    CAS  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Morsy MG. Arthroscopic remplissage: is it still an option? EFORT Open Rev. 2017;2(12):478–83.

    PubMed  PubMed Central  Google Scholar 

  35. 35.

    Moussa ME, Boykin RE, Earp BE. Missed locked posterior shoulder dislocation with a reverse Hill-Sachs lesion and subscapularis rupture. Am J Orthop (Belle Mead NJ). 2013;42(12):E121–4.

    Google Scholar 

  36. 36.

    Park KJ, Jeong HS, Park JK, Cha JK, Kang SW. Evaluation of inferior capsular laxity in patients with atraumatic multidirectional shoulder instability with magnetic resonance arthrography. Korean J Radiol. 2019;20(6):931–8.

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    Castagna A, Nordenson U, Garofalo R, Karlsson J. Minor shoulder instability. Arthroscopy. 2007;23(2):211–5.

    PubMed  Google Scholar 

  38. 38.

    Garofalo R, Pouliart N, Vinci E, Franceschi G, Aldegheri R, Castagna A. Anterosuperior labral tear without biceps anchor involvement: a subtle isolated cause of a painful shoulder. Arthroscopy. 2011;27(1):17–23.

    PubMed  Google Scholar 

  39. 39.

    Castagna A, Delle Rose G, Borroni M, Markopoulos N, Conti M, Maradei L, et al. Modified MacLaughlin procedure in the treatment of neglected posterior dislocation of the shoulder. Chir Organi Mov. 2009;93(Suppl 1):S1–5.

    PubMed  Google Scholar 

  40. 40.

    Arai R, Kobayashi M, Harada H, Tsukiyama H, Saji T, Toda Y, et al. Anatomical study for SLAP lesion repair. Knee Surg Sports Traumatol Arthrosc. 2014;22(2):435–41.

    PubMed  Google Scholar 

  41. 41.

    Li HF, Liu YJ, Cheng LQ, Li ZL, Wang JL, Qi W, et al. Diagnostic value of MRI and MR arthrography in the detection of injuries of anterior labrum in shoulder. Zhongguo Gu Shang. 2012;25(5):413–7.

    PubMed  Google Scholar 

  42. 42.

    Vogel LA, Moen TC, Macaulay AA, Arons RR, Cadet ER, Ahmad CS, et al. Superior labrum anterior-to-posterior repair incidence: a longitudinal investigation of community and academic databases. J Shoulder Elb Surg. 2014;23(6):e119–26.

    Google Scholar 

  43. 43.

    Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6(4):274–9.

    CAS  PubMed  Google Scholar 

  44. 44.

    Barile A, Lanni G, Conti L, Mariani S, Calvisi V, Castagna A, et al. Lesions of the biceps pulley as cause of anterosuperior impingement of the shoulder in the athlete: potentials and limits of MR arthrography compared with arthroscopy. Radiol Med. 2013;118(1):112–22.

    CAS  PubMed  Google Scholar 

  45. 45.

    Genovese E, Spano E, Castagna A, Leonardi A, Angeretti MG, Callegari L, et al. MR-arthrography in superior instability of the shoulder: correlation with arthroscopy. Radiol Med. 2013;118(6):1022–33.

    PubMed  Google Scholar 

  46. 46.

    De Filippo M, Araoz PA, Pogliacomi F, Castagna A, Petriccioli D, Sverzellati N, et al. Recurrent superior labral anterior-to-posterior tears after surgery: detection and grading with CT arthrography. Radiology. 2009;252(3):781–8.

    PubMed  Google Scholar 

  47. 47.

    Ek ET, Shi LL, Tompson JD, Freehill MT, Warner JJ. Surgical treatment of isolated type II superior labrum anterior-posterior (SLAP) lesions: repair versus biceps tenodesis. J Shoulder Elb Surg. 2014;23(7):1059–65.

    Google Scholar 

  48. 48.

    Wijdicks CA, Anavian J, Hill BW, Armitage BM, Vang S, Cole PA. The assessment of scapular radiographs: analysis of anteroposterior radiographs of the shoulder and the effect of rotational offset on the glenopolar angle. Bone Joint J. 2013;95-B(8):1114–20.

    CAS  PubMed  Google Scholar 

  49. 49.

    Wagner E, Arditi D, Guerne PA, Lanier C. Diagnostic imaging for atraumatic shoulder pain. Rev Med Suisse. 2013;9(399):1726–31.

    CAS  PubMed  Google Scholar 

  50. 50.

    Murachovsky J, Bueno RS, Nascimento LG, Almeida LH, Strose E, Castiglia MT, et al. Calculating anterior glenoid bone loss using the Bernageau profile view. Skelet Radiol. 2012;41(10):1231–7.

    Google Scholar 

  51. 51.

    Woertler K, Waldt S. MR imaging in sports-related glenohumeral instability. Eur Radiol. 2006;16(12):2622–36.

    PubMed  PubMed Central  Google Scholar 

  52. 52.

    Steinbach LS. Magnetic resonance imaging of glenohumeral joint instability. Semin Musculoskelet Radiol. 2005;9(1):44–55.

    PubMed  Google Scholar 

  53. 53.

    Hodler J, Kursunoglu-Brahme S, Snyder SJ, Cervilla V, Karzel RP, Schweitzer ME, et al. Rotator cuff disease: assessment with MR arthrography versus standard MR imaging in 36 patients with arthroscopic confirmation. Radiology. 1992;182(2):431–6.

    CAS  PubMed  Google Scholar 

  54. 54.

    Tian CY, Cui GQ, Zheng ZZ, Ren AH. The added value of ABER position for the detection and classification of anteroinferior labroligamentous lesions in MR arthrography of the shoulder. Eur J Radiol. 2013;82(4):651–7.

    PubMed  Google Scholar 

  55. 55.

    Song HT, Huh YM, Kim S, Lee SA, Kim SJ, Shin KH, et al. Anterior-inferior labral lesions of recurrent shoulder dislocation evaluated by MR arthrography in an adduction internal rotation (ADIR) position. J Magn Reson Imaging. 2006;23(1):29–35.

    PubMed  Google Scholar 

  56. 56.

    Kreitner KF, Botchen K, Rude J, Bittinger F, Krummenauer F, Thelen M. Superior labrum and labral-bicipital complex: MR imaging with pathologic-anatomic and histologic correlation. AJR Am J Roentgenol. 1998;170(3):599–605.

    CAS  PubMed  Google Scholar 

  57. 57.

    Bowen MK, Warren RF. Ligamentous control of shoulder stability based on selective cutting and static translation experiments. Clin Sports Med. 1991;10(4):757–82.

    CAS  PubMed  Google Scholar 

  58. 58.

    Zlatkin MB, Sanders TG. Magnetic resonance imaging of the glenoid labrum. Radiol Clin N Am. 2013;51(2):279–97.

    PubMed  Google Scholar 

  59. 59.

    Chandnani VP, Yeager TD, DeBerardino T, Christensen K, Gagliardi JA, Heitz DR, et al. Glenoid labral tears: prospective evaluation with MRI imaging, MR arthrography, and CT arthrography. AJR Am J Roentgenol. 1993;161(6):1229–35.

    CAS  PubMed  Google Scholar 

  60. 60.

    Palmer WE, Brown JH, Rosenthal DI. Labral-ligamentous complex of the shoulder: evaluation with MR arthrography. Radiology. 1994;190(3):645–51.

    CAS  PubMed  Google Scholar 

  61. 61.

    Beltran J, Bencardino J, Mellado J, Rosenberg ZS, Irish RD. MR arthrography of the shoulder: variants and pitfalls. Radiographics. 1997;17(6):1403–12 discussion 12-5.

    CAS  PubMed  Google Scholar 

  62. 62.

    Motamedi D, Everist BM, Mahanty SR, Steinbach LS. Pitfalls in shoulder MRI: part 1--normal anatomy and anatomic variants. AJR Am J Roentgenol. 2014;203(3):501–7.

    PubMed  Google Scholar 

  63. 63.

    Westrick RB, Fogarty BT, Johnson MP. Posterior labral tear with a paralabral cyst causing suprascapular nerve compression. J Orthop Sports Phys Ther. 2013;43(7):511.

    PubMed  Google Scholar 

  64. 64.

    Limbucci N, Rossi F, Salvati F, Pistoia LM, Barile A, Masciocchi C. Bilateral suprascapular nerve entrapment by glenoid labral cysts associated with rotator cuff damage and posterior instability in an amateur weightlifter. J Sports Med Phys Fitness. 2010;50(1):64–7.

    CAS  PubMed  Google Scholar 

  65. 65.

    Rhee RB, Chan KK, Lieu JG, Kim BS, Steinbach LS. MR and CT arthrography of the shoulder. Semin Musculoskelet Radiol. 2012;16(1):3–14.

    PubMed  Google Scholar 

  66. 66.

    O'Connell PW, Nuber GW, Mileski RA, Lautenschlager E. The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint. Am J Sports Med. 1990;18(6):579–84.

    CAS  PubMed  Google Scholar 

  67. 67.

    Faletti C, De Filippo M, Giudice G, Larciprete M, Seccia A, Regis G. Fibro-cartilaginous lesions of the glenoid labrum in shoulder instability: a proposed classification using sagittal-oblique arthro-MRI. Radiol Med. 2002;104(1–2):68–74.

    CAS  PubMed  Google Scholar 

  68. 68.

    Chandnani VP, Gagliardi JA, Murnane TG, Bradley YC, DeBerardino TA, Spaeth J, et al. Glenohumeral ligaments and shoulder capsular mechanism: evaluation with MR arthrography. Radiology. 1995;196(1):27–32.

    CAS  PubMed  Google Scholar 

  69. 69.

    Palmer WE, Caslowitz PL. Anterior shoulder instability: diagnostic criteria determined from prospective analysis of 121 MR arthrograms. Radiology. 1995;197(3):819–25.

    CAS  PubMed  Google Scholar 

  70. 70.

    Willemsen UF, Wiedemann E, Brunner U, Scheck R, Pfluger T, Kueffer G, et al. Prospective evaluation of MR arthrography performed with high-volume intraarticular saline enhancement in patients with recurrent anterior dislocations of the shoulder. AJR Am J Roentgenol. 1998;170(1):79–84.

    CAS  PubMed  Google Scholar 

  71. 71.

    Hajek PC, Sartoris DJ, Neumann CH, Resnick D. Potential contrast agents for MR arthrography: in vitro evaluation and practical observations. AJR Am J Roentgenol. 1987;149(1):97–104.

    CAS  PubMed  Google Scholar 

  72. 72.

    Radwan A, Francis J, Green A, Kahl E, Maciurzynski D, Quartulli A, et al. Is there a relation between shoulder dysfunction and core instability? Int J Sports Phys Ther. 2014;9(1):8–13.

    PubMed  PubMed Central  Google Scholar 

  73. 73.

    Noonan B, Hollister SJ, Sekiya JK, Bedi A. Comparison of reconstructive procedures for glenoid bone loss associated with recurrent anterior shoulder instability. J Shoulder Elb Surg. 2014;23(8):1113–9.

    Google Scholar 

  74. 74.

    De Filippo M, Bertellini A, Sverzellati N, Pogliacomi F, Costantino C, Vitale M, Zappia M, Corradi D, Garlaschi G, Zompatori. Multidetector computed tomography arthrography of the shoulder: diagnostic accuracy and indications. Acta Radiol. 2008 Jun;49(5):540–9. https://doi.org/10.1080/02841850801935559

  75. 75.

    De Filippo M, Castagna A, Steinbach LS, Silva M, Concari G, Pedrazzi G, et al. Reproducible noninvasive method for evaluation of glenoid bone loss by multiplanar reconstruction curved computed tomographic imaging using a cadaveric model. Arthroscopy. 2013;29(3):471–7.

    PubMed  Google Scholar 

  76. 76.

    Provencher MT, Bhatia S, Ghodadra NS, Grumet RC, Bach BR Jr, Dewing CB, et al. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am. 2010;92(Suppl 2):133–51.

    PubMed  Google Scholar 

  77. 77.

    Waldt S, Burkart A, Imhoff AB, Bruegel M, Rummeny EJ, Woertler K. Anterior shoulder instability: accuracy of MR arthrography in the classification of anteroinferior labroligamentous injuries. Radiology. 2005;237(2):578–83.

    PubMed  Google Scholar 

  78. 78.

    Skupinski J, Piechota MZ, Wawrzynek W, Maczuch J, Babinska A. The bony Bankart lesion: how to measure the glenoid bone loss. Pol J Radiol. 2017;82:58–63.

    PubMed  PubMed Central  Google Scholar 

  79. 79.

    De Filippo M, Saba L, Negrini G, Silva M, Pedrazzi G, Pogliacomi F, et al. Inter-observer agreement of CT measurement of the glenoid bone surface by the CT Pico method: comparison with laser in a cadaveric model. Skelet Radiol. 2015;44(10):1491–7.

    Google Scholar 

  80. 80.

    Ahmad CS, Freehill MQ, Blaine TA, Levine WN, Bigliani LU. Anteromedial capsular redundancy and labral deficiency in shoulder instability. Am J Sports Med. 2003;31(2):247–52.

    PubMed  Google Scholar 

  81. 81.

    Huijsmans PE, Haen PS, Kidd M, Dhert WJ, van der Hulst VP, Willems WJ. Quantification of a glenoid defect with three-dimensional computed tomography and magnetic resonance imaging: a cadaveric study. J Shoulder Elb Surg. 2007;16(6):803–9.

    Google Scholar 

  82. 82.

    Gyftopoulos S, Beltran LS, Yemin A, Strauss E, Meislin R, Jazrawi L, et al. Use of 3D MR reconstructions in the evaluation of glenoid bone loss: a clinical study. Skelet Radiol. 2014;43(2):213–8.

    Google Scholar 

  83. 83.

    Barile A, Bruno F, Mariani S, Arrigoni F, Reginelli A, De Filippo M, et al. What can be seen after rotator cuff repair: a brief review of diagnostic imaging findings. Musculoskelet Surg. 2017;101(Suppl 1):3–14.

    CAS  PubMed  Google Scholar 

  84. 84.

    De Filippo M, Pesce A, Barile A, Borgia D, Zappia M, Romano A, et al. Imaging of postoperative shoulder instability. Musculoskelet Surg. 2017;101(Suppl 1):15–22.

    PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Massimo De Filippo.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

ESM 1

(PNG 170 kb)

ESM 2

(PNG 86 kb)

ESM 3

(PNG 188 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

De Filippo, M., Schirò, S., Sarohia, D. et al. Imaging of shoulder instability. Skeletal Radiol 49, 1505–1523 (2020). https://doi.org/10.1007/s00256-020-03459-z

Download citation

Keywords

  • Shoulder instability
  • Magnetic resonance arthrography
  • Computed tomography arthrography
  • Shoulder anatomic variant