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    A Case of Anterior Shoulder Instability with Labral Tear

    When a 17-year-old patient is diagnosed with recurrent posterior subluxation, posterior shoulder instability, and labral tear without significant capsular laxity, the author recommends arthroscopic repair.

    Author

    Steven B. Cohen, MD

    Disclosures

    The author has no disclosures relevant to this article.

    Background

    Anterior instability of the shoulder is commonly associated with the young, active patient. A careful history, detailed physical examination, and utilization of advanced imaging often lead to an accurate diagnosis.

    For patients who are high-level recreational or competitive athletes, or patients who have functional instability with activities of daily living, arthroscopic repair can restore normal glenohumeral translation, improve pain, and optimally restore performance.

    The following case example illustrates a classic presentation of a patient who had recurrent anterior instability and underwent successful treatment via arthroscopic repair.

    Case Presentation

    Patient History

    A 17-year-old high school student presented 2 weeks after injuring his non-dominant left shoulder when he fell backwards while skiing. While his arm was away from his body, he felt it “pop out.” He stated that his shoulder “popped back in” when he rolled over.  Other than having a “loose joint,” he did not have any prior injury to his left shoulder.

    Following the injury, he felt his shoulder “slide out” again when he grabbed for the railing as he was walking down the stairs. He went to an emergency department when this happened. Radiographs were negative for a fracture and he was placed in a sling.

    Physical Examination

    • Inspection of both shoulders reveals no asymmetry or atrophy.
    • Palpation demonstrates mild anterior capsular tenderness.
    • Range of motion, both supine and elevated, is symmetric and full.
    • Strength testing of the rotator cuff musculature is 5/5 in all planes.
    • Provocative testing demonstrates:
      • Negative Neer and Hawkins impingement signs
      • Negative O’Brien’s active compression test
      • Positive apprehension and relocation tests
      • Pain with anterior load and shift test with 2+ laxity
      • Negative sulcus sign and posterior load and shift

    Differential Diagnosis

    • Superior labral anterior posterior tear (SLAP)
    • Anterior glenohumeral instability
    • Humeral avulsion of the glenohumeral ligament (HAGL)
    • Multi-directional instability (MDI)

    Imaging

    Radiographs

    • Normal (anteroposterior, Y, axillary, and Zanca views)
    • No obvious Hill-Sach’s lesion or bony Bankart

    MRI arthrography

    • Evidence of an anterior labral tear
    • No superior or posterior labral or rotator cuff pathology
    • No bony defects of the humeral head or glenoid

    Diagnosis

    • Recurrent posterior subluxation, posterior shoulder instability, and labral tear without significant capsular laxity.

    Treatment

    The patient underwent left shoulder arthroscopy with anterior labral repair and capsular shift (Video 1). 

    • Arthroscopy was performed in stepwise fashion in the beach-chair position with interscalene nerve block and general anesthesia. 
    • A posterior portal and two anterior arthroscopic working portals were established, and 7-mm (anteroinferior) and 5.5-mm (anterosuperior) cannulas were placed for easy access of arthroscopic instrumentation. 
    • A detailed arthroscopic examination was performed and the labral tear was identified. 
    • The labrum was then elevated off the anterior margin of the glenoid and the bone edge was slightly debrided with an arthroscopic shaver or burr. 
    • Once the labrum was adequately mobilized, 3.0-mm anchors were placed along the anterior glenoid face for arthroscopic fixation. 
    • The anterior suture limb of the anchor was passed through the labrum and capsule complex with a suture hook device (using standard shuttling techniques) to restore the labrum to the glenoid articular margin. 
    • Each suture anchor was then tied using arthroscopic knot tying techniques. 
    • This sequence was repeated until the labrum was completely repaired. Anchors are typically spaced 3 to 5 mm apart to allow for adequate bone bridge between fixation points. 

    Video 1. Click the player above to activate the video. The surgery is performed in the beach chair position. A diagnostic arthroscopy is performed initially, evaluating all intraarticular structures. The anterior labral tear and capsule are freed off the glenoid rim with an elevator. Three absorbable anchors are used to perform the labral repair and capsular shift, starting with the most inferior anchor at the 7 o’clock position. After a suture passer is utilized to repair the capsule and labrum from inferior to superior, subsequent anchors are sequentially placed at the 8 o’clock and 9 o’clock positions. The final repair and stability are assessed.

    Postoperative Management

    • The patient was placed in a well-padded postoperative sling and abduction pillow. Early passive range of motion of the shoulder was allowed and continued for 4 weeks. 
    • At 4 weeks, the patient began active assisted and active range of motion. When range of motion was nearly 80% of the contralateral shoulder, the patient started a light-strengthening program, which was then advanced based on his tolerance and ability. 
    • Most patients are allowed to return to competitive sport between 4 and 6 months after surgery. Patients who are overhead throwing athletes begin a structured throwing program during this time and are advanced with the prospect of full throwing by 7 to 10 months after surgery.
    • This patient presented for a 1-year follow-up with full range of motion and no sense of instability. He reported no pain in his shoulder and full participation in all athletics. He was then discharged from care.

    Discussion

    Anterior shoulder instability is a commonly recognized source of shoulder pain and dysfunction. Patients often present with specific symptoms or episodes of instability, as well as pain associated with these events.

    Anterior instability is common in contact sports such as football, wrestling, rugby, and hockey; however, it also occurs in other non-contact sports. High-resolution MRI arthrography combined with specific awareness has led to more accurate diagnosis in this patient population.

    Although physical therapy can be the initial treatment for many patients, it is not typically successful for the athlete who wishes to resume competitive sport, especially in those younger than age 20 at the time of their initial instability event.

    Many studies have shown excellent results with arthroscopic repair in high-demand, competitive athletes, with low rates of recurrence and low morbidity [2,3]. Arthroscopy has become the gold standard to treat most patients with anterior instability and subluxation, except in cases of glenoid or humeral osseous deficiency [1,4].

    Author Information

    Steven B. Cohen, MD, is from The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. He specializes in sports medicine surgery.

    Sports Medicine Section Editor, Rothman Institute Grand Rounds

    Fotios Paul Tjoumakaris, MD

    References

    1. Boileau P, Thélu CÉ, Mercier N, et al. Arthroscopic Bristow-Latarjet combined with bankart repair restoresshoulder stability in patients with glenoid bone loss. Clin Orthop Relat Res. 2014 Aug;472(8):2413-24.
    2. Godin J, Sekiya JK. Systematic review of arthroscopic versus open repair for recurrent anterior shoulder dislocations. Sports Health. 2011 Jul;3(4):396-404.
    3. Harris JD, Gupta AK, Mall NA, et al. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy. 2013 May;29(5):920-33.
    4. Streubel PN, Krych AJ, Simone JP, et al. Anteriorglenohumeral instability: a pathology-based surgical treatment strategy. J Am Acad Orthop Surg. 2014 May;22(5):283-94.