Imaging, 23 (2014), 20110084

MUSCULOSKELETAL IMAGING

Glenohumeral instability
C L MCCARTHY, MB ChB, FRCR

Radiology Department, Nuffield Orthopaedic Centre, Oxford, UK

Summary
Normal anatomical variants:
s Sublabral foramen
s Sublabral recess
s Buford complex
s Capsular insertions
Shoulder instability:
s Anterior glenohumeral instability
Anteroinferior labral tear
s Bankart lesion
s Anterior labroligamentous periosteal sleeve avulsion lesion
s Perthes lesion
s Glenolabral articular disruption lesion
Extensive anterior labral tear
Anterosuperior labral tear
Glenohumeral ligament injury
doi: 10.1259/img.20110084
s SLAP lesion
s Posterior glenohumeral instability 2014 The Author. Published by
s Posterior superior glenoid impingement the British Institute of Radiology

Cite this article as: McCarthy CL. Glenohumeral instability. Imaging 2014;23:20110084

Abstract. MR arthrography is useful in diagnosing and
characterizing the labralligamentous lesions resulting in
glenohumeral instability. The sublabral foramen, sublabral
recess and Buford complex are normal variants of the glenoid
labrum, which must not be confused with true labral
abnormalities. The most common type of glenohumeral
instability is anteroinferior instability, characterized by
avulsion of the anteroinferior labralligamentous complex,
which is termed a Bankart lesion. Variants of the Bankart
lesion, where the scapular periosteum remains intact, are the
anterior labroligamentous periosteal sleeve avulsion lesion,
the Perthes lesion and the glenolabral articular disruption
lesion. Anterosuperior labral tears are uncommon and must
be differentiated from a normal sublabral foramen. Anterior
glenohumeral instability also occurs following injury to the
glenohumeral ligaments, most commonly described as
humeral avulsion of the inferior glenohumeral ligament
lesion. The superior labral anteroposterior (SLAP) lesion is
a superior labral tear that extends both anterior and posterior
to the biceps tendon attachment. SLAP lesions have
Address correspondence to: Dr Catherine L. McCarthy. E-mail:
catherinemccarthy@doctors.org.uk
a complex classification but the presence and the extent of
biceps tendon involvement is the most important feature. A
SLAP II lesion must be distinguished from a normal
sublabral recess. Patterns of injury seen in posterior
instability are the reverse of those found following anterior
dislocation with posterior labral tears referred to as a reverse
Bankart lesion. Posterior superior glenoid impingement or
internal impingement is when the posterosuperior aspect of
the glenoid and the humeral head come into contact, causing
injury to the interposed rotator cuff and posterosuperior
labrum.
Glenohumeral instability refers to symptomatic sub-
luxation or dislocation of the humeral head in relation to
the glenoid fossa. The combination of the glenoid la-
brum, the superior, middle and inferior glenohumeral
ligaments is referred to as the labralligamentous com-
plex. This complex functions as a static stabilizer of the
shoulder joint by anchoring the humerus to the glenoid
rim. The labralligamentous complex is commonly in-
jured in young patients with instability leading to
a spectrum of abnormalities that may be shown using
MRI.

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Classification
The most common classification of shoulder instability
is traumatic and atraumatic. Differentiation between
these types can have implications in patient management.
Traumatic instability is the most common entity, re-
ferred to as TUBS (traumatic, unidirectional, Bankart and
surgical), which is characterized by a history of trauma
resulting in unilateral, unidirectional, anteroinferior in-
stability, commonly associated with a Bankart lesion that
usually requires surgical intervention. MRI is valuable in
this group to identify labroligamentous pathology.
Atraumatic instability can be related to microtrauma,
referred to as AIOS (acquired, instability, overstress and
surgery), or be part of a multidirectional instability syn-
drome referred to as AMBRI lesions (atraumatic, multi-
directional, bilateral, rehabilitation and inferior capsule
shift). AIOS injuries are mostly seen in athletic patients
with repetitive overhead activity. This pattern of injury is
also called microinstability.1 AMBRI injuries usually in-
volve both glenohumeral joints and are believed to be the
result of atraumatic ligamentous and capsular laxity. No
labral pathology is usually present at MRI. Treatment is
rehabilitation with muscle-strengthening exercises, fol-
lowed by inferior capsular shift if conservative treatment
fails.
Imaging technique
MR arthrography is the examination of choice in gleno-
humeral instability, providing excellent depiction of
associated intra-articular lesions.
Shoulder arthrography
Injection of the glenohumeral joint with a dilute
gadolinium solution is achieved under fluoroscopic or
sonographic guidance. The puncture approach ideally
avoids the site of instability. Thus, with anterior in-
stability, a posterior approach is favoured as contrast
leakage with an anterior approach may make interpre-
tation of pathology more difficult. At fluoroscopy, intra-
articular position is confirmed with a small amount of
iodinated contrast. Iodinated and gadolinium-based
contrast material can be safely mixed for MR arthrog-
raphy. At 3 T, the amount of iodinated contrast agent
should be minimized because signal-to-noise ratio peak
levels for iodinated contrast are lower at 3 T than at
1.5 T.2 Generally, 0.1 ml gadolinium/diethylene triamine
pentaacetic acid in approximately 20 ml of saline dilution
is used. About 1215 ml of contrast generally provides
adequate distension of the glenohumeral joint. Care must
be taken not to inject air into the joint as the resultant
artefact can simulate loose intra-articular bodies. Fol-
lowing injection, the patient is allowed only limited arm
movement, and MRI must be performed within 45 min to
prevent absorption of contrast and loss of articular
distension.3
MRI technique
The patient is positioned in the MR magnet in the su-
pine position with the arm at the side in mild external
rotation to optimize visualization of the glenohumeral
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CL McCarthy
ligaments and rotator cuff. A dedicated shoulder surface
coil is used with a small (1416 cm) field of view, at least
a 256 3 256 matrix and slice thickness of 3 mm. Imaging
is obtained in true axial, oblique coronal and oblique
sagittal planes. The initial axial sequence acts as a local-
izer for the oblique planes. The coronal oblique images
are acquired parallel to the supraspinatus tendon and the
sagittal oblique images parallel to the articular surface of
the glenoid fossa.
With the increasing use of 3-T MRI, studies have
addressed whether intra-articular contrast is in fact nec-
essary. In a study on 150 consecutive shoulder examina-
tions in patients aged 50 years or younger, both 3-T MRI
and MR arthrography were performed and correlated
with arthroscopy. MR arthrography had a statistically
increased sensitivity for the detection of anterior labral
tears (98% vs 83%) and superior labral anteroposterior
(SLAP) tears (98% vs 83%), altering management in 15
cases of labral pathology. There was no significant dif-
ference in the detection of posterior labral tears nor in the
specificity of any lesions.4 A more recent study also
confirmed the superior sensitivity of MR arthrography
compared with conventional 3-T MRI in the detection of
anterior labral tears (100% vs 60%).5
Similarly, the use of 3-T MRI has revisited the per-
formance of indirect arthrography, which is considered
to be less invasive than direct arthrography. A recent
study found similar performance of direct and indirect
MR arthrography at 3 T for the diagnosis of labral
lesions. For anterior labral tears, the sensitivity was
100% for both techniques, the specificity was 100% for
direct MR arthrography and ranged from 83% to 100%
for indirect MR arthrography. The study was, however,
limited by the small number of patients (19 with ar-
throscopic confirmation).6
MRI sequences
T1 weighted spin echo images with fat saturation
obtained in a true axial, oblique coronal and oblique
sagittal plane are the key imaging sequences. These
provide optimal visualization of the glenoid labrum,
glenohumeral ligaments, articular cartilage and rotator
interval.
A non-fat-saturated T1 weighted sequence should be
obtained to look for bone involvement. This is usually an
axial T1 weighted spin echo sequence, which is particu-
larly valuable to identify bony Bankart lesions, which are
not always clearly seen on fat-saturated images.
The coronal oblique sequence is repeated using a fast
short tau inversionrecovery or proton density sequence
with fat saturation. This is particularly important if the
patient presents with pain in addition to instability to
look for rotator cuff pathology, bone marrow oedema
and extra-articular fluid collections including paralabral
cysts.
The abducted and externally rotated (ABER) position
may be used in patients who can tolerate it and whose
clinical presentation warrants it. The patient is reposi-
tioned with the palm resting under the neck, placing the
arm in abduction and external rotation. If this position is
difficult, the hand may be placed above the head with
the elbow flexed. In this position, a true coronal localizer
Imaging 2014, 23, 20110084
Glenohumeral instability
is obtained. Oblique axial images are then acquired
parallel to the long axis of the humeral shaft. The ABER
position places the anterior band of the inferior gleno-
humeral ligament (IGHL) into tension, which stresses
the anteroinferior labrum and increases the sensitivity in
detecting anterior labral tears. Several studies have
shown that imaging in the ABER position is more ac-
curate in detecting and revealing the extent of an ante-
rior labral tear than conventional axial MR arthrograms
obtained with the arm in the neutral position.710 The ABER
position also kinks the rotator cuff, so the humeral head no
longer effaces the articular surface of the tendons. This
reduced tension allows intra-articular contrast to flow
more easily along the articular surface of the tendons, in-
creasing the detection of articular-sided partial thickness
tendon tears (Figure 1).
Virtual MR arthroscopy has been described in a few
reports using three-dimensional gradient echo sequences.
This can be used as an adjunct tool to MR arthrography
in assessment of labral tears by providing visual in-
formation similar to arthroscopy.11
Normal anatomy and variants
Glenoid labrum
The glenoid labrum is a fibrocartilaginous structure
that is situated along the periphery of the glenoid fossa
and demonstrates low signal intensity on all imaging
sequences. It increases the depth of the glenoid fossa and
serves as the site of attachment for the long head of biceps
Figure 1. Abducted and externally rotated image. Axial
oblique image parallel to the long axis of the humeral shaft
demonstrates the anterior band of the inferior glenohumeral
ligament (arrowhead) and the anteroinferior labrum (black
arrow). The articular surface of the rotator cuff (white arrow)
is no longer effaced by the humeral head.
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tendon and the glenohumeral ligaments. A number of
normal variants described in relation to the labrum must
not be confused with true labral abnormalities. If the
glenoid articular surface is viewed as the face of a clock,
most of the normal anatomical variants occur at the
113 oclock positions, involving the anterosuperior por-
tion of the labrum. Pathological findings associated with
anterior glenohumeral joint instability usually occur at
the 36 oclock position.
A sublabral foramen represents normal localized
detachment of the anterosuperior labrum from the
glenoid1,1217 at the 2 oclock position, anterior to the
biceps tendon attachment13 (Figure 2). A normal sublabral
foramen is present in approximately 10% of subjects1,18
and may be difficult to distinguish from an anterosuperior
labral tear at MR arthrography.
The sublabral recess refers to a normal synovial re-
flection between the cartilage of the glenoid cavity
and the superior labrum1216 located at the 12 oclock
position, at the site of the attachment of the biceps ten-
don13 (Figure 3). The sublabral recess may be continu-
ous with a sublabral foramen.13 This variant may be
misinterpreted as a SLAP tear (SLAP II lesion) at MR
arthrography.
The Buford complex is made up of a congenitally absent
anterosuperior labrum in association with a thickened
cord-like middle glenohumeral ligament (MGHL).1,1217,19
It is present in 1.26.5% of subjects.1 Axial MR images
obtained at the level of the superior half of the glenoid
depict the cross-section of the thickened MGHL close
to the anterior glenoid margin, which has an absent la-
brum (Figure 4). This combination of findings simulates
the appearance of an avulsed anterior labral fragment.15
Recognition that the apparent detachment is the
thickened MGHL is best identified in the oblique sag-
ittal plane and should aid in avoiding this pitfall.14,15 In
addition, the biceps anchor and sites of insertion of the
superior glenohumeral ligament (SGHL) and MGHLs
are normal.14,19
Figure 2. Sublabral foramen. Coronal oblique T1 weighted
spin echo MR arthrogram with fat saturation shows intra-
articular contrast extending between the anterosuperior
labrum (arrowhead) and the glenoid margin, reflecting
a normal sublabral foramen (arrow).
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Figure 3. Sublabral recess. Coronal oblique T1 weighted spin
echo MR arthrogram with fat saturation shows intra-articular
contrast extending medially into a normal sublabral recess
(arrow), between the glenoid and superior labrum at the
12 oclock position. The superior labrum maintains a normal
triangular configuration with a sharp free edge and contains
no abnormal signal within its substance.
Glenohumeral ligaments
The glenohumeral ligaments are thickenings of the gleno-
humeral joint capsule that act as tension bands and appear
as hypointense linear bands in MR arthrography.
The SGHL arises from the superior labrum between
the 12 and 1 oclock positions, just anterior to the origin
of the biceps tendon. It extends anteriorly parallel to
the coracoid process (Figure 5) and blends with the
coracohumeral ligament before inserting onto the superior
aspect of the lesser tuberosity. The SGHL and cor-
acohumeral ligament traverse the rotator interval, located
Figure 4. Buford complex. Axial T1 weighted spin echo MR
arthrogram with fat saturation illustrates a thickened cord-
like middle glenohumeral ligament (arrow) adjacent to the
anterosuperior glenoid rim with a congenitally absent
labrum. This combination of findings constitutes a normal
Buford complex and must not be confused with an avulsed
anterior labral fragment.
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CL McCarthy
Figure 5. Superior glenohumeral ligament (SGHL). Axial T1
weighted spin echo MR arthrogram with fat saturation
demonstrates a normal SGHL (arrow) extending parallel to
the coracoid process (C). The SGHL and coracohumeral
ligament form a sling around the intra-articular portion of
the long head of biceps tendon in the rotator interval.
in the space between the subscapularis and supraspinatus
tendons, where they form a sling around the intra-
articular portion of the long head of the biceps tendon.
The SGHL demonstrates variability in size and origin; it
may arise alone, with the MGHL or with the biceps ten-
don. The SGHL is absent in 10% of patients and is nor-
mally thin. When thicker, the MGHL tends to be absent
or thin.1,13,16,20
The MGHL varies the most in size and site of origin. It
arises from the anterosuperior aspect of the labrum, where
it may arise alone or combine with either the SGHL or
IGHL. It has an oblique orientation coursing inferiorly
adjacent to the glenoid rim and merges with the sub-
scapularis tendon before inserting medial to the lesser tu-
berosity (Figure 6). It may be absent in up to 30% of cases.
Duplication of the MGHL has been reported although
Figure 6. Middle glenohumeral ligament (MGHL). Axial T1
weighted spin echo MR arthrogram with fat saturation
demonstrates a normal MGHL (arrowhead) coursing beneath
the subscapularis tendon (arrow) before inserting medial to
the lesser tuberosity.
Imaging 2014, 23, 20110084
Glenohumeral instability
whether this represents a true normal variant or old lon-
gitudinal split tear is controversial.1,13,16,20
The IGHL consists of a thicker anterior band, a poste-
rior band and an interposed axillary recess. The bands
extend from the anteroinferior and posteroinferior
aspects of the labrum, respectively, to the surgical neck of
the humerus where the insertion has a fan-shaped ap-
pearance (Figure 7). The anterior IGHL may arise be-
tween the 2 and 5 oclock positions but is most commonly
visualized from the 3 oclock position. With the arm in
the ABER position, the anterior band of the glenohumeral
ligament becomes taut and can be visualized in almost its
entire extension (Figure 1). Injuries to the anterior band
are more likely to be associated with clinically evident
instability as this band is the single most important sta-
bilizer of the glenohumeral joint and should receive
careful attention during MR image analysis.1,13,16,20
Capsule
Variations in the anterior capsular insertions have been
described. Insertion at the glenoid margin is known as
Type I, Type II refers to insertion at the glenoid neck
within 1 cm of the labral base and Type III describes an
insertion on the scapula .1 cm medial to the labral
base.1417 It was generally believed that the further the
capsule attaches from the anterior glenoid margin, the
more unstable the joint; however, these insertion types
are currently not thought to correlate with clinically sig-
nificant instability and should be viewed with caution in
the absence of other signs. In addition, an overdistended
capsule at MR arthrography may produce prominent
anterior and posterior recesses, falsely simulating a Type
III insertion and capsular laxity.21
By contrast, the posterior capsule should always insert
on the glenoid rim and the presence of fluid or contrast
medial to the rim is indicative of capsular stripping and
posterior instability.22
Figure 7. Inferior glenohumeral ligament (IGHL). Axial T1
weighted spin echo MR arthrogram with fat saturation
demonstrates the anterior (arrow) and posterior (arrowheads)
bands of the IGHL, extending from the inferior labrum to the
surgical neck of the humerus. The anterior band of the IGHL is
the single most important stabilizer of the glenohumeral
joint.
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Shoulder instability
Anterior glenohumeral instability
Anteroinferior labral tear
Anteroinferior instability is the most common type
to involve the glenohumeral joint, occurring in 95% of
patients,12,16,17 and is seen secondary to anteroinferior
dislocation or subluxation, which produces a constel-
lation of lesions. Avulsion of the labralligamentous
complex from the anteroinferior aspect of the glenoid,
with complete disruption of the scapular periosteum, is
termed a fibrous or soft-tissue Bankart lesion1,12,1417,21
(Figure 8). As the labrum is completely separated from
the glenoid, it may migrate from its normal site of at-
tachment. With time, this displaced tissue may scar
into a rounded shape, which is known as a glenoid
labrum ovoid mass or GLOM.1 The presence of an as-
sociated adjacent anteroinferior glenoid rim fracture is
referred to as an osseous or bony Bankart lesion. Quanti-
fication of bony Bankart lesions is clinically important as
bone loss of .25% of the glenoid width, which typically
gives the glenoid an inverted pear shape, requires
open bone grafting to prevent recurrent disloca-
tion.23,24 A HillSachs impaction deformity or fracture
involving the posterosuperior humeral head is a fre-
quently associated finding.1,12,1417,21 HillSachs lesions
are found at the uppermost part of the humeral head,
above the level of the coracoid process, and should be
differentiated from a normal humeral groove, which is
located distal to the typical impaction site.
A number of variants of the Bankart lesion, where the
periosteum remains intact, have been described.1 The
anterior labroligamentous periosteal sleeve avulsion le-
sion is characterized by the torn anteroinferior labrum
being displaced inferomedially by the IGHL and rolling up
like a sleeve (Figure 9). The displaced labrum remains at-
tached to the scapula via an intact anterior scapular
periosteum. 1,12,1417,21 Using the sleeve analogy, the
Figure 8. Fibrous Bankart lesion. Axial T1 weighted spin echo
MR arthrogram with fat saturation, at the level of the
inferior glenoid labrum, demonstrates an avulsed displaced
anteroinferior labrum (arrow), with complete disruption of
the scapular periosteum, which constitutes the fibrous
Bankart lesion.
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Figure 9. Anterior labroligamentous periosteal sleeve avul-
sion (ALPSA) lesion. Axial T1 weighted spin echo MR arthro-
gram with fat saturation of an ALPSA lesion. The torn
anteroinferior labrum (arrow) remains attached to the
scapula via an intact anterior scapular periosteum and can
be seen displaced inferomedially, rolled up like a sleeve on
the scapular neck.
labrum and glenohumeral ligament are the shirt cuff,
which rolls along the periosteum that acts as a sleeve,
similar to rolling up a shirt sleeve as on a hot day.
Healing by fibrosis may occur in an abnormal anatom-
ical location, leaving a deformed and redundant
labrum.1416,21 The Perthes lesion represents a non-
displaced avulsed anteroinferior labrum with medial
stripping but not disruption of the scapular periosteum
(Figure 10). The periosteum is intact but redundant
and recurrent anterior instability may occur as the
humeral head moves into this lax portion of the joint.
As the avulsed labrum is not displaced, this lesion
Figure 10. Perthes lesion. Axial T1 weighted spin echo MR
arthrogram with fat saturation shows an undisplaced
avulsed anteroinferior labrum (arrow) with medial stripping
of an intact scapular periosteum (arrowhead) consistent
with a Perthes lesion. This lesion is better visualized when
stress is applied, such as during abduction and external
rotation.
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CL McCarthy
may not be detected at standard MRI, including MR
arthrography.1,10,12,14,16,17 Imaging in the ABER posi-
tion, which stretches the IGHL and its labral attach-
ment, may result in the displacement of the labral
tissue and increased diagnostic accuracy of these
lesions.10,14,17 The glenolabral articular disruption
(GLAD) lesion refers to an anteroinferior labral tear,
which is held in place by an intact anterior scapular
periosteum, with an adjacent glenoid articular cartilage
injury12,1417,21,25 (Figure 11). The pattern of chondral
injury can range from a cartilaginous flap tear to a de-
pressed osteochondral injury of the articular cartilage and
the underlying bone.25 This lesion typically results from
a fall on an outstretched arm with impaction of the hu-
meral head against the glenoid rather than from dislo-
cation. As the anterior ligamentous complex and anterior
scapular periosteum remain intact, the labrum is held
firmly in place, and it is usually a stable lesion.12,16,25
When a GLAD lesion is seen on MRI, one should look for
loose intra-articular bodies, which can occur from a de-
tached articular cartilage fragment.17
Extensive anterior labral tear
The second most frequent location of a labral tear
involves the entire anterior labrum, from the base of the
biceps tendon to the insertion of the IGHL.13,15,21
Anterosuperior labral tear
Isolated tears of the anterosuperior labrum are un-
common and, in the absence of other pathological find-
ings, the possibility that they represent a normal
sublabral foramen should be considered.13,15,21 A sub-
labral foramen has no residual labral tissue on the gle-
noid, and the anterosuperior labrum that is not attached
to the glenoid rim has a smooth medial margin, which
reattaches at approximately the 3 oclock position.16 An
isolated anterosuperior labral tear is very uncommon1315
and tends to occur in high-performance throwing ath-
letes.14 An appropriate clinical history of pain and
Figure 11. Glenolabral articular disruption (GLAD) lesion.
Axial T1 weighted spin echo MR arthrogram with fat
saturation illustrates a GLAD lesion consisting of an antero-
inferior labral tear (arrow), with an attached fragment of
adjacent articular cartilage, which is held in place by an intact
anterior scapular periosteum (arrowhead).
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Glenohumeral instability
instability when throwing together with periosteal de-
tachment and irregularity of the labrum are consistent
with an anterosuperior labral tear.15,21
Glenohumeral ligament injury
Anterior glenohumeral instability can involve tears of
the glenohumeral ligaments. The humeral avulsion of the
glenohumeral ligament lesion is an avulsion of the ante-
rior band of the inferior glenhumeral ligament from its
humeral attachment. There is inferomedial retraction of
the ligament, which appears thick and irregular, and on
the coronal oblique images, the normal U-shaped anterior
ligament and axillary recess is converted into a J-shape
(Figure 12). The anterior capsule is ruptured, and there is
extravasation of the contrast anterior to the humeral
neck.1,16,17,26 The accuracy of MR arthrography in the
detection of these lesions is not yet determined, and false
positives may occur when there is contrast or fluid
Figure 12. Humeral avulsion of the glenohumeral ligament
lesion. (a) Coronal oblique and (b) axial T1 weighted spin
echo MR arthrographic images with fat saturation demon-
strate avulsion of the anterior band of the inferior gleno-
humeral ligament (arrows) from its humeral attachment.
There is inferomedial retraction of the ligament, which
appears thickened and irregular with a J-shape on coronal
images. Anterior extravasation of contrast is best visualized
on the axial images.
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extravasation from other sources, such as capsular inju-
ries not involving the IGHL, soft-tissue trauma or even
iatrogenic.27 In 20% of cases, a medial humeral avulsion
fracture is present.16,26 Rarely, a floating avulsion of the
inferior glenohumeral ligament lesion occurs, where there
are simultaneous avulsions at both the glenoid and hu-
meral sites of insertion of the anterior band.26
Superior labral anteroposterior lesion
The SLAP lesion is a superior labral tear that extends
both anterior and posterior to the biceps tendon attach-
ment and commonly results from repetitive traction to
the biceps tendon as seen in throwing athletes. Clinical
findings include pain, clicking and instability. The origi-
nal classification described four types of SLAP lesions
depending on the extent of injury to the superior labrum
and biceps anchor. Type I is characterized by superior
labral degeneration and fraying; Type II, the most com-
mon of all SLAP lesions, consists of avulsion of the su-
perior labrum and long head of biceps tendon from the
glenoid; Type III is seen as an inferiorly displaced bucket-
handle superior labral tear with an intact biceps anchor;
and Type IV involves extension of a bucket-handle
superior labral tear into the proximal long head of
the biceps tendon.12,13,15,16,21,28 The classification has sub-
sequently been extended to include the so-called
extended SLAP tears, where the labral tear extends in-
to other structures. Simply put, any classification above
Type IV means that there is a further injury in addition to
the SLAP tear. Despite the complex classification, surgical
treatment is based on a compromise of the biceps anchor,
thus, as far as the surgeon is concerned, precise classifi-
cation is less useful than knowledge about the presence
and extent of the biceps tendon involvement.14
The key feature of a SLAP lesion on MR athrography is
tracking of contrast into the superior labral tear
(Figure 13). Contrast may be seen to extend into the biceps
tendon on coronal oblique images depending on the
Figure 13. Type II superior labral anteroposterior (SLAP)
lesion. Coronal oblique T1 weighted spin echo MR arthro-
gram with fat saturation illustrates intra-articular contrast
between the avulsed superior labralbiceps complex and the
glenoid margin, representing a Type II SLAP lesion, which is
orientated in a lateral direction away from the glenoid rim
(arrow).
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 CL McCarthy

configuration of the tear. A further feature may be a dis-
placed labral fragment resulting in a bucket-handle type
tear as seen in SLAP Types III, IV and VI (Figure 14).
A normal sublabral recess may be misinterpreted as
a SLAP II lesion at MR arthrography. Intra-articular
contrast, which extends into a normal sublabral recess, is
smooth and tapering, with a width of only 1 or 2 mm and
usually extends in a medial direction towards the glenoid
attachment of the superior labrum. The superior labrum
maintains a normal triangular configuration with a sharp
free edge and contains no abnormal signal within its
substance.12,13,16,29 In general, SLAP II lesions are orien-
tated in a lateral direction away from the glenoid
rim13,15,16,28,29 (Figure 13) and may extend posterior to
the biceps tendon.16,28,29 These lesions may be associated
with a concomitant anterosuperior labral tear.29 In addi-
tion, intra-articular contrast between the glenoid and
superior labrum has a more globular configuration and
delineates an irregular labral margin.13,16,29
anterosuperior humeral head gives rise to the reverse
HillSachs defect.1,12,1416,21
Paralabral cysts
Paralabral cysts are lobulated fluid collections that
are associated with labral tears and shoulder in-
stability. The cysts may arise from extrusion of shoul-
der joint fluid through labralcapsular tears, the
location of the cyst indicating the position of the labral
tear. Cyst extension into the spinoglenoid (between the
scapular spine and the glenoid cavity) or suprascapular
notch may result in neural compression with secondary
muscle atrophy.12,14,31

Posterior glenohumeral instability

Posterior instability makes up 24% of shoulder in-
stability problems12,16 and typically results from forced
adduction and internal rotation. Other causes of poste-
rior shoulder instability include glenoid retroversion
and congenital hypoplasia of the posterior glenoid, which
may be associated with posterior labral hypertrophy.1
Posterior glenoid hypoplasia is seen in CT and MRI as
blunting of the posterior glenoid rim in the axial plane.
Care must be taken not to confuse this pattern with
normal rounding of the glenoid rim seen in the most
distal axial images.30 The patterns of injury are usually
the reverse of those found following anterior disloca-
tion. Tears occurring in the posterior labrum are referred
to as a reverse Bankart lesion and impaction of the

Figure 15. Posterior superior glenoid impingement. (a)

Figure 14. Type III superior labral anteroposterior (SLAP)
lesion. Coronal oblique T1 weighted spin echo MR arthro-
gram with fat saturation shows intra-articular contrast
extending around an inferiorly displaced superior labral
fragment (arrow) resulting in a bucket-handle Type III SLAP
lesion.
Coronal oblique T1 weighted spin echo MR arthrogram with
fat saturation demonstrates a partial thickness undersurface
tear of the infraspinatus tendon (arrow) with cystic change in
the adjacent humeral head. (b) Abducted and externally
rotated image illustrates impingement of the rotator cuff
and posterosuperior labrum (arrow) between the postero-
superior glenoid and humeral head.

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Glenohumeral instability
Posterior superior glenoid impingement
Posterior superior glenoid impingement or internal
impingement occurs in athletes who perform overhead
activities. The exact aetiology of posterior superior gle-
noid impingement is still subject to discussion; however,
it is often attributed to repetitive stretching of the anterior
capsuloligamentous structures, with resultant anterior
microinstability, and contracture of the posterior capsule,
which lead to decreased internal rotation and postero-
superior shift of the humeral head in the late cocking
phase of throwing (shoulder in 90 abduction and maxi-
mal external rotation). The ABER view recreates this
position. The posterosuperior aspect of the glenoid and
the humeral head may come into contact, causing injury
to the interposed rotator cuff and posterosuperior la-
brum. MRI features are an articular surface partial
thickness tear of the posterior supraspinatous and/or
anterior infraspinatus tendon, a posterosuperior labral
tear and posterosuperior humeral head microfractures
and cystic change3234 (Figure 15).
Conclusion
MR arthrography is useful in diagnosing and charac-
terizing the labralligamentous lesions resulting in in-
stability. For diagnostic purposes, the glenoid can be
divided as a clock face. Most of the normal variants of
labral shape and attachment occur at the 13 oclock
positions. Labral pathology related to recurrent disloca-
tion is found at the 36 oclock positions. SLAP lesions
occur at 111 oclock and posterosuperior impingement
lesions, which may be associated with labral tears and
cysts, occur between the 9 and 11 oclock positions.
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Imaging 2014, 23, 20110084