Introduction

Shoulder instability and glenoid labral injuries are commonly seen in an athletic population. Traumatic lesions of the anterior glenoid labrum, Bankart lesions, were first described by Perthes¹ and Bankart.² The association between Bankart lesions and anterior glenohumeral instability has been well documented. Arthroscopic repair of anterior instability and posterior or reverse Bankart lesions for posterior glenohumeral instability has shown good results in returning athletes to their preinjury level of participation.^3–7 Superior labral lesions were first described by Andrews⁸ in a throwing athlete population. Snyder⁹ later classified the superior labrum anterior and posterior (SLAP) lesions into four categories and initially described arthroscopic repair techniques.

Labral lesions can exist in combination. Maffet¹⁰ expanded on Snyder’s original SLAP classification with three additional types. In a type V lesion, the SLAP extends into a Bankart lesion, giving a combined superior and anterior lesion. A type VI lesion demonstrates a flap tear of the bucket handle tear of the biceps, and is a variant of a type III lesion. A type VII tear is another combined superior-anterior tear, with the SLAP extending into the middle glenohumeral ligament. Mohana-Borges¹¹ described a type VIII lesion as a SLAP tear extending into the posterior inferior glenohumeral ligament. The most extensive of labral lesions was described by Powell et al¹² as a type IX, or panlabral lesion, denoting a complete circumferential tear of the glenoid labrum. Finally, Beltran¹³ noted a combined SLAP lesion with extension into the rotator interval on MR arthrography, now often described as a type X lesion. This classification system and each type’s unique quality are listed in Table 36-1.

Table 36-1 Classifications of SLAP Lesions*

The diagnosis and treatment of combined labral lesions is more complex than that of its isolated cousins. Making a complete and accurate diagnosis requires careful attention to patient history, physical examination, and appropriate imaging.¹⁴ Patient positioning, increased operative time and technical difficulty, order of repair, adequate resourcing, and postoperative rehabilitation precedence are all issues that must be addressed in a comprehensive approach to these lesions.

The purpose of this chapter is to address the combined and complex lesions of the glenoid labrum regarding preoperative workup, surgical approach and methodology, and postoperative rehabilitation.

Indications/contraindications

Preoperative history

Even experienced shoulder surgeons can miss complex labral lesions. Patients with isolated anterior instability often present with a chief complaint of the shoulder “coming out” but with little pain at rest. Patients with superior labral lesions more commonly present with pain and no true apprehension. Patients with posterior labral pathology often present with pain that may or may not accompany a sense of instability. Thus a key pearl in the history of the patient with a complex or combined labral lesion is the chief complaint, both pain and instability.

Furthermore, patients with prolonged symptoms with multiple dislocations should elevate one’s level of suspicion for a complex labral lesion. In a series comparing isolated Bankart lesions with combined Bankart and SLAP lesions, Hantes noted that the number of dislocations was significantly higher in the combined group.¹⁵ In a review of 41 panlabral lesions, Tokish¹⁴ et al, noted that all patients in their series had sustained at least 5 prior dislocations, and all had chief complaints of pain and instability. The authors noted that this complaint of pain persisted well after reduction of the joint. This was in contrast to their experience with isolated anterior lesions that were often relatively painless between instability episodes. They concluded that multiple dislocations and pain that persisted between instability episodes were clinical tips for diagnosing combined labral lesions.

Examination findings

The physical examination in patients with complex labral lesions can be difficult and misleading. Because these patients nearly always have pain, the physical examination can often be limited. The key to the physical examination of these lesions is a heightened level of suspicion from the history taken earlier.

Physical examination should proceed with the core principles of inspection, palpation, range of motion, strength testing, and provocation. The overall goal should be to try as closely as possible to exactly duplicate the patient’s symptoms with specific physical examination techniques.

Inspection should focus on overall posture, the presence of scapular winging, muscularity, and tone. Patients with multidirectional instability (MDI) can often present with similar complaints to the patient with a complex labral lesion. In general, patients with MDI may demonstrate generalized ligamentous laxity, scapular winging at rest, and a thin physique. Thus these findings may be pertinent negatives in the patient with a suspected complex labral tear.

Palpation should specifically target those areas that one would expect to be positive with labral pathology, as well as those pertinent negatives that can confuse the examination. In patients with complex labral pathology, the examiner may often be under impressed with tenderness on palpation at rest, though the anterior and/or posterior capsule may be mildly tender. Thus, tenderness on palpation of the acromioclavicular joint, greater tuberosity, and bicipital groove can be important red flags to suggest perhaps a different source of pain symptoms.

Range of motion in complex labral tears is often normal, though patients with SLAP tears may have pain in full elevation, and patients with anterior labral tears may have apprehension in abducted external rotation. If the patient can’t allow range of motion to normal, it is important to query as to whether this represents true stiffness, or pain-limited progression. Most patients with complex labral tears have a relatively preserved passive range of motion. However, patients with true restriction in passive range of motion, particularly globally, should raise the suspicion of glenohumeral arthritis. Although glenohumeral arthritis may present with a circumferential or near circumferential labral tears, these degenerative lesions should not be confused with a complex labral lesion. Inadvertent repair of these degenerative lesions may lead to increased pain; stiffness; and potentially, progression of osteoarthritis.

Strength testing is generally normal in labral lesions. There may be pain that limits a patient’s testing, but true weakness is unusual. Strength testing should be performed, however, in any patient with a suspected labral tear. If a true deficit is noted, it may lead the examiner to concomitant pathology.

Provocative tests can be quite helpful in making a diagnosis of a complex labral lesion. We recommend that every patient with a suspected labral lesion undergo cardinal testing for the anterior, posterior, and superior lesions. For the anterior (Bankart) lesion, the gold standard test is that of apprehension¹⁶ in an abducted externally rotated position. This test is performed by bringing the patient’s arm into maximum external rotation while at 90 degrees of abduction, in an attempt to reproduce the patient’s sensation that the shoulder is unstable. It is important to differentiate this sensation from a sensation of pain, which is more consistent with superior labral tears. Patients who have both apprehension and pain may demonstrate a combined SLAP and Bankart lesion.

Tests for determining tears of the superior labrum are notoriously nonspecific. This is likely because of the overlap with SLAP tears and impingement, especially in older populations. Nevertheless, we consider the active compression test¹⁷ as the cardinal test for superior pathology. In our experience, this test is rarely positive in patients with unidirectional instability, so a patient who has a history and physical examination consistent with dislocations and who demonstrates a positive active compression test raises our suspicion that the labral tear extends up into the superior labrum. This is especially true in the absence of impingement signs such as Neer and Hawkins¹⁶ sign.

The cardinal test for the posterior labral tear is the push-pull test.¹⁶ This test is performed with the patient supine, and the arm at 90 degrees of abduction and neutral rotation. The examiner “pushes” the shoulder out posteriorly, while “pulling” the grasped wrist to stabilize the arm. The resultant motion subluxes the shoulder in most patients. In patients with posterior labral pathology, this test often exactly reproduces a patient’s symptoms, and if it does, a posterior labral tear should be suspected. We have found this test to be nearly universally present in complex labral lesions with a posterior component.¹⁴ Other tests, such as a posterior load-and-shift, or jerk test, can be equally provocative but may be effectively guarded against by the apprehensive patient.

In summary, the physical examination of suspected complex labral lesions can be extremely difficult. Keys to success include a heightened level of suspicion in all patients with a history of subluxation. Direct findings include the presence of apprehension, a push-pull test, and an active compression test, along with an absence of impingement signs, acromioclavicular symptoms, or a body habitus suggestive of multidirectional laxity.

Radiographic findings

Radiographic evaluation is of critical importance in the diagnostic workup of suspected combined labral lesions. Although radiographs will not show a labral tear directly, a standard true AP, scapular Y view, and an axillary lateral view should be obtained in all patients. Such views can demonstrate subluxation or osseous pathology suggestive of instability, such as bony Bankart and Hill-Sachs lesions. These bony lesions can exist in the presence of combined labral lesions,¹⁴ and should be identified and addressed when necessary (Video 36-1). Radiographs also should be evaluated for the absence of concomitant pathology (e.g., glenohumeral arthritis).

Complete characterization of labral lesions can be difficult. The ideal imaging study for evaluation of the complex labral lesion is a magnetic resonance arthrogram (MRA). In one study, the addition of contrast helped identify 77% of panlabral lesions compared with only 9% completely identified with noncontrast MRI.¹⁴

Because the key to making the diagnosis of a complex labral lesion is a heightened level of suspicion, and it is the surgeon who obtains this from the history and physical examination, perhaps the most pertinent pearl regarding radiographic evaluation is that the treating orthopedist should become comfortable reading MR studies.