From Labral Tears to Bone Loss: Imaging the Spectrum of Shoulder Instability

Abstract

Glenohumeral instability results from disruptions in dynamic and static stabilizers of the glenohumeral joint, leading to dislocation, subluxation, or chronic apprehension. Although anterior glenohumeral instability is the most common form, posterior instability represents a distinct and often underrecognized condition with unique biomechanical and clinical characteristics. Imaging plays a critical role in evaluating shoulder instability, guiding diagnosis, and informing treatment decisions. Radiographs, computed tomography, and magnetic resonance imaging help assess structural abnormalities, such as labral tears, capsuloligamentous injuries, and osseous defects. Advanced imaging techniques, such as three-dimensional computed tomography and zero echo time magnetic resonance imaging, offer improved assessment of bone loss; magnetic resonance arthrography enhances the detection of soft tissue pathology. This article offers a comprehensive review of the imaging spectrum of glenohumeral instability, covering labral pathology, capsuloligamentous injuries, and bone loss. It highlights the critical role of precise imaging assessment in guiding optimal management strategies for both anterior and posterior instability patterns.

Keywords

glenohumeral instability - labral tears - Hill-Sachs lesion - Bankart lesion - glenoid track

Publikationsverlauf

Artikel online veröffentlicht:
20. Mai 2025

• References

• 1 Bencardino JT, Gyftopoulos S, Palmer WE. Imaging in anterior glenohumeral instability. Radiology 2013; 269 (02) 323-337
• 2 Galvin JW, Ernat JJ, Waterman BR, Stadecker MJ, Parada SA. The epidemiology and natural history of anterior shoulder instability. Curr Rev Musculoskelet Med 2017; 10 (04) 411-424
• 3 Burke CJ, Rodrigues TC, Gyftopoulos S. Anterior instability. Magn Reson Imaging Clin N Am 2020; 28 (02) 195-209
• 4 Waterman B, Owens BD, Tokish JM. Anterior shoulder instability in the military athlete. Sports Health 2016; 8 (06) 514-519
• 5 Bokshan SL, Kotchman HM, Li LT, DeFroda SF, Cameron KL, Owens BD. Incidence of posterior shoulder instability in the United States military: demographic considerations from a high-risk population. Am J Sports Med 2021; 49 (02) 340-345
• 6 Kido T, Itoi E, Lee SB, Neale PG, An KN. Dynamic stabilizing function of the deltoid muscle in shoulders with anterior instability. Am J Sports Med 2003; 31 (03) 399-403
• 7 Dodson CC, Cordasco FA. Anterior glenohumeral joint dislocations. Orthop Clin North Am 2008; 39 (04) 507-518 , vii
• 8 Tischer T, Vogt S, Kreuz PC, Imhoff AB. Arthroscopic anatomy, variants, and pathologic findings in shoulder instability. Arthroscopy 2011; 27 (10) 1434-1443
• 9 Walz DM, Burge AJ, Steinbach L. Imaging of shoulder instability. Semin Musculoskelet Radiol 2015; 19 (03) 254-268
• 10 Duprey S, Naaim A, Moissenet F, Begon M, Chèze L. Kinematic models of the upper limb joints for multibody kinematics optimisation: an overview. J Biomech 2017; 62: 87-94
• 11 Itoi E. ‘On-track’ and ‘off-track’ shoulder lesions. EFORT Open Rev 2017; 2 (08) 343-351
• 12 Abboud JA, Soslowsky LJ. Interplay of the static and dynamic restraints in glenohumeral instability. Clin Orthop Relat Res 2002; (400) 48-57
• 13 Hantes M, Raoulis V. Arthroscopic findings in anterior shoulder instability. Open Orthop J 2017; 11: 119-132
• 14 Calcei JG, Boddapati V, Altchek DW, Camp CL, Dines JS. Diagnosis and treatment of injuries to the biceps and superior labral complex in overhead athletes. Curr Rev Musculoskelet Med 2018; 11 (01) 63-71
• 15 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 (06) 579-584
• 16 Burkart AC, Debski RE. Anatomy and function of the glenohumeral ligaments in anterior shoulder instability. Clin Orthop Relat Res 2002; (400) 32-39
• 17 Matsen III FA, Harryman II DT, Sidles JA. Mechanics of glenohumeral instability. Clin Sports Med 1991; 10 (04) 783-788
• 18 Lippitt S, Matsen F. Mechanisms of glenohumeral joint stability. Clin Orthop Relat Res 1993; (291) 20-28
• 19 Beltran LS, Duarte A, Bencardino JT. Postoperative imaging in anterior glenohumeral instability. AJR Am J Roentgenol 2018; 211 (03) 528-537
• 20 Ruiz Santiago F, Martínez Martínez A, Tomás Muñoz P, Pozo Sánchez J, Zarza Pérez A. Imaging of shoulder instability. Quant Imaging Med Surg 2017; 7 (04) 422-433
• 21 Wintzell G, Haglund-Åkerlind Y, Tengvar M, Johansson L, Eriksson E. MRI examination of the glenohumeral joint after traumatic primary anterior dislocation. A descriptive evaluation of the acute lesion and at 6-month follow-up. Knee Surg Sports Traumatol Arthrosc 1996; 4 (04) 232-236
• 22 Day MS, Epstein DM, Young BH, Jazrawi LM. Irreducible anterior and posterior dislocation of the shoulder due to incarceration of the biceps tendon. Int J Shoulder Surg 2010; 4 (03) 83-85
• 23 Dumont GD, Russell RD, Robertson WJ. Anterior shoulder instability: a review of pathoanatomy, diagnosis and treatment. Curr Rev Musculoskelet Med 2011; 4 (04) 200-207
• 24 Griffith JF, Yung PSH, Antonio GE, Tsang PH, Ahuja AT, Chan KM. CT compared with arthroscopy in quantifying glenoid bone loss. AJR Am J Roentgenol 2007; 189 (06) 1490-1493
• 25 Acid S, Le Corroller T, Aswad R, Pauly V, Champsaur P. Preoperative imaging of anterior shoulder instability: diagnostic effectiveness of MDCT arthrography and comparison with MR arthrography and arthroscopy. AJR Am J Roentgenol 2012; 198 (03) 661-667
• 26 Gyftopoulos S, Yemin A, Mulholland T. et al. 3DMR osseous reconstructions of the shoulder using a gradient-echo based two-point Dixon reconstruction: a feasibility study. Skeletal Radiol 2013; 42 (03) 347-352
• 27 Stillwater L, Koenig J, Maycher B, Davidson M. 3D-MR vs. 3D-CT of the shoulder in patients with glenohumeral instability. Skeletal Radiol 2017; 46 (03) 325-331
• 28 Yanke AB, Shin JJ, Pearson I. et al. Three-dimensional magnetic resonance imaging quantification of glenoid bone loss is equivalent to 3-dimensional computed tomography quantification: cadaveric study. Arthroscopy 2017; 33 (04) 709-715
• 29 Vopat BG, Cai W, Torriani M. et al. Measurement of glenoid bone loss with 3-dimensional magnetic resonance imaging: a matched computed tomography analysis. Arthroscopy 2018; 34 (12) 3141-3147
• 30 Llopis E, Montesinos P, Guedez MT, Aguilella L, Cerezal L. Normal shoulder MRI and MR arthrography: anatomy and technique. Semin Musculoskelet Radiol 2015; 19 (03) 212-230
• 31 Nacey NC, Fox MG, Bertozzi CJ, Pierce JL, Said N, Diduch DR. Incidence of gadolinium or fluid signal within surgically proven glenoid labral tears at MR arthrography. Skeletal Radiol 2019; 48 (08) 1185-1191
• 32 Saba L, De Filippo M. MR arthrography evaluation in patients with traumatic anterior shoulder instability. J Orthop 2016; 14 (01) 73-76
• 33 Cantarelli Rodrigues T, Deniz CM, Alaia EF. et al. Three-dimensional MRI bone models of the glenohumeral joint using deep learning: evaluation of normal anatomy and glenoid bone loss. Radiol Artif Intell 2020; 2 (05) e190116
• 34 Feuerriegel GC, Weiss K, Tu Van A. et al. Deep-learning-based image quality enhancement of CT-like MR imaging in patients with suspected traumatic shoulder injury. Eur J Radiol 2024; 170: 111246
• 35 Feuerriegel GC, Kronthaler S, Weiss K. et al. Assessment of glenoid bone loss and other osseous shoulder pathologies comparing MR-based CT-like images with conventional CT. Eur Radiol 2023; 33 (12) 8617-8626
• 36 Zhao Q, Feng Q, Zhang J. et al. Glenoid segmentation from computed tomography scans based on a 2-stage deep learning model for glenoid bone loss evaluation. J Shoulder Elbow Surg 2023; 32 (12) e624-e635
• 37 Carretero-Gómez L, Fung M, Wiesinger F. et al. Deep learning-enhanced zero echo time MRI for glenohumeral assessment in shoulder instability: a comparative study with CT. Skeletal Radiol 2024 November 22 (Epub ahead of print)
• 38 Omoumi P. Advanced imaging of glenohumeral instability: it may be less complicated than it seems. J Belg Soc Radiol 2016; 100 (01) 97
• 39 Aydıngöz Ü, Yıldız AE, Huri G. Glenoid track assessment at imaging in anterior shoulder instability: rationale and step-by-step guide. Radiographics 2023; 43 (08) e230030
• 40 Abballe VD, Walter WR, Lin DJ, Alaia MJ, Alaia EF. Anterior shoulder instability in the aging population: MRI injury pattern and management. AJR Am J Roentgenol 2021; 216 (05) 1300-1307
• 41 Gottschalk IV LJ, Walia P, Patel RM. et al. Stability of the glenohumeral joint with combined humeral head and glenoid defects: a cadaveric study. Am J Sports Med 2016; 44 (04) 933-940
• 42 Kim JH, Park JW, Heo SY, Noh YM. Magnetic resonance imaging analysis of rotator cuff tear after shoulder dislocation in a patient older than 40 years. Clin Shoulder Elbow 2020; 23 (03) 144-151
• 43 Sanders TG, Zlatkin M, Montgomery J. Imaging of glenohumeral instability. Semin Roentgenol 2010; 45 (03) 160-179
• 44 Wischer TK, Bredella MA, Genant HK, Stoller DW, Bost FW, Tirman PFJ. Perthes lesion (a variant of the Bankart lesion): MR imaging and MR arthrographic findings with surgical correlation. AJR Am J Roentgenol 2002; 178 (01) 233-237
• 45 Freshman RD, Zhang AL, Benjamin Ma C. et al; MOON Shoulder Group collaborators. Factors associated with humeral avulsion of glenohumeral ligament lesions in patients with anterior shoulder instability: an analysis of the MOON shoulder instability cohort. Orthop J Sports Med 2023; 11 (10) 23 259671231206757
• 46 Mannem R, DuBois M, Koeberl M, Kosempa D, Erickson S. Glenoid avulsion of the glenohumeral ligament (GAGL): a case report and review of the anatomy. Skeletal Radiol 2016; 45 (10) 1443-1448
• 47 Carlson CL. The “J” sign. Radiology 2004; 232 (03) 725-726
• 48 Gumina S, Postacchini F. Anterior dislocation of the shoulder in elderly patients. J Bone Joint Surg Br 1997; 79 (04) 540-543
• 49 Lorente A, Mariscal G, Barrios C, Lorente R. Nerve injuries after glenohumeral dislocation, a systematic review of incidence and risk factors. J Clin Med 2023; 12 (13) 4546
• 50 Hurley ET, Matache BA, Wong I. et al; Anterior Shoulder Instability International Consensus Group. Anterior shoulder instability Part I-Diagnosis, nonoperative management, and Bankart repair-an international consensus statement. Arthroscopy 2022; 38 (02) 214-223.e7
• 51 Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am 1978; 60 (01) 1-16
• 52 Saito H, Itoi E, Sugaya H, Minagawa H, Yamamoto N, Tuoheti Y. Location of the glenoid defect in shoulders with recurrent anterior dislocation. Am J Sports Med 2005; 33 (06) 889-893
• 53 Gyftopoulos S, Albert M, Recht MP. Osseous injuries associated with anterior shoulder instability: what the radiologist should know. AJR Am J Roentgenol 2014; 202 (06) W541–W550
• 54 Kurokawa D, Yamamoto N, Nagamoto H. et al. The prevalence of a large Hill-Sachs lesion that needs to be treated. J Shoulder Elbow Surg 2013; 22 (09) 1285-1289
• 55 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 (01) 90-98
• 56 Ferreira F, Branco R, Silva R, Areias M, Oliveira C, Silva N. Recurrent anterior shoulder dislocation after trauma with coracoid apophysis fracture - a rare association. Rev Bras Ortop (Sao Paulo) 2023; 58 (04) e667-e671
• 57 Sadi J, Torchia E, Faber KJ. et al. Posterior shoulder instability classification, assessment, and management: an international Delphi study. J Orthop Sports Phys Ther 2020; 50 (07) 373-380
• 58 Woodmass JM, Lee J, Wu IT. et al. Incidence of posterior shoulder instability and trends in surgical reconstruction: a 22-year population-based study. J Shoulder Elbow Surg 2019; 28 (04) 611-616
• 59 DeLong JM, Bradley JP. Posterior shoulder instability in the athletic population: variations in assessment, clinical outcomes, and return to sport. World J Orthop 2015; 6 (11) 927-934
• 60 Albano D, Messina C, Sconfienza LM. Posterior shoulder instability: what to look for. Magn Reson Imaging Clin N Am 2020; 28 (02) 211-221
• 61 Arner JW, Nickoli MS, Lawyer TJ, Conway JE, Bradley JP. Dynamic posterior instability test: a new test for posterior glenohumeral instability. Indian J Orthop 2022; 56 (11) 2022-2027
• 62 Knight JA, Powell GM, Johnson AC. Radiographic and advanced imaging evaluation of posterior shoulder instability. Curr Rev Musculoskelet Med 2024; 17 (05) 144-156
• 63 Rixey A, Rhodes N, Murthy N, Johnson M, Larson N, Ringler MD. Accuracy of MR arthrography in the detection of posterior glenoid labral injuries of the shoulder. Skeletal Radiol 2023; 52 (02) 175-181
• 64 Ajuied A, McGarvey CP, Harb Z, Smith CC, Houghton RP, Corbett SA. Diagnosis of glenoid labral tears using 3-Tesla MRI vs. 3-Tesla MRA: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2018; 138 (05) 699-709
• 65 Calvo E, Itoi E, Landreau P. et al. Anterior and posterior glenoid bone augmentation options for shoulder instability: state of the art. J ISAKOS 2021; 6 (05) 308-317
• 66 Lansdown DA, Cvetanovich GL, Zhang AL. et al; MOON Shoulder Group. Risk factors for intra-articular bone and cartilage lesions in patients undergoing surgical treatment for posterior instability. Am J Sports Med 2020; 48 (05) 1207-1212
• 67 Aydıngöz Ü, Yıldız AE, Ergen FB. Zero echo time musculoskeletal MRI: technique, optimization, applications, and pitfalls. Radiographics 2022; 42 (05) 1398-1414
• 68 Harper KW, Helms CA, Haystead CM, Higgins LD. Glenoid dysplasia: incidence and association with posterior labral tears as evaluated on MRI. AJR Am J Roentgenol 2005; 184 (03) 984-988
• 69 Harish S, Nagar A, Moro J, Pugh D, Rebello R, O'Neill J. Imaging findings in posterior instability of the shoulder. Skeletal Radiol 2008; 37 (08) 693-707
• 70 Shah N, Tung GA. Imaging signs of posterior glenohumeral instability. AJR Am J Roentgenol 2009; 192 (03) 730-735