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Superior Labral Anteroposterior Tear: Classification and Diagnosis on MRI and MR Arthrography

¹ All authors: Department of Radiology, Veterans Affairs Medical Center and University of California, San Diego, 3350 La Jolla Village Dr., San Diego, CA 92161.

View larger version (27K): [in a new window]   Fig. 1A. —Labral division: two nomenclatures used for localization of labral abnormalities. Diagram shows labrum viewed as "time zones" on clock face. For both shoulders, 12- to 6-o'clock position faces anteriorly, and 6- to 12-o'clock position faces posteriorly.

View larger version (29K): [in a new window]   Fig. 1B. —Labral division: two nomenclatures used for localization of labral abnormalities. Diagram shows labrum divided into six areas.

View larger version (109K): [in a new window]   Fig. 2A. —MRI features of sublabral recess in 40-year-old woman with MR arthrogram of left shoulder. HH = humeral head, G = glenoid. Axial T1-weighted fat-suppressed spin-echo image (TR/TE, 400/11) shows that sublabral recess (arrowhead) has parallel orientation to glenoid cartilage in this plane.

View larger version (88K): [in a new window]   Fig. 2B. —MRI features of sublabral recess in 40-year-old woman with MR arthrogram of left shoulder. HH = humeral head, G = glenoid. Coronal T1-weighted fat-suppressed spin-echo image (400/11) shows that recess outlined by contrast material is linear and follows contour of glenoid cartilage (arrow).

View larger version (134K): [in a new window]   Fig. 3A. —MRI features of sublabral foramen in 57-year-old man with superior labral anteroposterior tear. HH = humeral head, G = glenoid. Axial T1-weighted fat-suppressed spin-echo MR arthrogram (TR/TE, 500/15) shows separation of anterosuperior labrum (arrowhead) from glenoid cartilage.

View larger version (122K): [in a new window]   Fig. 3B. —MRI features of sublabral foramen in 57-year-old man with superior labral anteroposterior tear. HH = humeral head, G = glenoid. Axial T1-weighted fat-suppressed spin-echo MR arthrogram (500/15) at 3-o'clock position shows that labrum (straight arrow) slips back and reattaches to glenoid cartilage. Curved arrow indicates middle glenohumeral ligament.

View larger version (120K): [in a new window]   Fig. 4. —MRI features of Buford complex in 65-year-old man. Proton density–weighted fat-suppressed image (TR/TE, 2,000/14) shows absence of anterosuperior labrum associated with cordlike middle glenohumeral ligament (arrow). HH = humeral head, G = glenoid.

View larger version (91K): [in a new window]   Fig. 5A. —Schematic representations of superior labral anteroposterior (SLAP) lesions I–IV in sagittal plane. In these diagrams, for better visualization, SLAP lesions II–IV are represented as displaced tears. Arrow = superior labrum tear, A = acromion, Cl = clavicle, C = coracoid process, S = supraspinatus myotendinous junction, I = infraspinatus myotendinous junction, T = teres minor myotendinous junction, Sub = subscapularis myotendinous junction, B = biceps tendon, SGHL = superior glenohumeral ligament, MGHL = middle glenohumeral ligament, IGHLC = inferior glenohumeral ligament complex. SLAP I lesion corresponds to fraying of superior labrum (arrow).

View larger version (95K): [in a new window]   Fig. 5B. —Schematic representations of superior labral anteroposterior (SLAP) lesions I–IV in sagittal plane. In these diagrams, for better visualization, SLAP lesions II–IV are represented as displaced tears. Arrow = superior labrum tear, A = acromion, Cl = clavicle, C = coracoid process, S = supraspinatus myotendinous junction, I = infraspinatus myotendinous junction, T = teres minor myotendinous junction, Sub = subscapularis myotendinous junction, B = biceps tendon, SGHL = superior glenohumeral ligament, MGHL = middle glenohumeral ligament, IGHLC = inferior glenohumeral ligament complex. SLAP II lesion corresponds to stripping of superior labrum and attached biceps tendon from glenoid (arrow).

View larger version (86K): [in a new window]   Fig. 5C. —Schematic representations of superior labral anteroposterior (SLAP) lesions I–IV in sagittal plane. In these diagrams, for better visualization, SLAP lesions II–IV are represented as displaced tears. Arrow = superior labrum tear, A = acromion, Cl = clavicle, C = coracoid process, S = supraspinatus myotendinous junction, I = infraspinatus myotendinous junction, T = teres minor myotendinous junction, Sub = subscapularis myotendinous junction, B = biceps tendon, SGHL = superior glenohumeral ligament, MGHL = middle glenohumeral ligament, IGHLC = inferior glenohumeral ligament complex. Lesions correspond to bucket-handle tear of labrum (arrow) with intact biceps tendon (SLAP III, C) and with tear extending into biceps tendon (SLAP IV, D).

View larger version (94K): [in a new window]   Fig. 5D. —Schematic representations of superior labral anteroposterior (SLAP) lesions I–IV in sagittal plane. In these diagrams, for better visualization, SLAP lesions II–IV are represented as displaced tears. Arrow = superior labrum tear, A = acromion, Cl = clavicle, C = coracoid process, S = supraspinatus myotendinous junction, I = infraspinatus myotendinous junction, T = teres minor myotendinous junction, Sub = subscapularis myotendinous junction, B = biceps tendon, SGHL = superior glenohumeral ligament, MGHL = middle glenohumeral ligament, IGHLC = inferior glenohumeral ligament complex. Lesions correspond to bucket-handle tear of labrum (arrow) with intact biceps tendon (SLAP III, C) and with tear extending into biceps tendon (SLAP IV, D).

View larger version (136K): [in a new window]   Fig. 6. —Type I superior labral anteroposterior lesion: proton density–weighted fat-suppressed coronal image shows fraying of superior labrum (arrow). Note full-thickness tear of supraspinatus tendon (arrowhead). HH = humeral head, G = glenoid.

View larger version (109K): [in a new window]   Fig. 7. —Proton density–weighted fat-suppressed coronal image (TR/TE, 3,000/20) shows type II superior labral anteroposterior lesion in 52-year-old man. Note globular area of increased signal intensity at base of superior labrum compatible with labral tear (arrow). HH = humeral head, G = glenoid.

View larger version (113K): [in a new window]   Fig. 8A. —Proton density–weighted coronal images (TR/TE, 2,500/15) of type III superior labrum anterior and posterior lesion. HH = humeral head, G = glenoid. Abnormal signal intensity is visible between superior labrum and glenoid cartilage (arrow) and between biceps tendon and superior labrum (arrowhead).

View larger version (110K): [in a new window]   Fig. 8B. —Proton density–weighted coronal images (TR/TE, 2,500/15) of type III superior labrum anterior and posterior lesion. HH = humeral head, G = glenoid. Note that labral abnormality extends posteriorly and biceps insertion (arrow) appears preserved.

View larger version (112K): [in a new window]   Fig. 9. —Type IV superior labral anteroposterior (SLAP) lesion in 52-year-old man after fall from ladder with progressive shoulder pain and weakness 1 month before MRI evaluation. Coronal proton density–weighted fat-suppressed image (TR/TE, 3,000/13) shows enlargement and abnormal signal intensity of biceps anchor (arrow) and adjacent superior labrum. SLAP IV lesion and dislocated torn biceps tendon were identified at surgery. HH = humeral head, G = glenoid.

View larger version (86K): [in a new window]   Fig. 10A. —Schematic representations of superior labral anteroposterior lesions V–VII in sagittal plane. A = acromion, Cl = clavicle, C = coracoid process, S = supraspinatus myotendinous junction, I = infraspinatus myotendinous junction, T = teres minor myotendinous junction, Sub = subscapularis myotendinous junction, B = biceps tendon, SGHL = superior glenohumeral ligament, IGHL = inferior glenohumeral ligament complex, MGHL = middle glenohumeral ligament. Type V lesion corresponds to Bankart lesion with superior extension (arrows) to include biceps tendon and superior labrum.

View larger version (92K): [in a new window]   Fig. 10B. —Schematic representations of superior labral anteroposterior lesions V–VII in sagittal plane. A = acromion, Cl = clavicle, C = coracoid process, S = supraspinatus myotendinous junction, I = infraspinatus myotendinous junction, T = teres minor myotendinous junction, Sub = subscapularis myotendinous junction, B = biceps tendon, SGHL = superior glenohumeral ligament, IGHL = inferior glenohumeral ligament complex, MGHL = middle glenohumeral ligament. Type VI lesion corresponds to anterior or posterior flap tear (arrow) in conjunction with separation of biceps tendon superiorly.

View larger version (89K): [in a new window]   Fig. 10C. —Schematic representations of superior labral anteroposterior lesions V–VII in sagittal plane. A = acromion, Cl = clavicle, C = coracoid process, S = supraspinatus myotendinous junction, I = infraspinatus myotendinous junction, T = teres minor myotendinous junction, Sub = subscapularis myotendinous junction, B = biceps tendon, SGHL = superior glenohumeral ligament, IGHL = inferior glenohumeral ligament complex, MGHL = middle glenohumeral ligament. Type VII lesion corresponds to biceps-labral complex tear (arrow) with extension to MGHL (arrowhead).

View larger version (106K): [in a new window]   Fig. 11A. —MR arthrography in 31-year-old man with history of shoulder dislocation shows type V superior labral anteroposterior lesion. HH = humeral head, G = glenoid. Coronal T1-weighted fat-suppressed image (TR/TE, 500/13) shows superior labral tear (curved arrow) and large Hill-Sachs lesion (straight arrow).

View larger version (124K): [in a new window]   Fig. 11B. —MR arthrography in 31-year-old man with history of shoulder dislocation shows type V superior labral anteroposterior lesion. HH = humeral head, G = glenoid. Axial T1-weighted fat-suppressed image (500/13) shows Bankart lesion (arrow). Sequential images in axial plane (not shown) depicted extension of Bankart lesion to superior labrum.

View larger version (116K): [in a new window]   Fig. 12A. —Type VI superior labral anteroposterior lesion in 40-year-old man with shoulder pain and superior labral tear. HH = humeral head, G = glenoid. Fat-suppressed T1-weighted MR arthrograms were obtained before (A) and after (B) arm traction. Note that morphology of abnormal superior labrum is best shown with arm traction (B) and displays small fragment of labrum partially attached to anchor (arrows). Pattern of superior labral tear was believed to be complex and most likely represented small flap tear.

View larger version (84K): [in a new window]   Fig. 12B. —Type VI superior labral anteroposterior lesion in 40-year-old man with shoulder pain and superior labral tear. HH = humeral head, G = glenoid. Fat-suppressed T1-weighted MR arthrograms were obtained before (A) and after (B) arm traction. Note that morphology of abnormal superior labrum is best shown with arm traction (B) and displays small fragment of labrum partially attached to anchor (arrows). Pattern of superior labral tear was believed to be complex and most likely represented small flap tear.

View larger version (112K): [in a new window]   Fig. 13A. —66-year-old man with type VII superior labral anteroposterior lesion showing extension to middle glenohumeral ligament. HH = humeral head, G = glenoid. Coronal T2-weighted fat-suppressed image (TR/TE, 2,000/80) obtained in oblique coronal plane shows superior labrum tear (arrow).

View larger version (125K): [in a new window]   Fig. 13B. —66-year-old man with type VII superior labral anteroposterior lesion showing extension to middle glenohumeral ligament. HH = humeral head, G = glenoid. Axial T2-weighted fat-suppressed image (2,600/63) shows thickening of middle glenohumeral ligament (arrow) associated with high signal.

View larger version (87K): [in a new window]   Fig. 14A. —Schematic representations of superior labral anteroposterior (SLAP) lesions VIII–X in sagittal plane. A = acromion, C l =clavicle, C = coracoid process, S = supraspinatus myotendinous junction, I = infraspinatus myotendinous junction, T = teres minor myotendinous junction, Sub = subscapularis myotendinous junction, B = biceps tendon, SGHL = superior glenohumeral ligament, MGHL = middle glenohumeral ligament, IGHLC = inferior glenohumeral ligament complex. Type VIII lesion corresponds to superior labral lesion with posterior extension (arrow) that is similar to type IIA lesion, although more extensive.

View larger version (91K): [in a new window]   Fig. 14B. —Schematic representations of superior labral anteroposterior (SLAP) lesions VIII–X in sagittal plane. A = acromion, C l =clavicle, C = coracoid process, S = supraspinatus myotendinous junction, I = infraspinatus myotendinous junction, T = teres minor myotendinous junction, Sub = subscapularis myotendinous junction, B = biceps tendon, SGHL = superior glenohumeral ligament, MGHL = middle glenohumeral ligament, IGHLC = inferior glenohumeral ligament complex. Type IX lesion corresponds to complete or almost complete detachment of labrum involving extensive anterior and posterior components (arrows).

View larger version (96K): [in a new window]   Fig. 14C. —Schematic representations of superior labral anteroposterior (SLAP) lesions VIII–X in sagittal plane. A = acromion, C l =clavicle, C = coracoid process, S = supraspinatus myotendinous junction, I = infraspinatus myotendinous junction, T = teres minor myotendinous junction, Sub = subscapularis myotendinous junction, B = biceps tendon, SGHL = superior glenohumeral ligament, MGHL = middle glenohumeral ligament, IGHLC = inferior glenohumeral ligament complex. Type X lesion corresponds to SLAP lesion with extension of labral tear (arrow) to rotator interval or structures that cross it.

View larger version (109K): [in a new window]   Fig. 15A. —Type VIII superior labral anteroposterior lesion in 31-year-old man with shoulder pain. HH = humeral head, G = glenoid. Coronal T1-weighted fat-suppressed image (TR/TE, 400/12) shows superior labral tear (arrow).

View larger version (110K): [in a new window]   Fig. 15B. —Type VIII superior labral anteroposterior lesion in 31-year-old man with shoulder pain. HH = humeral head, G = glenoid. Axial T1-weighted fat-suppressed image (400/12) shows tear extending to posterior labrum (arrowhead). Anterior labrum (arrow) is normal.

View larger version (108K): [in a new window]   Fig. 16A. —Type IX superior labral anteroposterior lesion in 34-year-old man with history of shoulder trauma. HH = humeral head, G = glenoid. Coronal proton density–weighted image (TR/TE, 2,600/15) reveals superior labral tear (arrow).

View larger version (131K): [in a new window]   Fig. 16B. —Type IX superior labral anteroposterior lesion in 34-year-old man with history of shoulder trauma. HH = humeral head, G = glenoid. Axial gradient-echo image (450/15; flip angle, 30°) shows superior labral tear that extends anteriorly (arrow) and posteriorly (arrowhead) below 3- and 9-o'clock positions.

View larger version (107K): [in a new window]   Fig. 17A. —Type X superior labral anteroposterior lesion in man with history of labral tear. HH = humeral head, G = glenoid. Coronal fat-suppressed T1-weighted arthrogram of right shoulder shows superior labral tear (arrow).

View larger version (113K): [in a new window]   Fig. 17B. —Type X superior labral anteroposterior lesion in man with history of labral tear. HH = humeral head, G = glenoid. Axial fat-suppressed T1-weighted arthrogram shows tear extending to area of rotator interval (arrow).

View larger version (116K): [in a new window]   Fig. 18. —36-year-old man with shoulder pain and clinical findings suggestive of impingement. Unstable superior labral anteroposterior II lesion was surgically confirmed. Coronal proton density–weighted fat-suppressed image (TR/TE, 2816/13) shows abnormal signal intensity at base of superior labrum with Y-shaped appearance.

View larger version (116K): [in a new window]   Fig. 19. —Coronal proton density–weighted fat-suppressed image (TR/TE, 3,000/30) obtained in 61-year-old man with superior labral anteroposterior lesion surgically confirmed. Note abnormal morphology of superior labrum. Sequential image (not shown) showed adjacent paraglenoid cyst.

View larger version (92K): [in a new window]   Fig. 20. —MR arthrogram in 38-year-old man shows transitional zone. Axial T2-weighted fat-suppressed image (TR/TE, 3,000/60) shows no fluid between anterosuperior labrum and adjacent glenoid cartilage. Area of intermediate signal intensity (arrow) represents transitional zone between fibrocartilage of labrum and hyaline cartilage of glenoid. HH = humeral head, G = glenoid.

View larger version (113K): [in a new window]   Fig. 21A. —MR arthrograms of right shoulder in man with shoulder pain and superior labral anteroposterior (SLAP) lesion. HH = humeral head, G = glenoid. Coronal T1-weighted fat-suppressed image (TR/TE, 600/15) shows abnormal morphology at insertion site of biceps tendon (arrow). This finding was initially interpreted as double Oreo cookie sign. Sequential images (not shown) revealed partial volume with superior glenohumeral ligament.

View larger version (123K): [in a new window]   Fig. 21B. —MR arthrograms of right shoulder in man with shoulder pain and superior labral anteroposterior (SLAP) lesion. HH = humeral head, G = glenoid. Coronal T1-weighted fat-suppressed image (600/15) obtained posterior to level of A reveals labral tear (arrow) characterized as SLAP II tear.

View larger version (53K): [in a new window]   Fig. 22A. —Schematic representations in coronal plane of single and double "Oreo cookie" configurations. Single Oreo cookie configuration is characterized by fluid between labrum and glenoid cartilage. This finding could be observed with either sublabral recess (arrow) or type II superior labral anteroposterior lesion.

View larger version (61K): [in a new window]   Fig. 22B. —Schematic representations in coronal plane of single and double "Oreo cookie" configurations. Double Oreo cookie configuration is characterized by fluid between labrum and glenoid cartilage and between two pieces of labrum. Arrow indicates sublabral recess and arrowhead indicates labral tear.

View larger version (120K): [in a new window]   Fig. 23A. —42-year-old man with posterior extension of superior labral anteroposterior tear on MR arthrograms. HH = humeral head, G = glenoid. Axial T1-weighted fat-suppressed image (TR/TE, 600/13) shows irregular margin of superior labral tear (arrow), oriented parallel to glenoid surface.

View larger version (101K): [in a new window]   Fig. 23B. —42-year-old man with posterior extension of superior labral anteroposterior tear on MR arthrograms. HH = humeral head, G = glenoid. Oblique coronal T1-weighted fat-suppressed image (600/13) shows tear extending posteriorly to biceps tendon origin (arrowhead).

View larger version (16K): [in a new window]   Fig. 24. —Diagram shows MRI algorithm for superior labral anteroposterior (SLAP) lesions based on specific abnormalities of biceps-labral complex, presence or absence of extension of tear, and presence or absence of abnormalities of additional structures.

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