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Consecutive axial fat-suppressed T1-weighted (repetition time/echo time [TR/TE], 617/8.6) MR arthrographic images demonstrate the coexistence of a sublabral sulcus and sublabral foramen in a 21-year-old woman. The https:// ensures that you are connecting to the It arises from the posterosuperior part of the glenoid neck, medial to the posterosuperior labrum and the origin of the long tendon of the biceps. The coracohumeral ligament extends between the coracoid process of the scapula to the tubercles of the humerus and the intervening transverse humeral ligament, supporting the joint from its superior side. Attachments The glenoid labrum forms part of the periarticular fiber system that is continuous with the rotator interval as well as 4: superiorly: tendon of the long head of biceps brachii anteriorly: superior glenohumeral ligament middle glenohumeral ligament (variably) These are the coracohumeral, glenohumeral and transverse humeral ligaments. The labrum typically measures approximately 4 mm in width and 3 mm in thickness; however, broad variation in labral size from 2 to 14 mm between normal individuals exist, thus rendering size criteria of little diagnostic utility. Instead, joint security is provided entirely by the soft tissue structures; the fibrous capsule, ligaments, shoulder muscles and their tendons. Located posteriorly between the posterior insertion of the joint capsule and synovial membrane and the adjacent articular cartilage, this bare area may be confused with a Hill-Sachs impaction injury ( Fig. A detached labrum can be repaired arthroscopically, with a small incision into which a scope and specialized tool is inserted. Despite the continuity of labrum and most of the capsuloligamentous structures, distension of the joint may also result in the appearance of three distinct types of medial capsular attachment at the inferior attachment [14]. This bare area is used by surgeons to quantify partial-thickness articular surface tears. As mentioned above, the coracoglenoid ligament belongs to the anterior limb of the superior glenohumeral ligament complex and is recently described as a third ligament in the rotator interval [16]. Springer. A bare area of the glenoid misdiagnosed as a cartilage ulceration, Morphology of the acromion and its relationship to rotator cuff tears. I would honestly say that Kenhub cut my study time in half. CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum and Labral-Bicipital Complex. Edinburgh: Elsevier Churchill Livingstone. The trapezius originates from the thoracic spinous processes and inserts into the distal clavicle, acromion and scapular spine. 2023 Nicola McLaren MSc Magnetic resonance (MR) imaging is the primary diagnostic imaging modality for the evaluation of patients with suspected internal derangement of the shoulder joint. Sagittal oblique PD-weighted MR image demonstrates the normal coracoacromial ligament at its acromial attachment that may mimic an osteophyte (arrows). However, in a subsequent study by Kralinger and colleagues in which 3-dimensional computed tomography of cadaveric specimens was performed, the investigators discovered variation in the location of the bare spot. What causes a SLAP tear? It is split into anterior and posterior bands, between which sits the axillary pouch. Coronal oblique images are oriented parallel to the scapula or parallel to the course of the supraspinatus tendon (determined on axial images); sagittal oblique images are oriented perpendicular to the coronal oblique plane, covering the deltoid muscle and the scapula to include rotator cuff muscle bellies; axial images are performed from the acromioclavicular joint to below the axillary pouch. In type III, the attachment is more than 1 cm medial to the labrum (Figure 8, additional material). The function of this entire muscular apparatus is to produce movement at the shoulder joint while keeping the head of humerus stableand centralized within the glenoid cavity. The sublabral foramen provides a communicating pathway between the glenohumeral joint and the subscapularis recess ( Fig. It shows many variations from extreme curvature to almost straight shape; increased thickness and curvature can be seen in manual workers [3,4,6]. De Maeseneer, M, Van Roy, P and Shahabpour, M. Normal MR imaging anatomy of the rotator cuff tendons, glenoid fossa, labrum, and ligaments of the shoulder. It is the most important glenohumeral ligament in terms of stability; it stabilizes the glenohumeral joint when the arm is abducted to approximately 90 [2,3,6]. The teres minor and deltoid muscles are innervated by branches of the axillary nerve passing through the quadrilateral (quadrangular) space created between the humeral shaft, the triceps muscle, and the teres major and minor muscles where also passes the posterior humeral circumflex artery. National Library of Medicine Philadelphia, PA: Saunders. However, the appearance of the anterior capsular insertion may vary with the arm in internal or external rotation. Get instant access to this gallery, plus: For a broader topic focus, try this customizable quiz. It presents smooth margins and measures less than 2 mm in width. Type I: flat; Type II: curved; Type III: hooked. The blood supply to the glenoid labrum was observed and noted during the dissection of all 140 shoulders. The supraspinatus muscle is required for normal lateral abduction of the upper extremity. There is variability in size, thickness and morphology of the labrum. It has a relatively wide range of attachment along the glenoid labrum and extends to the inferomedial part of the surgical neck of the humerus. This gives the labrum an appearance in some ways like a meniscus of the knee. Radiographics. At the superior labrum, fibers from the proximal origin of the long head of the biceps tendon blend with the labrum forming the biceps labral complex (BLC). Cortical bone has low signal intensity due to its high density and slow-moving protons. This review discusses the normal anatomy and anatomic variants of the glenoid labrum, articular cartilage, and glenohumeral ligaments. This ligament runs horizontally, almost parallel to the long head of the biceps tendon, straight in the direction of the coracoid process. 5 ). This is the strongest of the three GH ligaments, being thicker and longer than the other two. It also serves as a primary attachment site for the GHLs, joint capsule, and long head of the biceps tendon. The first is the rotator interval, an area of unreinforced capsule that exists between the subscapularis and supraspinatus tendons. Type 3 corresponds to a large sublabral sulcus which extends under the labrum and over the cartilaginous portion of the glenoid fossa [3]. [3], Labral injuries are named according to localisation, No general rules exist for management of labral lesions are resected and others fixed. Radiographics. It covers the intertubercular sulcus and the long head tendon of the biceps brachii muscle, preventing displacement of the tendon from the sulcus. infraglenoid tubercle of scapula, which is a rough area at the inferior margin of the glenoid fossa. The coracoglenoid ligament arises from the middle of the coracoid process and inserts posterior to the supraglenoid tubercle, covering the top of the glenoid rim, superior labrum, and long tendon of the biceps. Although this chapter is based on MRI, we should not forget the importance of standard radiographs for the evaluation of bone and joint structures. It can have a conjoined attachment together with the superior glenohumeral ligament, or together with the long head of the biceps tendon when the superior glenohumeral ligament is absent at the 12 and one oclock positions. In internal rotation, the capsular insertion may appear more medial (type III), and with the arm in external rotation it may appear more lateral (type I) [1]. Medial to the triceps muscle is the triangular space, bordered superiorly by the teres minor muscle and inferiorly by the teres major muscle. The ligament is composed by fibers of the subscapularis tendon, with contributions from the supraspinatus tendon and the coracohumeral ligament [2,3]. The .gov means its official. Patients with tears of the glenoid labrum present with an extensive range of non-specific symptoms including: The ability to predict the presence of a glenoid labral tear by physical examination was compared with that of magnetic resonance imaging (conventional and arthro gram) and confirmed with arthroscopy. With the administration of intra-articular contrast and distension of the joint, capsular apposition becomes less problematic. Glenoid Labrum Tear Treatment at Baptist Health: Our Approach. The anterolateral trapezoid and posteromedial conoid ligaments are identified on coronal oblique and sagittal oblique sections. The inferior glenohumeral ligament actually consists of an anterior and posterior band as well as the axillary pouch that is reinforced by the fasciculus obliquus (or spiral glenohumeral ligament) on the glenoid side (Figure (Figure16).16). The anterior capsular mechanism includes the anterior capsule, the glenohumeral ligaments, the synovial membrane and its recesses, the glenoid labrum, the subscapularis muscle and tendon, and the scapular periosteum. (A) Axial and (B) Sagittal fat suppressed T1-weighted MR arthrogram of a sublabral foramen. This ligament controls horizontal stability of the acromioclavicular joint. This is typically accompanied by thinning of the overlying cartilage. Additional smaller bursae exist within the shoulder and are not commonly visualized on MR imaging. Glenoid labrum. The shoulder joint is well suited to evaluation by ultrasonography (US) because of its easy accessibility. 4a, b). The sublabral recess is best seen with arthrographic technique. SLAP tears involve the superior glenoid labrum, where the long head of biceps tendon inserts. Take the following custom quiz for a rotator cuff workout! The labrum demonstrates its greatest variation in morphology and attachment above the equator. Reading time: 15 minutes. This method provides multiplanar reconstructions, surface rendering of the osseous structures with rotation of the reconstructions and subtraction Figure Figure2.2. Moore, K. L., Dalley, A. F., & Agur, A. M. R. (2014). 2008; Smith et al . Coracoid Process: The Lighthouse of the Shoulder. It corresponds to a synovial reflection medial to the superior edge of the glenoid rim at the biceps anchor, showing a normal defect of the attachment of the superior labrum to the superior glenoid cartilage. Accessibility Any injury that disturbs this balance can lead to instability, progressive . Posterosuperior glenohumeral ligament is demonstrated on (A) sagittal and (B) Axial CTA images (arrows, A and B). glenoid labrum:the cavity has a fibrocartilaginous structure on its margin called the glenoid labrum which is continuous superiorly with the tendon of the long head of biceps brachii, joint capsule:attaches to the glenoid outside the glenoid labrum and tendon of the long head of biceps brachii, superior, middle and inferior glenohumeral ligaments:thickenings of the joint capsule. The dorsal aspect of the scapula is divided by the scapular spine into the supraspinous and infraspinous fossa where the supraspinatus and infraspinatus muscles attach respectively [3,6]. The width of the medial border and depth of the groove both affect the risk of subluxation of the long head of the biceps tendon [2,3,4]. Subacromial pseudospur. Inclusion in an NLM database does not imply endorsement of, or agreement with, The inferior transverse scapular ligament (spinoglenoid ligament) forms the roof of the notch. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Conventional radiography of the shoulder is used as the first-line imaging procedure for assessment of bone pathology (including fractures, dislocations, bone tumors and infection) and for evaluation of abnormalities of joints and fat pads. Check for errors and try again. Become a Gold Supporter and see no third-party ads. Check for errors and try again. An example of different pulse sequences is represented in Table Table22. (A) Sagittal oblique T1-weighted and (B) Coronal oblique fat-suppressed PD-weighted MR images detect areas of red marrow in the proximal humeral diaphysis with low signal intensity on T1 (arrow, A) and increased signal on fat-suppressed PD (arrow, B). At the time the article was created Ayush Goel had no recorded disclosures. Sections were stained using haematoxylin and eosin. In their retrospective review of patients found tohave anteroinferior labroligamentous injury at arthroscopy, the investigators reported that ADIR was superior to ABER and neutral position in the discrimination between subtypes of Bankart injuries. In type II, the capsule attaches on the glenoid neck within 1 cm of the labral base. The fact that these folds are in the nondependent position of the recess will help distinguish them from true loose bodies [7]. This space contains the scapular circumflex artery (Figure 3, additional material) [1,2]. It stabilizes the anterior capsule, limiting externalrotation, particularly when the arm is in an abducted position (45o 60o abduction). Type 2 forms a small sulcus at the superior pole of glenoid. The glenoid or glenoid cavity/fossa is the shallow depression of the scapula found on the lateral angle. Inferior glenohumeral ligament. It also serves as a primary attachment site for the GHLs, joint capsule, and long head of the biceps tendon. Both bands stabilize the humeral head when the arm is abducted above 90. [1] [2] See Shoulder Instability, Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. When the anterior capsular attachment is far from the glenoid margin (type III), the glenohumeral joint will be more unstable. Kwak and colleagues described the ABER position as optimal for evaluation of the IGHL and advocated it as an adjunct to routine imagingexamination. Magnetic resonance arthrography (MRA) is especially useful in the diagnosis of labral and ligamentous pathology.4 In determining the difference between a labral tear and a GAGL lesion, imaging can be difficult to interpret, leaving arthroscopy as the definitive diagnostic tool. A focal well-demarcated articular cartilage defect at the central aspect of the glenoid termed the bare spot has been reported in the surgical and radiologic literature ( Fig. It can be identified on sagittal and coronal MR arthrographic images as a thin line of intermediate signal intensity interposed between the cartilage of the humeral head and the supraspinatus tendon. Overview What is a SLAP tear? This resulted in a triangular-shaped section of tissue with the glenoid labrum and fibrous capsule attachment at the periphery. Pouliart, N, Boulet, C, De Maeseneer, M and Shahabpour, M. Advanced imaging of the glenohumeral ligaments. The capsule remains lax to allow for mobility of the upper limb. ), Normal anatomy, variants and pitfalls on shoulder MRI. Radiographics. An interstitial lesion is located between the two strings at the insertion. Several reports have detailed the importance of proper shoulder positioning to optimize evaluation of its complex anatomy and specifically to aid in detection of subtle abnormalities of the glenoid labrum and GHLs. Example of standard MRA protocol of the shoulder (based on the guidelines of the European Society of Skeletal Radiology (ESSR) Sports Subcommittee 2016). It acts to deepen the socket on average 9 mm in the superior-inferior dimension and 5 mm in the anteroposterior plane which acts to add stability to the joint [ 35 ]. Humeral insertion of the supraspinatus and infraspinatus. The confluent attachment of the AIGHL to the labrum was 1.2 0.9 mm medial to the most lateral extent of the labral rim, corresponding to 3:30 to 4:05 on the glenoid clockface. Read more. Journal of Orthopaedic Surgery. Cord-like middle glenohumeral ligament. Compression of either of these structures can lead to subacromial impingement syndrome and/or subacromial bursitis [2]. The ligament provides stabilization of the glenohumeral joint when the shoulder is abducted 45 [2,6]. It courses between the anterosuperior glenoid rim and the humeral head, just above the greater tuberosity (Figure (Figure18)18) [3]. They have a weak stabilizing function, each acting to limit the maximum amplitude of certain arm movements; The superior glenohumeral ligament extends from the supraglenoid tubercle of scapula to the proximal aspect of the lesser tubercle of humerus. Additionally, the presence of several variations was reported to be conductive to lesions involving the glenoid labrum. Imaging of the shoulder in flexion, adduction, and internal rotation (FADIR) has been advocated to better evaluate the posterior capsulolabral complex. The combination of an absent anterosuperior labrum and a thickened cordlike MGHL is termed the Buford complex; this is a relatively uncommon normal variant, occurring in approximately 1.5% of patients ( Fig. Regarding muscle abnormalities as muscle atrophy, involvement of both the supra- and infraspinatus muscles suggests a proximal lesion in the region of the suprascapular notch; involvement of the infraspinatus muscle alone suggests a distal lesion in the region of the spinoglenoid notch [6]. The head of the upper arm bone is usually much larger than the socket, and a soft fibrous tissue rim called the labrum surrounds the socket to help stabilize the joint. in internal & external rotation) [1]. The axillary recess is located between the anterior and posterior bands of the inferior glenohumeral ligament [1]. The glenoid labrum forms part of the periarticular fiber system that is continuous with the rotator interval as well as 4: Arterial supply is from the ascending glenoid artery, branches of the suprascapular and circumflex scapular arteries,muscular branches of rotator cuff muscles, and anterior and posterior circumflex humeral arteries 5. The articular cartilage of the humeral head is thicker centrally and thinner peripherally contrary to the glenoid articular cartilage which is relatively thinner centrally and thicker peripherally [7]. Variant appearances of the middle glenohumeral ligament include absence of the middle glenohumeral ligament, a conjoint origin with either the superior glenohumeral ligament or inferior glenohumeral ligament, and a cord-like thickening of the middle glenohumeral ligament in combination with an absent anterosuperior labrum (Buford complex) [7]. Its attachment extends slightly above to the adjacent glenoid labrum and blends with the glenohumeral capsule of the shoulder joint, contributing to its stability. The head of the upper arm bone (humeral head) rests in a shallow socket in the shoulder blade called the glenoid. The glenoid labrum is a fibrocartilaginous complex that attaches as a rim to the articular cartilage of the glenoid fossa. Copyright It also represents the tendinous origin of a number of upper extremity and chest wall muscles, including the pectoralis minor and the long head of the biceps brachii. Failure to recognize and account for the bare area at imaging may lead to erroneous diagnosis or overestimation of partial thickness supraspinatus tendon tears. The capsular mechanism provides the most important contribution to the stabilization of the glenohumeral joint.

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