A: Infraspinatus tendinosis and tears, usually superior fibres at the humeral surface. What are the findings What is your diagnosis? Axial MR-arthrogram of a reverse Bankart. 2 Jobe CM. Humeral head cysts underlying the superior insertional fibers of infraspinatus which demonstrate undersurface fraying (white). Now you know that you have to look for a Bankart or variant. You can also sometimes see calcification of tendons around the shoulder joint on X-ray, which can be a sign of chronic impingement (although this is unlikely to be the reason for a shoulder X-ray request in an Emergency Department setting). This causes you to have pain when raising your arm overhead or out to the side. ENROLL IN OUR COURSE: http://bit.ly/PTMSKGET OUR ASSESSMENT BOOK http://bit.ly/GETPT OUR APP: iPhone/iPad: https://goo.gl/eUuF7w Android: https. This was an incidental finding on a chest-film. Internal impingement is one of many potential causes of shoulder pain in the overhead throwing athlete. On physical exam, posterior pain is recreated in abduction and external rotation. On images of the shoulder with the arm in a neutral position, the torn labrum may be held in its normal anatomic position by the intact scapular periosteum, which thereby prevents contrast media from entering the tear. 174 no. A collection of free medical student quizzes to put your medical and surgical knowledge to the test! How to Apply a Warm Compress & Clean the Eye | Eye First Aid | OSCE Guide. In the case of simple radiology, it should be suspected when typical changes are observed such as the tilt of the acromion or the decrease in acromiohumeral . Radiography. - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ 8 Burk DL, Torres JL, Marone PJ, et al. This video demonstrates how to apply a warm compress to the eye and clean away debris. Adapted from an original image by Emilios Pakos et al. Notice the abnormal contour of the anterior glenoid and the avulsed anterior rim (arrow). Check for errors and try again. Shoulder impingement syndrome develops when there is narrowing of the gap between the shoulder blade and shoulder bone, known as the subacromial space. - 700+ OSCE Stations: https://geekymedics.com/osce-stations/ Eur J Emerg Med. Arthroscopic capsulolabral reconstruction is an effective and reliable treatment for posterior shoulder instability with good patient-reported outcomes, low recurrence rates, and high rate of return-to-play. Download Citation | Calcific Tendinopathy of the Rotator Cuff in Adults: Operative Versus Nonoperative Management | Calcific tendinopathy of the shoulder implicates calcification and degeneration . You can now create flashcards with the help of AI using the Geeky Medics Flashcard App. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. A fat suppressed T2-weighted oblique coronal image (1a) and a gradient echo T2*-weighted axial image (1b). Jobe has categorized the clinical presentation of internal impingement into three stages.9 In Stage I, athletes present with shoulder stiffness that requires an extended warm-up period. Gor D. The Trough Line Sign. Early superficial chondral wear of the inferior portions of the glenohumeral joint. Bankart lesions with an osseus fragment are common findings in patients with an anterior dislocation and are frequently seen on the x-rays or CT-scan. The test is positive if the patient complains of deep posterior pain. Scroll through the images. Diagnosis is may clinically with worsening posterior shoulder pain during maximal abduction and external rotation (position of late cocking) associated with decreased internal rotation and supplemented with MRI showing posterior rotator cuff and posterior labral pathology. Instagram: https://instagram.com/geekymedics Typical X-ray findings in posterior shoulder dislocation include: The AC joint is visible in all views and is probably best assessed in the AP view. First notice the Hill-Sachs defect indicating a prior anterior dislocation (blue arrow). Some associated injuries are recognized, including 2: Point-of-care ultrasound (POCUS) can be utilized in the emergency department, particularly in situations of non-diagnostic radiographs, when CT is unavailable or in patients who have had recurrent dislocations 8. Glenoid: version and shape. 2. With a positive relocation test, pain and apprehension are relieved by application of pressure over the anterior humeral head. - Medical Finals Question Pack: https://geekymedics.com/medical-student-finals-questions/ Book appointments Online, View Fees, User Feedbacks. Defining posterior shoulder instability (PSI) is therefore difficult, not only defining it within this continuum but differentiating it from other shoulder pathologies. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Radswiki T, Rasuli B, Newman C, et al. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. Joint laxity is variably present. There are many labral variants that may simulate a labral tear. Occasionally, they can be the result of strength imbalance within the rotator cuff muscles. A fat suppressed T2-weighted oblique coronal image (1a) and a gradient echo T2*-weighted axial image (1b) are provided. A collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. Bilateral posterior ankle impingement syndrome has been described but is rare 5 . As the 'plantar flexion' movement occurs, the foot and ankle are angled away from the body to their greatest extent, with the ankle compressed. A structured approach toshoulder X-ray interpretationis discussed below. The arrow points to the disrupted periosteum. - Medical Finals Question Pack: https://geekymedics.com/medical-student-finals-questions/ Neep M & Aziz A. Radiography of the Acutely Injured Shoulder. The humeral head will also lie inferior to the coracoid process and this is typically most obvious in the lateral view. On MR-arthrography it may be difficult to depict the osseus fragment. Posterior ankle impingement (PAI) syndrome is one of the impingement syndromes involving the ankle. The image on the right shows a cartilage defect in the 4 o'clock position. Narrative Content In addition to stating that a posterior dislocation is present, any evidence of proximal humeral fractures or glenoid fractures should be sought and commented on. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Dixon A, Internal impingement of the shoulder. Setting during which symptoms arise (eg, pain during sleep, in various sleeping positions, at night, with activity, types of activities, while resting) Quality of pain (eg, sharp, dull, radiating, throbbing, burning, constant, intermittent, occasional) You can check out our guide to eye trauma here: COMING SOON These labral tears make the shoulder unstable and susceptible to repeated dislocations. The pain is usually described as posterior, and occurs during and after throwing. Shoulder (132) Foot & Ankle (97) Hand & Wrist (310) Pediatrics (71) Soft Tissues, Nerve, and Bone (138) Spine (215) Synovial Joints (187) Temporomandibular Joint (TMJ) (58) . Some authors have suggested that the cystic changes within the humeral head in the throwing athlete are due to repetitive avulsive trauma caused by deceleration during the follow-through motion of throwing.8 The anatomical relationships demonstrated in studies of internal impingement suggest impaction as perhaps a more likely etiology. Adapted from an original image by Jmarchn. Finally there is a medially displaced inferoanterior labrum at the 3-6 o 'clock position, i.e. Please write a single word answer in lowercase (this is an anti-spam measure). Arthroscopy 1995;11:530-536. Images of a patient with an ALPSA-lesion. The transducer is placed posteriorly on the shoulder using the humeral head position relative to the glenoid rim as the anatomical landmarks. 7 Giaroli EL, Major NM, Higgins LD. Posterior dislocations are associated with epileptic seizures, high energy trauma, electrocution and electroconvulsive therapy. Posterior dislocation may be missed initially on frontal radiographs in 50% of cases, as the humeral head appears to be almost normally aligned with the glenoid 1,2. - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ . The images in ABER-position demonstrate a detached anterior labrum. Figure 16: Oblique coronal T1-weighted fat-saturated MR arthrographic image in 22-year-old varsity swimmer with chronic posterior shoulder pain shows the typical findings of posterosuperior impingement. The extreme stress placed upon the shoulder by the throwing athlete can result in numerous causes of shoulder pain, including rotator cuff tears, labral tears, subacromial impingement, and glenohumeral instability. Jobe agreed with this concept and further expanded upon the entity2,3 by proposing that instability caused by anterior capsular stretching in throwers allowed increased angulation/external rotation, thus increasing contact at the posterior superior glenoid. Abnormalities in the glenoid shape and version has been described as more common in patients with atraumatic posterior instability. Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ Posterior impingement syndrome can occur in activities or sports that require repeated pointing of the foot such as kicking sports and ballet. Posterior ankle impingement should always be included in the differential diagnosis when evaluating a patient with chronic, deep posterior ankle pain, particularly in the very active patient or in a patient with a previous ankle injury. Only the collar bone connects your shoulder to the rest of the skeleton. 1 Walch G, Boileau P, Noel E, Donell ST. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. Licence: Geeky Medics. The shoulder is a very mobile and therefore unstable joint. Clinical presentation Impingement is a clinical scenario of painful functional limitation of the shoulder, [ 1] thought to be secondary to compression or altered dynamics that irritate and ultimately damage the tissues around the shoulder joint. Join the Geeky Medics community: 8. Jobe feels that such patients require surgical repair of their rotator cuff and/or labral pathology as well as a modified anterior capsulolabral shift. Internal impingement, also known as posterior superior glenoid impingement, is one of the most common etiologies of posterior shoulder pain in the throwing athlete. (2009) ISBN: 0387488979 -, 4. For assessment of chronic shoulder pain and subacromial impingement, X-rays are useful to assess lateral extension of the acromion on the anteroposterior view whereas lateral view allows to analyze the anterior coverage [ 8, 9, 10 ]. Posterior dislocations are uncommon and not as obvious on the X-rays as an anterior dislocation. The greater the retroversion of the glenoid the more prone it is to posterior dislocation. When a posterior dislocation presents to the emergency department, unlike anterior shoulder dislocations which are relatively easily reduced, posterior dislocations are more problematic and attempts at closed reduction should only be performed in consultation with a treating orthopedic surgeon 2. Twitter: http://www.twitter.com/geekymedics Radiology. They are broadly classified into external (also known as extrinsic) and internal impingements, which refer to extra-articular and intra-articular impingements of the rotator cuff tendons respectively. 4 Burkehart SS, Morgan CD, Kibler WB. HAGL is a Humeral Avulsion of the inferior Glenohumeral Ligament. Shoulder X-rays are common investigations in every Emergency Department, typically in the context of trauma, with shoulder dislocations being the most common pathology. As many orthopaedic surgeons feel that instability is an important factor in the pathogenesis of internal impingement, the correct diagnosis is critical so that instability can be addressed as needed at the time of rotator cuff or labral repair, thereby increasing the chances for a successful operative outcome. SLAP tears typically extend from the 10 to the 2 o'clock position, but can extend more posteriorly or anteriorly and even extend into the biceps tendon. Anterior acromioplasty for the chronic impingement syndrome within the shoulder: a preliminary report. Imaging interpretation of the postoperative shoulder is a challenging and difficult task for both the radiologist and the . Direct MR arthrography improves the visualization of both labral tears and partial articular surface cuff tears as compared to routine MRI.5 We have been successful in visualizing internal impingement utilizing MRI following intravenous administration of gadolinium chelates. Given that the most common reason a shoulder X-ray is requested is to look for dislocation or successful subsequent relocation, being familiar with alignment is arguably the most important part of shoulder X-ray interpretation. For a full list of available versions, see the Directory of published versions . With disease progression, loss of velocity and accuracy may ensue. This means that MR-arthrography with the arm in the neutral position may fail to detect the labral tear. MR arthrography or arthroscopy are optimal to diagnose Bankart or Bankart-like lesions. JMRI 1991: 1:385-389. During this motion, the posterior fibers of the supraspinatus tendon, anterior fibers of the infraspinatus tendon, or both can get impinged between the humeral head and the posterior glenoid. Instagram: https://instagram.com/geekymedics Due to these recurrent dislocations significant bone loss and erosion of the anterior glenoid rim may occur, which maintains the unstable situation. It is the most dislocated joint in the body. Harwood-Nuss, Ann. Posterior shoulder pain in a high-level tennis player. Posterosuperior impingement, also known as internal impingement, is a relatively uncommon form of shoulder impingement primarily involving the infraspinatus tendon and the posterosuperior glenoid labrum. Geeky Medics. This is a difficult case. Although somewhat controversial, recent work has supported the role of laxity in the pathogenesis of internal impingement.4. Hill-Sachs is a posterolateral depression of the humeral head. Today, were REALLY excited to announce Geeky AI; an intelligent assistant to help you write flashcards. 6 1707-1715. by Michel De Maeseneer et al Among several other pathologies, calcific tendinopathy of the rotator cuff tendons is frequently observed during the ultrasound examination of patients with painful shoulder. The images show a subtle Bankart fracture (arrows). Intercostal Drain) OSCE Guide, Ascitic Drain (Therapeutic Paracentesis) OSCE Guide, Assessing Nasogastric (NG) Tube Placement, Interpretation of Liver Function Tests (LFTs). Sometimes an axillary view can be of help, but when in doubt go to CT. It is above or at the level of the coracoid in the first 18 mm of the proximal humeral head. Posterior impingement can also occur if you have an enlarged bony prominence called an 'os trigonum' on the back of the foot bone or a bony anomaly in your ankle. You can learn more about the Arclight here: https://geekymedics.com/an-introduction-to-the-arclight/ 5 Figure 1 - Anatomy of Elbow (Lateral) A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. 5. Pitchers with internal impingement typically complain of pain in the late cocking or early acceleration phase of throwing. A high index of suspicion is helpful. Images of a MR-arthrogram. It is seen in 75-100% of patients with anterior instability. On MR-athrography the labrum is missing on the anterior glenoid and the labral fragment is displaced anteriorly (arrow). Normal radiographic measurements of the shoulder. There is also a Hill-Sachs defect (red arrow). DO NOT perform any examination or procedure on patients based purely on the content of these videos. The disabled throwing shoulder: spectrum of pathology. On the coronal image a large Hill-Sachs defect is seen. - Over 3000 Free MCQs: https://geekyquiz.com/ A , T1 fat-suppressed coronal oblique shoulder MR arthrogram. Shoulder disorders are very common in clinical practice. (2010) ISBN: 0781789435 -, 3. Developed by renowned radiologists in each specialty, STATdx provides comprehensive decision support you can rely on - Internal Impingement, Shoulder Underlying subchondral cystic changes and reactive marrow edema (arrowhead) are seen within the greater tuberosity. Ultrasound is the only dynamic technique but MRI is the best tool to depict rotator cuff disease [ 11, 12 ]. An ALPSA-lesion is an Anterior Labral Periosteal Sleeve Avulsion. Recently, it has been suggested that the repetitive contact of the greater tuberosity with the glenoid in abduction external rotation results in an inflammatory process, with increased vascularity accounting for the osseous changes.7 In some patients, post-operative MRI has revealed disappearance of the cystic lesions, lending support to an inflammatory etiology. The catching of the affected structures may be structural and/or functional in etiology 2. Posterior shoulder dislocation Posterior shoulder dislocation is both significantly less common and significantly harder to spot than anterior dislocation. Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ Pitchers with internal impingement typically complain of pain in the late cocking or early acceleration phase of throwing. Successful rehabilitation in Stage II patients results in pain resolution and a negative relocation test. Then continue reading. Q: What is the likely cause of posterior shoulder pain in this tennis player? 9 Figure 9:(9a) The corresponding fat-suppressed T1-weighted axial view demonstrates an irregular, enhancing posterior superior glenoid labrum (arrow). The recognition on MRI of the classic findings of articular surface partial rotator cuff tears, greater tuberosity osseous lesions, and posterior superior labral tears allows one to make an accurate diagnosis in such patients. Sagittal MR-arthrogram demonstrates the superior extension of the Bankart tear. The coronal images shows the medially displaced labrum (red arrow). With forceful repetition, articular surface rotator cuff tears (arrow) and labral tears (arrowhead) result. Shoulder impingement syndrome is a common cause of shoulder pain. Background:Contact athletes who experience posterior shoulder instability have a high likelihood of recurrence necessitating surgery.Indications:Patients with posterior shoulder instability without. A high index of suspicion is helpful. (5a) The area of interest from 4a is viewed in this illustration from a superoanterior angle. The relationship between external shoulder impingement and rotator cuff disease has been the subject of much research, but the theories of cause and effect remain controversial. Typical X-ray findings in anterior shoulder dislocation include: Posterior shoulder dislocationis both significantly less common and significantly harder to spot than anterior dislocation. The main differentiating feature is the location of the humeral head abnormality. Call us @ 7026-200-200 Medfin.in for more help (9a) The corresponding fat-suppressed T1-weighted axial view demonstrates an irregular, enhancing posterior superior glenoid labrum (arrow). Posterior internal impingement tes t. Starting position is supine . What is posterior ankle impingement? Here another patient with an osseus Bankart seen on four consecutive images of a MR arthrogram in ABER-view. 1. Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-12243, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":12243,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/posterior-shoulder-dislocation/questions/1381?lang=us"}, absence of external rotation on images in a standard shoulder series is a clue, acute angle of the scapulohumeral arch (Moloney's arch) is also present and can be used to distinguish from anterior dislocation, in particular fracture of the anatomical neck and/or lesser tuberosity, posterior labrocapsular periosteal sleeve avulsion (. 7. Adapted from an original image by Mikael Hggstrm. Lateral view: the humeral head will lie anterior and inferior to the glenoid fossa. Shoulder impingement describes a group of conditions characterized by the entrapment of musculoskeletal soft tissue within the shoulder, which primarily results in pain. This article reviews normal and abnormal imaging findings of the shoulder after surgery for subacromial impingement, rotator cuff tears, labral and instability lesions, and long head of the biceps tendon disorders. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. In the ABER-position it is obvious that there is a Perthes lesion (black arrow). MRI is well recognized as an effective means to diagnose internal impingement of the shoulder.5,6,7 The classic MRI findings of internal impingement, as seen in this months case, include partial articular surface tears at the posterior supraspinatus/anterior infraspinatus insertion, greater tuberosity bony changes, and tearing of the posterior superior glenoid labrum. Epidemiology It is usually a unilateral phenomenon. >8mm = injury to the acromioclavicular ligament, >13mm = injury to the coracoclavicular ligament, <7mm = possible supraspinatus tendon tear (a common rotator cuff injury), >12mm = joint widening (e.g. Robinson C & Aderinto J. Posterior Shoulder Dislocations and Fracture-Dislocations. by Asgar M. Saleem, Joong K. Lee, Leon M. Novak AJR 2008; 191:1024-1030, by Glenn A. Tung et al When assessing for joint disruption (especially AC joint) you will need to be familiar with commonly measured distances at the shoulder joint.7. It is the impingement of the rotator cuff (muscles and tendons within the shoulder which play a large part in lifting and twisting the arm) against other structures within the shoulder which form the basis of impingement syndromes. This video was produced in partnership with the University of St Andrews and the Arclight Project. Notice extention of the SLAP-tear further to posterior (red arrow). Christopher Ahmad. Sometimes this makes it easier to understand the anatomy. Bankart-lesions and variants like Perthes and ALPSA are injuries to the anteroinferior labrum. The impingement syndrome is an important source of shoulder pain that occurs when the bony and soft-tissue structures of the superior aspect of the shoulder encroach upon the coracoacromial ligamentous arch during abduction of the arm. AJR June 2000 vol. Adapted from an original image by Georg Mattiassich, Lucian Lior Marcovici, Rolf Michael Krifter, Reinhold Ortmaier, Peter Wegerer, Albert Kroepfl. This is a post-reduction view. A collection of surgery revision notes covering key surgical topics. Facebook: http://www.facebook.com/geekymedics Although much less common, it is also important to check the lungs for malignancy, as a Pancoast tumour may be visible in the apex of the lung. MRI of internal impingement of the shoulder. This is a Buford complex, which is a normal variant. Medial Meniscus Repair with Concomitant ACL Reconstruction . a tear). An important distinction to note is what we mean when we request a shoulder X-ray. If you'd like to support us and get something great in return, check out our awesome products: You don't need to tell us which article this feedback relates to, as we automatically capture that information for you. The images show a partial tear of the anteroinferior labrum with adjacent cartilage damage at the 4-6 o 'clock position (arrows). Posterior shoulder dislocation. General Inquiries. The presence of bony excrescences arising from . J Shoulder Elbow Surg1992; 1:238 245. Subacromial and subcoracoid impingement are primary external impingements. The humeral head is almost always displaced anteriorly and medially below the coracoid process. The tendon of the Infraspinatus muscle attaches on the posterior aspect of the greater tuberosity. This results in instability and recurrent dislocations. The acromioclavicular distance should be between 5-8mm: The coracoclavicular distance should be between 11-13mm: The acromiohumeral distance should be between 7-12mm: In all views, follow the outline of the cortex (outer white edge) of each bone, not forgetting to look at the ribs as well. 6 Halbrecht JL, Tirman P, Atkin D. Internal impingement of the shoulder: comparison of findings between the throwing and nonthrowing shoulders of college baseball players. Features of internal impingement of the shoulder with humeral head cysts underlying infraspinatus, superior fiber infraspinatus and posterior fiber supraspinatus tendinosis and posterosuperior labral fraying. The relief of pain is presumably related to both a reduction of humeral head subluxation and due to disengagement of the rotator cuff from the region of internal impingement. Ultrasound is uncommonly used, however, may be useful in the emergency setting. The arrow points to the intact periosteum. In the context of trauma, rib fractures and pneumothoraces are common and may not be noticed if the patients main complaint is shoulder pain. Arthroscopic Posterior Labral Repair Feat. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. In most cases, acute posterior dislocations have spontaneously reduced prior to imaging 3. Sometimes the displacement is difficult to appreciate, especially when the transscapular-Y view is slightly rotated. AP view: the humeral head will lie medial and inferior to the glenoid fossa. There are a combination of findings suggestive of internal shoulder impingement consisting of cysts within the humeral head underlying the superior fibers of infraspinatus, undersurface fraying of the superior fibers of infraspinatus, tendinosis and intrasubstance delamination involving the posterior fibers of supraspinatus, and significant fraying of the posterosuperior glenoid labrum. 1,2 Rotator cuff pathology is a common etiology for shoulder pain, with impingement of the rotator cuff often playing an important role. SLAP is an acronym that stands for 'Superior Labral tear from Anterior to Posterior'. The use of paramagnetic contrast has proven beneficial in the evaluation of internal impingement. J Bone Joint Surg Am. There is a Bankart lesion with extension into the cartilage, i.e a GLAD-lesion (red arrows). Unable to process the form. Here we will refer to internal and external. You can use Radiopaedia cases in a variety of ways to help you learn and teach. In the ABER position however there is tension on the antero-inferior labrum by the stretched anterior band of the inferior glenohumeral ligament and you have more chance to detect the tear. Clough T & Bale R. Bilateral Posterior Shoulder Dislocation: The Importance of the Axillary Radiographic View. The posterior-ankle impingement due to os trigonum can develop after disruption of the os trigonum through a significant acute injury (for example, fracture, fragmentation, and/or pseudoarthrosis). Hawkins R, Neer C, Pianta R, Mendoza F. Locked Posterior Dislocation of the Shoulder. Clayfield PhysioWorks provides excellence in the provision of Physiotherapy, Remedial Massage, Acupuncture and Nutritional services for the suburbs of Clayfield, Hendra, Ascot, Hamilton, Albion, Wooloowin, Wavell Heights, Toombul, Nundah, Northgate, Virginia, Chermside and other inner north Brisbane suburbs. When interpreting a shoulder X-ray, begin by confirming the patients details, reviewing the clinical history and ensuring the radiographs are adequate. The dislocation of the humeral head to antero-inferior causes damage to the antero-inferior rim of the glenoid in the 3 - 6 o'clock position (marked in red). Then bring the patient's shoulder into 90-110 degrees of abduction, 10-15 degrees of extension, and maximal external rotation. There are several ways in which impingement can be classified. Types of shoulder impingement include 1,2: subacromial impingement: most common CT). - Over 3000 Free MCQs: https://geekyquiz.com/ A positive test was correlated with undersurface tearing of the rotator cuff and/or . The red arrow points to the absent labrum - Buford complex. Special care should be taken to review the rest of the radiograph, especially the lungs and the ribs, as well as any other areas included in the image. Periprosthetic infections after complete shoulder arthroplasty: A 33-year perspective. Facebook: http://www.facebook.com/geekymedics Shoulder impingement syndromes are common causes of shoulder pain. Electrocution is a classic but uncommon cause of posterior shoulder dislocation. Images of another patient with an ALPSA-lesion. Licence: Geeky Medics. The image on the left shows an absent anterosuperior labrum, which is called a Buford complex. A Bankart tear can extend to the 1-3 o'clock position, but then there should also be a tear in the 3-6 o'clock position. 3 Jove CM. [1] [2] [3] [4] It is commonly described as a condition characterized by excessive or repetitive contact between the posterior aspect of the greater tuberosity of the humeral head and the posterior-superior aspect of the glenoid border when the arm is placed in extreme ranges of abduction and external rotation. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Especially in younger patients this results in a Bankart fracture or a Bankart lesion which is a tear of the anteroinferior labrum. TikTok: https://www.tiktok.com/@geekymedics Call today to schedule an appointment or fill out an online request form. We're excited to see what you do with this new tool - make sure to post examples in the comments! Posterior shoulder dislocations account for only 2-4% of all shoulder dislocations(the vast majority are anterior) 1,3. Clayfield PhysioWorks therapists . There is a large cyst in the posterolateral humeral head ( arrowhead ) that is filled with contrast material at the site of impaction between the humeral head and posterior labrum during overhead movements. - Geeky Medics OSCE App: https://geekymedics.com/geeky-medics-app/ On MR a Hill-Sachs defect is seen at or above the level of the coracoid process. As previously mentioned, if X-ray findings dont correlate with the clinical findings, consider alternate X-ray views or a different imaging modality (e.g. - Geeky Medics OSCE App: https://geekymedics.com/geeky-medics-app/ Arthroscopy 2003;19 : 404-420. Check for errors and try again. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. DO NOT perform any examination or procedure on patients based purely on the content of these videos. It is classically described in ballet dancers. 1987;69(1):9-18. There are two types of labral tears: SLAP tears and Bankart lesions. An impingement means that the soft tissue of your shoulder gets "pinched" where your collar bone (clavicle) and head of your shoulder bone meet. On CT it is easy to appreciate the osseus fragment of the anterior glenoid (arrow). an ALPSA-lesion (black arrow). The humeral head lies on top of the glenoid fossa, with the coracoid process anterior to it (the side of the ribcage represents anterior in this view). The clinical suspicion can be confirmed either with simple radiology or with a CT scan. an AP cephalic view of the clavicle). -. 713-798-1000. (2a) The fat-suppressed T2-weighted coronal image, a small partial articular surface tear (arrow) is evident at the posterior aspect of the supraspinatus insertion. External impingement, often commonly referred to by clinicians and providers as shoulder impingement, is best described as a painful condition of the shoulder that results from the inflammation, irritation, and degradation of the anatomic structures within the subacromial space. The mean posterior recess angle measured 65 (SD 27) for the controls and 94 (SD 38) for the athletes (P = .002).ConclusionsOverhead-throwing athletes with internal impingement pain and internal rotation deficit tend to have a thicker labrum and a shallower capsular recess in the posterior inferior shoulder joint than do non-overhead-throwing athletes. I. Pathoanatomy and biomechanics. Whether or not these views are required will largely be dictated by the patients history and the findings on clinical examination. This resulted in both a Hill-Sachs impression fracture on the posterior aspect of the humeral head (blue arrow) and an impression fracture on the anterior aspect as a result of posterior dislocation (red arrow). With disease progression, loss of velocity and accuracy may ensue. Motion in a posterior direction is limited by the posterior rim of the glenoid which is in an anteverted position. CT). There is an articular surfacing tear of the posterior supraspinatus fibers (arrow) combined with superior labral tear (arrowhead). Available from: Geeky Medics. On the images a posterior dislocation is seen with a fracture. This allows us to get in touch for more details if required. 2013;44(5):976-8. Empty Can Provocative Screen Place one arm in scapular plane thumb facing down and gently press down with other hand. The pathology associated with it as well as potential other pathology is well demonstrated with MRI. Twitter: http://www.twitter.com/geekymedics In most clinical scenarios this refers to a radiograph of the glenohumeral joint. Anterior and posterior impingement tests were positive and ROM (range of motion); right 75 degrees/left 105 degrees, extension right 15 degrees/left 20 degrees were elicited. . The infraspinatus muscle is a strong external rotator and additionally assists in both abduction and adduction. The shoulder almost always dislocates to anterior and inferior, because motion to superior is limited by the acromion, coracoid process and rotator cuff (figure). On coronal images you want to make sure whether this is a variant like a labral recess or labral foramen or whether this is a SLAP. In adults, convulsive disorders are the most common cause. Lateral view: the humeral head will lie posterior to the glenoid fossa. Posterior shoulder capsule pain usually is consistent with anterior instability, causing posterior tightness. SLAP tears start at the 12 o'clock position where the biceps anchor is located, which tears the labrum off the glenoid. Supraspinatus tendinosis and tear involving the posterior fibres. Lindsey grew up in Lake Havasu City, Arizona. First scroll through the images and try to find out what is going on. Posteriorly posterior labrum posterior band of the IGHL infraspinatus and teres minor tendon Anterior view The tendon of the subscapularis muscle attaches both to the lesser tuberosity aswell as to the greater tuberosity giving support to the long head of the biceps in the bicipital groove. (6a) T1- and (6b) fat-suppressed T2-weighted images in a professional baseball player with clinical signs of internal impingement reveal prominent cystic changes within the posterior greater tuberosity (arrows). Humeral head cysts underlying the infraspinatus tendon. On the AP-view the head looks strange due to the internal rotation. Licence: Geeky Medics. Look around the bones and joints for any signs of darkening/fluid levels that may represent blood or fat (lipohaemarthrosis), which suggests a fracture even if one cannot be seen. No labral tear was found in this patient. The arrow points to the cartilage defect. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-24454, Posterosuperior impingement of the shoulder. However, it is worth being aware that if you are unable to get an adequate view of the clavicle or the scapula, more specific dedicated radiographs can be requested (e.g. Arthroscopy 1999;15 : 253-258. Abstract. Walch et al first described internal impingement in 1992, in a study of 17 overhead athletes.1 Walch found that in abduction and external rotation, contact occurs between the undersurface of the rotator cuff and the glenoid, and that though the contact is physiologic, it may lead to disease when performed forcefully and repetitively, as in the throwing athlete (4a,5a). The posterior restraints to posterior translation of the humeral head are: 1. If requested before 2 p.m. you will receive a response today. - PSA Question Pack: https://geekymedics.com/psa-question-bank/ A comprehensive collection of medical revision notes that cover a broad range of clinical topics. Check out our NEW & IMPROVED quiz platform at geekyquiz.com, To be the first to know about our latest videos, subscribe to our YouTube channel . With Stage III internal impingement, pain and a positive relocation test persist after rehabilitation. (4a) Viewed from above, a pitcher in the late cocking phase of throwing places the shoulder into extreme abduction and external rotation. Notice the distance between the humeral head and the glenoid on the AP-view, which is abnormally wide. (7a) A T2-weighted coronal image in a professional baseball pitcher with clinically presumed internal impingement does not demonstrate a rotator cuff tear. J Bone Joint Surg Am. A Perthes lesion is a labroligamentous avulsion like a Bankart, but with a medially stripped intact periosteum. Simply enter your prompt on the front of the flashcard and let our intelligent assistant (Geeky AI) do the rest! The arrow points to the medially displaced labroligamentous complex. Posterior shoulder dislocations are far less common than anterior shoulder dislocationsand can be difficult to identify if only AP projections are obtained. Shoulder pain is a common musculoskeletal medical condition affecting 7% to 26% of individuals and is the third most common musculoskeletal-related complaint in the primary care setting. The anterior labrum is absent at the 1-3 o 'clock position The close-up view on the right demonstrates how the posterior supraspinatus may infold between the greater tuberosity and the posterior superior labrum. The anterior labrum is absent on the glenoid rim. Posterior impingement. Your shoulder girdle is made up of three bones, the arm bone, shoulder blade and the collar bone. Notice how this high signal continues posteriorly, which means that it is a SLAP-lesion. aDBS systems have emerged as a promising alternative to address significant limitations in conventional open-loop DBS . J Shoulder Elbow Surg 1993; 2(part 2):S19. This impingement is mostly occurs when to arm is abducted or extended beyond . Unable to process the form. - 2500+ OSCE Flashcards: https://geekymedics.com/osce-flashcards/ Illustrations courtesy of Michael E. Stadnick, MD. Another patient with an avulsion of the inferior glenohumeral ligament from the humeral insertion. Radiology trainee interested in medical education, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LmVsa0gtdG5pQzY0, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkhFQ2ZrSDhrZGJJ, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LmtzbGhFUlNHSFhN, Start typing to see results or hit ESC to close, Deep Vein Thrombosis (DVT) Examination OSCE Guide, Rash & Non-Pigmented Skin Lesion Examination OSCE Guide, Pigmented Skin Lesion Examination OSCE Guide, Arterial Line Insertion (Arterial Cannulation) OSCE Guide, Chest Drain Insertion (a.k.a. Call today to schedule an appointment or fill out an online request form. Features of internal impingement of the shoulder with humeral head cysts underlying infraspinatus, superior fiber infraspinatus and posterior fiber supraspinatus tendinosis and posterosuperior labral fraying. The only exception to this rule is the reverse Bankart, which is the result of a posterior dislocation and injury to the inferoposterior labrum. Posterior dislocations are uncommon and easily missed, because there is less displacement compared to the anterior dislocation. This page is part of the International Patient Summary Implementation Guide (v1.1.0: STU 1) based on FHIR R4.This is the current published version. There is discontinuity of the IGHL attachment on the humerus with leakage of contrast. Mackenzie D & Liebmann O. Point-Of-Care Ultrasound Facilitates Diagnosing a Posterior Shoulder Dislocation. Check out our other awesome clinical skills resources including: On the transscapular-Y view the humeral head is displaced posteriorly. P. Kongmalai, M. Wright, D. Song, W. Levine 04:31. They are not in the 3-6 o'clock position, which makes it easy to differentiate them from a Bankart tear. Magnetic Resonance Imaging in Orthopedic Sports Medicine. 3D-reconstruction of a large bony Bankart in the 2 - 6 o'clock position. The deposition of hydroxyapatite calcium crystals should not be considered as a static process but rather a dynamic pathological process with different/possible . 2011;17(3):188-92. Create Flashcards using AI | Geeky Medics AI . anti-clockwise. There is an osseus Bankart lesion (curved red arrow). 9 Jobe CM. Dr udayan das is an orthopedic surgeon. Throughout medical school, she volunteered in a free, student-run clinic for women and children, which is where she found her passion for women's health and underserved care. Focal enhancement is seen within a small partial articular surface supraspinatus tear (arrow) and within the adjacent greater tuberosity (arrowhead) on these (8a,8b) fat-suppressed T1-weighted coronal images obtained following intravenous contrast administration in a 25 year-old professional baseball pitcher. This test, performed on the supine patient, causes apprehension when pressure is placed upon the back of the humeral head in abduction and external rotation. Orthopaedic Department, University Hospital of Ioannina, Ioannina, Greece. Normal appearance of the coracoacromial ligament. The tear extends to superior (black arrows). In the supine position examiner is do to passively abducted to shoulder up to 90 ' to 110 ' with extension of shoulder is 15 'to 20' & do to maximum lateral rotation means external rotation . Clinical History: A 22 year-old professional baseball pitcher presents with persistent posterior shoulder pain after throwing. Notice the medially displaced labrum. research has shown posterior shoulder impingement syndrome occurs when the rotator cuff and greater tuberosity make contact with the posterior and superior glenoid rim and labrum at end range (er) of the shoulder with the arm in abduction to 90 degrees. it is most commonly found in overhead-throwing athletes, specifically in baseball players. The ABER-view shows an absent antero-inferior labrum. She received her bachelor of science in physiology as well as her medical degree from the University of Arizona. The joint permits a substantial range of movement in different planes, and is still inherently steady due to its bony anatomy and the static and dynamic stabilisers. It represents a patial tear of the anteroinferior labrum with adjacent cartilage damage. This impingement may occur when the shoulder is placed in the abducted and externally rotated (ABER) position, typically encountered during the late cocking-early acceleration phase of throwing but also experienced in other overhead activities such as tennis and swimming. Subtle articular surface partial tearing is seen at the posterior supraspinatus insertion on the T2-weighted view (arrowhead). 2001;8(2):161-3. In General, the radiographic phenotype is the clear cut to finalize the diagnostic process. This field is for validation purposes and should be left unchanged. Constellation of findings in keeping with internal shoulder impingement. A scapular Y view has been shown to be unreliable for diagnosing posterior shoulder dislocations 4. Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI, Collateral Ligament Injuries of the Fingers. Harwood-Nuss' Clinical Practice of Emergency Medicine. In both situations, bilateral dislocations are not infrequent 1-3. As with all radiographs, make sure you dont stop looking once you have found a fracture or the specific abnormality you requested the investigation for (the presence of an obvious shoulder dislocation doesnt rule out the possibility of other bony injuries). MR imaging of shoulder injuries in professional baseball players. Posterior fiber supraspinatus tendinosis with intrasubstance delamination and overlying bursal fluid (black arrow). However, it usually develops insidiously as a result of repeated forced plantar flexion of the foot and chronic injury to posterior osseous and soft . It occurs when the shoulder is abducted and externally rotated ( ABER position ). 2 articles feature images from this case There is a detachment of the anteroinferior labrum (3-6 o'clock) with complete tearing of the anterior scapular periosteum. A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. AJR 2005; 185:925-929. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. Patients with symptoms of external impingement are referred for imaging to identify bony abnormalities of the coracoacromial arch and associated bursal and rotator cuff . October 2000 RadioGraphics, 20, S67-S81. ADVERTISEMENT: Supporters see fewer/no ads. Christopher Ahmad. TikTok: https://www.tiktok.com/@geekymedics There is mild thickening of the inferior glenohumeral ligament and anterior joint capsule. - 700+ OSCE Stations: https://geekymedics.com/osce-stations/ A collection of anatomy notes covering the key anatomy concepts that medical students need to learn. Widening of the gap between the clavicle and the coracoid process may indicate pathology affecting the coracoclavicular ligament (e.g. Next notice the high signal at 12 o' clock (red arrows). 5 Tirman PFJ, Bost FW, Garvin GJ, et al. show answer, A: Internal impingement (also known as posterosuperior impingement of the shoulder), Q: What are the typical MRI features of internal impingement of the shoulder? This can sometimes be difficult and is an easy heuristic trap that can be prevented by being thorough and having a framework or system to follow. The image on the right is rotated 90? Although the classic MRI appearance of internal impingement involves abnormalities of all three regions, variations often occur in which lesions may predominate in two of the affected areas (6a, 6b). Loss of internal rotation and a positive relocation test (for instability) are common findings. When looking at the GHJ, the glenoid fossa (the socket) should be visible as a concavity medial to the humeral head (the ball). Internal (posterosuperior) impingement syndrome is typified by a painful shoulder due to impingement of the soft tissue, including the RC, joint capsule and the posterosuperior part of the glenoid. The MR-images are of a patient who had undergone both an anterior aswell as a posterior dislocation. Shoulder impingement is currently subdivided into external (subacromial) and internal impingement. The NIH BRAIN Initiative has made a substantial investment to accelerate the development of adaptive deep brain stimulation (aDBS) systems for improving clinical management of treatment-resistant psychiatric and motor disorders. The C1 posterior tubercle is palpated, and then the soft tissue overlying the C1 posterior arch can be indifferent. - 2500+ OSCE Flashcards: https://geekymedics.com/osce-flashcards/ Call. There is a superior dislocation of the humeral head. It happens when the bones of your shoulder pinch upon the soft-tissues in the area. An uncommon cause of anterior dislocation is inpatients with a dysplasia of the glenoid. a tear). 6. The structure anterior to the glenoid is not a thorn labrum, but the middle glenohumeral ligament. Check out our other awesome clinical skills resources including: The yellow arrow points to the anterior glenoid rim. CT-images in another patient show a reversed osseus Bankart in a patient with posterior dislocation. Clinical presentation ADVERTISEMENT: Supporters see fewer/no ads. On the images a posterior dislocation is seen with a fracture. This is doubly true in the context of trauma, as rib fractures and the subsequent complications may be missed by a distracting injury like a fractured humerus or dislocated shoulder. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. Join the Geeky Medics community: You might also be interested in our awesome bank of 700+ OSCE Stations. Posterior shoulder pain produced by contact of the greater tuberosity with the posterosuperior aspect of the glenoid, when the shoulder is abducted to approximately 90 degrees and fully externally rotated, produces impingement of the posterior rotator cuff, capsule, and labrum (Gold 2007, Walch 1992 ). This is a bone defect as result of the impaction of the glenoid rim on the humeral head. On the transscapular-Y view the humeral head is displaced posteriorly. This may be from bone spurs, bursitis or shoulder instability. Superior glenoid impingement: current concept. Mild degenerative hypertrophy of the AC joint with mild capsular hypertrophy and adjacent marrow edema. Robert Pedowitz (Editor), Donald Resnick (Editor), Christine B. Chung (Editor). Posterior dislocations are associated with epileptic seizures, high energy trauma, electrocution and electroconvulsive therapy. Radiology 1994;193: 431-436. Posterosuperior glenoid impingement of the shoulder: findings at MR imaging and MR arthrography with arthroscopic correlation. An axial view can also be used as an alternative to the scapula Y view if the patient is unable to tolerate the positioning required to obtain this view. This is probably the result of a very large long-standing rotator cuff tear with progressive cranialisation of the humeral head and erosion of the acromion. There is a group of primary osteoarthritis patients with joint impingement, posterior erosion, . Plain film seriesusually suffices in making the diagnosis, although cross-sectional imaging (CT or MRI) is often used to assess the presence and extent of articular surface injury (reverse Hill-Sachs defect), glenoid injury (reverse Bankart lesion) or ligamentous injury. Bankart tears may extend to superior, but this is uncommon. Licence: Geeky Medics. Ideally, a shoulder radiograph series will provide adequate views of the clavicle, acromioclavicular joint (ACJ), glenohumeral joint (GHJ) and the scapula. If requested before 2 p.m. you will receive a response today. Simply write a prompt and let Geeky AI do the rest. This is especially important in the context of dislocations, where a history of recurrent dislocation may indicate the need for operative intervention. Anterior shoulder dislocation is significantly more common than posterior dislocation, representing >95% of all shoulder dislocations. Labral variants however may mimick a SLAP tear. Another example of a reverse Bankart. AP view: the glenohumeral joint will be widened and the humeral head will take on a classic light bulb appearance due to forced internal rotation of the humerus. Although overhead athletes such as baseball pitchers, tennis players, and javelin throwers are the most at risk, internal impingement may also be seen in the general population due to occupational overhead lifting activities. Impingement is diagnosed as either primary, secondary, or posterior (internal). Licence: Dr Naim Qaqish, Dr Matt Skalski et al. A Velpeau, Wallace or modified trauma axial view is an alternative 5,7. Approximately half of the posterior shoulder dislocations go undiagnosed on initial presentation, because of a low level of clinical suspicion and insufficient imaging. In Stage II, patients complain of posterior shoulder pain and have a positive relocation test. Adapted from an original image by Nevit Dilmen. Check the radiographs adequacy to ensure you are able to clearly see all relevant structures. Immediate post-contrast imaging in patients with internal impingement reveals enhancement within articular surface rotator cuff tears, labral tears, and within humeral head osseous abnormalities (8a,8b,9a). (Weishaupt,2000). Shoulder Impingement: Internal / Posterior Impingement Internal Impingement, often refereed to as posterior impingement, typically presents with pain/pinching in the posterior shoulder with the combination of External rotation and Horizontal Abduction regardless of whether the movement is active or passive. - PSA Question Pack: https://geekymedics.com/psa-question-bank/ A Bankart lesion is an injury of the anterior glenoid labrum due to anterior shoulder dislocation. Bankart lesions are labral tears without an osseus fragment. Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, Usefulness of the Abduction and External Rotation Views in Shoulder MR Arthrography, MR Imaging and MR Arthrography of Paraglenoid Labral Cysts, CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum and Labral-Bicipital Complex. It is not clear whether the labrum is normal. Notice the very large fracture of the glenoid rim with displacement. Impingement is a frequently described pathological condition in the overhead athlete. Request Now. Additionally, if the shoulder has been dislocated for 3 weeks (particularly common in debilitated elderly patients) or if the anterior humeral articular injury (reverse Hill-Sachs defect) involves >20% of the articular surface, then the closed reduction is contraindicated 2. Associate Professor of Radiology and Neurosurgery, Interim Chief of Neuroimaging and Neurointervention. Posterior elbow impingement has been also been referred to as "valgus extension overload" and "pitcher's elbow" and involves a repetitive compression injury to the posterior elbow. Subacromial bursitis, bicipital tendinitis, and rotator cuff disruptions are common sequelae of this abnormality. (3a) The gradient echo axial image reveals a complex tear of the posterior superior glenoid labrum (arrow). However, an osseous lesion is present within the posterior greater tuberosity (arrow) and striking degeneration and edema (arrowheads) are apparent within the posterior aspect of the superior labrum. These injuries are always located in the 3-6 o'clock position because they are caused by an anterior-inferior dislocation. Significant fraying of the posterosuperior glenoid labrum (grey arrow). Monday - Friday 8 a.m. - 5 p.m. ONLINE. Adapted from an original image by Nevit Dilmen. 2002;224(2):485-6. Adapted from an original image by Hellerhoff. Internal impingement is a condition that occurs in athletes in which the shoulder is put in extreme abduction and external rotation during overhead movements. On the coronal-oblique and sagittal reconstruction the displaced fragment of the glenoid rim is seen in the 3-6 o'clock position. Posterior dislocations account for 2-4% of all shoulder dislocations. LESSON 9, TOPIC 1. Mechanism A GLAD-lesion is a GlenoLabral Articular Disruption. Elbow Posteromedial Impingement 06:49. Place palm of one hand on opposite shoulder and, without allowing your palm to come off the shoulder, lift your elbow. This triad of structures has been documented via arthroscopy, MRI, and cadaveric studies to contact each other in the position of abduction and external rotation. As previously mentioned, if X-ray findings don't correlate with the clinical findings, consider alternate X-ray views or a different imaging modality (e.g. Posterior view of the shoulder Infraspinatus The infraspinatus muscle is located posterior to the scapula, inferior to the scapular spine. Posterior dislocations may even go unnoticed, especially in elderly patients 1. Footballers, ballet dancers, gymnasts and fast bowlers (due to the impact on their leading leg), are among those frequently affected by posterior ankle impingement. Acetabular Paralabral Cyst Causing Obturator Nerve Compression in the Setting of Femoroacetabular Impingement Syndrome: A Case Report December 2022 JBJS Case Connector 12(4) Notice the detatched labrum at the 6-9 o'clock position on the sagittal MR-arthrogram. Mild subcoracoid and rotator interval edema is evident. It is incredibly easy to get tunnel vision and focus entirely on the shoulder. This can misdirect management down the path of anterior instability and should be avoided. Due to the ABER-position the anterior band of the inferior GHL creates tension on the anteroinferior labrum and contrast fills the tear. Begin by confirming you have the correct patient and the correct radiograph by assessing the following: If previous radiographs are available, these should also be reviewed to provide a point of reference. If they dont, you should look closely at the distance between: Widening of the gap between the acromion and clavicle may indicate pathology affecting the acromioclavicular ligament (e.g. Typically the humeral head is forced posteriorly in internal rotation while the arm is abducted 1,3. Images of another patient with a posterior dislocation. A potential radiologist pitfall in internal impingement is interpreting posterior humeral head remodeling as a Hill-Sachs lesion. Posterosuperior labral tear or fraying. The physiologic groove in the humerus or cysts and erosions at the attachment site of the infraspinatus tendon can simulate a Hill-Sachs, but usually this is not a diagnostic problem (figure). Subacromial bursal thickening and increased fluid indicating co-existing subacromial bursitis. Fortunately, neurovascular compromise is uncommon, but associated glenolabral and capsular injuries can lead to posterior shoulder instability2,3. J Emerg Med. Clin Orthop 1996;330: 98-107. Bankart lesions are typically located in the 3-6 o'clock position because that's where the humeral head dislocates. The osteochondral lesions seen within the humeral head in internal impingement are of uncertain etiology. Evidence for a superior glenoid impingement upon the rotator cuff. FMS Impingement Clearing Screen This is the exact screen the FMS uses to "clear" someone for impingement. The pain is usually described as posterior, and occurs during and after throwing. Posterior Shoulder Instability Definition/Description A continuum of shoulder instability exists with laxity at one end and complete dislocation of the joint at the other. Scroll through the images. 2005;87(3):639-50. Posterior shoulder dislocations are far less common than anterior shoulder dislocations and can be difficult to identify if only AP projections are obtained. Posterior superior glenoid impingement: expanded spectrum. In this view, you should see the inferior borders of the acromion and the clavicle line up in a healthy individual. An axillary view is a preferred view for diagnosis. Even though you requested a shoulder X-ray, due to the nature of the imaging technique you will be given an image that contains more than just the shoulder girdle.