Occult, Incomplete, and Complete Posterior Labral

Tears Without Glenohumeral Instability on Imaging

Underestimate Labral Detachment
Jae-Hyung Kim, M.D., Jonghyun Ahn, M.D., and Sang-Jin Shin, M.D., Ph.D.

Purpose: To introduce a classification of posterior labral tear and describe clinical characteristics, magnetic resonance
imaging (MRI)/magnetic resonance arthrography (MRA) findings, arthroscopic findings, and outcomes after arthroscopic
repair for patients with posterior labral tears without glenohumeral instability. Methods: Sixty patients with posterior
labral tear who underwent arthroscopic repair were analyzed retrospectively. Patients with shoulder instability were
excluded. Tear patterns were classified into 3 types; occult (type 1), incomplete (type 2), and complete (type 3) based on
MRI/MRA studies. A visual analog scale score for pain, American Shoulder and Elbow Surgeons score, Single Assessment
Numeric Evaluation score for satisfaction, and return to sports were evaluated at a minimum follow-up of 2 years.
Computed tomography arthrography was performed at a year follow-up for assess labral healing. The diagnosis was
confirmed in arthroscopy, and arthroscopic labral repair without capsular plication was performed. Results: The mean
patient age was 30.4  6.9 years, and all patients were male. Forty-four patients (73.3%) were participating in sports.
MRI/MRA studies identified 10 patients with type 1, 18 with type 2, and 32 with type 3 tears. Type 1 tear patients showed
a significantly longer symptom duration than those with type 3 (32.5  17.2 vs 18.2  17.1 months; P ¼ .015). In
arthroscopic findings, 70% of type 1 tear was confirmed as incomplete or complete tears. The American Shoulder and
Elbow Surgeons score improved from 79.6  10.3 to 98.1  3.7, and pain was relieved from 2.4  0.7 to 0.2  0.5 at the
last follow-up visit with high labral healing rate (95%). Thirty-nine (88.6%) patients returned to sports at preinjury levels.
Conclusions: In active young men with shoulder pain during daily activities or sports despite programmed conservative
treatment, posterior labral tears should be considered even when MRI/MRA findings are ambiguous. Arthroscopic pos-
terior labral repair without capsular plication provided satisfactory clinical outcomes and a high labral healing rate. Level
of Evidence: Level IV, case series.

See commentary on page 68

P osterior labral tears have not received much

attention as a result of their low prevalence in
patients with shoulder instability. The incidence of the
reported that labral tears involving the posterior labrum
occurred in 74% to 86.3% of patients, which was
greatest compared with other labral regions, drawing
posterior labral tear is lower, at approximately 10% of attention to its importance.8,9
shoulder instability compared with 47% to 90% of Posterior labral tears are known to be closely related
anterior labral tear.1-4 However, there is a growing with posterior instability.10-14 However, posterior labral
body of evidence that suggests that the incidence of injuries are caused by various mechanisms. Repetitive
posterior labral tears is more prevalent than previously microtrauma such as weight training, rowing, and
known, especially in military and athletic pop- swimming or acute traumatic events during seizures,
ulations.4-7 Recently, retrospective studies regarding heavy weight exercises, and acute shoulder dislocations
patients who underwent arthroscopic labral repair have can damage the posterior capsulolabral structure.

From the Department of Orthopedic Surgery, College of Medicine, Ewha Gonghang-daero, Gangseo-gu, Seoul, 07804, Korea. E-mail: sjshin622@
Womans University Seoul Hospital, Seoul, Republic of Korea. ewha.ac.kr
The authors report no conflicts of interest in the authorship and publication Ó 2023 by the Arthroscopy Association of North America
of this article. Full ICMJE author disclosure forms are available for this article 0749-8063/234/$36.00
online, as supplementary material. https://doi.org/10.1016/j.arthro.2023.06.015
Received January 2, 2023; accepted June 1, 2023.
Address correspondence to Sang-Jin Shin, M.D., Ph.D., Department of
Orthopaedic Surgery, Ewha Womans University Seoul Hospital, 260,

58 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 40, No 1 (January), 2024: pp 58-67
 POSTERIOR LABRAL TEAR CLASSIFICATION 59

Atraumatic causes including generalized laxity or gle- dislocation or recurrent subluxation of the shoulder joint
noid hypoplasia also can lead to a posterior labral with positive physical examination for instability tests;
tear.15-19 The clinical presentations of posterior labral (2) patients with multidirectional instability on physical
tear are vague due to various injury mechanism; thus, examinations including the Beighton score, load shift
patients often do not complain of instability symptoms test, and sulcus sign; (3) patients with posterior glenoid
even if they have physical examination findings related hypoplasia on a computed tomography (CT) scan; and
to posterior instability.9,20,21 In some patients with (4) patients who underwent surgical treatment of the
symptomatic posterior labral tear, laxity or insufficiency capsular component such as rotator interval closure or
of the glenohumeral joint capsule is not observed on capsular plication. Considering both clinical features and
magnetic resonance imaging (MRI). Furthermore, some imaging tests, patients who were suspected of having a
posterior labral lesions might not be clearly visible on posterior labral tear received an intra-articular cortico-
magnetic resonance studies and may only be identified steroid injection and rested for a month as the primary
as incomplete tears during arthroscopic examinations.11 treatment. Then, after 2 months of performing
Therefore, it is necessary to evaluate the clinical char- strengthening rehabilitation exercises, the patients were
acteristics of posterior labral tear especially in patients allowed to return to sports in stages. Patients whose
without clinical evidence of glenohumeral instability. symptoms were not improved despite the programmed
The purpose of this study was to introduce a classifi- conservative treatment for at least three months un-
cation of posterior labral tear and to describe the clinical derwent operative treatment. We have received
characteristics, findings on MRI/ magnetic resonance approval from the Ewha Womans University Seoul
arthrography (MRA) and arthroscopy, and outcomes Hospital Institutional Review Board (SEUMC 2022-06-
after arthroscopic repair for patients with posterior 021). This study has been carried out in accordance with
labral tears without glenohumeral instability. It was the ethical standards in the 1964 Declaration of Helsinki
hypothesized that classified posterior labral tears and relevant regulations of the U.S. Health Insurance
without glenohumeral instability on imaging would Portability and Accountability Act, and informed consent
underestimate labral detachment. was obtained from all participants.

Methods Clinical Outcomes and Radiographic Evaluations

The patients were asked about their clinical symptoms
Patient Selection according to a prepared questionnaire form including
A total of 127 patients with symptomatic posterior demographic data, events associated with injuries,
labral tear who underwent arthroscopic posterior labral duration of symptoms, and previous shoulder joint in-
repair from February 2014 to April 2020 were enrolled. jection history. Preoperative physical examinations
This study was conducted at a single institution, and the included Kim’s test,22 the posterior jerk test, the
patient data were collected consecutively. All the O’Brien test, and the forced shoulder abduction and
collected patient data were analyzed retrospectively elbow flexion test.23 For functional assessment, a visual
using the physician practice’s electronic medical record. analog scale (VAS) for pain and the American Shoulder
Patients who met the following inclusion criteria were and Elbow Surgeons (ASES) score were assessed pre-
included: (1) symptomatic patients who had isolated operatively and postoperatively at 3, 6, 12 months and
posterior labral tear without clinical evidence of gle- at the last follow-up visit. Satisfaction with surgery was
nohumeral instability on physical examinations, evaluated using the Single Assessment Numeric Eval-
including apprehension test, relocation test, posterior uation (SANE) score, and return to sports was evalu-
jerk test, load shift test, and inferior translation test; the ated with 3 levels: preinjury, less than before, and did
apprehension test was used to exclude patients with not return. All functional assessments were consistently
both posterior and anterior instability pathologies. In evaluated by a physician assistant with 7 years of
the posterior jerk test, patients who felt a “clunking” experience in orthopaedics who was not involved in
sensation due to subluxation of the humeral head were this study. Physical examinations were performed by a
defined as positive in posterior instability and excluded board-certified orthopedic surgeon (S.-J.S.).
in this study. (2) Patients who had a confirmed poste- All patients underwent preoperative MRA or MRI to
rior labral tear on arthroscopy and underwent arthro- evaluate for the presence of a posterior labral tear. A CT
scopic posterior labral repair using suture anchors as the scan to evaluate bony glenoid lesions also was per-
primary operation. (3) Patients who underwent MRI/ formed preoperatively. Two orthopaedic surgeons (J.-
MRA preoperatively and computed tomography H.K., J.A.), both currently undergoing a specialized
arthrography (CTA) at 1 year of follow-up. (4) Patients fellowship program in shoulder surgery, evaluated the
with outpatient at a minimum follow-up of more than imaging tests independently inter-observer reliability
2 years. Patients who met the following criteria were were assessed. After the initial evaluation, one ortho-
excluded: (1) patients who experienced any frank paedic surgeon (J.-H.K.) independently re-labeled the
60 J-H. KIM ET AL.

Fig 1. Three types of posterior labral tears of right shoulder in MRI/MRA. (A) Type 1, an occult tear with a normal posterior
labral structure without evidence of labral detachments or cracks. (B) Type 2, an incomplete tear with a partial detachment
(arrow) in superficial aspect of the posterior labrum without evidence of a complete tear or contrast leakage. (C) Type 3, a
complete tear (arrow) in which the posterior labrum is detached from the glenoid. (MRA, magnetic resonance arthrography;
MRI, magnetic resonance imaging.)

patients with blinded processing and shuffled the order however, demonstrate a tear after probing; incomplete
to perform a second classification for intraobserver tears show partial detachment of the posterior labrum
reliability. The MRI/MRA findings of a posterior labral and can be delineated as torn with probing; and com-
tear are classified into 3 types; type 1 is an occult tear plete tears present definitive detachment of the poste-
with a normal posterior labrum appearance on MRI/ rior labrum from the posterior glenoid. Posterior labral
MRA; type 2 is an incomplete tear with partial tear patterns were analyzed by reassessing the type
detachment of the posterior labrum visible on MRI; and determined by the MRI/MRA to review how the tear
type 3 is a complete tear with a definitive detachment of would appear arthroscopically. The location of the tear
the posterior labrum from the posterior glenoid (Fig 1). was described by expressing the glenoid face as a clock.
Patient demographic data were reanalyzed according to The number of suture anchors used during posterior
the MR study classification to verify whether there labral repair also was reviewed.
were any differences based on the classification. CTA
scans also were reviewed to evaluate for labral healing Surgical Technique and Postoperative
at the 12-month follow-up visit. Rehabilitation
The diagnosis was confirmed during arthroscopic All operations were performed by a single orthopaedic
surgery. In arthroscopic findings, occult tears appear surgeon (S.-J.S.). The arthroscopic surgery was per-
morphologically normal with inspection by the scope, formed in the lateral decubitus position with the arm at
 POSTERIOR LABRAL TEAR CLASSIFICATION 61

Fig 2. Arthroscopic view of left shoulder from anterosuperior portal. (A) A curved suture hook, which is introduced through
posterior portal, is passed between the posterior labrum and the capsule to avoid catching posterior capsule. (B) The posterior
labrum is securely fixed without capsular plication using all suture anchors.

40 abduction and 10 flexion using a traction device 4 weeks. At the beginning of the fifth week, passive
under an interscalene block and general anesthesia. A range of motion and active-assisted exercises were
standard posterior portal and anteroinferior portal in the encouraged after discontinuation of the immobilization.
rotator interval were used for initial intra-articular Shoulder muscle-strengthening exercises were allowed
structure examination. Then, an anterosuperior after 12 weeks postoperatively. Return to sports was
viewing portal was made through the musculotendinous allowed 6 months postoperatively when shoulder range
junction of the rotator cuff posterior to the long head of of motion and strength had been recovered.
the biceps tendon. When the posterior labrum had only
cracks or a normal appearance, light pressure on the Statistical Analysis
junction between the glenoid cartilage surface and the A paired t-test was used to compare differences be-
labrum was applied to assess for occult tears using a tween the preoperative and final follow-up VAS scores
probe. If an occult tear is present, the labrum detaches for pain and ASES scores, and P < .05 was considered
easily from the glenoid surface with light pressure statistically significant. In addition, we evaluated the
applied through the probe, while this does not occur in clinical significance of our results by determining
the case of a normal labrum. Once a posterior labral tear whether the VAS scores for pain, ASES, and SANE
was identified, the labral tissue was debrided using a scores achieved the minimal clinically important dif-
shaver; then, the glenoid attachment site was decorti- ference (MCID) at the final follow-up. The MCID values
cated with a rasp. An additional posterolateral portal was (VAS: 1.5; ASES: 8.5; SANE: 13) were based on previ-
created at the midportion between the posterior and ously published values.24-27 The Cohen kappa coeffi-
anterosuperior portals for suture anchor insertion to the cient (k) was calculated to measure inter- and
posterior glenoid. All suture anchors (1.4-mm ICONIX1; intraobserver reliability for evaluation of MRI/MRA.28
Stryker, Mahwah, NJ) were placed in the area of the The difference in demographic data between the MRI/
labral lesion of the glenoid. A crescent suture hook MRA types was analyzed using the KruskaleWallis test,
introduced from the posterior portal was passed through and the difference between each group was analyzed
the junction between the labrum and capsule to prevent using the ManneWhitney U test; according to the
the capsule tissue from being sutured together (Fig 2A). Bonferroni method; P < .017 was considered statisti-
When the suture hook was passed through the labral cally significant. Proportion factors between each type
tissue, one strand of the anchor was passed using the were compared using the c2 test, but sports activities
shuttle relay technique. The labrum was tied with a and types were compared using Fisher exact test. All
sliding locking knot to apply strong tension to the statistical analyses and tests were conducted with SPSS
labrum. The steps were repeated until the lesion was (version 26.0.0; IBM, Armonk, NY).
completely repaired (Fig 2B).
The same postoperative rehabilitation protocol was Results
applied in all patients. Shoulder immobilization sup- Of 127 patients, 18 patients with a history of posterior
ported by an abduction brace was prescribed for the first shoulder dislocation, 14 patients with a history of
62 J-H. KIM ET AL.

Table 1. Demographic Data of Patients With Posterior Labral interobserver agreement of the MRI/MRA evaluations
Tear was almost perfect with an intraclass correlation coef-
Age at surgery, y 30.4  6.9 ficient of 0.836 (95% confidence interval 0.81-1.00, P
Symptom duration, mo 22.4  19.8 < .001) for the intraobserver reliability and substantial
Insidious onset/traumatic episode 39:21 with an intraclass correlation coefficient of 0.729 (0.61-
Male/female ratio 60:0 0.80) for interobserver reliability (both P < .001). The
Injuries on dominant shoulder, n (%) 40 (66.7)
demographic data for each type are described in
Sports activities participant, n (%) 44 (73.3)
Types of participating sports Table 2. No significant differences in demographic data
Weight training 30 were found among the 3 posterior labral tear types
Overhead sports 13 except for symptom duration. The symptom duration of
Competitive sports 3 patients with type 1 tears was significantly longer than
Swimming 2
that of those with type 3 tears (P ¼ .015). There was no
Others 2
Number of steroid injections 2.9  3.2 statistically significant difference between type 1 and
NOTE. Values are presented as mean  standard deviation or
type 2 tears or between type 2 and type 3 tears (P ¼
number only. .072, P ¼ .283). No posterior glenoid bone loss was
found on any patient’s preoperative CT scan. Sclerotic
changes of the posterior glenoid rim were observed in
recurrent subluxation, 24 patients with significant six patients, and bone cysts were found in two patients.
instability on physical examinations, and 11 patients The mean time between preoperative MRI/MRA and
who had undergone a capsular plication procedure surgery was 8.0  7.6 months. On arthroscopic find-
were excluded. Finally, 60 patients who met the in- ings, 36 patients had an isolated posterior labral tear,
clusion criteria were included in the study with a and the accompanying pathologic findings included
follow-up duration of 34.2  14.1 months. The pa- type I SLAP lesions (n ¼ 24). The most common pos-
tients’ preoperative demographic data and clinical terior labral tear locations were at 7, 8, 9, and 10 o’clock
findings are described in Table 1. All patients that met (n ¼ 34); followed by 8, 9, and 10 o’clock (n ¼ 9); 7, 8,
inclusion criteria were male, and 73.3% of patients and 9 o’clock (n ¼ 8); 9 and 10 o’clock (n ¼ 5); and 7
were active participants in sports. and 8 o’clock (n ¼ 4). The arthroscopic tear patterns
All patients complained of shoulder pain or discom- were matched to 3 types classified on MRI studies (Fig
fort that occurred during daily activities or sports ac- 3). The relationship between the MRI/MRA and
tivities but did not have resting pain. The most common arthroscopic findings is summarized in Table 3. In
positive test on physical examination was the forced arthroscopic findings, 7 patients (70%) of type 1 tear
shoulder abduction and elbow flexion test (32 patients, were confirmed as incomplete (5 patients) and com-
56.1%), followed by the O’Brien test (23 patients, plete tear (2 patients). Consequently, 3 of 10 (30%)
40.4%), Kim’s test (18 patients, 31.6%), and posterior type 1 posterior labral tears had matching preoperative
jerk test (11 patients, 19.3%). MRI/MRA and arthroscopic findings. In type 2 tears, 8
Preoperative MRI/MRA identified type 1 tears in 10 of 18 (44.4%) showed a match between the imaging
patients (16.7%), type 2 tears in 18 patients (30.0%), and arthroscopic findings. For type 3 tears, the corre-
and type 3 tears in 32 patients (53.3%). The intra- and spondence was greater, with 30 of 32 (93.8%) posterior

Table 2. Demographic Data of Patients Sorted by MRI/MRA Findings

Type 1 (Occult; n ¼ 10) Type 2 (Incomplete; n ¼ 18) Type 3 (Complete; n ¼ 32) P Value
Age at surgery, y 29.6  5.5 30.2  6.6 30.7  7.5 .950
Symptom duration, mo 32.5  17.2 24.1  22.9 18.2  17.1 .037 *
Insidious onset/traumatic episode 8:2 10:8 21:11 .427
Injuries on dominant shoulder, n (%) 6 (60) 10 (55.6) 24 (75) .333
Sports activities participant, n (%) 8 (80) 14 (77.7) 22 (68.8) .787
Types of participating sports .284
Weight training 8 11 11
Overhead sports 0 4 9
Competitive sports 0 1 2
Swimming 0 1 1
Others, 0 0 2
Number of steroid injection 2.7  1.6 2.9  3.4 3.0  3.6 .782
NOTE. Values are presented as mean  standard deviation or number only.
MRA, magnetic resonance arthrography; MRI, magnetic resonance imaging.
*Statistical significance is present between type 1 and 3 (P ¼ .015).
 POSTERIOR LABRAL TEAR CLASSIFICATION 63

A B

C D

Fig 3. Arthroscopic view of right shoulder from anterosuperior portal. (A) Type 1. A normal-appearing occult tear is present in
the posterior labrum that is easily overlooked during diagnosis. (B) The type 1 tear is easily penetrated by applying gentle
pressure with a probe (arrow). (C) Type 2. An incomplete tear with partial detachment of the posterior labrum (arrow). (D) Type
3. A complete tear with definite detachment of the posterior labrum from the glenoid (asterisk).

labrum demonstrating a match. The average number of improved from 79.6  10.3 preoperatively to 98.1  3.7
suture anchors used for posterior labral repair was at the last follow-up visit (P < .001), and pain was
2.9  0.7. relieved from 2.4  0.7 preoperatively to 0.2  0.5 at
Statistically significant shoulder functional improve- the last follow-up visit (P < .001). At the last follow-up
ment was obtained postoperatively. The ASES score visit, the SANE score showed satisfactory results at
97.4  7.2. Regarding clinically significant differences,
the proportion of patients who achieved the MCID at
Table 3. Correlation Between MRI/MRA Types and the last follow-up was 66.6% for VAS scores for pain,
Arthroscopic Findings 83.3% for ASES, and 78.3% for SANE score.
Thirty-nine (88.6%) of 44 patients who participate
MRI/MRA Findings (MRI/MRA)
sports activities preoperatively were able to return to
Arthroscopic Findings Type 1 Type 2 Type 3 sports at a preinjury level, and 5 patients (11.3%) did
Occult 3 (0/3) 2 (2/0) 0 (0/0) not return to sports, 4 of whom were participated in
Incomplete 5 (2/3) 8 (5/3) 2 (2/0)
Complete 2 (2/0) 8 (6/2) 30 (22/8)
overhead sports and, 1 in weight training. There were 3
patients (5.0%) with contrast leakage and a suspected
NOTE. Values in parentheses indicate participants who underwent
an MRI/MRA procedure. retear on the 12-month follow-up CTA; However, since
MRA, magnetic resonance arthrography; MRI, magnetic resonance no clinical symptoms related to retear were found, it
imaging. was decided to observe without revision. During the
64 J-H. KIM ET AL.

whole follow-up period, no postoperative complica- Many studies have reported that a physical exami-
tions such as infection or neurovascular injury were nation is highly sensitive for the diagnosis of a posterior
observed. labral tear. Kercher et al.21 reported that the O’Brien
test was positive in 71.9% of patients and that the
Discussion relocation test was positive in 50% of patients with a
The important findings in the current study were that posterior labral tear. Kim et al.22 reported that in pos-
3 types of posterior labral tears were found on MRI/ terior labral lesions, the sensitivity of the test was 80%,
MRA studies. However, the tear types observed on and that of the relocation jerk test was 73%; when both
MRI/MRA often underestimated the actual severity of tests were performed simultaneously, the sensitivity
tears when confirmed during arthroscopic surgeries. was 97%. SLAP lesionespecific tests also showed high
Especially, an MRI occult tear looks normal on the MRI positive rates for posterior labral tears such as in a study
studies, even though a tear actually exists, and an in which all patients were 100% positive on the
arthroscopic occult tear also looks morphologically modified SLAP test17 or 71.9% positive on the O’Brien
normal when inspected with the scope; however, after test.21 However, none of these studies controlled for
probing the labrum, it becomes evident that a tear patient instability. Therefore, the accuracy of the widely
actually exists. Arthroscopic posterior labral repair used tests for posterior labral tear and SLAP lesion is
achieved satisfactory clinical outcomes with a high re- low when applied in patients who had posterior labral
turn to sports rate in patients with posterior labral tears tear without instability. We routinely used two con-
without instability. ventional posterior labral tear tests and two SLAP lesion
All patients who had posterior labral tear without specific tests. The sensitivity of SLAP lesion specific tests
instability complained of pain in the range of shoulder is higher than that of conventional posterior labral tear
motion during daily activities and sports activities in test in patients who had posterior labral tear without
this study. The patients did not have resting pain, as instability in this study. This may be because 80% of
evidenced by the low VAS for pain score preopera- patients had tears at the 10-o’clock area; thus, the SLAP
tively. Alexeev et al.9 demonstrated that a posterior test could stimulate the lesions directly through the
labral tear that does not cross the midline of the joint biceps anchor in the immediate vicinity. In contrast,
is more likely to demonstrate pain than instability. conventional posterior labral tear tests such as the test
Savoie et al.29 also suggested that a posterior labral by Kim et al. or the relocation jerk test, which stimulate
tear is not an essential lesion of instability and that a the lesion through the humeral head, seem to have
posterior labral tear itself does not induce subjective difficulty stimulating the lesion properly when no
instability. One study in contact athletes with poste- instability is present.
rior labral tear without instability demonstrated the The diagnosis of posterior labral tears using MRI/
injury mechanism that the labrum could be damaged MRA has improved, with a sensitivity ranging from
without injury to the posterior capsule due to the 57% to 85.7%.9,32-34 Based on the current diagnostic
posterior shearing force that occurs when the shoul- rates in MRI/MRA, posterior labral tear in patients
der musculature is already applying a compressive without instability are more difficult to diagnose using
force to the glenohumeral joint.30 These patients MRI/MRA, as a complete posterior labral tear was
mainly complained of pain when performing move- diagnosed only in 53.3% of the patients. However, we
ments applied in the posterior shoulder direction, found that patients who showed incomplete and occult
such as performing a bench press and weight lifting. posterior labral tear on MRI/MRA also had clinical
This pattern is also seen in rugby players and soldiers symptoms that were not relieved after thorough con-
who perform many push-ups.7,31 Arthroscopic pos- servative treatment. Therefore, the current study did
terior labral repair aims to secure the labrum to the not classify the MR images by the presence or absence
glenoid, preventing pain generation caused by of tears alone and instead added 2 types of tears cor-
shearing forces. Thus, it is expected to alleviate the responding to an incomplete and a complete tear on the
pain experienced by patients during movements arthroscopic examination. Eight of 18 patients with
applied in the posterior shoulder direction. In the type 2 tears on MRI/MRA showed a complete tear, and
current study, 73.3% of the patients engaged in sports 7 of 10 patients with type 1 tears on MRI/MRA showed
activities, and 50% of the patients participated in a complete or an incomplete tear on arthroscopy,
weight training in which the force is directed to the demonstrating that posterior labral tears without
posterior labrum. However, considering that the instability could be underestimated on MRI/MRA. In
remaining 50% of sports participants were engaged in the absence of instability, some posterior labral tears
other kinds of sports activities and that 26.4% of the have a normal anatomical appearance superficially,
patients did not play sports, a similar posterior labral however there is a loose connection or an impending
injury mechanism might also occur in other sports tear in the deep portion of the labrum. Therefore, the
activities or activities of daily living. joint fluid or arthrography dye, which indicates the tear
 POSTERIOR LABRAL TEAR CLASSIFICATION 65

density on MRI/MRA, does not penetrate well between posterior instability studies,41 we obtained a high rate of
the glenoid cartilage and the torn labrum. This factor labral healing and return to sports rate after surgery to
may contribute to the similarities in diagnostic accuracy repair only the torn labrum without capsular plication
between MRI and MRA. In our study, 19 patients un- in patients who had posterior labral tear without
derwent MRA, whereas 41 patients underwent MRI for instability.
diagnosing posterior labral tears. In line with our find-
ings, several studies have reported that there is no Limitations
substantial difference between MRI and MRA in terms This study had several limitations. First, this study was
of diagnosing labral lesions.35,36 The absence of indirect a retrospective study with a relatively small number of
findings suggesting posterior labral tear, such as poste- patients; thus, selection bias may have occurred. In
rior capsular laxity and loss of labral contour or height, addition, the absence of female participants in the
also makes diagnosis of posterior labral tear without study, which limits the applicability of our findings to
instability difficult. Although Pennington et al.20 re- female patients and could potentially result in a sex-
ported that the diagnostic accuracy was 96% when MRI specific bias. Since the operative indications for poste-
was performed in conjunction with physical examina- rior labral tear were decided after thorough conserva-
tion in patients with posterior labral tears when 89% of tive treatment including corticosteroid injections with
patients had instability. However, the sensitivity of controlled shoulder strengthening exercises, the num-
physical examination is low in patients who had pos- ber of patients who underwent surgical treatment was
terior labral tear without instability. These points make small. Second, MRA, which has a high diagnostic rate
it difficult to diagnose patients with posterior labral for labral tears, was not performed in all patients. The
tears, making them suffer from symptoms for a long reason is that MRA was not used primarily because the
time, as this study showed that the symptom duration patients’ symptoms did not clearly suggest instability.
tended to increase from type 3 tears to type 1 tears. It is Third, no control group was used to compare the clin-
important to recognize that posterior labral tears that ical outcomes from different treatment methods or
are not definitively apparent on MRI/MRA can also surgical techniques. Fourth, because the study was
cause persistent pain and discomfort, especially in conducted on patients who underwent surgery, the
young men who participate in sports activities. Corre- data do not represent entire treatment outcomes in
lation with clinical features as well as imaging studies patients who had posterior labral tear without
and patient selection still should be carefully consid- instability.
ered, and a program of conservative treatment is rec-
ommended before deciding on operative treatment. Conclusions
Kim et al.11 reported a posterior labral tear with an In active young men with shoulder pain during daily
incomplete crack at the chondrolabral junction or a activities or sports despite programmed conservative
normal appearance on the arthroscopic examination as treatment, posterior labral tears should be considered
Kim’s lesion in patients with symptomatic posterior even when MRI or MRA findings are ambiguous.
labral tears. Kim’s lesion requires restoration of the Arthroscopic posterior labral repair without capsular
labral height and repair of redundant joint capsule for plication provided satisfactory clinical outcomes and a
joint stabilization. However, in this study, satisfactory high labral healing rate.
clinical outcomes were obtained only by labral repair
without labroplasty or posterior capsular plication in References
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