Since the advent of shoulder arthroscopy, pathology of the superior glenoid labrum and biceps anchor has been increasingly recognized as a source of shoulder pain and disability. Additional biomechanical testing has substantiated the role of the superior labrum and biceps anchor in glenohumeral stability. The diagnosis of superior labral injury such as the superior labrum anterior posterior (SLAP) lesion remains difficult, as the history, clinical examination, and radiographic evaluation can only raise suspicion. The ultimate diagnosis of the SLAP lesion can only be made with a well-directed diagnostic glenohumeral arthroscopy. The treatment of SLAP lesions depends on the type of SLAP lesion encountered at arthroscopy. This includes debridement of most type I and III lesions, and repair of type II and many type IV SLAP lesions. In this report, we will present our basic approach towards evaluation and treatment of SLAP lesions at the Southern California Orthopedic Institute.

Between 1985 and 1993 140 injuries of the superior glenoid labrum were identified on arthroscopic evaluation and were recalled from a data bank of 2375 shoulder procedures performed during that time. The average patient age was 38 years, and 91% of the patients were men. The most common problem was pain, with 49% of all patients noting mechanical catching or grinding in their shoulders. No preoperative imaging modality consistently defined disease in the superior labral area. Fifty-five percent of all lesions were type II, 21% were type I, 10% were type IV, 9% were type III, and 5% were complex. Twenty-nine percent of lesions were associated with a partial-thickness tear of the rotator cuff, 11% with a full-thickness tear, and 22% with an anterior Bankart lesion. Twenty-eight percent of the superior labral lesions seen were isolated and did not have any associated rotator cuff or anterior labral disease. Type I lesions were debrided. Fifty-six percent of type II lesions were debrided in conjunction with an abrasion of the underlying glenoid rim. More recently suture anchors have been used to stabilize type II lesions. Treatment of type III and IV lesions depended on the extent of labral tissue disruption and involved either debridement or suture repair. Repeat arthroscopies were performed on 18 shoulders. Three of five type lesions treated with debridement and glenoid abrasion were healed. Four of five type II lesions treated with an absorbable anchor were healed. Three type III and one type IV lesion treated with debridement had normal superior labrums. Two type IV injuries treated with suture repair had completely healed. Two complex type II and III injuries treated with debridement and anchor fixation were healed.

Although magnetic resonance imaging is very sensitive and even though pathology in the rotator cuff is readily detected, it is often difficult to distinguish between complete rotator cuff tears, partial rotator cuff tears, and area of tendinitis. This article reports the results of a new technique for evaluation of shoulder pathology, which the authors have labeled magnetic resonance arthrography, and compares the results of magnetic resonance arthrography with those of conventional magnetic resonance imaging.

Standard proton-density- and T2-weighted magnetic resonance (MR) imaging and MR arthrography were used to depict rotator cuff disease in 36 shoulders in 36 patients; the findings were compared with arthroscopic findings in every patient. In 19 rotator cuffs normal at arthroscopy, MR arthrography revealed no tear in 16 patients, a partial tear in one patient, and a full-thickness tear in two patients. Standard proton-density- and T2-weighted images were normal in 15 of these patients and revealed a partial tear in two patients and a full-thickness tear in two patients. In 13 partial tears found at arthroscopy, MR arthrography showed a partial tear in six patients, no tear in five patients, and a full-thickness tear in two patients; standard MR imaging revealed a partial tear in one patient, no tear in 10 patients, and a full-thickness tear in two patients. All four full-thickness tears proved with arthroscopy were correctly diagnosed with both MR imaging methods. The main advantage of MR arthrography was better depiction of partial tears in the articular surface.

The goal of this investigation was to describe the MR appearance of traumatic fraying or detachment of the superior portion of the glenoid labrum including the insertion of the tendon of the long head of the biceps. This condition is caused either by an acute injury or by repeated overhead motion during participation in sports. In nine patients with such a lesion, the arthroscopic report and MR images were available for review. These patients were 22-64 years old (mean, 38). In four patients only fraying was noted during arthroscopy, in four patients the superior part of the labrum was detached together with the insertion of the biceps tendon, and in one case there was a bucket-handle tear of the superior portion of the labrum. The MR images were retrospectively evaluated by three osteoradiologists in conference. Signal changes within the labrum and detachment of the labrum were noted, and the findings were compared with the results of arthroscopy. MR imaging did not allow recognition of simple fraying. In two of the five cases with arthroscopic findings of detachment of the superior labrum from the glenoid rim, differentiation between complete and partial labral detachments was not possible even with MR arthrography. However, in these cases the patient's age and history led to the correct diagnosis. We conclude that early traumatic abnormalities of the superior portion of the labrum cannot be detected with MR imaging. Complete detachment, however, can be demonstrated if the patient's age and history are taken into consideration.

We studied 31 patients (17 females, 14 males; average age, 34) with more than 2 years of followup who had chronic anterolateral ankle pain following inversion injury. All had failed to respond to at least 2 months of conservative treatment and had negative stress radiographs to rule out instability. On physical examination, tenderness was localized to the anterolateral corner of the talar dome. Magnetic resonance imaging was the most useful diagnostic screening test, showing synovial thickening consistent with impingement in the anterolateral gutter. At an average of 24 months after injury, all patients underwent ankle arthroscopy, which showed proliferative synovitis and fibrotic scar tissue in the lateral gutter, often with associated chondromalacia of the talus. Operative arthroscopic treatment consisted of partial synovectomy with debridement of scar tissue from the lateral gutter. Postoperatively, patients walked with crutches allowing weightbearing as tolerated. Average return to sports was 6 weeks. Histopathologic analysis performed on the resected tissue showed synovial changes consistent with chronic inflammation. Results of treatment after at least 2 year followup were 15 excellent, 11 good, 4 fair, and 1 poor. Since there are several distinct causes of chronic ankle pain, we prefer to call this problem "anterolateral impingement of the ankle" and believe the term "chronic sprain pain" should be discarded.