HC Chang Orthopaedic Surgery | Singapore

Persistent and Vague Shoulder Pain – Consider Posterior Inferior Labral Tear

Case Example

A 30 year old man presented with increasing deep seated shoulder pain for the past 1 year. It was attributed to a work accident where his left shoulder was forcefully pusshed backward while supporting against a heavy container. He did not feel as if his left shoulder was dislocated but started to have deep seated left shoulder pain when performing overhead activity.

The pain became increasingly more obvious over time and he was not comfortable elevating his left upper limb over the shoulder level without pain by the time he consulted me.

Examination

He had full range of motions in his left shoulder.

Anterior apprenhension test for shoulder instability in the anterior direction was negative.

Posterior apprehension test for shoulder instability in the posterior direction caused pain.

O’Brien’s test for Superior Labral (SLAP) tear was negative.

Kim’s test for a posterior inferior labral tear was also positive.

Lim’s Test

Test Description:

A – With the patient in a sitting position with the arm 90 degrees of abduction, the examiner holds the elbow and lateral aspect of the proximal arm, and a strong axial loading force is applied.
B – while the arm is elevated 45 degrees diagonally upward, downward and backward force is applied to the proximal arm.
A sudden onset of posterior shoulder pain indicates a positive test result, regardless of accompanying posterior clunk of the humeral head.

Tests for shoulder cuff tendon impingement or tear were all negative.

Investigations

X-rays of the left shoulder were normal.

MRI scan of the left shoulder was negative for rotator cuff tendon tear, SLAP tear, anterior or posterior labral tear.

My clinical diagnosis was that of a left shoulder Posterior Inferior Labral Tear despite a normal looking MRI scan.

How Did It Occur?

It came about most likely from a posterior subluxation of the shoulder.

Posterior Subluxation of the Shoulder Causing Kim’s Lesion

Kim’s Lesion

Treatment

The patient was counseled on the likely diagnosis and that the MRI may not pick up the posterior inferior labral tear in some instances.

He was agreeable for left shoulder arthroscopic repair of posterior inferior labral tear.

During key-hole surgery to his left shoulder, a tear in the posterior inferior glenoid labrum could be seen. This was the cause of his persistent vague shoulder pain.

Kim’s lesion

The tear was delineated with an arthroscopic liberator and rasp.

Delineating the Tear

A pilot hole is drilled for the passage of the suture anchor. This drill is inserted through the posterior shoulder portal with the camera in the antero-superior portal.

Drilling the hole for the anchor

The 2.9mm bioabsorbable suture anchor is inserted. I like to use a double loaded suture anchor.

Suture Anchor Deployed

The sutures are passed around the labral tear using a shuttle suture (blue).

Shuttling of Suture through the Tear

The suture is looped around the torn labrum and ready for tying.

Suture Looped Around the Tear

The sutures are tied and the labral tear is reattached to the posteroinferior glenoid labrum.

Labral Tear Repaired

This is how it looks like post-repair –

Kim;s lesion repaired

The tear was repaired through key-hole surgery and his pain resolved.

For more information on shoulder pain treatment and labral repair surgery, please contact Dr HC Chang at 6694-1928 or visit us at http://www.ortho.com.sg