Internal impingement syndrome is a painful shoulder condition related to the impingement of the soft tissue, including the rotator cuff, joint capsule and the long head of the biceps tendon and glenoid labrum. Two types of internal impingement syndrome can be differentiated: posterior-superior impingement and anterior-superior impingement (ASI). The aetiology of ASI in particular is not clear. The purpose of this paper is to discuss the different aetiological theories relating to ASI, try to clarify the clinical, radiological and arthroscopic findings and, finally, suggesting treatment for this complex shoulder syndrome. The article is based on own research and clinical experience, as well as a non-systematic search in the PubMed database. The aetiology of ASI appears to be related to the pulley lesion and instability of the long head of the biceps tendon. It can be caused by trauma or degenerative factors, which produces anterior shoulder pain in middle-aged patients, particularly when performing overhead activities. The ASI is probably more frequent than previously reported. There is no evidence to prove the efficacy of a specific rehabilitative protocol, and the gold standard of surgical management has to be ascertained. However, in patients with a pulley lesion, there is some evidence that early surgical management, when minor soft injury lesions are present, produces better clinical outcomes.

BACKGROUND Rotator cuff injury in the setting of type II superior labrum anterior posterior lesions is a common finding. Although predictable surgical outcomes can be expected after type II superior labrum anterior posterior repair, the effect of rotator cuff tears on surgical outcome is unknown. HYPOTHESIS Rotator cuff tears will not negatively affect surgical outcome of type II superior labrum anterior posterior repairs. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study group included 93 patients younger than 50 years who underwent arthroscopic type II superior labrum anterior posterior repair and were available for review at a minimum of 2 years after surgery. Group 1 patients were identified as having normal rotator cuffs at the time of repair. Group 2 patients were identified as having rotator cuff injury at the time of repair (either partial-thickness or full-thickness tears). Statistical analysis was performed comparing the postoperative University of California, Los Angeles shoulder scores and overall improvement in University of California, Los Angeles score using the Student t test for significance. RESULTS Mean follow-up was 2.54 years; 52.7% of patients had evidence of rotator cuff tears at the time of surgery. The mean postoperative University of California, Los Angeles score for group 1 was 32.9 (improvement of 11.0), and the mean postoperative University of California, Los Angeles score for group 2 was 33.3 (improvement of 12.2). There was not a significant difference in any of the outcome measures between groups. CONCLUSION Predictable short-term surgical results and return to activity can be expected after repair of type II superior labrum anterior posterior lesions in patients younger than 50 years who have coexistent rotator cuff tear. Although cuff lesions did not have a negative effect on the short-term outcome in patients with type II superior labrum anterior posterior lesions, longer-term follow-up is needed to determine natural history of this pathologic condition.

PURPOSE The purpose of this report is to present a new provocative maneuver, the passive distraction test (PDT), as an examination tool to be used in the evaluation of patients thought to have a SLAP lesion and to compare its accuracy, precision, and reproducibility alone and in conjunction with previously published maneuvers. METHODS A retrospective analysis of 319 consecutive arthroscopies performed between May 2001 and November 2003 was performed. A total of 65 cases were excluded, 53 because of limitation of elevation to less than 150 degrees or pain in the starting test position and 12 who had previous shoulder procedures performed by the senior author, leaving 254 cases for review. A thorough history was obtained and a thorough physical examination performed with a focus on the involved shoulder including specific provocative maneuvers for the clinical diagnosis of a SLAP lesion. The active compression test, the anterior slide test, and the PDT were used to clinically diagnose a SLAP lesion. The results from the 3 provocative maneuvers were compared with the arthroscopic findings to determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value of each test alone and in a logical combination. RESULTS Of 254 shoulder arthroscopies, 61 had a clinically significant SLAP lesion, for an incidence of 24%. The sensitivity and specificity for the PDT were 53% and 94%, respectively, with an NPV of 87% and positive predictive value of 72%. In combination, the PDT and the active compression test yielded an NPV of 90.5%. CONCLUSIONS The PDT can be used alone or in combination to aid in the clinical evaluation and diagnosis of a SLAP lesion. LEVEL OF EVIDENCE Level IV, retrospective, diagnostic, sensitivity-specificity study.

BACKGROUND Clinical tests are a key element in diagnosing shoulder lesions. PURPOSE This study examined the clinical utility of traditional and new examination tests, the upper cut for biceps injuries, and the modified dynamic labral shear for superior glenoid labral lesions. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS A total of 325 consecutive patients who were seen for shoulder pain underwent a standardized clinical testing battery. Six clinical tests that have been previously reported in the literature (Yergason's, Speed's, bear hug, belly press, O'Brien's, and anterior slide) and 2 new examination tests (upper cut and modified dynamic labral shear) were performed. Clinical examination findings were correlated with findings in those who came to surgery (101 patients). Sensitivity, specificity, accuracy, positive/negative predictive value, and positive/negative likelihood ratio were calculated for each test. A binary logistic regression analysis was used to determine which tests produced the most significant findings. RESULTS For biceps disease, the bear hug and upper cut were most sensitive (0.79 and 0.73, respectively), whereas the belly press and Speed's test were most specific (0.85 and 0.81, respectively). The upper cut was most accurate (0.77) and produced the highest positive likelihood ratio (3.38). For labral injury, the modified dynamic labral shear demonstrated sensitivity of 0.72, specificity of 0.98, accuracy of 0.84, and a positive likelihood ratio of 31.57. A binary logistic regression analysis revealed that the combination of the upper cut and Speed's tests were significantly better at detecting biceps lesions (P =.021, R(2)=.400) than other tests, whereas labral lesions were best identified by combination of the modified dynamic labral shear and O'Brien's maneuvers (P =.045, R(2)=.641). CONCLUSION The new tests are helpful additions to the clinical examination for shoulder injury. The modified dynamic labral shear test demonstrates high scores for clinical utility and exhibits a high likelihood ratio, indicating a significant probability of affecting the clinical decision, which should moderately or significantly improve the diagnostic conclusion and allow the clinician to be more efficient in making an accurate diagnosis.

BACKGROUND Rotator cuff tears commonly occur in combination with other shoulder injuries such as superior labral anterior posterior (SLAP) lesions. The incidence of these associated lesions increases with age; however, the management of concomitant SLAP and rotator cuff tears has yet to be convincingly addressed in the literature. HYPOTHESIS Patients over the age of 45 years who have concomitant arthroscopic rotator cuff repair and debridement of their type II SLAP lesions will have improved patient satisfaction and functional outcome compared with those who undergo simultaneous rotator cuff and type II SLAP repair. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS We recruited 48 patients (mean age, 51.9 years; range, 45-60 years) who had concomitant rotator cuff and type II SLAP tears. All underwent arthroscopic rotator cuff repair with subacromial decompression. Patients were randomized intraoperatively into 2 groups: repair versus debridement of their type II SLAP lesions. Ten patients were lost at final follow-up (4 in debridement and 6 in repair group). The outcome was assessed by the Tegner score and University of California at Los Angeles (UCLA) score and clinically to evaluate range of motion (forward elevation/internal rotation/external rotation). RESULTS At 2 years postoperatively, both the debridement and repair groups showed significant improvement in Tegner score, UCLA score, and range of motion. Patients who underwent rotator cuff repair in combination with debridement of their SLAP tears had significantly better overall UCLA scores (34 vs 31; P <.001) and improved function (5.5 vs 3.8; P <.005) and pain relief (9.6 vs 7.7; P <.001) compared with those who underwent simultaneous rotator cuff and SLAP repair. Range of motion in both internal and external rotation was also significantly better in those patients who had SLAP debridement as compared to SLAP repair. CONCLUSION In patients over the age of 45 years with a minimally retracted rotator cuff tear and associated SLAP lesion, arthroscopic repair of the rotator cuff with combined debridement of the type II SLAP lesion may provide greater patient satisfaction and functional outcome in terms of pain relief and motion.

Superior labrum anterior and posterior (SLAP) lesions are well-evaluated with magnetic resonance (MR) arthrography. This article discusses a practical approach to interpretation of MR arthrography exams for the evaluation of suspected SLAP lesions.

The advent of arthroscopy and the scientific study of the efficacy and accuracy of that examination have led to important advances in our understanding of the shoulder examination in the overhead and throwing athlete. In this review, we address current physical examination techniques and how to perform them, and explore their reported clinical efficacy, providing the practicing clinician with a better understanding of the proper application and interpretation of the shoulder examination in the overhead and throwing athlete.

BACKGROUND Many types of physical examinations have been used to diagnose superior labrum anterior and posterior lesions; no decisive clinical test is available for confirming the diagnosis. HYPOTHESIS A selection from 10 well-established physical tests, alone or in combination, can be used to differentiate lesions with biceps anchor detachment from those with an intact biceps anchor with arthroscopic correlation. STUDY DESIGN Case control study (diagnosis); Level of evidence, 3. METHODS Among 297 patients who underwent shoulder arthroscopy between January 2004 and July 2005, 146 patients were enrolled in the study as a type II superior labrum anterior and posterior lesion group and an age-matched control group. Sensitivity, specificity, and predictive values of each test and all possible combinations of 2 and 3 tests were analyzed. The same procedures were repeated in patients younger than and older than 40 years. RESULTS The sensitivities of the Whipple, O'Brien, apprehension, and compression-rotation tests and the specificities of the Yergason, biceps load II, and Kibler tests were relatively high. No single physical examination was found to be simultaneously highly sensitive and specific for the diagnosis of a type II superior labrum anterior and posterior lesion. When 2 of the 3 relatively sensitive tests (O'Brien, apprehension, or compression-rotation test) were combined with 1 of the 3 relatively specific tests (Speed, Yergason, or biceps load II test), sensitivity and specificity reached approximately 70% and 95%, respectively. Similar trends were noted in the younger and older patient groups and in the isolated type II superior labrum anterior and posterior lesion group. CONCLUSION The data suggest that some combinations of 2 relatively sensitive clinical tests and 1 relatively specific clinical test increase the diagnostic efficacy of superior labrum anterior and posterior lesions. Requiring 1 of the 3 chosen tests to be positive will result in a sensitivity of about 75%, whereas requiring all 3 to be positive will result in a specificity of about 90%.

Although the rotator cuff interval and the adjacent ligaments are gaining interest because of their importance for glenohumeral instability and adhesive capsulitis, there seems to be some confusion about their anatomy. This study reinvestigates the superior capsular structures in 110 cadaveric shoulders by a combination of arthroscopy, dissection, histology, and functional analysis. The structure of the superior capsule was found to be more complex than suspected until now. The coracohumeral, coracoglenoid, and superior glenohumeral ligaments joined with a circular transverse band to form the anterior limb of a suspension sling. This was 9 to 26 mm wide at its midportion. In 90% of the specimens, there also was a posterior limb composed of a broad fibrous sheet, 6 to 26 mm wide at its midportion. This hitherto unrecognized posterosuperior glenohumeral ligament joined posterolaterally with the circular transverse band. Four types of configuration for the superior complex could be identified. The suspension sling formed by the superior complex functions in the same way as the hammock formed by the inferior glenohumeral ligament complex. The posterior limb seems to restrict internal rotation, like the anterior limb restricts external rotation. The expanded knowledge of the superior capsular complex increases the understanding of the pathology involved in anterosuperior and posterosuperior impingement, as well as articular-sided rotator cuff tears. It also has clinical implications for rotator cuff interval and biceps pulley lesions, because these areas are bordered by the anterior limb of the superior complex, as well as for adhesive capsulitis, where we can now understand why internal rotation is limited and why the release needs to be extended posterosuperiorly.

Among the many causes of shoulder instability are traumatic capsular injury associated with the Bankart lesion and capsular laxity as seen in multidirectional instability. Previously, open surgical procedures were the most commonly accepted surgical treatment of these disorders. However, because of the foresight of surgeons such as Richard Caspari, arthroscopy rapidly is becoming the surgical treatment of choice. Current studies have shown a 97% satisfactory outcome of arthroscopic Bankart repair. Similarly, the arthroscopic treatment of multidirectional instability has produced a 93% satisfactory outcome. These results parallel the gold standard open surgical techniques of the past and subsequently have led to a change in the treatment of shoulder instability.

We retrospectively reviewed 105 consecutive patients aged 62 years and older who had undergone a repair of a rotator cuff tear to evaluate the efficacy of this surgery in patients in this age range. Six patients died, and 7 had less than 2 years of follow-up or were incapable of returning for examination. Ninety-two patients with 97 rotator cuff tears were re-examined. The average preoperative UCLA (University of California, Los Angeles) score was 12.9 (range 8 to 20), and the average postoperative score was 32.4 (range 12 to 35). Five patients (5%) had failure of the repair, accounting for the poor results. Severe complications included infection (1 patient) and brachial plexus stretch injury (1 patient). Four additional patients sustained minor complications, for an overall rate of 6%. Overall, 87% of patients had good or excellent results. Eight additional patients, while satisfied, were classified as fair. Of the 5 failures, 3 were revised to a satisfactory result. Thus 90 of the 92 patients in the study were satisfied with the result of the surgery at final follow-up. Rotator cuff repair in patients 62 years and older results in increased function, decreased pain, and satisfactory results.

Since its original description by O'Driscoll in 1991, PLRI is becoming increasingly recognized as a significant cause of elbow pathology. It is well documented that this problem results from an insufficiency of the radial ulnohumeral ligament and its related lateral structures, and that this insufficiency is usually the result of elbow trauma. Diagnosis has improved with the introduction of the PLRI test to identify the instability and advancing MR imaging capabilities of illustrating the injury. Whereas open reconstruction was previously the only definitive treatment, improving arthroscopic techniques provide a satisfactory alternative in stabilizing the elbow.

A case series consisting of 20 consecutive patients with persistent ulnar-sided mechanical wrist pain, lunotriquetral interosseous (LTIOL) ligament tears resulting in joint incongruity and increased laxity, and traumatic triangular fibrocartilage complex (TFCC) tears was reviewed. Each patient underwent an arthroscopic reduction and internal fixation (ARIF) of the lunotriquetral joint, arthroscopic disk-carpal (disklunate-ulnocapitate-disktriquetral, DL-UC-DT) ligament plication, and TFCC repair or débridement. There were 12 right wrists and 8 left wrists, of which 12 were dominant. The mean patient age was 33 years; 7 patients had workers' compensation claims and 2 had legal claims. Fourteen patients recalled a specific injury mechanism, such as hyperextension or rotation. The accompanying traumatic TFCC tears were peripheral in 15 and linear radial in 6 patients (one patient had concomitant peripheral and radial linear tears), and in 6 cases, the palmar ulnocarpal extrinsic ligaments were partially torn. The mean preoperative modified Mayo Wrist Score was 50, and at a mean of 3.1 years after surgery, the score had increased to 88. There were 13 excellent, 5 good, and 2 fair results. Four patients had complications, including transient tenderness along the extensor carpi ulnaris and persistent neuritis of a dorsal branch of the ulnar nerve. Overall wrist comfort and function, as indicated by the modified Mayo Wrist Scores, improved after arthroscopic stabilization of ulnar-sided wrist injuries (pinning of the lunotriquetral joint, disk-carpal ligament plication, and TFCC repair or débridement).

The authors offer concise procedural advice for arthroscopic treatment of flexion contractures of the elbow, bracketed by indications for treatment and recommendations regarding postoperative complications.

Osteochondritis dissecans of the elbow remains a difficult problem to manage in the young athlete. Though the etiology is unclear, a definite association between overuse with repetitive microtraumatic insult and OCD has been established. Early detection and appropriate treatment can provide the best chance for preventing an unfavorable outcome. In many cases, conservative treatment regimens will provide complete resolution of symptoms, return of function, and full recovery, including return to sports participation. Surgical indications should be recognized, however, and surgical management carried out when warranted. Most authors treat unstable lesions primarily by excision of the fragment, accompanied by drilling or burring of the base of the lesion. Symptoms usually improve significantly, but approximately half of all patients will continue to experience chronic pain or limitation of elbow motion, highlighting the significance and severity of OCD of the elbow.

Management of partial-thickness tears of the rotator cuff should include consideration of tear size, tear depth, patient age and activity level, and tear etiology. We present an arthroscopic technique for repair of articular surface partial-thickness tears that may promote healing by closing the tendon side-to-side, placing the debrided tendon end in contact with an abraded humeral surface. By repairing selected partial-thickness tears, progression of the tear and the need for subsequent repair may be prevented. Our preliminary results in 28 patients are encouraging and suggest that this technique is a useful adjunct to tendon debridement for articular surface partial-thickness tears of the rotator cuff.

PURPOSE The purpose of this study was to review the clinical results of laser-assisted capsulorrhaphy performed on 27 shoulders in 26 patients for multidirectional shoulder instability with minimum follow-up of 2 years. TYPE OF STUDY Prospective case series. METHODS Laser shrinkage was performed on the entire capsule. In patients in whom the rotator interval did not shrink, suture plication of this area was performed. All patients were evaluated with respect to the incidence of recurrent instability, need for reoperation, and ability to return to their previous level of activity or sports participation. In addition, all patients were rated as satisfactory or unsatisfactory using criteria established by Neer. RESULTS Twenty-six of 27 shoulders (96%) remained stable and asymptomatic a minimum of 2 years after surgery. Of 14 athletes in the study group, 12 (86%) returned to their previous level of sports participation. CONCLUSION Our results suggest that laser-assisted capsulorrhaphy is an effective treatment alternative for multidirectional instability.

With more innovation in arthroscopic equipment and surgical technique, elbow arthroscopy will continue to evolve and new indications will emerge. Strict adherence to the principles outlined above will allow the use of arthroscopy to treat a variety of elbow disorders in a safe and effective manner.

BACKGROUND Shoulder instability is not uncommon in the adolescent athlete, and yet the ability for either clinical examination or magnetic resonance imaging (MRI) with arthrogram to accurately detect pathology in this younger population has not been elucidated yet. This study was performed to characterize the ability of physical examination and MRI to identify intra-articular pathology in those adolescents suspected of having anterior shoulder instability. METHODS A retrospective review of patients treated over a year between 2008 and 2009 was undertaken. Included were patients with detailed physical examinations, preoperative MRI, and shoulder arthroscopy. Patients with previous shoulder surgery for instability, those who underwent surgery for brachial plexopathy, and those without an MR arthrogram were excluded. Demographics, age, sex, sports participation, and physical examination findings were recorded. Diagnostic arthroscopy findings were then compared with the clinical suspicion (based on history and physical examination) and the MRI findings. Imaging and arthroscopic results were categorized as anterior tear, anterior + tear (anterior tear with extension superior or posterior), other intra-articular pathology, or normal examination. An anterior instability cohort was then created by applying an exclusion criterion against patients without a clinical suspicion of anterior instability. RESULTS Forty-three patients were included after application of all inclusion and exclusion criteria. The clinical suspicion of anterior labral tear was 59% accurate (positive predictive value of 79%) and the MRI was 86% accurate (positive predictive value of 95%). Among all included patients, 23 adolescents (24 shoulders) were identified with a preoperative clinical suspicion of anterior labral tear based on history, physical examination, and plain radiographs (8 girls/15 boys). Mean age at surgery was 15.9 years (13.3 to 18.8). In this suspected anterior labral tear cohort, 79% had arthroscopic confirmation of the clinical suspicion, but 58% had extension of the labral tear either superior or posterior. MRI was 100% sensitive, 55% specific for an isolated anterior tear; yet, the MRI was 46% sensitive, 100% specific at identifying the larger anterior + labral tears. A statistically significant difference existed between the extent of the labral tear found on MRI and that found at the time of surgery (P=0.006), with tears of the glenoid labrum often extending beyond what was predicted by MRI. CONCLUSION Clinical suspicion and preoperative MR arthrogram of anterior instability in adolescents seem to detect evidence of labral pathology but have limited success in identifying the true extent of the labral pathology as proven by arthroscopy. LEVEL OF EVIDENCE Level III Diagnostic Studies.

Repair of rotator cuff tears is a common procedure. Prior to approaching this surgery, it should be realized that each surgical step can lead to complications, including those related to positioning and anaesthesia. Stiffness, infection and failure of repair are the more frequent complications reported.

BACKGROUND The Snyder classification scheme is the most commonly used system for classifying superior labral injuries. Although this scheme is intended to be used for arthroscopic visual classification only, it is thought that other nonarthroscopic historical variables also influence the classification. PURPOSE This study was conducted to evaluate the intrasurgeon and intersurgeon agreement in classifying variable presentations of the superior labrum and to evaluate the influence of clinical variables on the classification and treatment choices of surgeons. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 3. METHODS A group of arthroscopic shoulder surgeons were asked to rank in order of importance clinical variables considered in diagnosing and treating the superior labrum. The surgeons then watched 50 arthroscopic videos of the superior labrum, ranging from normal to pathologic, on 3 different occasions. The first and third viewings were accompanied by no clinical information. The second viewing was accompanied by a detailed clinical vignette for each video. The surgeons selected a classification and treatment for each video. RESULTS A patient's job/sport, age, and physical examination findings were considered the most important clinical variables surgeons consider during management of the superior labrum. Comparing the 2 viewings without clinical information, surgeons selected a different classification 28.5% of the time from the first to the second time. A different classification was chosen 71.5% of the time when the surgeon was supplied a clinical vignette at the subsequent viewing. Similarly, the treatment selected changed in 36% and 69.1% of cases when viewed again without vignettes and with vignettes, respectively. Intersurgeon agreement was moderate without clinical vignettes and fair with vignettes. Historical, physical examination, and surgical observations were found to influence the odds of change of classification. CONCLUSION There is significant intrasurgeon and intersurgeon variability in classification and treatment of the superior labrum. Clinical historical, examination, and surgical findings influence classification and treatment choices.

The treatment of labral pathologic condition of the hip has become a topic of increasing interest. In patients undergoing hip arthroscopy, tears of the acetabular labrum are the most commonly found pathologic condition and most common cause of mechanical symptoms. Although a labral tear may occur with a single traumatic event, often another underlying cause may be already present, predisposing the individual to injury. This article discusses the structure and function of the acetabular labrum, the diagnosis of labral injury through physical examination and imaging modalities, and the current treatment options, including labrectomy, labral repair, and reconstruction.

Although the results of operative treatment of posterior and multidirectional instability (P-MDI) of the shoulder have improved, they are not as reliable as those treated for anterior instability of the shoulder. This may be attributed to the complexities in the classification, etiology, and physical examination of a patient with suspected posterior and multidirectional instability. Failure to address the primary and concurrent lesion adequately and the development of pain and/or stiffness are contributing factors to the failure of P-MDI procedures. Other pitfalls include errors in history and physical examination, failure to recognize concomitant pathology, and problems with the surgical technique or implant failure. Patulous capsular tissues and glenoid version also play in role management of failed P-MDI patients. With an improved understanding of pertinent clinical complaints and physical examination findings and the advent of arthroscopic techniques and improved implants, successful strategies for the nonoperative and operative management of the patient after a failed posterior or multidirectional instability surgery may be elucidated. This article highlights the common presentation, physical findings, and radiographic workup in a patient that presents after a failed P-MDI repair and offers strategies for revision surgical repair.

Shoulder pain is a common complaint in overhead athletes, and superior labrum anterior posterior (SLAP) lesions are a common cause of this pain. The pathological cascade which results in the SLAP lesion consists of a combination of posterior inferior capsular tightness and scapular dyskinesis, resulting in a 'peel back' phenomenon at the biceps anchor and leading to the SLAP tear. Physical exam tests vary in their sensitivity and specificity in detecting SLAP lesions, so MRI is helpful in demonstrating the anatomical alteration. Treatment can be conservative, with posterior inferior capsular stretching and scapular open and closed chain exercises. Many SLAP lesions in overhead athletes require surgical treatment that involves repair of the labrum back to the glenoid. Treatment of concomitant injuries such as rotator cuff tears and Bankart lesions in conjunction with the SLAP repair may be necessary.

BACKGROUND Rotator cuff injury in the setting of type II superior labrum anterior posterior lesions is a common finding. Although predictable surgical outcomes can be expected after type II superior labrum anterior posterior repair, the effect of rotator cuff tears on surgical outcome is unknown. HYPOTHESIS Rotator cuff tears will not negatively affect surgical outcome of type II superior labrum anterior posterior repairs. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study group included 93 patients younger than 50 years who underwent arthroscopic type II superior labrum anterior posterior repair and were available for review at a minimum of 2 years after surgery. Group 1 patients were identified as having normal rotator cuffs at the time of repair. Group 2 patients were identified as having rotator cuff injury at the time of repair (either partial-thickness or full-thickness tears). Statistical analysis was performed comparing the postoperative University of California, Los Angeles shoulder scores and overall improvement in University of California, Los Angeles score using the Student t test for significance. RESULTS Mean follow-up was 2.54 years; 52.7% of patients had evidence of rotator cuff tears at the time of surgery. The mean postoperative University of California, Los Angeles score for group 1 was 32.9 (improvement of 11.0), and the mean postoperative University of California, Los Angeles score for group 2 was 33.3 (improvement of 12.2). There was not a significant difference in any of the outcome measures between groups. CONCLUSION Predictable short-term surgical results and return to activity can be expected after repair of type II superior labrum anterior posterior lesions in patients younger than 50 years who have coexistent rotator cuff tear. Although cuff lesions did not have a negative effect on the short-term outcome in patients with type II superior labrum anterior posterior lesions, longer-term follow-up is needed to determine natural history of this pathologic condition.

Lesions of the superior labrum are complex and difficult to both diagnose and treat effectively. The clinical diagnosis is challenging due to the nonspecific history and physical examination. MRI has substantially improved our ability to detect SLAP tears, although experience is necessary to distinguish pathologic findings from normal anatomic variants. Treatment is determined by patient age, functional demands, and the type of lesion identified.

The diagnosis and treatment of posterior and multidirectional instability of the shoulder remain challenging because of complexities in the classification and etiology of the condition and the physical examination of a patient with suspected posterior and multidirectional instability. With an improved understanding of pertinent clinical symptoms and physical examination findings, a successful strategy for nonsurgical and surgical management can be developed. It is essential to understand the biomechanics of repair procedures, relevant pathoanatomy, and techniques of surgical management to optimize surgical success. Arthroscopic techniques have allowed improved diagnosis and treatment of this condition.

PURPOSE The purpose of this study was to evaluate the effectiveness of arthroscopic posterior shoulder reconstruction. METHODS We treated 136 shoulders in 131 patients with a diagnosis of primary posterior instability who failed 6 months of vigorous rehabilitation by operative stabilization between 1989 and 2001. Inclusion criterion was primary posterior instability that failed an extensive rehabilitative program with functional impairment and pain. Exclusion criterion was less than 12 months of follow-up and Suretac (Smith & Nephew, Andover, MA) or laser stabilization, leaving 92 shoulders in 90 patients available for the study (69 male, 21 female). Follow-up ranged from 12 to 132 months (average, 28 months). Each patient underwent diagnostic arthroscopy and surgical repair at the same time using one of several primary procedures. The procedure used was based on the pathologic entity noted at the time of surgery. RESULTS At an average follow-up of 28 months, 97% of the shoulders were stable and considered a success based on the Neer-Foster rating scale. Posterior pathology varied, and a reverse Bankart lesion alone was found 51% of the time, a stretched posterior capsule 67% of the time, and a combination of a reverse Bankart lesion and capsular stretching 16% of the time. The rotator interval was obviously damaged in 61% of cases. Multiple accompanying lesions were found, including anterior-superior labral tears and SLAP tears (20%), superior glenohumeral ligament injury (7%), middle glenohumeral ligament injury (38%), anteroinferior glenohumaral ligament injury (37%), and an enlarged axillary pouch (20%). CONCLUSIONS No essential lesion is present for posterior instability. Multiple varied pathologies will be present in a shoulder presenting with posterior instability. Arthroscopic surgery allows inspection of the joint and anatomic-specific repairs based on pathology. Careful attention to all the supporting structures of the shoulder, including the rotator interval, the anterior-superior labrum, and its attached superior glenohumeral ligament, the coracohumeral ligament, the inferior glenohumeral ligament complex, and the infraspinatus, in addition to the posterior labrum and capsule, allows excellent outcomes to be achieved with arthroscopic posterior reconstruction techniques. LEVEL OF EVIDENCE Level IV, therapeutic case series.