A 19-year-old Caucasian male patient, previously healthy, presented to the orthopaedics department complaining of left recurrent shoulder dislocations after falling from a horse 6 months before. At clinical examination the shoulder was unstable and painful with abduction and external rotation. A magnetic resonance arthrography (MRA) was performed.
MRA preformed after intra-articular contrast administration, using T1 weighted sequences on the three space planes, and T2 weighted images on the coronal plane, all made using fat saturation.
In axial and coronal images there is contrast infiltration within an oblique chondral lesion at the anterior inferior glenoid. The lesion reaches the glenoid cortical surface without evidence of underlying bone lesion. There is an associated anterior inferior glenoid labrum tear with intact periosteum and cortical glenoid bone. The rotator cuff was intact. The patient was submitted to shoulder arthroscopy whitch confirmed the chondral and labrum lesions that were treated by debriding and reattaching the anterior inferior labrum. The patient's recovery was uneventful.
The anterior labroligamentous complex is composed of the inferior glenohumeral ligament and the anterior inferior labrum and is considered the most important structure providing anterior stability to the shoulder[1] - figure 1.
The glenolabral articular disruption (GLAD) lesion was first described by Neviaser[2] as a superficial tear of the anterior-inferior labrum with an associated injury of the adjacent glenoid articular cartilage - figure 2. The lesion is often stable because of the non-displaced labrum which remains attached to the glenoid rim through the anterior scapular periosteum and intact anterior band of the inferior glenohumeral ligament[3, 1].
The lesion is usually caused by a forced adduction injury to the shoulder with the arm in abduction and external rotation[3]. It results from an impaction of the humeral head against the glenoid.
The patient usually presents with persistent shoulder pain without evidence of anterior instability of the shoulder on physical examination[3], although in our case there was instability.
Shoulder x ray is normal. Compued tomography may be used in case of doubt about any bone lesion. MR arthrography is the gold standart imaging modality to look at the labrum and cartilage, showing the intraarticular contrast passing through the chondral and labrum lesions, their extension and associated findings. To better visualize the articular space we may do MR arthrography using the ABER positioning (abduction and external rotation) [4].
The pattern of chondral injury can vary from a cartilaginous flap tear to a depressed osteochondral injury of the articular cartilage and the underlying bone[4].
The main radiological differential diagnosis is established with other lesions that affect the anterior inferior capsule labrum complex such as:
- the Bankart lesion - avulsion of the labroligamentous complex from the anteroinferior aspect of the glenoid, with complete disruption of the scapular periosteum[2],
- the Perthes lesion - non-displaced avulsed anteroinferior labrum with medial stripping with intact scapular periosteum,
-the ALPSA lesion - torn anteroinferior labrum being displaced inferomedially by
the inferior glenohumeral ligament and rolling up like a sleeve with an intact anterior scapular periosteum [1, 4]
or with lesions that affect only the cartilage.
Imaging distinguishing between these lesions is important, because treatment varies.
Knowledge of the anatomy and type of lesions you may find is crucial to a correct diagnosis.
The glenolabral articular disruption (GLAD)
Based on the provided shoulder MR arthrography images and the patient’s clinical symptoms, there is a localized lesion of the glenoid cartilage at the anteroinferior portion of the shoulder joint, along with mild signs of an anterior-inferior labral tear. The arthrographic contrast appears to extend to the interface between the labrum and the glenoid rim, indicating partial disruption at the junction of the cartilage and labrum. The local bony signal remains acceptable, and there is no obvious evidence of a large-scale fracture. The labrum as a whole remains attached to the anterior rim; however, a superficial tear line and changes in the cartilage surface can be seen in the anteroinferior region. No obvious major morphological abnormalities or extensive injuries are observed in the rotator cuff tendon area or other major ligament areas.
Considering the imaging findings and clinical history, along with partial disruptions of the labrum and cartilage but preservation of their general attachment, a GLAD lesion is most consistent with these findings.
Taking into account the patient’s history of a fall, recurrent shoulder dislocation, and the imaging findings, the most likely diagnosis is GLAD (Glenolabral Articular Disruption).
Although the patient shows signs of shoulder instability, imaging indicates that the labrum is not completely detached, which aligns with the partial tear and accompanying glenoid cartilage involvement characteristic of a GLAD lesion.
Overview of Treatment Strategy:
Rehabilitation and Exercise Prescription Principles (FITT-VP):
Precautions:
This report provides a reference analysis based on the current clinical and imaging data and cannot replace an in-person consultation or professional medical advice. If any questions arise or symptoms worsen, please seek timely medical attention for further evaluation and treatment.
The glenolabral articular disruption (GLAD)
