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  • Title
  • Introduction
  • 1. Overview
  • 2. Portal Placement and Diagnostic Arthroscopy
  • 3. Prepare and Mobilize Labrum
  • 4. Place Anchors and Repair Labrum
  • 5. Inspect Results
  • Discussion

Arthroscopic Repair of Posterior Labral Tear with Paralabral Cyst Decompression


Fotios Tjoumakaris, MD
Shore Medical Center

Main Text

Posterior shoulder instability is a relatively rare phenomenon compared to anterior instability, comprising only 5-10% of all shoulder instability. Posterior instability most often occurs either as a result of high force direct trauma to the shoulder such as from a motor vehicle accident or indirect trauma such as from seizures or electrocution. Many cases of posterior shoulder instability are the result of micro-trauma that cause repetitive subluxation of the joint, ultimately compromising the shoulder in certain provocative positions. Surgical treatment of posterior instability is indicated only after an extended trial of rest and physical therapy has failed.

  • What injury, trauma or repetitive shoulder motions have contributed to the current problem?
  • Has the patient dislocated? If so, how many times and what was the mechanism?
  • What maneuvers provoke pain? What is the patient’s reported pain severity on a scale of 1-10 for each of these maneuvers?
  • What limitations in activity, if any, have occurred as a result of the instability?
  • Is pain or instability present at rest? Does it interfere with sleep?
  • Has the patient had conservative treatments including physical therapy, rest, anti-inflammatory medication, and if so, to what degree did these help?
  • Palpate the shoulder for tenderness and document range of motion compared to the contralateral, normal extremity.
    • Any restriction in motion should be compared to the contralateral shoulder.
    • Differences between active and passive motion may indicate pain or capsular contracture.
  • Impingement signs are tested to determine whether any associated rotator cuff tendinitis is present.
  • If weakness is present during strength testing, it may be from deconditioning or from underlying rotator cuff or deltoid pathology.
  • The degree of pathologic subluxation is assessed with a Load and Shift test, as well as any apprehension or pain experienced by the patient during provocative testing.
    • Pathologic posterior subluxation is indicated by a positive Jerk Test
    • A positive Kim test suggests a posteroinferior labral tear or subluxation.
    • Circumduction test. A positive test result is highly suspicious of posterior subluxation or dislocation.
    • Sulcus sign evaluation. A positive sulcus sign suggests multidirectional instability.
Axial T1 WeightedAxial T1 Weighted
Axial Proton-density fat saturationAxial Proton-density fat saturation
Coronal Proton-density fat saturationCoronal Proton-density fat saturation
T2 Fat suppressed Axial views show a tear of the posterior labrum and a fluid filled paralabral cyst. No apparent bony defects, such as a reverse Hill Sachs lesion, are identified.Posterior instability can be the result of trauma in the form of a direct blow to the anterior shoulder or may occur as the result of indirect forces acting on the shoulder, causing the combined movements of shoulder flexion, adduction, and internal rotation.13 Electrocution and seizures are the most common causes of an indirect mechanism resulting in posterior dislocation. Patients with recurrent posterior subluxation may present with more vague symptoms, with pain being the chief complaint. Athletes may report that velocity with throwing is diminished, and a sharp pain may accompany the follow-through phase of throwing. Associated injuries may include superior labrum anterior posterior (SLAP) lesions, rotator cuff tears, reverse Hill-Sachs defects, and chondral injuries.4The options for treatment at this time would be a continuation of conservative treatment including physical therapy and NSAIDs, however, the patient has failed extensive conservative treatment (>1 year) and continues to be symptomatic with pain and instability. Another option would be an open surgical repair.Advantages of an arthroscopic technique include a shorter recovery and rehabilitation time, less risk of joint infection, less risk of bleeding, the ability to visualize the entire shoulder joint with the arthroscope and address any associated pathology, and decreased pain for the patient during the recovery process.If there is good reason to believe that the patient would not be compliant with the post operative rehabilitation, this would be a relative contraindication to the procedure. Failure of the patient to comply with the recommended post-operative restrictions and therapy protocols could result in a failure of the repair, necessitating re-operation, infection, a stiff shoulder, or an otherwise sub-optimal result. Patients with large bone defects or developmental abnormalities of the shoulder with dysplasia may require a more extensive, open approach. Normal neurologic function of the upper extremity is a necessity for a successful outcome.
  • The patient leaves the operating room in an abduction sling that can be removed for passive range-of-motion exercises at home.
  • We allow 90 degrees of forward elevation and external rotation to 0 degrees by 4 weeks after surgery.
  • The sling is discontinued 6 weeks after surgery and active assisted range-of-motion exercises and gentle passive range of motion exercises are progressed.
  • Pain-free, gentle internal rotation exercises are instituted at 6 weeks.
  • At 2 to 3 months after surgery, range of motion is progressed to achieve full passive and active range of motion.
  • Stretching exercises can be instituted for any deficiency in motion at this point.
  • After 4 months, the shoulder is often pain-free and eccentric rotator cuff strengthening is begun.
  • At 5 months, isotonic and isokinetic exercises are advanced.
  • At 6 months, throwing athletes undergo isokinetic strength testing. If 80% of the strength and endurance of the contralateral extremity is attained, a throwing program is begun.
  • Full, competitive throwing is typically not attained until 12 months after surgery. Nonthrowing athletes are often released to a sport-specific program by 6 months, when 80% of their strength has returned.
The important stabilizing structures of the glenohumeral joint are the articular surfaces and congruity of the humerus and glenoid of the scapula, the capsular structures, the glenoid labrum, the intra-articular portion of the biceps tendon, and the rotator cuff muscles. Histologic evaluation of the posterior capsule shows it to be relatively thin and composed of only radial and circular fibers, with minimal cross-linking.Pathologies of the posterior capsule and labral complex are believed to be the main contributors to posterior instability. With the arm forward-flexed to 90 degrees, the subscapularis provides significant stability against posterior translation, and as the arm is placed in neutral, the coracohumeral ligament resists this force. With internal rotation of the shoulder (follow through phase of throwing), the posterior band of the inferior glenohumeral ligament complex is the main restraint to posterior translation.1Patients with a chronically locked posterior dislocation have an increased risk of developing chondral injuries and degenerative osteoarthritis. Static posterior subluxations of the humeral head left untreated have been correlated with the presence of arthritis in young adults.14Studies have shown rates of recurrence of 0% to 8% and rates of return to sport of 89% to 100%. 3,7,15 With the advancement of arthroscopic techniques have come better outcomes for both athletes and non-athletes alike. While open posterior labral repair and reconstructive surgery are still viable options, for the majority of patients, an arthroscopic repair will likely achieve a superior outcome.
  • Recurrent instability
  • Stiffness
  • Infection
  • Neurovascular injury
  1. Arthroscope, Stryker, Kalamazoo, MI
  2. 2.3mm Bio-Raptor Suture Anchors loaded with No. 2 Ultrabraid, Smith and Nephew, Andover, MA
  3. Spectrum Hook, Linvatec, Largo, FL
  4. 0 PDS Sutures, Ethicon, Somerville, NJ
The author has no financial relationship with any of the companies mentioned in this article.The patient undergoing the filmed procedure gave consent to being filmed for this video article and is aware that it may be published online.


  1. Blasier RB, Soslowsky LJ, Malicky DM, Palmer ML. Posterior glenohumeral subluxation: active and passive stabilization in a biomechanical model. J Bone Joint Surg Am. 1997;79(3):433-440. doi:10.2106/00004623-199703000-00018.
  2. Boyd HB, Sisk TD. Recurrent posterior dislocation of the shoulder. J Bone Joint Surg Am. 1972;54(4):779-786. doi:10.2106/00004623-197254040-00008.
  3. Bradley JP, Baker CL III, Kline AJ, Armfield DR, Chhabra A. Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: a prospective study of 100 shoulders. Am J Sports Med. 2006;34(7):1061-1071. doi:10.1177/0363546505285585.
  4. Gartsman GM, Hammerman SM. Superior labrum, anterior and posterior lesions: when and how to treat them. Clin Sports Med. 2000;19(1):115-124. doi:10.1016/S0278-5919(05)70299-4.
  5. Hawkins RJ, Koppert G, Johnston G. Recurrent posterior instability (subluxation) of the shoulder. J Bone Joint Surg Am. 1984;66(2):169-174. doi:10.2106/00004623-198466020-00002.
  6. Keppler P, Holz U, Thielemann FW, Meinig R. Locked posterior dislocation of the shoulder: treatment using rotational osteotomy of the humerus. J Orthop Trauma. 1994;8(4):286-292. doi:10.1097/00005131-199408000-00003.
  7. Kim SH, Ha KI, Park JH, et al. Arthroscopic posterior labral repair and capsular shift for traumatic unidirectional recurrent posterior subluxation of the shoulder. J Bone Joint Surg Am. 2003;85(8):1479-1487. doi:10.2106/00004623-200308000-00008.
  8. Kim SH, Park JS, Jeong WK, Shin SK. The Kim test: a novel test for posteroinferior labral lesion of the shoulder—a comparison to the jerk test. Am J Sports Med. 2005;33(8):1188-1192. doi:10.1177/0363546504272687.
  9. Kim SH, Park JC, Park JS, Oh I. Painful jerk test: a predictor of success in nonoperative treatment of posteroinferior instability of the shoulder. Am J Sports Med. 2004;32(8):1849-1855. doi:10.1177%2F0363546504265263.
  10. McLaughlin HL. Posterior dislocation of the shoulder. J Bone Joint Surg Am. 1952;34(3):584-590. doi:10.2106/00004623-195234030-00011.
  11. Pollock RG, Bigliani LU. Recurrent posterior shoulder instability: diagnosis and treatment. Clin Orthop Relat Res. 1993;291:85-96.
  12. Silliman JF, Hawkins RJ. Classification and physical diagnosis of instability of the shoulder. Clin Orthop Relat Res. 1993;291:7-19.
  13. Tibone JE, Bradley JP. The treatment of posterior subluxation in athletes. Clin Orthop Relat Res. 1993;291:124-137.
  14. Walch G, Ascani C, Boulahia A, Nové-Josserand L, Edwards TB. Static posterior subluxation of the humeral head: an unrecognized entity responsible for glenohumeral osteoarthritis in the young adult. J Shoulder Elbow Surg. 2002;11(4):309-314. doi:10.1067/mse.2002.124547.
  15. Williams RJ III, Strickland S, Cohen M, Altchek DW, Warren RF. Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med. 2003;31(2):203-209. doi:10.1177/03635465030310020801.

Cite this article

Tjoumakaris F. Arthroscopic repair of posterior labral tear with paralabral cyst decompression. J Med Insight. 2014;2014(3). doi:10.24296/jomi/3.

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