Skeletal Radiol
DOI 10.1007/s00256-017-2646-1
CASE REPORT
Shoulder Bankart lesion with posterior instability: A case report
of ultrasound detection
Ryuzo Arai 1 & Taisuke Ito 2 & Shuzo Okudaira 1 & Shuichi Matsuda 1
Received: 26 December 2016 / Revised: 21 March 2017 / Accepted: 28 March 2017
# ISS 2017
Abstract Minor instability of the shoulder has recently drawn
attention as a cause of shoulder pain in athletes. However, it is
difficult to correctly diagnose the direction in which the hu-
meral head translates and subluxates, and to clarify the pathol-
ogy of the instability. We present a case of a 20-year-old male
with an unstable shoulder who could not raise his left arm due
to pain. Since 6 years prior to the onset of pain, the patient
could asymptomatically perform voluntary subluxation, but it
was slight and the direction of the subluxation could not be
confirmed. On physical examination, the conventional appre-
hension test and Castagna test were positive, but the jerk test
was negative. Imaging studies including arthroscopy showed
a Bankart lesion associated with anterior labrum detachment.
There was no posterior Bankart lesion. Due to painful anterior
shoulder instability, arthroscopic Bankart repair was success-
fully done; however, 9 months later the patient began
experiencing symptomatic subluxation of the shoulder. At this
time, the conventional apprehension test and Castagna test
were both negative. It was difficult to detect the direction of
the subluxation, just like in the preoperative condition. We
performed an ultrasonographic examination from the posterior
side; this clearly revealed the posterior subluxation mecha-
nism as posterior slide of the humeral head and anterior shift
of the glenoid. Based on these findings, we modified the re-
habilitation and the subluxation resolved. This case suggests
that ultrasound imaging can be an effective practical option for
* Ryuzo Arai
arairyuzo@gmail.com
1
Department of Orthopaedic Surgery, Kyoto University, 54
Kawahara-cho, Shogoin, Sakyo-ku, Kyoto City, Kyoto
Pref 606-8507, Japan
2
Rehabilitation Unit, Kyoto University, Kyoto City, Japan
evaluating shoulder instability, especially in cases of slight
posterior subluxation.
Keywords Shoulder . Bankart lesion . Ultrasound . Posterior
instability
Introduction
Recently, shoulder instability has been identified as a cause of
shoulder pain in athletes [1]. Shoulder instability can be clas-
sified by the translating direction of the humeral head, and it
has been advocated that in some cases the direction of humeral
head movement corresponds to the portion of the injured
capsulolabral complex; anterior instability corresponds to a
superior labrum anterior posterior lesion [2] and middle
glenohumeral ligament lesion [3], anteroinferior instability
corresponds to anteroinferior capsulolabral complex injuries
including Bankart lesion (anteroinferior labrum detachment)
[4], and posterior instability corresponds to posterior labrum
detachment [5, 6]. This suggests that the direction of the in-
stability must be determined in order to create appropriate
plans for rehabilitation and surgery [7]. However, the com-
plaint in most unstable shoulder cases is pain rather than ap-
prehension of subluxation, and the instability of the shoulder
itself tends to be overlooked [3, 4, 7]. Moreover, one patient
can have multiple lesions, which causes difficulty in clarifying
the whole picture of the unstable shoulder [1].
We present a case of an unstable shoulder that was difficult
to evaluate and treat, even with meticulous physical examina-
tions and several imaging modalities, and we describe our
ultrasound imaging technique that can detect slight posterior
subluxation of the humeral head. In addition, we discuss the
reasons that this case was especially tough to evaluate

correctly and the benefits of ultrasonography for diagnosing
posterior instability of the shoulder.
Case report
A 20-year-old male had experienced shoulder pain that was
causing difficulty in raising the left arm. The patient, who was
a college student majoring in sports science and regularly
practiced various kinds of sports, had felt subluxation in the
left shoulder while performing the butterfly and crawl swim-
ming strokes 2 weeks and 1 week before presentation at our
clinic, respectively. Since the age of 14 years, the patient had
been able to voluntarily subluxate the left shoulder, but had
not previously experienced any problems associated with this
subluxation.
There was no deficit in the range of motion of the left
shoulder, but during passive flexion in the supine position
the patient felt subluxation just as the humeral head rode on
the glenoid edge. This sensation of subluxation was relieved
when the humeral head was pushed posteriorly through the
humeral shaft.
The conventional apprehension test for anterior shoulder
dislocation (forced external rotation at abducted positions of
≥90 degrees) and its relocation test were positive, which sug-
gested anteroinferior instability and anteroinferior
capsulolabral complex injury [8]. The Castagna test (forced
external rotation at a midabducted position) and its relocation
test were also positive, which suggested a lesion of the anterior
capsulolabral complex including the middle glenohumeral lig-
ament [3]. During both tests the patient experienced pain, but
no apprehension of subluxation.
The patient could voluntarily subluxate the left shoul-
der during forearm pronation at 90 degrees flexion. We
confirmed shoulder popping during this maneuver, but
Fig. 1 Preoperative computed tomography images. a The blue arrow indicates a Hill-Sachs lesion that was small and shallow with sclerotic change. b A
reconstructed three-dimensional image viewed from the posterior side revealed a Hill-Sachs lesion (blue arrow)
Skeletal Radiol
could not detect the direction in which the humeral head
subluxated. The jerk test for posterior instability was
negative [9].
There were no remarkable findings on radiography. Three-
dimensional computed tomography revealed a sharp depres-
sion in the cortical surface of the posterosuperior portion of
the humeral head (Hill-Sachs lesion). There was no glenoid
defect or erosion seen (Fig. 1). A T1-weighted magnetic reso-
nance arthrogram revealed a Bankart lesion with anterior la-
brum detachment on axial and coronal views. In the sagittal
view, there was a bone marrow intensity change in the poste-
rior humeral head, which was thought to correspond to the
Hill-Sachs lesion. We did not detect a posterior capsulolabral
lesion or reverse Hill-Sachs lesion, which would have sug-
gested posterior translation of the humeral head (Fig. 2).
From the findings described above, we considered that the
patient had lost control of the ‘voluntary anterior subluxation’
[10] during his swimming practice, and this had become pain-
ful anterior shoulder instability. Hence, we performed arthro-
scopic labral fixation. The anterior-anteroinferior labrum de-
tachment and Hill-Sachs lesions were confirmed intraopera-
tively. The posterior labrum was normally attached to the
glenoid neck (Fig. 3). The inferior-anterior capsule and rotator
interval tissue, including the middle glenohumeral ligament,
were adequately tensed up through the surgery.
There were no complications, and the patient returned to
sports activity 6 months postoperatively, but the subluxa-
tion recurred during swimming practice 9 months after the
operation. The patient felt apprehension of subluxation
during every stroke while performing breaststroke, and
the left shoulder hurt when he carried heavy objects. The
conventional apprehension test and Castagna test were
negative, in contrast to the preoperative condition. The
patient could voluntarily subluxate the left shoulder during
forearm pronation at 90 degrees flexion, and we confirmed
Skeletal Radiol
Fig. 2 Preoperative T1-weighted magnetic resonance arthrography. Fat-
suppression was added. A Bankart lesion with anterior labrum detach-
ment was seen on a coronal and b axial views (yellow arrows). A
shoulder popping; however, we could not detect the direc-
tion of subluxation, similarly to preoperatively. However,
in contrast to the preoperative state, the sensation of sub-
luxation worsened when the humeral head was pushed pos-
teriorly through the humeral shaft.
We performed ultrasound imaging to evaluate the direction
of subluxation. In subluxating limb position, an ultrasono-
graphic probe was set just below the scapular spine, and the
glenohumeral joint was observed from the posterior side.
When the patient voluntarily subluxated the shoulder, we
could confirm that the humeral head slid posteriorly without
rotation and the posterior edge of the glenoid shifted anterior-
ly, which resulted in posterior subluxation of the humeral head
relative to the glenoid. We could not detect any change in the
surface morphology of the deltoid muscle (Fig. 4).
The patient underwent rehabilitation and modified his
swimming stroke, and subsequently passed his swim-
ming examination. The patient had no problems during
practice of other kinds of sports. Four years postopera-
tively, the patient graduated from college and became a
policeman.
Fig. 3 Photographs taken during arthroscopic surgery. The left
glenohumeral joint viewed from the cranial side. a Anterior-
anteroinferior labral detachment was confirmed (yellow arrow). b In the
relatively low intensity area was seen in the posterior humeral head on
c sagittal view (blue arrow heads). There was no posterior capsulolabral
lesion or reverse Hill-Sachs lesion
Discussion
The present patient experienced posterior instability of the
shoulder postoperatively. It is unclear whether this posterior
instability existed preoperatively. The symptomatic subluxa-
tion shown postoperatively could no longer be termed physio-
logic; however, the voluntary asymptomatic subluxation had
been made in the posterior direction in the preoperative period,
so the patient must have had the physiologic posterior instabil-
ity since the age of 14 years, although neither preoperative
examinations nor arthroscopic findings could confirm this.
The chief preoperative complaint was pain during the pos-
itive conventional apprehension test and Castagna test, which
corresponded to anterior-anteroinferior labrum detachment.
This symptom was resolved by arthroscopic anterior-
anteroinferior labrum fixation. However, pain is also the most
common presenting complaint with posterior shoulder insta-
bility [7], and pain due to posterior instability might have been
overlooked. Preoperatively, we had considered the possibility
that the patient had both posterior and anterior-anteroinferior
instability; hence we performed the jerk test, which is
posterior portion, the labrum was attached normally to the glenoid edge
(green arrows). G: glenoid, H: humeral head

Fig. 4 Ultrasound imaging of the slight posterior subluxation of the
humeral head. a The ultrasound probe was held just below the scapular
spine to evaluate the glenohumeral joint from the posterior side. At 90
degrees anterior elevation, the humeral head slightly slid out from the
original (b) to the posteriorly subluxating position (c) in association
with forearm pronation. We confirmed the posterior slide of the
reportedly positive in almost all patients with posterior insta-
bility of the shoulder [9]. The jerk test, in which the humeral
head is slid posteriorly against the stabilized glenoid through
the humeral axial load, should be adequately effective in de-
tecting posterior shoulder instability. As voluntary posterior
displacement of the humeral head has classically been thought
to be the result of activation of the muscles around the head
and stabilization of the scapula against the thorax [10], both
the jerk test and the classical concept of voluntary posterior
subluxation have similar ‘scapular stabilization’. However, in
Fig. 5 The ultrasound images of a tennis player who felt shoulder
subluxation during his overhand serve and during horizontally
abducting motion from a 90 degrees anteriorly elevated position. a, b
This case shows very similar findings to Fig. 4: posterior slide of the
Skeletal Radiol
humeral head (purple arrow) and the anterior shift of the posterior
glenoid edge (green arrow heads). We did not detect humeral head
rotation during subluxation. The surface of the deltoid muscle (red
arrow heads) did not change shape, even in the subluxating position,
which means that the slight positional changes were difficult to detect
during ordinary physical examination. G: glenoid, H: humeral head
the present case the glenoid shifted anteriorly associated with
the posteriorly sliding humeral head (as our ultrasound tech-
nique demonstrated), and so the jerk test could not detect the
posterior subluxation because the test should stabilize the
glenoid by manually added axial loading. We consider that
the anterior translation of the posterior glenoid edge was due
to the very slight internal rotation of the scapula. Given that
the contraction of the infraspinatus without rotation of the
humeral head should generate the compression force to the
glenoid, the scapular internal rotation should make the vector
humeral head (purple arrow), anterior shift of the posterior glenoid edge
(green arrow heads), and unchanged shape of the deltoid surface (red
arrow heads). G: glenoid, H: humeral head
Skeletal Radiol
of the compression force off-vertical to the glenoid face,
which would result in posterior subluxation of the humeral
head.
If we had performed ultrasonography preoperatively, we
could have detected the posterior instability and modified
the surgery to also give tension to the posterior capsule, as
posterior capsular tightening is the most reliable treatment
method for symptomatic posterior instability [11] and this
surgical intervention can make the rehabilitation itself easier.
Ultrasound imaging has a high spatial resolution and a
relatively low cost. It allows for accurate correlation with
physical examination findings, increasing the likelihood of
detecting the abnormality [12]. In particular, for evaluation
of shoulder instability it is vital to differentiate between phys-
iologic posterior laxity, which may be present in the asymp-
tomatic shoulder, and instability, where excessive
glenohumeral translation leads to symptoms [7]. The high
accessibility of ultrasonography makes it easy to compare
the affected side with the healthy side. Another advantage of
ultrasound imaging is the availability of dynamic diagnosis.
As far as we know, ultrasonography for evaluation of shoulder
instability has only been applied in measurement of the infe-
rior subluxation in hemiplegia patients [13]. Our method
showed that ultrasonography can be used to easily detect ab-
normal movement of the posteriorly unstable shoulder, even
slight movements such as in the present case.
Our ultrasonography method could potentially diagnose
more athletes with slight posterior shoulder instability than
previously thought. Figure 5 shows the ultrasound imagery
of the right shoulder of a tennis player who experienced a
subluxation during overhand serving. Since then, the patient
has felt shoulder subluxations during overhand serving and
during a horizontally abducting motion at a 90 degree flexed
position. Similarly to the present case, this figure demonstrates
the posterior head slide with the concomitant anterior shift of
the glenoid.
In conclusion, we presented a case of a patient with a pain-
ful shoulder with a Bankart lesion who postoperatively expe-
rienced recurrent posterior subluxation. The slight humeral
posterior slide and simultaneous anterior glenoid shift was
easily and clearly demonstrated through ultrasonography.
Ultrasound imaging can be an effective practical option for
evaluating slight posterior shoulder instability.
Compliance with ethical standards
Funding None.
Conflict of interest The authors declare that they have no conflict of
interest.
Informed consent Informed consent was obtained from the patient in
the present case.
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