REVIEW ARTICLE
Magnetic Resonance Imaging and Arthroscopic
Correlation in Shoulder Instability
Derrick M. Knapik, MD*† and James E. Voos, MD*†
Abstract: The shoulder is the most inherently unstable joint in the
body, prone to high rates of anterior dislocations with subsequent
injuries to soft tissue and bony stabilizing structures, resulting in
recurrent shoulder instability. Advanced imaging utilizing magnetic
resonance (MR) imaging and MR arthrography allows for thor-
ough evaluation of lesions present in the unstable shoulder and is
critical for preoperative planning. Arthroscopic shoulder stabiliza-
tion in the appropriately selected patient can help restore stability
and function. This review highlights correlations between MR
imaging and arthroscopy of the most commonly reported soft tissue
and bony injuries present in patients with shoulder instability.
Key Words: magnetic resonance imaging, arthrography, shoulder
arthroscopy, Bankart lesion, shoulder instability
(Sports Med Arthrosc Rev 2017;25:172–178)
A s the most inherently unstable joint in the body, the
glenohumeral joint is prone to frequent subluxation or
dislocation with a reported incidence of 24/100,000 cases per
year.1,2 As such, the shoulder is second to only the knee
based on joint imaging demand3 and represents the third
most common cause for musculoskeletal consultation.4
Over 90% of dislocations are reported to occur anteriorly1
with subsequent injury to the anterior stabilizing structures
predisposing the shoulder to instability.3,5 Following a dis-
location episode, a significant percentage of patients experience
recurrent instability that may result in additional damage to
the shoulder.6 An unstable shoulder can also be accompanied
by functional disability, decreasing occupational capacity,7 and
altered financial earnings.8,9 Younger patients below 20 years
of age possess not only the highest incidence of shoulder
dislocation,10 but also the highest rate of recurrence with rates
as high as 94%.11–13
In patients presenting with an unstable shoulder, an
initial thorough clinical history and physical examination is
essential. Appropriate imaging starting with plain radio-
graphs can provide information regarding the source of
symptoms by depicting associated fracture, degenerative
changes, or persistent dislocation.5,8 However, advanced
imaging modalities such as magnetic resonance imaging
(MRI) allow for superior visualization and comprehensive
evaluation of tendons, muscles, articular cartilage, capsular
structures, and the labrum.5 As such, MRI, especially when
accompanied with intra-articular contrast during magnetic
resonance (MR) arthrography, has become the imaging
From the *Department of Orthopaedic Surgery, University Hospitals
Sports Medicine Institute; and †Department of Orthopaedic Surgery,
Case Western Reserve University School of Medicine, Cleveland, OH.
Disclosure: J.E.V. is consultant for Arthrex. The remaining author
declares no conflict of interest.
Reprints: James E. Voos, MD, University Hospitals Cleveland Medical
Center, 11100 Euclid Ave., Cleveland, OH.
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study of choice in the evaluation of patients with shoulder
instability.14,15
To minimize the risk of attritional injury from recur-
rent instability while preserving joint stability and thus
proper function, surgical fixation is generally recommended,
especially in the younger patient.16–18 As such, evaluation of
the pathology causing shoulder instability on MRI is critical
for guiding preoperative planning.8 Shoulder arthroscopy
offers direct visualization and dynamic examination of the
shoulder, enabling the trained surgeon to treat various
pathologies afflicting the unstable shoulder.8
The purpose of this review is to provide an overview with
MRI and arthroscopic correlation of commonly encountered
lesions present in patients with shoulder instability. An
appropriate understanding and recognition of pathology
affecting the unstable shoulder is essential to ensure patients
undergoing arthroscopic stabilization are properly selected and
all lesions are addressed. Failure to do so may lead to con-
tinued instability with further damage, pain, and disability.
MRI
In the setting of shoulder instability, MRI is routinely
obtained following clinical examination and radiographic
evaluation to evaluate underlying structural derangements
causing instability.9 As the majority of instability lesions
involve soft tissue and labroligamentous structures sur-
rounding the glenohumeral joint in the younger patient,
MRI has become the gold standard in the evaluation of
glenohumeral instability.3,19 MRI is minimally invasive and
contraindicated only in patients with cardiac pacemakers,
ferromagnetic foreign bodies, some cochlear implants, and
those with severe claustrophobia.9
The addition of intra-articular contrast with MR
arthrography offers improved accuracy in the detection of
subtle lesions associated with instability.20,21 By distending
the joint with contrast material, labral, cartilage, and liga-
mentous structures can be separately analyzed. When
compared with conventional MRI, MR arthrography offers
higher sensitivity in the detection of subtle pathologic
lesions.15,22 As most injuries leading to shoulder instability
are difficult to evaluate intraoperatively, appropriate eval-
uation of preoperative imaging and diagnosis using MRI is
critical to determine whether patients can be successfully
treated with an arthroscopic versus open approach.
SHOULDER ARTHROSCOPY
In the setting of shoulder instability, shoulder arthro-
scopy allows for direct visualization, detection, and con-
firmation of preoperative imaging of the glenoid labrum,
bony glenoid, humeral head, chondral surface, capsule, and
associated ligaments of the shoulder.5 As such, arthroscopic
repair has become the gold standard in the treatment
of shoulder instability.23–25 It represents a safe and
Sports Med Arthrosc Rev  Volume 25, Number 4, December 2017
cost-effective intervention demonstrating improved out-
comes in patients with shoulder instability compared with
those treated conservatively.8 Furthermore, in the hands of
the experienced arthroscopist, few reported complications
have been documented.26,27 However, the efficacy and
success of shoulder arthroscopy is largely dependent on
appropriate patient selection and preoperative identification
of the pathoanatomy of the unstable shoulder, as patients
with significant glenoid bone loss or engaging Hill-Sachs
lesions are unlikely to benefit from arthroscopic
intervention.28,29
BANKART LESIONS
Bankart lesions are characterized by avulsion of the
labral complex from the anteroinferior glenoid with dis-
ruption of the medial scapular periosteum.21,30 Bankart
lesions represent the most commonly identified lesions in the
unstable shoulder, occurring in up to 86% of patients with
acute anterior shoulder instability.3,8,21
Bankart lesions possess a variable appearance on MRI
based on the age of the lesion, but are typically charac-
terized by loss of the normal triangular configuration seen
on axial views, appearing irregular, attenuated, amphorous,
or even absent (Fig. 1A). The detection of non-or-minimally
displaced tears on conventional MRI suffer from low sen-
sitivity and may prove challenging given the shared intensity
and proximity of the labrum with the capsule and cortical
bone.9 Use of MR arthrography has been shown to improve
visualization and diagnosis with a reported specificity of
93% and sensitivity of 88% for the detection of Bankart
lesions based on arthroscopic reference standards.15,31
Arthroscopic management of Bankart lesions sub-
stantially reduces the rate of instability following stabilization.32
Arthroscopic visualization is best accomplished via the stand-
ard posterior portal, demonstrating fraying to frank detach-
ment of the anterior labroligamentous complex from the
glenoid following acute injury (Fig. 1B). However, in chronic
cases, the labrum may be scarred back down on the glenoid,
making visualization challenging. Successful arthroscopic
A B
FIGURE 1. A, Axial section demonstrating avulsion of anteroinferior labrum from glenoid (red arrow). B, Arthroscopic images of ante-
roinferior avulsion, better visualized using surgical probe.
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MRI and Arthroscopic Correlation in Shoulder Instability
management involves not only reducing and fixing the labrum
to the glenoid rim, but shifting or plication of the anteroinferior
capsule, as some degree of capsular injury generally occurs in
the setting of shoulder dislocation.33
PERTHES LESION
Perthes lesions represent a variant of the Bankart lesion,
identified in up to 17.9% of patients with acute shoulder
instability and 4% with chronic symptoms.21 On MRI,
Perthes lesions are characterized by an intact medial scapular
periosteum, resulting in a nondisplaced tear of the ante-
roinferior labrum34,35 (Fig. 2). Up to 50% of confirmed
Perthes lesions are reported to be initially missed on axial
sequence MRI6 due to the labrum remaining in nearly ana-
tomic position and tears eventually resynovializing, Visual-
ization and detection rates increase using MR arthrography
when obtained with the arm externally rotated and abducted,
putting the anterior band of the Inferior glenohumeral liga-
ment (IGHL) and anteroinferior capsule on stretch34,36 while
pulling the detached labrum from the glenoid and allowing
the tear to fill with contrast material.5 Identification and
treatment of Perthes lesions is essential as glenohumeral
instability persists in the setting of untreated lesions.35 During
arthroscopy, the anterior labrum must be thoroughly probed
to assess the competency of the labrum to determine if a
nondisplaced tear is present as the labrum may appear
attached to the periosteum but provide no stability.
ANTERIOR LABROLIGAMENTOUS PERIOSTEAL
SLEEVE AVULSION (ALPSA) LESION
ALPSA lesions represent another Bankart variant
which may be present in patients with shoulder instability.
ALPSA lesions have been reported in 12.5% of patients with
acute anterior instability and 31% of patients with chronic
instability.21 Lesions are characterized by complete dis-
ruption and detachment of the anteroinferior labrum in
which the torn fragment becomes medially displaced and
inferiorly rotated on the glenoid rim and scapular neck3,8,34
(Fig. 3). Although the periostuem along the scapular neck
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Knapik and Voos
FIGURE 2. Axial section on magnetic resonance imaging demon-
strating nondisplaced tear of the anteroinferior labrum (red arrow)
without injury to scapular periosteum characteristic of Perthes lesion.
generally remains intact, instability results due to loss of the
integrity of the anterior labrum to protect against anterior
translation of the humeral head.8 Acute lesions are identified
on MRI and arthroscopically by medial displacement of the
labrum, whereas chronic lesions are more challenging to
identify on MRI due to resynovilization and the presence of
scar tissue formation on the medialized labrum.5 Medial
displacement and identification of ALPSA lesions may be
more accurately visualized on MR arthrography.21,37 Acute
lesions are treated arthroscopically by reattachment of the
labrum to its anatomic position on the glenoid, whereas
more chronic lesions require scar tissue debridement before
fixation.38
FIGURE 3. Axial section on magnetic resonance imaging show-
ing anteroinferior labral disruption with medial displacement of
the labrum (red arrow), indicative of anterior labroligamentous
periosteal sleeve avulsion lesion.
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Sports Med Arthrosc Rev  Volume 25, Number 4, December 2017
SUPERIOR LABRUM ANTERIOR TO POSTERIOR
(SLAP) LESIONS
A SLAP lesion involves tearing of the superior labrum at
the attachment of the long head of the biceps, with potential
extension to the anterior or posterior labrum or adjacent
structures, such as the biceps root.5,8,39 Injuries are generally
sustained secondary to traumatic falls onto the outstretched arm
or repetitive overhead activity in young, high-level athletes.3,5
SLAP tears are best visualized on MR arthrography
with contrast material extending into the substance of the
superior labrum or biceps anchor (Fig. 4A). Subtle and
small SLAP lesion may be difficult to visualize due to
inadequate spatial resolution on MRI as the coronal images
may not be oriented along the long axis of the glenoid,
resulting in volume loss when averaged with the adjacent
tissue and fluid.40,41 MR arthrography increases diagnostic
sensitivity and accuracy, allowing for characterization of the
extent and type of SLAP tear, as well as the integrity of the
biceps anchor.21 True SLAP tears must be distinguished
from anatomic variants affecting the anterosuperior quad-
rant of the labrum, namely superior labral recess, sublabral
foramen, and Buford complex.
Moreover, proper identification is critical as 87% to
97% of patients treated with arthroscopic fixation report
good to excellent results.42,43 Surgical success is dependent
on accurate detection of tear extension into adjacent struc-
tures, including the anterior, inferior, and posterior labrum,
as well as the superior and middle glenohumeral ligaments
and rotator cuff. Arthroscopic management is based on the
type of SLAP tear diagnosed on advanced imaging. On the
basis of the classification system establish by Snyder et al44
type I lesions (degeneration and fraying of the superior
labrum without detachment) and type III lesions (displaced
bucket handle tearing of the superior labrum with intact
biceps anchor) are managed with debridement, whereas type
II (avulsion of labral-bicipital complex) and type IV lesions
(bucket handle tearing of superior labrum with extension
into biceps anchor) require repair23,42,45 (Fig. 4B).
ANTERIOR GLENOHUMERAL LIGAMENT (HAGL)
Although less commonly reported, humeral avulsion
of the HAGL lesions have a reported incidence of 7.5% to
9.3%46,47 following traumatic dislocation with resultant shoulder
instability. Injury typically involves an external rotation force
with hyperabduction of the shoulder.8 The resulting lesion
involves rupture of the IGHL alone or with bony avulsion.48
Instability develops as the compromised IGHL no longer
provides stability to the arm while in abduction and external
rotation. HAGL lesions have been identified as the cause of up
to 39% of shoulder undergoing surgery for recurrent instability
without discrete Bankart lesions.46
MRI on oblique coronal views typically demonstrate
avulsion of the IGHL from its medial humeral attachment.
This results in the anterior or posterior portion of the IGHL
band to fall inferiorly, resulting in the normally shaped “U”
appearance of the distended axillary pouch of the IGHL to
transform in a “J,” commonly known as the “J sign”49
(Fig. 5A). Assessment for concomitant bony avulsion off the
medial cortex of the humerus, reported to occur in up to
20% of HAGL lesion,48 as well as subscapularis injuries, are
important to rule out preoperatively.50,51 Visualization of
lesions improves with placement of the arm in abduction
and external rotation.52 Operative repair is essential to
reestablish shoulder stability47,53 and proper preoperative
Sports Med Arthrosc Rev  Volume 25, Number 4, December 2017 MRI and Arthroscopic Correlation in Shoulder Instability

A B

FIGURE 4. A, Sagittal section on magnetic resonance imaging demonstrating tearing of the superior labrum (red arrow) with extension
in the anterior and posterior labrum (blue arrows). B, Arthroscopic image showing superior labral tear with anterior and posterior
extension, characteristic of superior labrum anterior to posterior lesion.

identification is critical as HAGL lesions are difficult to treat
using the standard arthroscopic portals and techniques,
generally requiring an open approach for optimal repair.5
BONY BANKART LESIONS
In addition to Bankart lesions, anterior shoulder dis-
locations may results in acute fracturing of the anteroinferior
glenoid, whereas recurrent episodes of dislocation or subluxation
result in attritional bone loss from the glenoid.54–56 The loss of
bone from the glenoid, known as a “bony” or “osseous Bankart
lesion,” further destabilizes the shoulder due to the loss of the
bony restraint, allowing for further damage to the labrum,
glenoid, and adjacent structures.8,34
Advanced imaging is critical for detection and quan-
tification of these osseous lesions, as well as for appropriate
surgical planning. Although computed tomography is con-
sidered the most accurate imaging modality to visualize
cortical bone loss from the glenoid.56,57 MRI allows for
similarly accurate measurements of glenoid bone loss58 with
the advantages of also detecting concomitant labrocapsular
pathology while decreasing radiation exposure.59 Assess-
ment of glenoid bone loss on advanced imaging is essential
as the size of the bony defect influences surgical approach.
MRI demonstrates blunting of the anteroinferior glenoid
with associated detachment of the labrum (Fig. 6). Three-
dimensional reconstructions of the glenoid fossa demonstrate
an inverted pear-shaped appearance, occurring when defects

FIGURE 5. Coronal section on magnetic resonance imaging

showing humeral avulsion of the glenohumeral ligament lesion FIGURE 6. Axial section on magnetic resonance imaging show-
with characteristic “J” sign (red arrow) from distension of ing loss of bony contour from anteroinferior glenoid (red arrow),
axillary pouch. indicative of Bony Bankart lesion.

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Knapik and Voos Sports Med Arthrosc Rev  Volume 25, Number 4, December 2017

FIGURE 7. Axial section on magnetic resonance imaging show-
ing bony defect in the posterosuperior aspect of the humeral
head (red arrow), characteristics of Hill-Sachs lesion.
are > 25% of the glenoid width.60 Currently, no consensus
exists on the exact size of osseous defect requiring operative
repair or increasing the risk for redislocation.61,62 However,
authors have reported that osseous loss 20% to 25% of the
glenoid as being the critically sized and necessitating open
repair,28,61,63 with Burkhart and De Beer reporting that in
patients with lesions involving at least 25% of the glenoid
treated with arthroscopic Bankart repair, 67% experienced
redislocation.28 In the setting of significant bone loss, bony
augmentation procedures are necessary to restore osseous
stability. Although authors have reported on the short-term
success utilizing the arthroscopic Latarjet procedure64,65 long-
term outcomes are limited. As such, in the setting of bony
Bankart lesion requiring bony augmentation to restore sta-
bility, many surgeons prefer open repair.
HILL-SACHS LESIONS
Hill-Sachs lesions represent the most common osseous
injury sustained in the anteriorly dislocated shoulder, occurring
in 47% to 80% of cases.3,8,34 Injury occurs due to as the post-
erosuperior aspect of the humeral head impacts the ante-
roinferior glenoid rim during anterior dislocation,5 causing a
compression fracture associated with cortical bone loss. Hill-
Sachs lesions are characterized by a wedge-shaped lesion to the
posterosuperior humeral head with associated bone marrow
edema (Fig. 7). Appropriate assessment of the size of the Hill-
Sachs defect is critical on preoperative imaging, as the presence
of an engaging Hill-Sachs lesions influences operative man-
agement. Significant, engaging lesions have been defined as
measuring > 37.5% of the humeral head,66 capable of engaging
the anterior rim of the glenoid, resulting in recurrent instability
with less force and anterior translation.28,67 When engaging
lesions are present, arthroscopic soft tissue stabilization will
likely result in failure and recurrent instability,28,68 necessitating
capsular shift, humeral head-plasty, humeral head allograft
transplantation, or remplissage to restore stability.69
LESIONS ASSOCIATED WITH POSTERIOR
INSTABILITY
Posterior shoulder dislocations with resultant posterior
shoulder instability are rare, occurring in only 2% to 4% of
unstable shoulders.3,70 Injuries typically occur from an acute
traumatic events, seizure, or electric shock, as well as the
result from repetitive microtrauma from loading the poste-
rior elements of the shoulder as is seen in American football
linemen, weight-lifters, hockey, and rugby athletes.71,72 The
term “reverse” is generally applied to lesions associated with
posterior instability. These lesions include reverse Bankart
lesions with detachment of the posterior labrum (Figs. 8A, B),
reverse Hill-Sachs lesions with bone loss to the anteromedial
aspect of the humeral head,73 and reverse HAGL lesions from
avulsion of the posterior attachment of the shoulder capsule
from the posterior humeral neck with tearing of the posterior
band of the IGHL.74 MRI is capable of detecting posterior

A B

FIGURE 8. A, Axial magnetic resonance image demonstrating tearing of the posterior labrum (red arrow). B, Visualized on arthroscopy
with avulsion of the posterior labrum from the glenoid using surgical probe.

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Sports Med Arthrosc Rev  Volume 25, Number 4, December 2017
labral tearing with high signal contrast extending into the tear
with potential displacement, as well as characterizing reverse
Hill-Sachs and reverse HAGL lesions.74 When indicated,
arthroscopic management is accomplished by identification
and appropriate preoperative planning for all lesions contrib-
uting to posterior instability with suitable portal placement
and fixation techniques.
CONCLUSIONS
Conventional MRI and MR arthrography represent
the modalities for choice for preoperative evaluation of
injuries in the unstable shoulder due to their multiplanar
capabilities and excellent soft tissue resolution. Identi-
fication of all osseous and soft tissue pathologies is critical in
guiding therapy and determining if stabilization can be
successfully performed by arthroscopy alone or necessitating
an open approach. Although more randomized clinical trials
with long-term follow-up are necessary, advancements in
MRI capabilities coupled with the evolution of arthroscopic
techniques and instrumentation ensure that treatment and
associated outcomes following arthroscopic shoulder stabi-
lization will continue to improve.
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