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Superior Labrum Anterior-Posterior (SLAP) Tears: Evaluation of Three MR Signs on T2-weighted Images¹

¹ From the Department of Radiology, University of Wisconsin Hospitals and Clinics, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792. Received May 3, 1999; revision requested July 15; final revision received September 13; accepted September 17. Address correspondence to M.J.T. (e-mail: mjtuite@facstaff.wisc.edu).

	Abstract

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
PURPOSE: To compare the sensitivity and specificity of three magnetic resonance (MR) imaging signs for the diagnosis of superior labrum anterior-posterior (SLAP) tears.

MATERIALS AND METHODS: The study involved 23 consecutive patients with a type 2, 3, or 4 SLAP tear at arthroscopy and 31 age-matched control patients with an arthroscopically normal or type 1 SLAP lesion. The superior labrum was evaluated on MR images for high signal intensity extending to the articular surface in the posterior third of the labrum, an irregular or laterally curved area of high signal intensity, or two high-signal-intensity lines.

RESULTS: The sensitivity, specificity, and accuracy of posterior high signal intensity for a type 2, 3, or 4 SLAP tear were 48%, 94%, and 74%, respectively, for observer 1 and 61%, 81%, and 72%, respectively, for observer 2. For laterally curved area of high signal intensity, these values were 65%, 84%, and 76%, respectively, and 56%, 84%, and 72%, respectively. For two high-signal-intensity lines, these values were 17%, 94%, and 61%, respectively, and 13%, 94%, and 59%, respectively. For the presence of either posterior or laterally curved high signal intensity, the sensitivity was 65% for both observers, whereas the specificity was 84% for observer 1 and 74% for observer 2. The values for interobserver agreement were 0.60 for posterior high signal intensity and 0.58 for laterally curved high signal intensity.

CONCLUSION: Laterally curved and posterior high signal intensities are specific signs for distinguishing a SLAP tear from a normal-variant superior sublabral recess.

Index terms: Shoulder, abnormalities, 414.4199 • Shoulder, injuries, 414.4199 • Shoulder, MR, 414.121411, 414.121415, 414.121416

	Introduction

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Correctly diagnosing superior labrum anterior-posterior (SLAP) tears on conventional magnetic resonance (MR) images can sometimes be difficult; an accuracy as low as 0.63 was reported in a large series by Yoneda et al (1). Although the low accuracy in the study of Yoneda et al may have been partly because they used a 7-mm oblique coronal section thickness, interpreting the superior labrum with MR imaging can be difficult also because not all linear areas of high signal intensity in this region represent a SLAP tear (1–3). One cause of high signal intensity between the superior labrum and the glenoid is the superior recess, or sublabral sulcus, which is a normal variant where the caudal portion of the base of the superior labrum is not attached to the superior glenoid near the insertion of the long head of the biceps tendon (Fig 1). This variant is present in more than 70% of individuals (2,3). Although the biceps tendon–labrum complex is stable, these smoothly marginated, blind-ending recesses can be up to 1.4 cm deep (3).

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Normal-variant superior recess at arthroscopy in a 42-year-old man. Oblique coronal T2-weighted MR image (2,000/90 [repetition time msec/echo time msec]) shows an area of medial curving high signal intensity (arrow) at the junction of the labrum with the glenoid hyaline cartilage. The patient also has a complete rotator cuff tear.

The purpose of our study was to determine the sensitivity and specificity of these three signs on T2-weighted MR images for the diagnosis of surgically important SLAP tears.

	MATERIALS AND METHODS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Of 181 consecutive patients who underwent shoulder MR imaging, after which arthroscopy was performed by a single orthopedic surgeon (J.F.O.) who specializes in shoulder surgery, 23 (18 male, five female; mean age, 42 years; age range, 17–78 years) had a type 2, 3, or 4 SLAP tear diagnosed at arthroscopy. The manner of injury was dislocation (diagnosed by a physician) in seven patients, direct blow in nine, athletic throwing in four, traction to the arm in two, and overuse in one.

A SLAP tear was identified prospectively on the MR images in nine patients. The preoperative diagnosis after clinical examination and MR imaging was SLAP tear in three of these patients and SLAP tear and impingement in two patients. In the other four patients, the surgeon believed that the MR findings were subtle and the clinical examination results were not consistent with a SLAP tear. Therefore, SLAP tear was not included in the preoperative diagnoses in these patients.

The preoperative diagnoses in the other 18 patients were listed as impingement in nine, instability in five, impingement and instability in three, and loose bodies in one. In addition to the SLAP tear diagnosed at arthroscopy in these patients, there was a partial-thickness rotator cuff tear in eight patients, a full-thickness cuff tear in three, a Bankart tear in five, a posterior labral tear in one, and loose bodies in one. The SLAP tear was treated with débridement in all 23 patients. Clinical follow-up information was available from the medical records at an average of 9 months (range, 1 day to 44 months) after arthroscopy. Nine patients were pain free, and eight had minimal pain with certain movements. Six patients had continued pain, five of whom had been referred for worker's compensation.

Thirty-one (21 male, 10 female; mean age, 37 years; age range, 16–73 years) of the 181 patients with an arthroscopically normal (26 patients) or minimally frayed (five patients with a type 1 SLAP lesion) superior labrum were included as control patients. We selected the patients who underwent imaging with the same oblique coronal pulse sequence and whose ages were most similar to those of each of the study patients. If two control patients had the same age, both were selected. The findings at arthroscopy in these patients were a partial rotator cuff tear in 11 patients, a full-thickness cuff tear in four, a partial cuff tear and posterior labral tear in one, and no rotator cuff or labral tear in 15.

A superior recess was identified at arthroscopy in 17 of the 31 control patients (Fig 1). A recess separate from the SLAP tear was identified at arthroscopy in five of the 23 study patients, although the SLAP tear often involved the labral-glenoid junction.

All of the study patients and control patients underwent imaging with a 1.5-T unit (GE Medical Systems, Milwaukee, Wis) with a phased-array shoulder coil (Medical Advances, Milwaukee, Wis) before arthroscopy. The mean interval between MR imaging and arthroscopy was 102 days (range, 12–243 days). The MR images obtained included transverse fast spin-echo T2-weighted images (2,200/88 effective; echo train length, four; three signals acquired) with frequency-selective fat suppression, a 3-mm section thickness, and a 1-mm intersection gap. In addition, oblique coronal MR images that were either intermediate-weighted or T2-weighted (2,000/17, 90) were obtained in six patients with SLAP tears and in eight control patients, and coronal oblique, fat-suppressed, fast spin-echo T2-weighted MR images (2,200/88[effective]) were obtained in 17 patients with SLAP tears and in 23 control patients. The section thickness for the oblique coronal images was 4 mm with a 1-mm intersection gap. All images were obtained with a 14-cm field of view and a 256 x 192 matrix.

The transverse and oblique coronal MR images were reviewed separately by two musculoskeletal radiologists (M.J.T., A.A.D.S.) who were blinded to the patients' medical histories and arthroscopic results. The MR images of the patients with SLAP tears were randomly mixed in with those of the control patients. The radiologists evaluated the superior labrum for each of three patterns of abnormal increased signal intensity that extended to the articular surface. For the first MR sign, the three oblique coronal images that contained the greatest craniocaudal section of the glenoid fossa were determined, and then the most posterior image of these three was evaluated for high signal intensity (Fig 2). The high signal intensity on this image could be located either at the labral-glenoid junction or more laterally toward the tip of the labrum.

View larger version (85K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Type 3 SLAP tear at arthroscopy in a 41-year-old man. Three consecutive oblique coronal T2-weighted images (2,000/90) with the greatest craniocaudal sections of the glenoid fossa from the posterior (left image) to anterior (right image) regions demonstrate an area of high signal intensity in the labrum (arrow) extending to the articular surface on the posterior image. The patient was also judged by both observers to have two high-signal-intensity lines (arrowhead).

View larger version (119K): [in this window] [in a new window] [Download PPT slide]   Figure 3. Type 2 SLAP tear at arthroscopy in a 28-year-old man. Oblique coronal, fast spin-echo T2-weighted image (2,200/88 [effective]) with fat suppression shows a laterally curving linear area of high signal intensity (arrow) within the labrum.

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 4. Type 3 SLAP tear at arthroscopy in a 24-year-old man. Oblique coronal, fast spin-echo T2-weighted image (2,200/88 [effective]) with fat suppression shows two high-signal-intensity lines (ie, double Oreo cookie sign) (arrowheads) in the superior labrum; the more lateral line (large arrowhead) represents the SLAP tear. The patient was also judged by both observers to have irregular high signal intensity.

One of the authors (M.J.T.) determined whether a glenohumeral joint effusion was present on the oblique coronal MR images by noting whether fluid distended into either the axillary recess, subscapularis recess, or biceps tendon sheath (6). This author also determined whether a superior recess was present on the MR images.

	RESULTS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
The sensitivity of high signal intensity on the most posterior of the three middle oblique coronal images for a type 2, 3, or 4 SLAP tear was 48% (11 of 23 patients) for observer 1 and 61% (14 of 23 patients) for observer 2 (Table). The specificities were 94% and 81%, respectively, and the accuracies were 74% and 72%, respectively. For an irregular or laterally curved high-signal-intensity line, the sensitivity, specificity, and accuracy were 65% (15 of 23 patients), 84%, and 76%, respectively, for observer 1 and 56% (13 of 23 patients), 84%, and 72%, respectively, for observer 2 (Table). For two high-signal-intensity lines, the sensitivity, specificity, and accuracy were 17% (four of 23 patients), 94%, and 61%, respectively, for observer 1 and 13% (three of 23 patients), 94%, and 59%, respectively, for observer 2 (Table). Eighteen of the patients with a SLAP tear and 27 of the control patients had an effusion. The number of patients who had a joint effusion with each of the signs is noted in the Table.

A superior recess was identified on the MR images obtained in 14 of the 31 control patients and on those obtained in the four study patients with a double Oreo cookie sign. A medial curvilinear high-signal-intensity line at the labrum-cartilage junction that was isolated to the anterior half of the superior labrum also was seen in five patients with false-negative findings. Because the rest of the labrum was normal, the signal intensity in these five patients was probably from the SLAP tears mimicking a superior recess.

The value for interobserver variability was 0.60 for high signal intensity on the most posterior of the three middle oblique coronal images and 0.58 for irregular or laterally oriented high signal intensity. These values corresponded with moderate to good interobserver agreement.

	DISCUSSION

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Superior labral lesions are usually categorized into one of four basic types, as described by Snyder et al (7). A type 1 SLAP lesion refers to degenerative fraying of the labrum and is not considered to be a lesion that warrants surgery (8). Type 2, 3, and 4 SLAP tears, however, are often painful and therefore usually treated surgically with débridement or reattachment of the labrum back to the glenoid. Although painful, type 2, 3, and 4 SLAP tears are not associated with a specific clinical symptom; therefore, at clinical examination, patients often are believed to have other injury patterns, such as impingement or instability (1,8). In a study by Maffet et al (8), 56% (47 of 84) of patients with type 2, 3, or 4 SLAP tears had a misleading positive Neer primary impingement sign.

We often perform a conventional MR imaging examination in patients with shoulder pain who do not improve after several months of physical therapy. Accurately diagnosing type 2, 3, or 4 SLAP tears with conventional MR imaging, especially in patients whose shoulders are otherwise normal at MR imaging, may be important for identifying those patients who can benefit from arthroscopic surgery.

Smith et al (3) described two MR signs in an attempt to distinguish a superior recess from a SLAP tear. They first noted that no superior recess extended into the posterior third of the superior glenoid, which they postulated was posterior to the insertion of the long head of the biceps tendon. They therefore reported that the high signal intensity between the labrum and the glenoid in the posterior third of the superior glenoid represented a SLAP tear. We obtained oblique coronal images with a 4-mm section thickness and 1-mm intersection gap and defined the posterior third of the labrum as that present on the most posterior of the three images through the middle of the glenoid. We found that the high signal intensity extending to the articular surface on this section was a useful MR sign of a type 2, 3, or 4 SLAP tear that was present in about half of the tears.

In several articles (9,10) it has been reported that the tendon of the long head of the biceps inserts into the posterior portion of the superior labrum and supraglenoid tubercle in up to 22% of patients. Although Smith et al (3) did not identify a superior recess involving the posterior third of the superior labrum, this area may not be posterior to the biceps anchor in some patients. Kreitner et al (2) reported a superior recess involving the entire superior labrum in one of the 12 shoulders assessed in their study, but they did not state whether the tendon of the long head of the biceps inserted posteriorly. We were unable to confidently determine the exact insertion site of the long head of the biceps tendon in our study, but this may explain our 6%–19% false-positive rate for high signal intensity on the most posterior of the three middle oblique coronal images.

The second sign reported by Smith et al (3) is that of two high-signal-intensity lines in the superior labrum, only one of which could represent the superior recess. They termed this appearance the double Oreo cookie sign because of the MR appearance of two white lines—one being the tear and the other being the superior recess—separated and circumscribed by three low-signal-intensity regions, which represent labral tissue and the glenoid cortex. Although we found this to be a highly specific sign for SLAP tear, it was present in less than 20% of patients with a type 2, 3, or 4 SLAP tear.

The third MR sign of a SLAP tear has been described by Beltran et al (4) as laterally curved high signal intensity. These authors noted that because the normal-variant superior recess occurs at the junction between the superior labrum and the adjacent hyaline cartilage, the recess curves medially as it extends over the superior glenoid. We expanded their definition of this sign to include any area of high signal intensity that did not curve smoothly and medially at the base of the labrum. According to our study results, an irregular or laterally curved area of high signal intensity was present in 56%–65% of patients with a type 2, 3, or 4 SLAP tear.

We observed an MR imaging sensitivity for the detection of SLAP tears of 65% (15 of 23 patients), which is in the lower portion of the 41%–100% range cited in previous articles (1,11–15) in which the sensitivity of conventional MR imaging for the detection of SLAP tears was evaluated. The statistical significance of three of these studies (11–13) is uncertain because only six, eight, and 12 patients, respectively, were examined. One of the larger studies was that of Yoneda et al (1), and it involved 37 patients with SLAP tears. They reported a sensitivity of 41% and a specificity of 86%, but the images were obtained by using a 0.2-T unit with a 7-mm section thickness (1). Our higher sensitivity may have been due to the superior signal-to-noise ratio achieved by using a 1.5-T imaging unit and to less volume averaging owing to our use of 4-mm-thick sections. Gusmer et al (14) reported an MR imaging sensitivity of 86% and a specificity of 100% for the detection of SLAP tears in 36 patients, but they obtained 256 x 256-matrix intermediate- and T2-weighted fast spin-echo oblique coronal images. In a more recent series from the same institution, a sensitivity of 98% and a specificity of 90% were observed with MR imaging in the detection of SLAP lesions, including type 1 tears, again with use of two pulse sequences in each plane and up to a 512 x 384 matrix (15).

The lower accuracy in our study probably was partly because we obtained only a single acquisition in each plane with a 256 x 192 matrix. Scheduling constraints, however, have made it difficult to lengthen our 5-minute imaging times or add additional pulse sequences to our routine shoulder imaging protocol.

Other authors have reported that a joint effusion often improves the depiction of intraarticular structures on T2-weighted images (16). We also found in our small study that several of the patients with a SLAP tear that was missed on the MR images did not have a glenohumeral joint effusion. In our study, however, only five study patients and four control patients did not have an effusion, so we could not reliably determine the influence of effusion on the accuracy of MR imaging for the detection of SLAP tears. False-negative findings were found in several patients with an effusion in the study of Schweitzer et al (6), but in some of these patients fluid did not bathe the superior labrum. MR arthrography distends the joint and ensures that fluid surrounds the labrum, which may be one of the reasons that it improves the depiction of labral tears (17).

The results of two studies (17,18) of SLAP tears have shown that MR arthrography is very accurate in the diagnosis of labral tears; however, its accuracy in the diagnosis of SLAP tears specifically was not reported. In a study by Chandnani et al (17), in which 17 SLAP tears among 28 labral tears were assessed, MR arthrography was slightly more sensitive than conventional MR imaging (96% versus 93%). Palmer et al (18) reported that MR arthrography had a sensitivity of 91% and a specificity of 93% in the diagnosis of 32 labral tears, 14 of which involved the biceps origin.

Although it is invasive, MR arthrography is probably the preferred imaging technique for the diagnosis of SLAP tears, and the shoulder surgeon at our institution often requests that an MR arthrogram be obtained when a SLAP tear is clinically suspected. The surgeon at our institution determined whether a conventional MR image or an MR arthrogram was ordered, and a SLAP tear was not suspected before the MR examination was performed in any of our study patients. The fact that our study involved patients with low degrees of clinically suspicious findings of SLAP tear may have introduced bias regarding the conspicuity of the SLAP tears on the MR images in our study.

CT arthrography also can be used to image SLAP tears, and in a study by Hunter et al (19), SLAP tears were correctly identified retrospectively in 16 of 17 patients. MR arthrography is probably preferable to CT arthrography because direct oblique coronal images can be obtained (17). We are aware of no large study in which standard arthrography of SLAP tears has been evaluated.

In 18 of the 23 patients with a SLAP tear in our study, another lesion was diagnosed and treated at arthroscopy. Several authors (1,8) also have reported that SLAP tears are often seen in association with other lesions, such as Bankart labral tears and partial-thickness rotator cuff tears. Although we did not determine the contribution of the SLAP tear to the patients' symptoms in our study, most authors believe that type 2, 3, or 4 SLAP tears are painful and should be treated surgically (1,7).

We included only arthroscopically proved SLAP tears in our study. This bias toward more symptomatic tears, which may be easier to identify on MR images, is a weakness in shoulder MR imaging studies in which arthroscopy is the standard-of-reference procedure.

In summary, two-thirds of type 2, 3, or 4 SLAP tears can be identified on T2-weighted images with moderately good interobserver reliability by using the two MR signs of high signal intensity in the posterior one-third of the labrum and an irregular or laterally curved area of high signal intensity. In our study, the specificity of these two signs for the correct identification of a normal superior labrum, including that in shoulders with a superior recess, was 74%–84%. The double Oreo cookie sign was uncommon and did not improve the sensitivity of T2-weighted images for the diagnosis of SLAP tears.

	Acknowledgments

 
The authors would like to thank Glen Leverson for assistance with statistical analysis, and Beth Washa and Holly Lefeber for help in preparing the manuscript.

	Footnotes

 
Abbreviation: SLAP = superior labrum anterior-posterior

Author contributions: Guarantor of integrity of entire study, M.J.T.; study concepts and design, M.J.T.; definition of intellectual content, M.J.T.; literature research, M.J.T., R.L.C.; clinical studies, J.F.O.; data acquisition, M.J.T., A.A.D.S., J.F.O.; data and statistical analyses, M.J.T., R.L.C.; manuscript preparation, editing, and review, M.J.T.

	References

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This Article Abstract Figures Only Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tuite, M. J. Articles by Orwin, J. F. Search for Related Content PubMed PubMed Citation Articles by Tuite, M. J. Articles by Orwin, J. F.