Shoulder instability, especially in younger, active individuals, can stem from various structural injuries. While a Bony Bankart lesion is a common culprit following anterior shoulder dislocations, several other conditions can present with overlapping symptoms. These include SLAP tears, Perthes lesions, GLAD lesions, HAGL injuries, and rotator cuff tears.
Distinguishing among these pathologies is crucial for accurate diagnosis and treatment. In this guide, we compare these entities based on clinical presentation, imaging findings, and anatomical disruption.
1. Bony Bankart Lesion Overview
A Bony Bankart lesion involves an avulsion of the anteroinferior labrum along with a fragment of the glenoid rim, typically due to traumatic anterior dislocation.
Key Features:
- Associated with anterior instability
- Often accompanied by a Hill–Sachs lesion
- Best visualized on CT for bony involvement and MRI/MR arthrography for soft tissue
2. SLAP Tear (Superior Labrum Anterior to Posterior)
Description
Involves tearing of the superior labrum where the biceps tendon anchors.
Symptoms
- Deep shoulder pain
- Clicking or popping
- Pain with overhead activity
Imaging
- Best detected with MR arthrography
- Contrast enters the tear between the labrum and glenoid
Differentiation
- Pain is more chronic and related to biceps loading
- Not associated with glenoid bone loss or shoulder dislocation
3. Perthes Lesion
Description
A variant of Bankart lesion where the labrum is avulsed but remains in anatomical position due to intact periosteum.
Symptoms
- Similar to Bankart: instability, vague discomfort
Imaging
- MR arthrography reveals intact labrum appearance but contrast dissecting beneath periosteum
Differentiation
- Can mimic a normal labrum on plain MRI
- Recognized by subtle signs of contrast undercutting the labrum
4. GLAD Lesion (Glenolabral Articular Disruption)
Description
Combination of anterior labral tear and adjacent articular cartilage injury without instability.
Symptoms
- Shoulder pain with activity
- Clicking or catching
Imaging
- MR arthrography shows cartilage damage adjacent to labral tear
Differentiation
- Not linked with shoulder dislocation
- Typically no bone involvement or instability findings
5. HAGL Injury (Humeral Avulsion of Glenohumeral Ligament)
Description
Avulsion of the inferior glenohumeral ligament (IGHL) from its humeral insertion.
Symptoms
- Anterior shoulder pain
- Instability episodes
Imaging
- MR arthrography shows contrast tracking along the humeral neck
- “J-sign” on axial images
Differentiation
- Soft tissue disruption on the humeral side, not glenoid
- No labral involvement
6. Rotator Cuff Tear
Description
Tearing of the tendons of the rotator cuff muscles, most often the supraspinatus.
Symptoms
- Pain during lifting
- Weakness and limited range of motion
- Night pain
Imaging
- MRI shows tendon discontinuity or retraction
- High signal in the rotator cuff footprint
Differentiation
- More degenerative, common in older patients
- Not associated with dislocations or labral damage
7. Comparative Overview
| Condition | Key Injury Site | Instability | Bone Involvement | Best Imaging |
| Bony Bankart | Anteroinferior glenoid | Yes | Yes | CT + MR Arthrography |
| SLAP | Superior labrum | No | No | MR Arthrography |
| Perthes | Anteroinferior labrum | Possibly | No | MR Arthrography |
| GLAD | Labrum + cartilage | No | No | MR Arthrography |
| HAGL | IGHL at humerus | Yes | No | MR Arthrography |
| Rotator cuff | Supraspinatus tendon | No | No | MRI |
FAQs
1. Can SLAP and Bony Bankart lesions occur together?
Yes, though rare, combined lesions may occur, especially in high-energy injuries.
2. Which condition is most likely to be missed on regular MRI?
Perthes lesions are notoriously difficult to detect without contrast, often requiring MR arthrography.
3. How is a GLAD lesion managed compared to Bankart?
GLAD lesions usually don’t need stabilization surgery unless there’s significant cartilage damage; Bankart lesions often do.
4. Is a HAGL injury surgical?
It can be, especially if conservative measures fail or if instability is significant.
5. Do rotator cuff tears mimic instability symptoms?
Not typically. They present more with weakness and pain rather than mechanical instability or dislocation.
Properly distinguishing Bony Bankart lesions from other shoulder injuries like SLAP, Perthes, GLAD, HAGL, and rotator cuff tears is essential for appropriate management. Each has distinct clinical clues and imaging characteristics that guide diagnosis and treatment. A focused, comparative approach ensures no condition is overlooked, and patients receive tailored care based on the true underlying issue.
