Evaluating a failed shoulder labral repair requires a comprehensive diagnostic approach. Combining patient history, physical examination, and advanced imaging helps uncover underlying issues and informs decisions about revision surgery.

Clinical Evaluation

A detailed history and physical exam are critical starting points. Physicians assess:

  • Persistent pain, instability, clicking, or functional limitation.
  • Provocative maneuvers such as apprehension tests or labral-specific tests (e.g. active compression, biceps load II, labral shear) to assess superior labrum integrity.
  • Comparison of active and passive range of motion to exclude stiffness patterns like adhesive capsulitis.

Imaging Modalities

Standard MRI

Conventional MRI (1.5 T or 3 T) is the first imaging choice for detecting soft tissue pathology. It can reliably identify most labral tears and associated rotator cuff or biceps tendon injuries. However, subtle lesions may be missed, particularly in postoperative shoulders.

MR Arthrography

MR arthrogram (direct contrast injection followed by MRI) significantly improves sensitivity in detecting labral tears—especially SLAP lesions and subtle detachments that standard MRI misses. In one study, MR arthrography uncovered additional tears in ~37% of cases that were not seen on conventional MRI.

CT Arthrography

CT arthrography provides high-resolution visualization of osseous anatomy. It is particularly useful in assessing glenoid bone loss, anchor positions, or Hill–Sachs lesions in instability cases. For evaluating combined soft tissue and bony pathology, CT arthrography is a strong complement to MR arthrogram.

Plain Radiographs

X-rays have limited utility for labral tears but can identify indirect signs such as bone fragments, degenerative changes, or hardware positioning. They may help rule out other causes when combined with other imaging.

Combined Assessment Algorithm

  1. History + Physical Exam → Establish symptom pattern, mechanical instability versus pain, and physical exam findings.
  2. Obtain Standard MRI → First-line evaluation; assess for obvious labral tears, tendon injuries, fluid collections, hardware failure.
  3. If MRI is inconclusive or normal but suspicion remains → Proceed to MR arthrography to uncover subtle or missed labral pathology.
  4. If bone loss or anchor malposition is suspected → Use CT arthrography especially in revision instability planning.
  5. Arthroscopy may serve as definitive confirmatory assessment and dynamic evaluation of tissue quality and repairability.

Applications in Revision Planning

  • Chronic instability or recurrence: quantify glenoid bone loss (often >15–20%) and evaluate engagement pattern of humeral head defects.
  • Persistent pain without overt instability: use MR arthrogram to investigate ongoing labral pathology or adhesive capsulitis.
  • Suspected anchor complication: CT allows clear visualization of anchor trajectory, position, and surrounding bone integrity.

Frequently Asked Questions

1. When is MR arthrography preferred over standard MRI?
When standard MRI is negative or uncertain, yet clinical findings suggest labral pathology, MR arthrography often reveals tears missed initially.

2. Can CT alone provide enough information?
CT arthrography offers better bone detail and can detect tight gaps around anchors; it’s preferred when anatomical bony defects are suspected.

3. Does imaging replace the need for arthroscopy?
No. Arthroscopy remains the gold standard, especially when tissue quality, tear chronicity, or scar tissue must be assessed for surgical planning.

4. Are clinical tests reliable for SLAP lesions?
Physical tests alone are not highly diagnostic; they are most useful when combined with imaging findings to build a complete clinical picture.

5. What imaging strategy is recommended for revision suspicion?
Start with MRI. If that’s inconclusive, proceed to MR arthrography. Use CT arthrography for bone assessment or for precise anchor planning ahead of revision.