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Athlete with shoulder pain.

Contributed from the case records of the 
Indiana University Department of Radiology

History:  Athlete with shoulder pain.
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Which choice best localizes the salient finding(s)?

Bicipital tendon.Anterior glenoid.Posterior glenoid.A and B.B and C.
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Athlete with shoulder pain.



Same images are again shown below. Given that there are labral tears (anterior and posterior), which choice best describes the composition of a visible accompanying abnormality?

Bone.Intra-articular fluid.Extra-articular fluid.Cartilage.Fat.Click for galleryClick for galleryClick for galleryClick for gallery
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Athlete with shoulder pain.



Can you name the actual diagnosis?

Bennett lesion.Bankart lesion.HAGL lesion.Calcific tendonitis.GLOM lesion.
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Athlete with shoulder pain.

Findings:  Sagittal PD FSE and multiple axial T2* GRE images through the right shoulder demonstrate a hypointense, heterotopic ossification posterior to the posterior glenoid. Also present are tears of the anterior and posterior labrum.
Bennet lesion is shown by yellow arrows below.

Image


Differential diagnosis:

  • Bennett lesion
  • Posterior labral tear
  • Posterosuperior glenoid impingement
  • Posterior capsular tear
  • Scapular fracture
  • Calcific tendonitis
Diagnosis:  Bennett lesion
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Athlete with shoulder pain.


Key points - Bennett lesion:

  • Definition:
    • Extraarticular, posterior dystrophic/heterotopic ossification at the posterior or posteroinferior glenoid rim
    • Size of ossification can range from several mms to >1 cm
    • Ossification is crescentic +/- fragmentation
    • Adjacent to torn or degenerated posterior labrum
  • Etiology:
    • Posterior capsular avulsion secondary to traction from the posterior band of the Inferior glenohumeral ligament
    • Deceleration phase of pitching
  • Presentation:
    • Posterior shoulder pain especially with throwing activities
    • Tenderness at posterior inferior glenoid region
    • Occurs in young athletes, commonly in baseball players (e.g., professional pitchers)
  • Imaging:
    • Radiography and CT findings
      • Mineralization adjacent posterior glenoid
      • Subchondral sclerosis and cysts
    • MR findings
      • T1WI:
        • Globular to crescent like ossification within posterior soft tissues
        • Decreased subchondral signal representing sclerosis
      • T2WI:
        • Hypo intense area of ossification at insertion of posterior joint capsule
        • May have adjacent chondromalacia (increased signal intensity within the hyaline articular cartilage, +/- surface irregularity)
      • PD FSE
        • Increased signal in surrounding soft tissues representing edema and hemorrhage
        • Labrum torn or markedly heterogenous
      • T2*GRE: Calcium "bloom"
    • Arthrogram (CT or MR)
      • Associated posterior labral tear with contrast extending into the tear
  • Treatment:
    • Conservation: PT and NSAIDS, pain may subside with cessation of throwing activity
    • Surgical: Arthroscopic debridement of soft tissue ossification

Reference:

  1. Tirman, P.F. Statdx.com. Bennett Lesion. 2011.
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Athlete with shoulder pain.


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