What is Glenolabral Articular Disruption (GLAD)?
A Glenolabral Articular Disruption (GLAD) lesion is a very specific type of soft tissue injury that occurs in the shoulder. This injury combines a superficial, or surface-level tear of the anterior-inferior labrum, which is a sort of fibrous hoop that surrounds the glenoid fossa or socket of the shoulder joint, along with damage to the nearby articular cartilage, which is a smooth slippery substance that covers and protects the ends of the bones in the socket.
Because the deep fibers of the labrum are still intact in a GLAD lesion, the labrum isn’t actually unstable. As a result, you’re more likely to feel pain than any overt signs of instability. The level of damage to the glenoid cartilage can differ, ranging from minor tearing, or fibrillation, to a total loss of the cartilage.
GLAD lesions were first reported by Neviaser in 1993 and have since been acknowledged as a rare but known source of shoulder pain after a traumatic incident. They often occur as a result of a fall that forces the shoulder to make an adduction movement, which means drawing the shoulder in towards the body while it’s abducted or away from the body and externally rotated or turned away from the center of the body. In some instances, this injury can also occur from throwing activities or due to a subluxation or dislocation injury, in which the shoulder joint partially or completely moves out of place.
Diagnosing GLAD lesions can be tricky because the signs may be vague, such as pain at the front of the shoulder or a generalized pain throughout the shoulder while moving the arm out to the side and rotating it away from the body. In the past, it was observed that GLAD lesions were associated with a stable shoulder joint, meaning that people with this injury could move their shoulder fully without any apprehension or fear that the shoulder would dislocate. However, more recent reports show that GLAD lesions can occur even in the context of isolated or recurrent dislocations, making the stability of the joint not a distinctive factor in identifying this lesion.
Because of these vague signs, diagnosing a GLAD lesion can be challenging and often requires imaging tests to confirm its presence.
What Causes Glenolabral Articular Disruption (GLAD)?
GLAD lesions are injuries that typically occur in the shoulder due to trauma. Imagine this like accidentally falling onto an arm that’s extended outwards. This action can force the head of the upper arm bone into the shallow shoulder socket, then keep moving, applying a tearing force that damages the cartilage. The energy from the injury ultimately tears the thin layer of tissue in the shoulder socket, which aligns with this type of situation. This injury can also happen due to a forceful movement like throwing, which slightly changes the way it happens.
With the modern use of medical imaging techniques like MRI, MRI with injections to improve viewing (MRA), and the process of examining the interior of a joint with a scope (arthroscopy), we’re now able to identify this injury more often. This has also helped us understand that there are more ways this type of injury can happen, such as instability in the front of the upper arm and shoulder joint.
Risk Factors and Frequency for Glenolabral Articular Disruption (GLAD)
GLAD lesions, a type of shoulder injury, are poorly understood because there’s not a lot of research on them. Most of what we know comes from individual case studies or small research projects that mostly focus on evaluating and repairing these injuries rather than collecting extensive data.
From the limited research available, we know that GLAD lesions are quite rare. Most of the shoulder injuries that doctors see involve tears in the labrum, a type of cartilage in the shoulder joint. These tears usually occur on the front and bottom parts of the labrum, although they are not common when isolated at the bottom.
- GLAD lesions are estimated to appear in 1.5 to 2.9% of all traumatic labral tear cases.
- Most case reports of GLAD lesions pertain to young men. This is consistent with who typically experiences traumatic labral damage in general.
- However, no specific patterns related to age or gender have been found.
Signs and Symptoms of Glenolabral Articular Disruption (GLAD)
When someone injures their shoulder, doctors usually start by asking about the patient’s medical history and doing a physical examination, that includes testing special nerve responses. However, identifying a specific type of injury called a GLAD lesion can be tricky because the signs and symptoms are often unclear. These injuries usually occur in younger men as a result of a high-energy event, like falling on an outstretched arm or receiving an impact while the arm is abducted and externally rotated. They typically feel a sudden onset of pain, which may be more generalized, but often felt towards the front of the body.
Based on how the arm was positioned during the injury and the direction of impact, doctors may suspect a GLAD lesion is present, but it can also merely be ongoing pain after a trauma that caused instability, such as shoulder joint displacement or a partial dislocation.
During an examination, pain may be felt when the arm is moved away from the body and rotated outward, while forcing the arm towards the body might cause a ‘popping’ sensation. The patient may feel pain deep within the front joint of their shoulder. Usually, these signs occur in a stable shoulder joint as only the surface tissue around the joint gets damaged, leaving the rest intact. However, recent studies have also linked GLAD lesions with instability at the front of the shoulder.
Nonetheless, because these symptoms can be quite vague and not specific to only GLAD lesions, appropriate imaging tests play a critical role in establishing a definitive diagnosis.
Testing for Glenolabral Articular Disruption (GLAD)
Diagnostic imaging is important if your doctor suspects that you might have GLAD lesion (glenoid labrum articular disruption) – a shoulder condition. Early imaging can spot this condition more effectively. Some older types of imaging, like MRI or CT scans without contrast (a type of dye that helps show up your tissues more clearly), might have a difficult time spotting these lesions. However, newer high-definition 3T MRI scanners could be more effective, even without using contrast.
The best method to identify or characterize a GLAD lesion is Magnetic Resonance Arthrography (MRA). This procedure involves injecting a contrast dye directly into the joint which allows for detailed images.
Typically, a GLAD lesion will appear on MRA as a shallow tear to the front-and-bottom part of your labrum (a type of cartilage in the shoulder) associated with a defect in the underlying bony surface of the socket in the shoulder joint. The defect in the cartilage can range from a superficial scratch to a full-thickness tear that reveals the bone beneath. With MRA, you will see the contrast dye tracing along the labrum tear, filling the cartilage defect, or slipping underneath a damaged cartilage flap.
For the best results, it’s often recommended that the shoulder be positioned in a specific way during the scan – in a lifted and outwardly rotated position, if the patient is able to move their shoulder this way. This positioning helps to improve the accuracy and sensitivity in finding front labral tears in your shoulder.
This specific position is not normally standard when investigating more common front-and-bottom labral tears, and protocols may vary per individual and depending on the level of suspicion before the imaging.
Treatment Options for Glenolabral Articular Disruption (GLAD)
Both surgical and non-surgical treatments for GLAD lesions (a type of shoulder injury) have been reported and should be considered on a patient-to-patient basis. The best option will depend on the individual’s expectations, the time since the injury, the severity of symptoms, the person’s activity levels, and how well the injury has responded to treatment so far.
While it’s important to understand that our knowledge of GLAD lesions is limited, this injury usually concerns younger, more active patients who often suffer from high-energy sports or traumatic injuries. While time, painkillers, and physical therapy may help some patients, surgery is also an option to improve the condition of the shoulder joint and damage to the labrum (the ring of fibrous tissue that lines the shoulder socket). Surgery becomes especially relevant for patients who do not respond well to non-surgical treatment or cannot manage their pain effectively.
Older patients should be cautious as incidental findings on imaging are more common with increasing age. Cartilage and labral degeneration are also common as we get older. Therefore, even if the onset of the GLAD lesion was due to trauma, non-invasive approaches such as pain management and physiotherapy are typically the preferred treatment options for this age group. This helps to control pain and optimize function.
If surgery is needed, it will likely involve treating of the damaged labrum and cartilage. This process could include removing any unstable labral fibers. Any partial tears might be suitable for a procedure that provides stability. Loose cartilage material will be removed and if there is any exposed bone it may be microfractured (a technique to stimulate new cartilage growth). The exact procedure will often depend on the size of the cartilage defect discovered during surgery, or indeed, the combination of labral and cartilage injury. Sometimes, if there is a full-thickness cartilage defect in the glenoid (part of the shoulder joint), it may be cleaned out and the labrum advanced over it to cover the defect. If the defect is too big, only the joint surface is cleaned out, and the labrum is left in its place.
What else can Glenolabral Articular Disruption (GLAD) be?
GLAD lesions, which relate to shoulder injuries, can be hard to pinpoint due to their vague symptoms and connection to both stable and unstable shoulder issues. That means doctors need to consider a wide range of other things that might be causing the problem. These can include various types of injury to the shoulder’s labrum (a type of cartilage) and associated ligaments.
Here’s a list of some of the primary conditions that might be confused with GLAD lesions:
- Common traumatic labral tears. These involve the tearing of the labrum and related ligaments either partially or entirely off the glenoid, most commonly in the anterior-inferior region (also known as Bankart lesions).
- Anterior-Inferior instability lesions, including a fracture on the glenoid rim (bony Bankart lesions).
- Perthes lesion, which is an injury of the labral complex, but with the labrum remaining attached to the glenoid through a periosteal sleeve.
- Anterior Ligamentous Periosteal Sleeve Avulsion. This is another type of labral injury, but it dislocates medially on the glenoid neck. There’s a further variant known as Bony HAGL, where the anterior-inferior glenohumeral ligament is torn from the humerus rather than from the labral attachment.
Accurate diagnosis is crucial for choosing the appropriate treatment for these conditions.
What to expect with Glenolabral Articular Disruption (GLAD)
Because GLAD lesions are relatively uncommon, we don’t have a wealth of data about their prognosis. So, it’s hard to say with certainty what outcome patients can expect. However, when these lesions were first reported in 1993, all five patients documented could return to their normal activities and had full movement after surgery.
Additional case studies back this up, suggesting patients generally have very good results after surgical treatment of GLAD lesions. These studies focus on pain relief and improved physical functioning. More comprehensive assessments are needed to confirm these early observations, and over time, as our knowledge grows, we’ll be better equipped to make well-informed decisions about patient care.
Possible Complications When Diagnosed with Glenolabral Articular Disruption (GLAD)
Research suggests that GLAD (glenoid labrum articular disruption) lesions could be related to occurrences of instability in the front of the shoulder. One research study observed that if the patient has a GLAD lesion, there is a higher chance that a surgical procedure known as arthroscopic Bankart repair could fail.
Another study suggested the existence of a link between GLAD lesions and a decrease in shoulder stability. This was observed in a group of cadaveric (dead) shoulders, indicating that the lesion could be a risk factor for shoulder instability. One theory to explain this phenomenon is that the GLAD lesion lowers the depth of the joint’s natural hollow space – which is not very deep to start with – potentially affecting the joint’s stability.
Moreover, it is theorized that patients may be at greater risk of developing osteoarthritis, a type of joint disease, following a GLAD injury. This theory has been developed based on what’s been observed in hip surgery and knee meniscectomy, considering the similarities between these three joints.
So, here are the main points:
- GLAD lesions can be linked to instability in the front of the shoulder, potentially increasing the failure rates of certain shoulder surgeries.
- These kinds of lesions may also be a risk factor for shoulder instability.
- Patients with GLAD injuries might be at an increased risk of developing osteoarthritis.
Recovery from Glenolabral Articular Disruption (GLAD)
After surgery, physiotherapy plays a crucial part in helping patients recover and enhance their physical abilities. A specialist physiotherapist is usually involved in this process to make sure it is done correctly. The type of physical therapy needed after surgery can change based upon the kind of operation a patient experienced (for example, repair vs. debridement, whether or not microfracture was involved).
If the patient’s surgical procedure involved a labral repair, their post-surgery care typically follows a standard path for recovery after a type of surgery known as ‘arthroscopic instability repair’.
An example of this process might be: For the first four weeks after surgery, the patient would use a sling and do exercises for their elbow, wrist, and hand. They would also perform pendular movements with their shoulder to prevent stiffness. After this period, they would start doing more active exercises. Over the next 6 to 8 weeks, the therapy plan would gradually increase the intensity and range of these movement exercises, encouraging rotation, stretching and light strengthening work.
After this 6-to-8-week period, the patient can progressively begin more critical strength conditioning work.
In the case of athletes, non-contact sports can typically be resumed around five months after surgery, and contact sports around six months. However, it’s important to note that these timelines can vary depending on how quickly a patient meets the necessary recovery milestones.
Preventing Glenolabral Articular Disruption (GLAD)
When a GLAD (glenoid labrum articular disruption) lesion is diagnosed, it can be helpful to understand what the condition is and how it affects your body. A doctor may use models and diagrams to show you the specific parts of your body that have been affected. This lesion is located in the shoulder joint, affecting the ring of cartilage (labrum) that surrounds the socket of your shoulder blade (glenoid). Understanding the condition and how it works can help you engage more in your own rehabilitation process. With guidance from a healthcare professional, becoming more involved in your recovery journey can help you heal faster and more effectively.
