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<v ->Dr P. Here.

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Here's a 41-year-old with pain

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and decreased range of motion.

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Let's do a little review

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before we delve into this next SLAP lesion,

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which is known as a SLAP VIII,

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which means we're entering

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the Modarresi classification systems.

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So quick review of the classification systems.

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You've got your pear-shaped glenoid,

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and we've got a little ridge up top here,

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the superior tubercle of the glenoid right there.

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And we said that the biceps is going to take off

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from the superior tubercle of the glenoid posterior to it,

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and sometimes with a little bit of it on top.

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And this is how the takeoff is in about 56% of individuals.

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About 20, 25, 30% it'll come off completely in the back.

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And then in a small percentage, about 16,

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it's kinda balanced from about there to there.

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So let me show you the balanced portion

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with a little drawing right there.

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That's the balanced portion.

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So then we talked about the different types of SLAP lesions,

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and we said let's draw the labrum,

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we've got the glenoid here.

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So let's get a little bit of labrum right here

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goin' around the periphery.

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And now we start making some labral tears.

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So the first one, which doesn't involve the biceps in red,

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is the sort of the gentle frayed SLAP I?

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So then we'll take that one away.

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And the one that's more well-defined and deeper,

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almost like you cut it with a scissors, is the SLAP II.

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And the SLAP II is going to go up,

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and it's going to affect the base of the labrum

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almost every time.

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Occasionally maybe you'll get one in the back

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of the superior labrum and a balanced takeoff of the biceps

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that misses the biceps.

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But that's the exception rather than the rule.

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Now we already said in a bucket handle tear

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some of the labrum stays.

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So I'll make labrum here in dark blue.

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I'll draw over it.

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Some of the labrum stays at the base of the biceps,

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some separates.

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So you get your Cheerio sign.

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There's the middle of the Cheerio right here

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at a different color blue.

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And this would be a SLAP III, the bucket handle tear.

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Now in a SLAP IV, a misconception,

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in a SLAP IV you often have a bucket handle tear

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with extension into the biceps.

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So that means that you've got two tears going on here.

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Occasionally you'll have a SLAP II

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with extension into the biceps.

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If you have a SLAP II, the base of the biceps is bare,

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but if you have a SLAP III the base of the biceps

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still has labored labrum at its base.

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Then we get into SLAP V and on.

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And that would be the Maffet Classification System.

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So the first four, I through IV is Snyder.

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The Maffet, V, easy,

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that's just one that goes down and around

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in the front and could be a collision lesion

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or associated with a shoulder dislocation.

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Then you've got VI, which we haven't discussed yet,

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which is a flap-like lesion that kind of falls down

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either in the front or in the back.

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So it's a flap tear.

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That'll be a story for another vignette.

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And then you've got the VII,

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which comes down and around and dissects into the MGHL.

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So now let's take a look at this case.

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This case is defined by its axial,

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but I'm gonna show you the coronals and the axials together,

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and immediately on scrolling the axials

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everybody sees this huge cyst

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spilling over the spinoglenoid rim

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into the suprascapular notch.

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And the poster label rim is just a complex mess.

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However, when we look at the coronal projection,

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especially the PD fat suppression,

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more than the T2 for this lesion is chronic.

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So it doesn't show up so well on the T2,

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but on the very heavily water-weighted image,

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let's scroll.

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Perhaps it's there.

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It's certainly there.

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It should go away as you go posteriorly, if it's normal.

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It doesn't.

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It keeps transitioning into this tear.

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And here it comes.

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There's the rest of the tear coming down

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with these multiple cysts.

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Let's go in the axial projection

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and see just how high it goes.

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Here we are at about the mid-equator level.

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We still have a very robust tear.

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Now let's work our way up, craniad.

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We still have the tear and our cyst still working craniad.

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That is not a normal triangular hypointense labrum.

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Upper quadrant, still not a normal labrum.

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Still not normal, too gray and too swollen.

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And now we're probably into normal labrum.

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So posterosuperior quadrant, going around the back,

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often seen, by the way, in weightlifters

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and bench pressers and military pressers.

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This is an example of a chronic SLAP VIII,

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the first one in the Modarresi Classification System.

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Let's move on, shall we?