Working Diagnosis:
Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA)

Treatment:
- In-season: Physical Therapy, Diclofenac 75mg PO, shoulder stabilizing bracing
- Offseason: Left shoulder arthroscopy with labral repair of an ALPSA/Bankart tear

Outcome:
He was able to participate in his senior year football season and after the season underwent arthroscopic repair and is recovering and progressing well post-operatively.

Author's Comments:
The point of this case is to inform primary care sports medicine physicians on the different variants of labral injuries. ALPSA lesions are more prevalent among male athletes, typically less than 20 years old and involved in contact sports. These injuries are important to recognize given their increased recurrence of instability, and glenoid bone loss2,3. Delayed recognition or mismanagement can lead to more complicated procedures such as Latarjet, and is an injury pattern where early orthopedic referral improves outcomes. Post-operatively, ALPSA lesions have a higher postoperative dislocations rate compared to Bankart repairs4,5,6.

Editor's Comments:
As the author points out, this case is of particular interest because it illustrates one of the important variants of labral pathology that can result from a traumatic shoulder dislocation. What occurs in an ALPSA lesion is the anterior inferior labrum and attached inferior glenohumeral ligament complex avulse from the glenoid rim but the periosteum remains intact such that the whole complex displaces and scars down medially on the glenoid neck. Unfortunately, healing in this position renders the anterior inferior glenohumeral ligament incompetent, leading to recurrent anterior dislocations.

As shown in this case, MR Arthrogram of the shoulder will reveal a medialized labrum with intact periosteum.

As the author states, the clinical implication of an untreated ALPSA lesion include recurrent instability, greater glenoid bone loss, and a higher postoperative recurrence risk. Therefore, early recognition and surgical referral are key to improved outcomes.

References:
1. Arner JW, Peebles LA, Bradley JP, Provencher MT. Anterior Shoulder Instability Management: Indications, Techniques, and Outcomes. Arthroscopy. 2020 Nov;36(11):2791-2793. doi: 10.1016/j.arthro.2020.09.024. PMID: 33172578.
2. Bernhardson AS, Bailey JR, Solomon DJ, Stanley M, Provencher MT. Glenoid bone loss in the setting of an anterior labroligamentous periosteal sleeve avulsion tear. Am J Sports Med. 2014 Sep;42(9):2136-40. doi: 10.1177/0363546514539912. Epub 2014 Jul 15. PMID: 25028704.
3. Reiter CR, Satalich JR, Johnson MA, Nelson CT, Cyrus JW, Vap AR. Surgical Outcomes and Associated Injuries of Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) Lesions: A Systematic Review. Orthop Rev (Pavia). 2023 Apr 17;15:74255. doi: 10.52965/001c.74255. PMID: 37091317; PMCID: PMC10115448.
4. Ozbaydar M, Elhassan B, Diller D, Massimini D, Higgins LD, Warner JJ. Results of arthroscopic capsulolabral repair: Bankart lesion versus anterior labroligamentous periosteal sleeve avulsion lesion. Arthroscopy. 2008 Nov;24(11):1277-83. doi: 10.1016/j.arthro.2008.01.017. PMID: 18971059.
5. Hoyt BW, Yow BG, Feeley SM, Bloom ZJ, Kilcoyne KG, Rue JH, Dickens JF, LeClere LE. Mid- to Long-Term Clinical Outcomes and Failure Rates After ALPSA Lesion Repair. Am J Sports Med. 2025 Jan;53(1):17-23. doi: 10.1177/03635465241295387. PMID: 39741482.
6. Arner JW, Cooper JD, Elrick BP, Rakowski DR, Ruzbarsky JJ, Horan MP, Millett PJ. Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up. Am J Sports Med. 2022 May;50(6):1512-1519. doi: 10.1177/03635465221090902. Epub 2022 Apr 13. PMID: 35416079.

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