-

1. Shoulder Sports-Related Injuries
What the clinician needs to know
Manos Antonogiannakis
Orthopaedic Surgeon
Director of 3rd Orthopaedic Department
Centre for Arthroscopy & Shoulder Surgery
Hygeia General Hospital
Athens Sports Imaging Course
19 May 2017

2. Shoulder:a complex
unstable joint
vulnerable to injury
Shoulder injuries:
extremely painful,
restricting the freedom of
movement and function
drastically.

3. Every sport can lead to acute injuries and pain of the
shoulder joint or chronic injuries due to overuse
Contact Sports, sports with a ball, mountain biking,
snowboarding, windsurfing, climbing, horse riding
fall
shoulder injury

4. By throwing a ball, the shoulder joint is subject to high
loads and accelerations . Due to the repetitive throwing
movement, chronic overload and microtrauma occurs.
A shoulder joint with a very good mobility has a major
advantage for a good throw due to the better acceleration
moments, the better throwing force and the higher ball
speed.
This -high speed- movement of the arm must be every
time stabilized from the joint capsule, the ligaments and
the surroundings tendons.

5. 5-8% of all acute injuries affect the shoulder joint
Sport injuries more commonly affect male active persons
from puberty up to the age of 45.

6. Correct diagnosis ist important
A well-established network of orthopedics, radiologists,
physiotherapists and trainers is a major requirement for a
efficient medical care.
The early and correct diagnosis will lead to the early
and correct therapy of the injury.

7. So what does the clinician want to know

8. As clinical doctors we know the history
and examine the patient
We need information from imagining and
the radiologist :
In order to arrive to a diagnosis
In decision making about the type of treatment

9. The four major clinical entities of the shoulder
Instability
Stiffness
Loss of congruity
Loss of power

10. Most common acute shoulder injuries
i. Shoulder traumatic dislocation
ii. AC-Joint dislocation
Tear of the rotaror cuff
i. Rupture of the long head of the biceps tendon
ii. SLAP Lesion
iii. Fracture of the clavicle, scapula, humerus head
Usually caused by direct force or contact with other players

11. Chronic overload damage
i. Rotator cuff tendinopathy
ii. Long biceps tendinopathy
iii. Impingement syndrome/Bursitis subacromialis
iv. GIRD Syndrome
v. SLAP Lesion
vi. AC Joint Arthritis

12. X-rays serve to:
Confirm the diagnosis:
–Dislocated
–Reduced with notch (Hill Sachs).
Eliminate an associated fracture.
–Great tubercle
–Hill Sachs
–Glenoid bone
loss

13. Field strength : High field strength 1, 1.5, 3 Tesla
Low field strength 0.5 Tesla
Low field strength : longer time to generate images
High signal to noise ratio
Surface coils (transmitter and receiver of radiofrequency pulses) that generate
Pulse sequences
T1-weighted sequence (fat bright,- water , muscle intermediate – fibrous, calcioum
dark)
T2-weighted sequence(water ,fat bright-muscle intermediete-fibrous, calcioum dark
Proton density
Gradient echo
Fat saturation techniques (supress the signal from fat so that pathology to be more
obvious)
MRI nomenclature
The patient is placed into a magnetic field created by a strong
magnet

14. Benign tumors around the shoulder
Primary and metastatic malignant tumors
Subtle fractures of the upper part of the humerous or
the scapula
Sinovial diseases ( osteochondromatosis , PVS)
Neuropathies of the peripheral nerves that innervate
the muscles of the scapula and the shoulder
MRI for other diagnosis
Be especially suspicious when the clinical presentation is not
familiar

15. Metastatic disease - Lung cancer Osteoid osteoma

16. Pancoast tumor

17. Shoulder traumatic dislocation
 Greatest Range of Motion in the body
 Motion in all 3 planes of movement
 Prone to instability
Sacrifices stability for mobility

18. Routine films
● AP
● Scapular Y view
● Axillary view

19. True a.p X-Ray

20. History:
degree of violence
level of athletic participation
number of dislocations
age of the patient
Clinical examination:
generalized joint laxity
direction of apprehension

21.  Biomechanical Dysfunction
 Failure of static and dynamic stabilizers
 Ranges from mild subluxation to traumatic dislocation
What is Instability?

22. A patient with some degree of laxity dislocates his
shoulder after a minor or major accident
The most common presentation

23. MRI
•Best for Soft Tissue Injuries

24. Conventional MRI provides a good
overview of shoulder lesions and anatomy
MR arthrography modality of choice to
evaluate the labrum. It has the highest
sensitivity and specificity
But it is invasive and inconvenient for the
patient

26. Anterior shoulder dislocation

27. Posterior Dislocation Caution!!

32. Conventional MRI provides a good overview
of shoulder lesions and anatomy,
particularly the soft-tissue structures.
However, it is less accurate than MR
arthrography for depiction of small
labroligamentous lesions associated with
shoulder dislocation.
MR arthrography is the imaging modality of
choice to evaluate the labrum. It has the
highest sensitivity and specificity of all
available modalities.
But it is invasive and inconvenient for the
patient

33. Glenoid Shape
The inferior 2/3 of the glenoid is nearly a
perfect circle with avg diameter 24mm
Huysman et al. JSES 2006

34. Normal Glenoid
inverted
pear
Bony Bankart
pear
Compression
Bankart
loss of
anterior rim

35. Although a bony bankart and glenoid and
humeral bone defects are being depicted on
MRI at present CT-scans are better for the
quantification of the defects

36. CT Scan
Bony Bankart

37. What is the critical limit of Glenoid Bone
loss?
>25 – 30% bone loss
6.5 – 8.6mm AP width
Inverted pear appearance
Bone block procedures
Piasecki et al. AAOS J17 (8): 482. (2009)

38. Taverna et al. Pico Method 2D CT – measurement of
glenoid surface Critical Limit 25% loss of glenoid surface
Quantification of Glenoid Bone loss

39. Our practice
The percentage of the glenoid defect was evaluated on the en face reconstructed
view with the humeral head eliminated
Quantification of Glenoid Bone loss

40. Humeral Bone Defects
Hill-Sachs lesion

41. Engaging Hill Sachs

42. OP Goal
Restoration of the anatomical structure and
biomechanical function of the joint to ensure:
• stability
• normal function, painlessness, normal range of
movement
• prevention of development of osteoarthritis

43. AC-Joint dislocation
Direct trauma: lateral or
laterocranial impact of the
shoulder (fall from a bicycle or
horse, American Football)

44. Pain over the AC Joint
Painfully limited mobility of the
shoulder
Clavicle higher in X-Rays than
Acromion
CAVE: Fracture of Proc. coracoideus

45. SC-Joint dislocation
Rare
High energie trauma with potential
other life-threatening injuries
Anterior > posterior dislocation
Posterior dislocation: danger for
compression of the trachea, major
vessels or mediastinum
CT with contrast is recommended

46. Tear of the rotaror cuff
• Dynamic stabilizer of the shoulder
• Contributes strength to the arm (50% of the abduction
strength is generated by supraspinatus)
• Couple forces stabilize and regulate the motion of the
shoulder
• Internal and external rotation of the shoulder

47. Natural History of a Tear
• Tears DO NOT HEAL
• Some but NOT ALL of them will progress
• Rot cuff arthropathy is the end stage (4-20%)
• 50% of newly symptomatic tears will progress in size
• 20% of asymptomatic tears will progress
• No Tear decrease in size
• 80% of partial tears progress in size or become full thickness in 2 years
[Yamaguchi K., 2006, Nice Shoulder Course]

48. Philosophy of treatment
Restore the equilibrium between
functional demands and capacity of the rotator cuff
 Lower the functional demands of the patient.
 Increase the functional capacity of the remaining intact cuff
 Repair the cuff
Restore the anatomy even partially in an
atraumatic way

49. Prognosis
 Dimensions and extent of tear
 Condition of the involved tendon (retraction – elasticity)
 Tear morphology
 Chronicity of tear
 Evidence of muscle atrophy, fatty degeneration

50. Partial Thickness Tears
grade Ι : < 25% tendon thickness (< 3mm)
grade ΙI : 25-50% tendon thickness (3-6mm)
grade ΙII: > 50% tendon thickness (> 6mm)
A: Articular B: Bursal C: Intresubstance

51. Partial Tears
Partial tears are better imaged by MR direct
arthrography
High(fluid) signal intensity due to Gadolinioum through a portion of the tendon
Common in young athletes in combination with SLAP tears

52. Steps in measuring the size of RCT
Measure L (medial to lateral length) Measure W (anterior to posterior length)

53. Complete Tears
 Small 1cm
 Medium 2-3cm
 Large 3-5 cm
 Massive >5cm
90-95% excellent in small and medium size tears
at 4 to 10 years follow-up
Good to excellent results in massive tears with
less than 75% fatty infiltration of the
Infraspinatus even at 10 years follow-up

54. Classification
Type Description Preoperative MRI Findings Treatment Prognosis
1 Crescent Short and wide tear
End-to-bone
repair
Good to excellent
2
Longitudinal
(L or U)
Long and narrow tear
Margin
convergence
Good to excellent
3
Massive
contracted
Long and wide
> (2 x 2 cm)
Interval slides
or partial repair
Fair to good
4
Cuff tear
arthropathy
Cuff tear arthropathy Arthroplasty Fair to good.

55. Preoperative estimation of fatty infiltration of
infraspinatus and supraspinatus muscle bellies
affects the prognosis

56. Fatty Infiltration
According to Goutallier et al.
in CT scan
0 Normal
1
Some fatty
streaks
2 More muscle
3 Muscle = Fat
4 More fat

57. Fatty infiltration

58. Ruptur of the long head of the biceps tendon
Long biceps tendon
• length: 10cm
• diameter: 5-6 mm
• intraarticular fraction
• extraarticular fraction
intratubercular fraction
extratubercular fraction
Sliding 2cm in and out of the joint

59. Anterior pain at the sulcus bicipitalis
Distalisation of the muscle belly
Loss of force
5%-20% elbow flexion
10-20% forearm supination

60. Tenotomy vs Tenodesis
• Damage/Quality of the tendon
• Age of the patient
• Activity level
• Cosmetic issues
• Wish of the patient
Young, slim patient with high
activity level and cosmetic issues
Bad quality of tendon, old patient
Tenodesis
Tenotomy
Decision for tenotomy or tenodesis:

61. SLAP Lesion
Young patients
Anterior deep pain of the shoulder
O´ Brien Test: +
MRI with i.a contrast

62. SLAP lesions

64. SLAP - Type I

65. SLAP - Type II

66. SLAP - Type III

67. SLAP - Type IV

68. Fracture of the clavicle
Most common cause: fall on the extended hand
Clavicle fractures: 3% of all fractures
Clavicular fractures:
i) of the middle third: 70%
ii) lateral clavicle fractures: 25%
iii) medial clavicle fractures: 5%

69. Conservative therapy
i) no additional nerve-, vascular- or major soft tissue
injuries
ii) Length shortening <15-20 mm
iii) Angle of the fracture <20-25 °
Clavicle 8-Brace
•so tight that the patient tolerates it
•no neurological or venous problems

70. OP Indication
• Vascular or nerve injuries
• Open fracture
• Tranverse intermediate fragment (poor healing)
• Fragment pressure to the skin or danger of skin perforation
• ´Floating shoulder´ (ipsilateral clavicle fracture and fracture
of the neck of glenoid)
• Pathological fractures
• Pseudoarthrosis

71. Fracture of the scapula
nearly 1% of all fractures
High energie trauma, fall from greater
height, shoulder dislocation
often associated with other severe injuries
such as thorax injuries or clavicle
fractures

72. Fracture of the humerus head
5% of all fractures
70% of all patient with humerus head fracture are older
than 60 years old
Danger for posttraumatic osteonecrosis due to the
reduced vascularisation

73. Conservative therapy
Dislocation of fracture < 1cm
Rotation of the humerus head < 45°
OP Indication
Tuberculum dislocation >5mm (<65 years old)
>10mm (<65 years old)
Axis Deviation > 45°
Intraarticular formation of a gap >2mm

74. FROZEN SHOULDER
when overestimation of MRI reports can lead to clinical
mistakes

75. Frozen Shoulder
Thickened coracohumeral ligament
Thickening of soft tissue in the rotator interval
Thickened inferior glenohumeral ligament

76. Thank you
for your
attention

77. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart

78. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
Group Glenoid Defect Hill-Sachs Lesion Recommended Treatment
1 <25% On track Arthroscopic Bankart repair
2 <25% Off track Arthroscopic Bankart repair plus remplissage
3 >25% On track Latarjet procedure
4 >25% Off track Latarjet procedure with or without humeral
sided procedure (humeral bone graft or remplissage),
depending on engagement of Hill-Sachs lesion
after Latarjet procedure

79. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
A.Three-dimensional CT scan with en face view of a normal glenoid, with subtraction of the humeral head
The width of the glenoid track without a glenoid defect is 83% of the glenoid width.
B. Relation of glenohumeral joint in abduction and external rotation.
The distance from the medial margin of the contact area (M) to the medial margin of the cuff footprint (F) is 83%±14%
of the glenoid width: F - M = 83% of glenoid width = glenoid track.

80. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
A. 3D CT scan with en face view of a glenoid with bone loss of width d.
In such a case with glenoid bone loss, the glenoid track will be 83% of the normal glenoid width minus d.
B. Relation of glenohumeral joint in abduction and external rotation.
One should note the loss of contact of the intact humeral articular surface with the articular surface of the glenoid.
In this case the large Hill-Sachs interval (i.e., distance from posterior rotator cuff attachments to medial margin of Hill-
Sachs lesion) is wider than the glenoid track, whose width has been reduced because of the glenoid bone loss.

81. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
How to Determine Whether Hill-Sachs Lesion Is “On
Track” or “Off Track”
1. Measure the diameter (D) of the inferior glenoid, either by arthroscopy or from 3D CT scan
2. Determine the width of the anterior glenoid bone loss (d).
3. Calculate the width of the glenoid track (GT) by the following formula: GT = 0.83 D - d.
4. Calculate the width of the HSI, which is the width of the Hill-Sachs lesion (HS) plus the width
of the bone bridge (BB) between the rotator cuff attachments and the lateral aspect of the
Hill-Sachs lesion: HSI=HS + BB.
5. If HSI > GT, the HS is off track, or engaging. If HSI < GT, the HS is on track, or non-engaging.

82. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart

83. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart

84. ●From engaging Hill Sachs to On-
track & Off-track lesions
No Bone Loss Arthroscopic Bankart Repair
Glenoid Bone Loss
> 25%
Arthroscopic Bankart Repair + Bone grafting procedure
What
happens in
between?
It is the combination of the existing lesions
Large Hill-Sachs lesion + No glenoid bone loss
=
Small Hill-Sachs lesion + 15% -20% glenoid bone loss