MRI of the shoulder
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Anatomy, protocol, and MRI of the shoulder: rotator cuff injury, impingement, ligament and labrum
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MRI of the shoulder
- 1. MRI of the shoulder PANJAI-THORSANG-SURASIT PRINCE OF SONGKLANAGARIND, THAILAND 17.05.2016
- 3. Bony Anatomy of Shoulder Coracoid process Spine of scapula
- 5. Stabilizer of Shoulder Joint Dynamic • Surrounding muscles • Rotator cuff m. Static • Gleniod Labrum • Fibrous capsule • Glenohumeral ligament • Coracohumeral ligament
- 7. Rotator cuff Four muscles : blend with reinforce fibrous capsule, dynamic stabilizers of glenohumeral joint Supraspinatous muscle Infraspinatous muscle Teres minor muscle Subscapularis muscle Insert on lesser tuberosity Insert on greater tuberosity
- 9. Supraspinatus O: Supraspinous fossa I: Superior facet on greater tubercle of humerus A: Initiates & assists deltoid in abduction N: Suprascapular nerve
- 10. Infraspinatus O: Infraspinous fossa I : Middle facet on greater tubercle of humerus A: External rotates the arm N: Suprascapular n.
- 11. Teres minor O: Middle third of the lat. scapula border I: Inferior facet on greater tubercle of humerus A: External rotates the arm N: Axillary nerve
- 12. Subscapularis O: Subscapular fossa I: Lesser tubercle of humerus A: Internal rotation of arm & adduction N: Upper & lower subscapular
- 13. Rotator Cuff Insertion At the distal aspect of the rotator cuff, the tendons splay out with broad and sheet-like at their humeral insertions
- 17. Biceps muscle and tendons Short head O: Coracoid process I: Upper ulnar Long head O: Supraglenoid tubercle & superior glenoid labrum I: Tubercle of radius
- 18. Deltoid Muscle O : Ant. border & upper surface of lateral 3rd clavicle, acromion, scapula spine I : Deltoid tuberosity of humerus A : Abduction flexion & extension N : Axillary nerve
- 19. Articular and Soft tissue Anatomy
- 20. Glenohumeral joint Articular surface of glenoid and humerus Cover with hyaline cartilage Humeral head : central thickness, larger Glenoid cavity : central thinnest, smaller
- 21. Fibrous capsule • Strength by its intimate, surrounding ligament & tendon • Superior : supraspinatus, coracohumeral ligament • Inferior : long head of triceps • Anterior : subscapularis • Posterior : infraspinatous, teres minor
- 22. Glenohumeral Joint Synovial membrane Coat inner aspect of joint capsule Synovial membrane Axillary pouch Articular surface Labrum Bursa
- 23. Glenoid Oval in shape Shallow Central depression
- 24. Labrum Fibrocartilagenous structure Rim around the glenoid about 3 mm Anterior usually larger than posterior Increases surface area & depth of glenoid fossa Add stability of glenoidhumeral articulation
- 25. Labrum Most frequently triangular in cross-section Low signal intensity on all MRI sequences
- 26. Glenoid labrum Sagittal-oblique T1W-FS MR arthrogram : The six labral zones of the glenoid labrum 12 6 39 Post. Ant.
- 28. Glenohumeral ligaments Extend from anterior aspect of glenoid cavity to proximal humerus Superior (SGHL) Middle (MGHL) Inferior (IGHL) Anterior BandPosterior Band
- 29. Glenohumeral ligaments Thick fibrous bands within the anterior portion of the joint Important contributors to anterior shoulder stability The thickest and most important: IGHL
- 30. Coracoid
- 31. Anterior and Posterior bands of the IGHL Sag T1W-FS MR arthrogram Anteriro Band Posterior Band
- 32. Coracohumeral ligament Arises from lateral edge of coracoid process to greater tuberosity
- 34. Bursae Subacromial bursa Separate from articular cavity by rotator cuff Subdeltoid bursa Lies between deltoid m. & joint capsule
- 35. MRI shoulder
- 36. MRI Technique Supine position with the arm in slight external rotation 3 planes Coronal oblique : Parallel to supraspinatus tendon and scapula spine Axial: Above AC joint to inferior margin of the glenohumeral joint Sagittal oblique: Perpendicular to supraspinatus tendon
- 38. MRI Sequences Axial: PDW-FS Sagittal oblique: T2W Coronal: T1W, PDW-FS MR arthrography (Intra-articular Gd.) : T1W-FS (3 planes) + ABER (ABduction and External Rotation)
- 39. Axial way 45 degrees off the coronal plane MRI: ABER view
- 42. Axial
- 51. Coronal
- 65. Sagittal
- 73. ABER view
- 79. ROTATOR CUFF By THORSANG CHAYOVAN R2
- 80. ROTATOR CUFF TEAR 1. Supraspinatus muscle 2. Infraspinatus muscle 3. Subscapularis muscle 4. Teres minor muscle
- 81. ROTATOR CUFF TEAR Classification Full-thickness tear Articular-bursal surface Complete/incomplete Partial-thickness tear Articular/bursal/Intratendinous Massive tear: full-thickness tears involving multiple tendons of the rotator cuff
- 82. ROTATOR CUFF TEAR Prevalence Partial-thickness tear > full-thickness tear Articular side > bursal side > Intratendinous
- 83. ROTATOR CUFF TEAR Cause & pathogenesis Repetitive microtrauma > acute trauma Full-thickness tear occurred by combination of Age Repetitive stress/impingement syndrome Corticosteroid injection Hypovascularity DM
- 84. ROTATOR CUFF TEAR Men > 40 years Dominant arm Partial-thickness: pain Full-thickness: pain, limited ROM
- 85. Normal MRI Signal All tendons: low SI on all MRI sequences High SI on short TE (T1W, PD, GRE) without increase SI on T2W magic angle phenomenon
- 86. Magic-angle Phenomenon Collagen fibers: oriented at about 55 degrees to main magnetic field Specific location: 1 cm from insertion of supraspinatus tendon on greater tuberosity
- 90. ROTATOR CUFF TEAR Radiographic abnormalities Acute Chronic rotator cuff tear Narrowing acromiohumeral space Reversal of normal inferior acromial convexity Cysts and sclerosis of acromion and humeral head
- 91. ROTATOR CUFF TEAR Arthrographic abnormalities Complete tear: abnormal communication between glenohumeral joint cavity & subacromial (subdeltoid) bursa Interstitial tear and bursal surface tear of cuff not demonstrated on glenohumeral joint arthrogram False-negative in partial tear: too small lesion, a fibrous nodule has occluded defect
- 92. ROTATOR CUFF TEAR MR abnormalities Full-thickness tear: high SI on T2WI Direct signs Tendon discontinuity Fluid signal in tendon gap Retraction of musculotendinous junction Associated findings Subacromial/ subdeltoid bursal fluid Muscle atrophy
- 93. ROTATOR CUFF TEAR MR abnormalities Partial-thickness tear Increased SI on T1 & T2 Higher signal than muscle on T2 (similar to joint fluid) Tear on joint surface fills with Gd on MR arthrogram Degeneration Intrasubstance increased SI T1 & T2 Not as high signal as joint fluid
- 94. Rim rent tear
- 96. MR Information Tear depth/thickness Tear shape Tendon retraction Tear extension to adjacent structures muscle atrophy/fatty degeneration Coracoacromial arch and impingement
- 97. Dimensions of a Full-Thickness Tear The dimensions of rotator cuff tears may have Selection of treatment and surgical approach Tear recurrence Rotator cuff tears greater than 1 cm2 are associated with an unfavorable outcome if treated conservatively
- 98. Dimensions of a Full-Thickness Tear DeOrio & Cofield classification Small 1 cm Medium 1–3 cm Large 3–5 cm Massive >5 cm
- 99. Depth of a Partial-Thickness Tear Grade according to depth Grade 1 (3 mm) Grade 2 (3–6 mm) Grade 3 (6 mm) The normal rotator cuff is 10–12 mm thick Grade 3 tears considered significant tears involving >50% of cuff
- 100. Tear Shape U shaped massive rotator cuff tears that may extend medially to the level of the glenoid fossa Crescentic the tendon pulls away from the greater tuberosity but typically does not retract far medially L shaped massive tears with a longitudinal component along the orientation of the rotator cuff fibers and a transverse component along the cuff insertion
- 101. Tear shape crescentic tear U-shaped tear
- 102. Tendon Retraction Suggestive to be irreparable : retraction of tendon edge medial to glenoid fossa
- 103. Tear Extension: supraspinatus Extend anteriorly to involve The medial aspect of the coracohumeral ligament Superior subscapularis tendon fibers Extend posteriorly to involve Infraspinatus tendon Teres minor tendon (rare) Poor prognosis
- 104. Thomazeau et al: 4 segments of the rotator cuffs Tear Extension: supraspinatus
- 106. Muscle Atrophy and Fatty Degeneration Supraspinatus muscle atrophy Function Associated with tear recurrence after repair Occupation ratio Tangent sign
- 108. Tangent sign
- 109. Goutallier [1994] Clin Orthop 304: 78-83 Grade 0 Normal muscle, no fat 1 Some streak of fat 2 Fat < muscle 3 Fat = muscle 4 Fat > muscle Muscle fatty degeneration
- 111. Adhesive capsulitis (Frozen shoulder) Inflammatory process progressive capsular retraction, scar tissue F>M Causes: Idiopathic, Trauma, Immobilization, DM Symptom: Pain at rest, at night, and motion Limitation of movement(abduction and external rotation)
- 112. Freezing - painful stage: acute synovitis (3- 9 months) • Progressive, pain worsens and restricted ROM Frozen - transitional stage: (4 to 12 months) • Stable pain due to limited ROM Thawing stage: (12 to 42 months ) • Begins when ROM begins to improve • Gradual return of shoulder mobility Adhesive capsulitis (Frozen shoulder)
- 113. Rotator interval: including LBT Labral-biceps anchor Superior GHL CHL Anterior margin of supraspinatus tendon Superior margin of subscapularis tendon Joint capsule
- 114. MRI: Complete obliteration of the fat triangle under the coracoid process (subcoracoid triangle sign) Scar tissue Thickening of the CHL Axillary recess thickening Arthrography: Decreased joint capacity Small capsular recesses Serrated appearance of capsular attachments Adhesive capsulitis (Frozen shoulder)
- 115. T1 sagittal oblique shoulder MR arthrogram: subcoracoid fat is replaced with scar in this patient with adhesive capsulitis
- 116. Long Head of Biceps Tendon Tear/ degeneration Proximal to bicipital groove Associated with impingement Associated with supraspinatus tear Older population Musculotendinous junction Acute, traumatic injury Younger population
- 117. Long Head of Biceps Tendon Dislocation Associated disruption Transverse humeral ligament Usually subscapularis tendon MRI Empty bicipital groove (axial) Tendon displaced medially Subscapularis tendon avulsed from tuberosity
- 118. Biceps tendon tear
- 120. Infraspinatus Tendon Tear Isolation after acute trauma Associated with posterosuperior impingement Infraspinatus tendon, posterosuperior labrum and humeral head Overhead movement with abduction and external rotation Posterosuperior pain and anterior instability
- 121. Infraspinatus Tendon Tear MRI Infraspinatus tendon undersurface tears Posterosuperior labral tear Humeral cyst adjacent to infraspinatus tendon insertion
- 122. Subscapularis Tendon Tear Associations Anterior shoulder dislocation Anterosuperior impingement Long head of biceps tendon dislocation
- 123. MRI: Detachment from lesser tuberosity Increased SI, thin/thick Contrast over the lesser tuberosity Subscapularis Tendon Tear
- 125. Classification of impingement Primary impingement: Alterations in coracoacromial arch Non-athletes Subacromial impingement External impingement Coracoid impingement External impingement Secondary impingement: Related to either glenohumeral or scapular instability Mainly in athletes: overhead movement of arm Glenohumeral instability External impingement Posterosuperior impingement Internal impingement Anterosuperior impingement Internal impingement
- 126. Loss of normal gliding mechanism between superior periarticular soft tissue around glenohumoral joint and coracoacromial arch Entrapment of soft tissue between coracoacromial arch and humeral head and tuberosities “subacromial space” External impingement
- 127. Symptoms Acute or chronic shoulder pain induced by: Abduction and external rotation Elevation and internal rotation Stiffness Weakness
- 128. Coracoacromial arch: 1. Anterior third of acromion 2. Coracoacromial ligament 3. Coracoid process Impingement interval Rotator cuff tendons Long head biceps tendon Bursa Coracohumeral ligament Humeral head
- 129. Effects of impingement Bones Degenerative cysts, sclerosis of greater tuberosity and/or humeral head Bursa Subacromial/subdeltoid bursitis Tendons Supraspinatous tendon Proximal long head biceps brachii tendon Degeneration Partial tear Complete tear
- 130. High-riding humerus with decreased acromiohumeral distance Radiographic abnormalities • No diagnostic of an acute rotator cuff tear • Chronic rotator cuff tear ▫ Narrowing of acromiohumeral space < 0.5 cm ▫ Reversal of normal inferior acromial convexity ▫ Cystic lesions and sclerosis of acromion and humeral head
- 131. Acromiohumeral interval (AHI) True AP shoulder radiograph >12mm - Shoulder dislocation, subluxation 9-10mm (range 8-12mm) - Normal 6-7mm - Thinning of supraspinatus tendon <6mm - Supraspinatus tear
- 132. Structural factors Acromioclavicular(AC) joint Congenital anomalies or degenerative joint (osteophytes) Acromion Alterations in shape, malunion or nonunion, os acromiale or osteophytes Coracoid process Congenital anomalies, post traumatic/surgical changes Thickening of coracoacromial ligament: no related to impingement.
- 133. Structural factors Subacromial-subdeltoid bursa Inflammation, thickening, foreign bodies Rotator cuff Calcification, thickening Irregularity related to tendon tears or postoperative/traumatic scars Over development: athletes Humerus Congenital anomalies, malunion or altered position of a humeral head prosthesis
- 134. Causes Degenerative AC joint Os acromiale Thick coracoacromial ligament Post traumatic osseous deformity Instability Muscle overdevelopment
- 136. •Type I (flat) •Type II (curved downward) •Type III (hooked downward anteriorly) •Type IV (curved upward) Bursal-surface tear found in type III and possibly in type II
- 137. Acromial orientation • Coronal oblique Lateral down-slopping or inferolateral tilt Low-lying Sagital oblique Anterior down-slopping
- 138. Acromial orientation
- 139. Acromial orientation
- 141. Degenerative acromioclavicular Joint Inferiorly projecting osteophytes Fibrous overgrowth of capsule Radiographs, underestimated for osteophytes and fibrous overgrowth Obliteration of fat between supraspinatus muscletendon and overlying acromioclavicular joint
- 143. ซ Os acromiale: Accessory ossification center Fused by 25 years Fat-saturated T2W
- 144. Os acromiale
- 145. Internal impingement
- 146. Posterosuperior impingement (PSI) Anterosuperior translation of humeral head microtraumatic instability Humeral head (greater tuberosity) Supraspinatus and infraspinatus tendons and posterosuperior labrum Posterior glenoid rim
- 147. Abduction and external rotated (ABER) position Professional throwing athletes (overhead motion): baseball pitchers, tennis , javelin throwers and swimmer. Posterior shoulder pain: late cocking phase and acceleration phase
- 148. Kinematic of throwing < 2 sec 6 phases Phase I (wind-up) - Minimal stress put on shoulder Phase II (early cocking) - Abducted arm to 90° prepared for maximum external rotation Phase III (late cocking) - Rotated shoulder externally (maximum extent): athletes reach up to 170° - Lead to posterior translation of humeral head maximum stress on anterior capsule 1.5 seconds 0.5 second
- 149. Phase IV (acceleration phase): 0.05 seconds - Highest angular velocities and largest rotational movement - Peak rotational velocity Phase V (deceleration phase) Most violent phase - Deceleration occurs from point of ball release to point of 0° of rotation - Marked eccentric contraction of rotator cuff to slow down arm motion - Maximal posterior capsule stress: posterior-inferior-compressive shear forces Phase VI (follow through) - Rebalancing phase: muscles return to resting level
- 150. Abduction external rotation position (ABER) 1. 5 osseous and chondral lesions 2. Articular sided rotator cuff tear (SSP, ISP) 3. Posterosuperior labral and biceps anchor lesion 4. Laxity of anterior capsule (IGHL): Controversy: Risk factor in posterosuperior impingement
- 151. Posterosuperior labral lesion Produces a posterior type: superior labrum anterior and posterior (SLAP) lesion Not associated with shoulder instability Common in falling onto out-stretched arm or in throwing sports
- 153. type I: fraying of labrum type II: detachment of labrum and biceps anchor from glenoid (partial thickness tear) <40 years: associated with Bankart lesions >40 years: associated with rotator cuff tears type III: bucket handle tear of labrum(full thickness tear) type IV: bucket handle tear of labrum with extension into long head of biceps tendon Tx: Type II tears: surgical reattachment Type III tears: resection of bucket handle tear
- 157. Prevalance: 11% Anterosuperior labrum at 1-3 o'clock position Not involves biceps anchor (SLAP always involve bicep anchor)
- 158. Congenital labral variant Absent anterosuperior labrum (1-3 o'clock) and middle glenohumeral ligament (MGHL) thickened
- 159. Glenohumeral internal rotation deficit (GIRD) Scarring of posterior joint capsule leading to: Restriction of internal rotation Excessive external rotation
- 160. Bennett lesion Traction of posterior band of inferior glenohumeral ligament during decelerating phase of pitching MRI: • Thickened low signal posteroinferior capsule (mineralization) • May be associated with posterior labral tear
- 161. Posterosuperior impingement: 1. Tearing of posterior undersurface fibers of supraspinatus and anterior undersurface of infraspinatus tendon 2. Tearing of posterosuperior glenoid labrum (SLAP) 3. Humeral head impaction or subcortical cysts 4. Laxity of anterior capsule 5. Thickening of posterior capsule
- 163. Labral tears: Resulting in tension on anteroinferior labrum allowing intra-articular contrast to get between labral tear and glenoid Excellent for assessing anteroinferior labrum (3-6 o'clock)=Bankart lesion and its variant: most common labral tear. MRI: ABER view
- 164. Rotator cuff tears: Releases tension on cuff relative to normal coronal view(arm adduction) and intra-articular contrast can enhance visualization of tear Result, subtle articular-sided partial thickness tears ABER position: nonpathologic entrapment of articular surface fibers of supraspinatus tendon occurs in all normal individuals “isolated this finding not suggest pathologic impingement” MRI: ABER view
- 165. Anterosuperior impingement Internal impingement between humeral head and anterosuperior glenoid rim Position of horizontal adduction and internal rotation of arm Anterior superior shoulder pain Masonry or sports related (pole vaulting)
- 166. Partial tears of: 1. Deep fibers of subscapularis tendon along lesser tuberosity 2. Biceps pulley lesion
- 167. Biceps pulley Capsuloligamentous complex that acts to stabilize the long head of the biceps tendon in the bicipital groove. Located within the rotator interval between the anterior edge of the supraspinatus tendon and the superior edge of the subscapularis tendon. Pulley complex: capsuloligamentous complex Superior glenohumeral ligament Coracohumeral ligament Distal attachment of subscapularis tendon
- 168. Biceps pulley lesion Instability of LBT Acute trauma, repetitive microtrauma or degenerative Fall on an outstretched arm while arm full internal or external rotation
- 169. Level biceps
- 170. Habermeyer et al studied: subdivided pulley lesions into four different patterns 1 = CHL 2 = LBT 3 = superior GHL 4 = lesser tuberosity 5 = greater tuberosity 6 = anterior glenoid labrum G = glenoid H = humeral head Ssc = subscapularis tendon Ssp = supraspinatus tendon
- 171. Isolated superior GHL lesion (group 1) Isolate superior GHL tear Normal superior GHL
- 172. Superior GHL lesion with a partial articular-side supraspinatus tendon tear (group 2) Biceps tendon: slightly dislocated anteriorly
- 173. Superior GHL lesion with a partial articular-side subscapularis tendon tear (group 3) Biceps tendon: dislocated into torn subscapularis tendon Superior GHL tear Partial articular-side subscapularis tendon tear
- 174. Superior GHL lesion with partial articular-side supraspinatus and subscapularis tendon tears (group 4) Biceps tendon: dislocated completely outside biceps pulley and located in torn subscapularis tendon. Superior GHL tear Articular-side supraspinatus tendon tear Medial dislocation of LBT
- 179. Anterior impingement Contact between the rotator cuff and superior labrumglenoid. Non-athletic. In shoulder forward flexion: forward elevation of arm and overhead use of arm. Anterior rotator cuff area tender.
- 180. Entrapment of the long head of the biceps tendon Entrapment LHBT within joint Pain and locking of shoulder on elevation of arm Arthrography: Hypertrophy of intra-articular biceps tendon “Hourglass biceps” • Intraoperative hourglass test: forward elevation of arm with elbow extended buckling of tendon
- 181. Markedly irregularly thickened biceps tendon (arrow) resemblance of an hourglass Clinical history+imaging+surgical findings
Hinweis der Redaktion
- Anterior graphic of the shoulder. The tendon of the subscapularis muscle attaches both to the lesser tubercle aswell as to the greater tubercle giving support to the long head of the biceps in the bicipital groove. Dislocation of the long head of the biceps will inevitably result in rupture of part of the subscapularis tendon. The rotator cuff is made of the tendons of subscapularis, supraspinatus, infraspinatus and teres minor muscle.
- Posterior graphic of the shoulder. The supraspinatus, infraspinatus and teres minor muscles and tendons are shown. They all attach to the greater tuberosity. The rotator cuff muscles and tendons act to stabilize the shoulderjoint during movements. Without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. Large tears of the rotator cuff may allow the humeral head to migrate upwards resulting in a high riding humeral head.
- The glenohumeral joint has the following supporting structures: Superiorly coracoacromial arch and coracoacromial ligament long head of the biceps tendon tendon of the supraspinatus muscle Anteriorly anterior labrum glenohumeral ligaments - SGHL, MGHL, IGHL (anterior band) subscapularis tendon Posteriorly posterior labrum posterior band of the IGHL infraspinatus and teres minor tendo
- Ref >>> articular surface
- ABER view Labral tears The abduction external rotation (ABER) view is excellent for assessing the anteroinferior labrum at the 3-6 o'clock position, where most labral tears are located. In the ABER position the inferior glenohumeral ligament is stretched resulting in tension on the anteroinferior labrum, allowing intra-articular contrast to get between the labral tear and the glenoid. Rotator cuff tears The ABER view is also very useful for both partial- and full-thickness tears of the rotator cuff. The abduction and external rotation of the arm releases tension on the cuff relative to the normal coronal view obtained with the arm in adduction. As a result, subtle articular-sided partial thickness tears will not lie apposed to the adjacent intact fibers of the remaining rotator cuff nor be effaced against the humeral head, and intra-articular contrast can enhance visualization of the tear (3)
- Images in the ABER position are obtained in an axial way 45 degrees off the coronal plane (figure). In that position the 3-6 o'clock region is imaged perpendicular. Notice red arrow indicating a small Perthes-lesion, which was not seen on the standard axial views.
- Axial anatomy and checklist Look for an os acromiale. Notice that the supraspinatus tendon is parallel to the axis of the muscle. This is not always the case. Notice that the biceps tendon is attached at the 12 o'clock position. The insertion has a variable range.
- Notice superior labrum and attachment of the superior glenohumeral ligament. At this level look for SLAP-lesions and variants like sublabral foramen. At this level also look for Hill-Sachs lesion on the posterolateral margin of the humeral head. The fibers of the subscapularis tendon hold the biceps tendon within its groove. Study the cartilage. At this level study the middle GHL and the anterior labrum. Look for variants like the Buford complex. Study the cartiage.
- The concavity at the posterolateral margin of the humeral head should not be mistaken for a Hill Sachs, because this is the normal contour at this level. Hill Sachs lesions are only seen at the level of the coracoid. Anteriorly we are now at the 3-6 o'clock position. This is where the Bankart lesion and variants are seen. Notice the fibers of the inferior GHL. At this level also look for Bankart lesions.
- Coronal anatomy and checklist Notice coracoclavicular ligament and short head of the biceps. Notice coracoacromial ligament. Notice suprascapular nerve and vessels. Look for supraspinatus-impingement by AC-joint spurs or a thickened coracoacromial ligament
- Study the superior biceps-labrum complex and look for sublabral recess or SLAP-tear. Look for excessive fluid in the subacromial bursa and for tears of the supraspinatus tendon. Look for rim-rent tears of the supraspinatus tendon at the insertion of the anterior fibers. Study the attachment of the IGHL at the humerus. Study the inferior labral-ligamentary complex. Look for HAGL-lesion (humeral avulsion of the glenohumeral ligament). Look for tears of the infraspinatus tendon. Notice small Hill-Sachs lesion.
- Sagittal anatomy and checklist Notice rotator cuff muscles and look for atrophy Notice MGHL, which has an oblique course through the joint and study the relation to the subscapularis tendon. Sometimes at this level labral tears at the 3-6 o'clock position can be visualized. Study the biceps anchor. Notice shape of the acromion Look for impingement by the AC-joint. Notice the rotator cuff interval with coracohumeral ligament. Look for supraspinatus tears.
- ABER - anatomy Notice the biceps anchor. The undersurface of the supraspinatus tendon should be smooth. Look for supraspinatus irregularities. Study the labrum in the 3-6 o'clock position. Due to the tension by the anterior band of the inferior GHL labral teras will be easier to detect. Notice smooth undersurface of infraspinatus tendon and normal anterior labrum. Notice smooth undersurface of infraspinatus tendon and normal anterior labrum.
- Motion + stabilizes the glenohumeral joint. The four fan-shaped muscles all arise from the scapula and attach to the humerus subscapularis inserting on the lessertuberosity and the other three muscles inserting on the greater tuberosity.
- The cigar-shaped supraspinatus muscle runs horizontally. musculotendinous junction is located just lateral to the acromioclavicular joint. The tendon (arrows) is located between the acromion and the humerus, attaches to the top of the greater tuberosity, and is low signal. broad footprint of the tendon insertion onto the greater tuberosity (arrowheads)
- Normal infraspinatus tendon. T2* coronal oblique image of the shoulder. The low signal infraspinatus tendon runs obliquely (arrows) in a craniocaudal direction, attaching to the posterior and superior aspect of the greater tuberosity of the humerus.
- NO MRI นะครัช
- ยากจะแยกกัน มักเกิดร่วมกันอยู่แล้ว tendinopathy
- Partial supraspinatus tear (rim rent tear). A, T1 fatsuppressed, coronal oblique image of the shoulder. The broad footprint of the normal insertion of the supraspinatus tendon onto the greater tuberosity is interrupted with fl uid (arrow), which indicates a partial articular-sided cuff tear. B, T1 fat-suppressed, sagittal oblique image of the shoulder. Sagittal image confi rms fl uid disrupting the cuff insertion (arrow).
- supraspinatus tendon is torn and retracted a long distance medially (curved arrow). There is narrowing between the acromion and humeral head because of absence of the tendon. AC joint is degenerated, and high signal contrast material fills it from joint injection. B, T1 sagittal oblique--The superior mass (open arrow) is a small synovial cyst arising from the acromioclavicular joint. The absence of tendons overlying the humeral head indicates multiple tendon tears with retraction infraspinatus, supraspinatus, and subscapularis tendons (from left [posterior] to right [anterior]) are absent. The biceps tendon remains intact (middle arrow), but no supraspinatus is seen above it.
- Focal full-thickness supraspinatus tendon tears -Coronal oblique (a) and sagittal (b) fat-saturated T2WI (3000/60) obtained in two different patients show focal full-thickness tears of the supraspinatus tendon (SST) -Double-headed arrow indicates the greatest dimension of the tears
- fat-saturated T2WI
- Medial tendon retraction of supraspinatus tendon (SST) and subscapularis tendon (SSC) almost to glenoid fossa Ts fs
- sagittal fat-saturated T2WI
- Axial fat-saturated T2WI Involvement of the rotator interval anterior tear of supraspinatus tendon (SST) tear extends anteriorly to involve lateral aspect of coracohumeral ligament
- Atrophy=irreversible
- Sagittal fat-saturated T2 the ratio between the cross-sectional area (green) of the belly of the supraspinatus muscle (SST) and that of the scapular fossa (orange) volume loss in the supraspinatus muscle (SST) cross-sectional area (green) much smaller than scapular fossa
- + = supraspinatus muscle lies entirely below the tangent
- Sagittal T1WI --severe fatty degeneration and volume loss in the supraspinatus muscle and infraspinatus muscle belly Coronal oblique T1--fatty degeneration of the infraspinatus muscle belly (IST)
- Anteriorly: Coracohumeral ligament, superior glenohumeral ligament, and capsule • Superiorly: Supraspinatus tendon • Inferiorly: Subscapularis tendon • Medially: Coracoid process • Laterally: Transverse humeral ligament • Long biceps tendon courses through the interval
- Rotator interval in adhesive capsulitis. A, T1 sagittal oblique shoulder MR arthrogram. The subcoracoid fat is replaced with scar in this patient with adhesive capsulitis. B, FSE T2 sagittal oblique shoulder MR arthrogram. Note the intermediate signal scar in the rotator interval and posterosuperior joint.
- Biceps tendon tear. T2* axial image of the shoulder. The bicipital groove (arrow) is empty, without evidence of the oval, low signal long head of the biceps tendon, indicating a complete rupture.
- Dislocated biceps tendon. A, T1 fat-suppressed axial shoulder MR arthrogram. The bicipital groove is empty. The biceps tendon (arrowhead) is located over the anterior glenohumeral joint and posterior to the subscapularis tendon (arrow), which has been avulsed from its attachment to the lesser tuberosity of the humerus. B, T1 fat-suppressed coronal oblique shoulder MR arthrogram. The biceps tendon (arrowheads) is dislocated medially overlying the shoulder joint
- The end of the torn infraspinatus tendon (arrow) is seen retracted inferomedially to its normal attachment to the posterolateral humerus.
- Subscapularis tendon tears; subcoracoid impingement. A, T1 fat-suppressed axial shoulder MR arthrogram. The subscapularis has been detached from the lesser tuberosity (arrowhead). The biceps tendon is subluxed medially from the bicipital groove. Contrast material covers the lesser tuberosity. B, T1 fat-suppressed axial shoulder MR arthrogram (different patient than in A). The coracoid process (C) was excessively long in this patient, causing narrowing of the space between it and the humerus (subcoracoid impingement). This is associated with tears of the subscapularis tendon, as was evident in this case (arrow). The tendon is thickened, longitudinally split, and fi lled with contrast material.
- Internal impingement External impingement
- ท่าขว้างของ
- Figure 10-12 Anterior-sloping acromion. T1 sagittal oblique image of the shoulder. The acromion is downward sloping anteriorly (anterior is to the left), which is believed by many to be a cause of impingement.
- Figure 10-14 Acromial orientation. FSE T2 oblique coronal images showing the relationship of the acromion to the distal clavicle in three different shoulders. A, Horizontal; this is the normal orientation. B, Low-lying; the acromion is inferior to the distal clavicle. C, Inferolateral; the acromion is laterally sloping in relation to the clavicle. The low-lying and inferolateral positions are thought to be associated with impingement.
- marrow projects from the anterior surface of the acromion OA AC joint RW: enthesis of deltoid เป็นริมดำๆได้
- SST subscapularis tendon
- Articular surface of supraspinatus + superoposterior aspect of glenoid labrum
- SLAP โดน biceps anchor แน่ๆ
- Figure 10-51 Superior labral tear propagating anterior and posterior (SLAP) lesion: detachment. A, T1 fat-suppressed coronal oblique shoulder MR arthrogram. The superior labrum is completely separated from the adjacent glenoid with no attachment identified (arrow). High signal contrast material fills the space between the glenoid and the detached labrum. If the labrum had an attachment to the glenoid, this high signal line would simply represent the normal sulcus between labrum and bone. B, T1 fat-suppressed axial shoulder MR arthrogram. The contrast material between the detached labrum and glenoid is seen (arrow) all the way across the top of the labrum, extending posterior to the predicted attachment site of the biceps tendon, which is located anterior on the superior labrum. C, T1 fat-suppressed sagittal oblique shoulder MR arthrogram. The separation between the labrum (arrows) and glenoid is filled with contrast material and involves the superior half of the glenoid.
- Kaplan แบ่งได้เยอะมาก 12 แบบ
- On coronal view At biceps anchor >>> NOT extend ไปหน้า-หลัง
- thickening of the posterior capsule and labral irregularity
- Capsular fibrosis (long arrow) supraspinatus tear (short arrows) microfractures/cysts in the humeral head (arrow) GIRD (black arrow) SLAP (white arrow) partial thickness rotator cuff tear (oval)
- Bankart (3-6 o'clock) Reverse Bankart posteroinferior labrum (6-9 o'clock) Perthes Detachment labrum (3-6 o'clock) with intact periosteum ALPSA = Anterior Labral Periosteal Sleeve Avulsion. Medially displaced labroligamentous complex with absence of labrum on glenoid rim. GLAD = GlenoLabral Articular Disruption. partial tear labrum with adjacent cartilage damage
- Drawing illustrates the normal anatomy of the biceps pulley. The CHL is cut so that the superior glenohumeral ligament (SGHL), focal capsular thickening, and the intraarticular portion of the LBT can be seen. Ac = acromion, Cl = clavicle, Cp = coracoid process, GT = greater tuberosity, LT = lesser tuberosity, Ssc = subscapularis tendon, Ssp = supraspinatus tendon. (b) In the corresponding cadaveric photograph (anterolateral view), the subscapularis tendon (arrows) and the joint capsule (arrowhead) are cut. Cp = coracoid process, dotted line indicates the rotator interval.