Shoulder

JL Gielen

J Veryser

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Coracohumeral Ligament

Medial Lateral

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Radiograph

US

Radiograph

Decubitus Dorsalis

Endorotatio

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

US

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Coracohumeral Ligament

Medial Lateral

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Radiograph

US

Radiograph

Decubitus Dorsalis

Endorotatio

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

US

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Coracohumeral Ligament

Medial Lateral

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Radiograph

US

Radiograph

Decubitus Dorsalis

Endorotatio

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

US

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Coracohumeral Ligament

Medial Lateral

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Radiograph

US

Radiograph

Decubitus Dorsalis

Endorotatio

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

US

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Coracohumeral Ligament

Medial Lateral

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Radiograph

US

Radiograph

Decubitus Dorsalis

Endorotatio

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

US

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Coracohumeral Ligament

Medial Lateral

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Radiograph

US

Radiograph

Decubitus Dorsalis

Endorotatio

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

US

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Radiograph

US

Radiograph

Decubitus Dorsalis

Endorotatio

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

US

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Radiograph

US

Radiograph

Decubitus Dorsalis

Endorotatio

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

US

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Radiograph

Decubitus Dorsalis

Endorotatio

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

US

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

US

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Infraspinatus Muscle gt Tendon Insertion

US

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

AC Joint

Neutral

Cross Arm Test

US

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

AC Joint

AC Joint

Clavicular compression

US

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Superior-Posterior Labrum

US

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Superior-Posterior Labrum

US

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Internal Impingement Test

bull Video EndogtExorotatie

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Crass

Infraspinatus T

Infraspin

US

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Crass

Infraspinatus T

Infraspin

US

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Crass

Supraspinatus T

Supraspin

US

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Crass

Infraspinatus T

Transverse IS

US

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Crass

Supraspinatus T

Transverse SS

US

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Crass

Supraspinatus T

Transverse SS

Interval

US

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Neutral

Cuff Interval

Transverse SS

Interval

US

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Exorotation

Sulcus Intertubercularis

Transverse

Biceps CL

US

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Exorotation

Biceps C L

Longitudinal

Biceps CL

US

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

SS Crass Modified Crass

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Modified Crass

SS and Biceps

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Modified Crass

SS

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Modified Crass

Coraco-acromial Ligament

US

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Coraco-acromial Ligament Dynamic Examination

US

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Coracohumeral ligament

Superior glenohumeral lig

Distal superficial part

US

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Exorotation

Coracohumeral ligament

Origin

US

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Coracohumeral Ligament Test

bull Video EndogtExorotatie

US

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Exorotation

Subscapular T

Supscapular

US

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Exorotation

Subscapular T

Supscapular

US

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Pectoralis M T

Teres Major

Latissimus Dorsi

Pect Major

US

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Supraspinatus M

SS

Muscle Mass

US

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Suprascapular Notch

Suprascap

Notch

US

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Suprascapular Notch

Suprascap

Notch

US

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Glenohumeral Capsule Axillary Aproach

US

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Reference Level Axial C6 Root

STCLM

Long Col

Jug I

A Car

C6

Scal Ant

US

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Reference Level Axial C6 Root

US

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Axial Roots C 5-6-7

Scal Ant Scal Med

Scal Post

STCLM

US

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Roots Coronal-Oblique C6

US

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Roots Coronal-Oblique C7

US

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Roots Coronal-Oblique C5

US

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Roots Coronal-Oblique C4

US

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Ultrasound

bull Scanning procedure

bull Minimal still image requirements

bull Annotations lateralisation

ndash AC joint longitudinal with cross arm test

ndash RC components longitudinal with thickness

bull SS SSC IS

ndash Subdeltoid space thickness

ndash RC interval

ndash Biceps long head longitudinal

ndash Pathology

US

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Ultrasound Abduction Endorot AC gt IS gt SS

US

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Ultrasound Abduction Endorot Transverse

US

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Ultrasound Neutral Position Interval - Biceps

US

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Ultrasound Neutral Position Biceps tendon

US

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Ultrasound Neutral Position

US

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Ultrasound Exorotation Subscapularis

US

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Index

bull Normal Anatomy

bull Examination Procedure

bull Pathology

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Pathology

bull Minor Glenohumeral Instability

bull Cuff Lesions

bull AC Joint

bull Biceps Caput Longum

bull Impingement

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Minor Glenohumeral Instability

bull Purpose Detection and Grading of

ndash Causes of minor shoulder instability

bull Anatomical variants

bull Congenital disorders

bull Lesions

ndash Lesions due to (minor) shoulder instability

bull Techniques

ndash Radiography

ndash Ultrasound

ndash CT-arthrography

ndash MRI direct and indirect arthro-MRI

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Minor Shoulder Instability

bull Static Constraints

bull Dynamic Constraints

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Subacromial Bursitis

Normal

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

WH deg620609 ed 110701

RA Biceps Tendon Sheat Subdeltoid Bursa

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Rotator Cuff Components

bull Supraspinatus

bull Infraspinatus

bull Teres minor

bull Subscapularis

ndash tendinous insertions merge with glenohumeral

joint capsule and ligaments

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Rotator Cuff Lesions

bull Histologic abnormalities 50 age gt 40y

ndash glycosaminoglycan infiltration

ndash fibrocartilaginous transformation

ndash loss of collagen fiber organisation

ndash degenerative changes

bull Inflammatory infiltrates not predominant

bull Clinical and functional relevance

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Cuff Ultrastructure

bull Layer 1 corocohumeral ligament superficial fibres

bull Layer 2 thick main cuff portion parallel bundles

bull Layer 3 thick cuff portion smaller bundles with

less uniform orieumlntation

bull Layer 4 rotator cable or transverse band force

distribution through perpendicular bundle

orientation deep fibres of coracohumeral

ligament

bull Layer 5 capsule random fibre orientation

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Rotator Cable (C) and Crescent (B)

Cable transverse force distribution

Articular side tears at cable greater functional impact

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Rotator Cuff Injury Etiology

bull Intrinsic mechanism

ndash Direct tendon overload

ndash Intrinsic degeneration

ndash Location intratendinous critical area

bull Extrinsic mechanism

ndash Compression against surrounding structures impingement

ndash Subacromial impingement bull Painfull arc 60 ndash 120deg humeral elevation

bull Location tendon insertion

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Rotator Cuff Lesions

bull Tendinopathy-tendinosis ndash Calcific tendinosis

bull Partial thickness tear (PTT)

bull Full thickness tear (FTT) and complete tear (CT)

bull Interval tears

bull Subscapularis and pectoralis major tear

bull Postoperative repair

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Calcifying tendinosis

Tendinosis - swelling SA-SD bursitis

Normal

US

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Rotator Cuff Calcifications

Reflective tendon bundle stony lane

US

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Calcifying Tendinopathy

1 Silent phase

2 Mechanical phase

1 elevation of bursal

floor

2 subbursal rupture

3 intrabursal rupture

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

SS Calcification

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

SS Calcification Bursal Extrusion MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

VDEO deg500507 ed 110310

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

VDEO deg500507 ed 110310

Calciumextrusion bursa Calcium milk at SS

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Subscapular Calcification

Anterior Impingement

US

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Male WW deg640416 ed 110218

Acute Shoulder Pain Started 4 Days Ago

bull Calcium extrusion to subbursal floor at anterior

portion of subdeltoid bursa

US

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Male BM deg580608 ed110318 US

Calcium Milk at SADB

Rotator Interval widened Tear SSC and SS

US

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Pectoralis Major Tendon Calcification

Courtesy of L Carpentier

US

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

SS Tendinosis

bull Hypoechogenic

bull Swollen

bull Loss of normal fibrillar pattern

US

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Cuff Tears

bull Partial Thicknesstears (PTT)

ndash Bursal

ndash Articular

bull Fraying rimrent

ndash Intrasubstantial

bull Full thicknesstears (FTT)

ndash Partial width

ndash Complete full width

bull retraction fatty atrophy

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Supraspinatus Tear Partial Thickness

Articular Side

Bursal Side

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Supraspinatus Tear Fraying Bursal Side

US

MR

Cor Intermed FS Cor T1 FS Gad Sag T1 Gad

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Supraspinatus Tear Insertion Area Partial Thickness Bursal Side

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Supraspinatus Tear Partial Thickness Bursal Side

US

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Supraspinatus Tear Intrasubstantial delamination

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

DGA deg460315 US MRI

Insertion Tendinosis with Delamination SS

Cor T1 FS Gad Cor Intermed FS

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Supraspinatus Tear Small Full Thickness

Ultrasound

Arthrography Arthro-CT

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Indirect Arthro Small Full Thickness SS Tear

US

MR

Cor Intermed FS Cor T1

FS Gad

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Female LC deg550426

SS Full Thickness Tear Critical Area

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Supraspinatus

Full Thickness and Full Width Complete

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Direct Arthro-MRI

Supraspinatus Tear

Full Thickness Tendon Insertion

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Female A-CH deg480701 MR US

Total Thickness Tear SS

US

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

End Stage

Naked Tub Maius

Effusion AC-joint

Effusion Subdelt

Caput Longum Bic

Supraspinatus tear

US

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Grading RC Tears

bull FT Dimensions Anteroposterior and lateral

bull CT Goutallier

ndash Position of retracted SS tendon relative to the

acromion

bull Grade 1 lateral to the acromion

bull Grade 2 subacromial

bull Grade 3 medial to the acromion

MR

US

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Grading Supraspinatus Muscle Atrophy MRI and CT

bull Complete or Massive Supraspinatus Tear

bull Goutallier classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than muscle

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration

ndash Goutallier classification

ndash 2 = fat less extensive

than muscle

bull Muscle volume

ndash Zanetti Tangent Sign

ndash + muscle below

tangent line

Clin Orthop Relat Res 1994 Jul(304)78-83

Fatty muscle degeneration in cuff ruptures Pre- and

postoperative evaluation by CT scan

Goutallier D Postel JM Bernageau J Lavau L Voisin MC

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Supraspinatus Muscle Atrophy US grading

bull Structure

ndash 0 = clearly visible muscle contours fibers and central tendon

ndash 1 = partially visible structures

ndash 2 = structures no longer visible

bull Echogenicity in comparison to deltoid muscle

ndash 0 = iso- or hypoechoic

ndash 1 = slightly more echoic

ndash 2 = markedly more echoic

bull Substantial fatty atrophy = grade 2 in at least one

of the evaluated US criteria

Strobel et al Fatty atrophy of the supraspinatus accuracy of US Radiology 2005

US

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Muscle volume

bull Zanetti Tangent Sign

ndash + muscle below

tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR

Supraspinatus M

SS

Muscle Mass

US

bull Fatty infiltration Goutallier

classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than

muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than

muscle

bull Muscle volume Zanetti Tangent

Sign

ndash + muscle below tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

bull Fatty infiltration Goutallier

classification

ndash 0 = no intramuscular fat

ndash 1 = some fatty streaks

ndash 2 = fat less extensive than

muscle

ndash 3 = fat equal to muscle

ndash 4 = fat more extensive than

muscle

bull Muscle volume Zanetti Tangent

Sign

ndash + muscle below tangent line

Invest Radiol 1998 Mar33(3)163-70

Quantitative assessment of the muscles of the rotator cuff with

magnetic resonance imaging

Zanetti M Gerber C Hodler J

US

MR Massive Supraspinatus Tear

Supraspinatus Muscle Evaluation CT and

MRI

SS-IS CT grade 3

Grade 3 Fat Infiltration

Positive Zanetti Tangent Sign

US

MR

DSE deg520518 ed 100225 Postop SS

Massive Tear Deltoid Tear

Sag T1 Cor T2 FS

US

MR

DSE deg520518 ed 100225 Postop SS

Massive Tear Deltoid Tear

US

MR

Indirect Arthro

Postop SS Reinsertion

US

MR

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

Accuracy

Sens Spec Acc PPV Correlation (r) Tear

Measurement

Plain MRI

FTT 85 83 83 99

Plain MRI

PTT 83 85 39

Plain MRI

FTTgt 1cm 96 83 83

Arthrography

All lesions 96 75 89 090 (046 retear)

US

Tear 91 86 89

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC Coracohumeral

Transverse Lig

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

DSE deg520518 ed 100225 Postop SS

Massive Tear Deltoid Tear

Sag T1 Cor T2 FS

US

MR

DSE deg520518 ed 100225 Postop SS

Massive Tear Deltoid Tear

US

MR

Indirect Arthro

Postop SS Reinsertion

US

MR

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

Accuracy

Sens Spec Acc PPV Correlation (r) Tear

Measurement

Plain MRI

FTT 85 83 83 99

Plain MRI

PTT 83 85 39

Plain MRI

FTTgt 1cm 96 83 83

Arthrography

All lesions 96 75 89 090 (046 retear)

US

Tear 91 86 89

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC Coracohumeral

Transverse Lig

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

DSE deg520518 ed 100225 Postop SS

Massive Tear Deltoid Tear

US

MR

Indirect Arthro

Postop SS Reinsertion

US

MR

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

Accuracy

Sens Spec Acc PPV Correlation (r) Tear

Measurement

Plain MRI

FTT 85 83 83 99

Plain MRI

PTT 83 85 39

Plain MRI

FTTgt 1cm 96 83 83

Arthrography

All lesions 96 75 89 090 (046 retear)

US

Tear 91 86 89

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC Coracohumeral

Transverse Lig

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Indirect Arthro

Postop SS Reinsertion

US

MR

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

Accuracy

Sens Spec Acc PPV Correlation (r) Tear

Measurement

Plain MRI

FTT 85 83 83 99

Plain MRI

PTT 83 85 39

Plain MRI

FTTgt 1cm 96 83 83

Arthrography

All lesions 96 75 89 090 (046 retear)

US

Tear 91 86 89

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC Coracohumeral

Transverse Lig

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

Accuracy

Sens Spec Acc PPV Correlation (r) Tear

Measurement

Plain MRI

FTT 85 83 83 99

Plain MRI

PTT 83 85 39

Plain MRI

FTTgt 1cm 96 83 83

Arthrography

All lesions 96 75 89 090 (046 retear)

US

Tear 91 86 89

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC Coracohumeral

Transverse Lig

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

FJ deg510611 ed 100526

Massive Tear SS without atrophy and IS with atrophy

US

Accuracy

Sens Spec Acc PPV Correlation (r) Tear

Measurement

Plain MRI

FTT 85 83 83 99

Plain MRI

PTT 83 85 39

Plain MRI

FTTgt 1cm 96 83 83

Arthrography

All lesions 96 75 89 090 (046 retear)

US

Tear 91 86 89

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC Coracohumeral

Transverse Lig

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Accuracy

Sens Spec Acc PPV Correlation (r) Tear

Measurement

Plain MRI

FTT 85 83 83 99

Plain MRI

PTT 83 85 39

Plain MRI

FTTgt 1cm 96 83 83

Arthrography

All lesions 96 75 89 090 (046 retear)

US

Tear 91 86 89

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC Coracohumeral

Transverse Lig

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC Coracohumeral

Transverse Lig

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC Coracohumeral

Transverse Lig

US

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull (Supporting musculature)

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Biceps Tendon (Sub)luxation

CT ndashArthrography

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Subluxation Biceps Tendon

US

Axial T1 FS Gad

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Biceps Dislocation

Deep to SSC Sup to Teres Major

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

DDI deg651002 ed1 30314

SS Complete Tear Biceps CL superficial to SSC

Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Dynamic Constraints

bull Rotator cuff

ndash Through Joint Compression

ndash Individual components of rotator cuff

ndash Rotator cuff through preloading glenohumeral ligaments

bull Long head of biceps tendon

bull Supporting musculature

bull (Proprioception and reflexes)

bull (Scapulothoracic motion)

US

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Tear Teres Major ndash Lattisimus Dorsi

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Dysplasia malformations

Discongruent GH Joint

Normal joint

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

AC Dislocation

US

Type II

Type III

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Female DRE deg940929

Traction Epiphysiolysis R Proximal Humeral

Epiphysis

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

DJH deg550301 ed 120715

Retractile Capsulitis SLAP VIII

Cor T1 FS Gad Cor T1 FS Gad Ax T1 FS Gad

Sag T1 FS Gad Cor Intermed FS Cor Intermed FS

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

VDVL deg621208 ed100422

US Retractile Capsulitis

Axillary Examination Endorotation deficit

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

EMF deg710314

Retractile Capsulitis Glenohumeral Distension USrdquoArdquo

US

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Static Constraints

bull Bony structures

ndash Humeral and glenoid version

ndash Surface area and articular conformity

ndash Coracoacromial arch

ndash (Acromioclavicular joint)

bull Soft tissues

ndash Glenohumeral ligaments and capsule

ndash Glenoid labrum

ndash Subacromial bursa

bull (Intraarticular pressure)

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Coracoacromial Arch

bull Acromion

bull Coracoacromial ligament

bull Coracoid process

Roof above supraspinatus tendon outlet

through which tendon must pass

US

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Subacromial Space

Coracoacromial arch area

Indirect MR-arthrography

SE T1 WI

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Impingement

bull Subacromial

bull Subcoracoidal - anterior

bull Anterocranial

bull Internal

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Impingement Classification

bull Primary (external) impingement

ndash anatomy static

bull Subacromial impingement

bull Anterior - Subcoracoid impingement

bull Secondary (internal) impingement

ndash biomechanics dynamic

bull Internal or Posterior superior impingement (Walsh)

bull Anterior superior impingement (Gerber)

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Impingement

bull Subacromial (classical)

ndash Elevation abduction

bull Acromion lt-

gtTuberculum major

bull SA-SD bursa

bull Supraspinatus

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Contusion Mechanical Osteitis

Indirect MR-A

SE T1 FS

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Erosions

Sclerosis

OA AC Calcifications

Radiography Impingement

US

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Subacromial Spur

Post Acromioplasty

US

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Acromion Bigliani Types

1

flat

Plain radiograpy Scapular Y-view

2

curved 3

hooked

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Acromion Type 4

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Type 3 increased likelihood

of being associated with

full-thickness cuff tear

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Os Acromiale

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Subacromial Spur

Direct MR-arthrography

RefMagnetic Resonance Imaging in

Orthopaedics and Sports medicine

David W Stoller 2nd ed

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Coracoacromial Ligament Thickening - Inflammation

TSE T2 FS

SE T1 FS Gad SE T1 FS Gad

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Acromioclavicular Joint OA

Impingement SS lesion

Indirect

arthro-MR

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Impingement

bull Subcoracoid anterior

ndash Endorotation

bull Coracoid process lt-gt

Tub minor

bull Subscapularis tendon

bull Interval coracohumeral

ligament Biceps tendon

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Subcoracoidal Space

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

SSC FT Tear

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Indirect Arthro SS full thickness tear

Subcoracoidal impingement

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Indirect Arthro SS full thickness tear

Anterior impingement (2)

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation

US

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

BH deg361218 Fall on Shoulder

Complete SS tear Biceps CL Dislocation SSC tear

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

BE deg350123 ed20100527 US

Geiser Phenomenon Complete SS and IS

Tear Biceps Disclocation deep to the SSC

US

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

MH deg480129 US

Biceps CL Dislocation

US

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

deg441001 US

Longitudinal split CL Biceps tenovaginitis

US

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

deg441001 US

CL Biceps Subluxation with Longitudinal Split

and Tenovaginitis

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

AK deg730403 US CR

Hypertrophic Ossification SSC with

Subcoracoidal Impingement

US

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Impingement

bull Anterosuperior

Impingement

ndash Follow through phase

ndash RC interval

bull Cranial glenohumeral

ligament

bull Coracohumeral

ligament

ndash Biceps CL tendon

ndash Subscapularis tendon

bull Cranial portion

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

6 Follow through endorotation

anterior

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Secondary anterosuperior impingement

bull Mechanisms

bull Pathology on imaging

ndash Subscapularis tears

ndash Anterosuperior labrum tear

ndash CL pulley lesions

ndash Degenerative changes anterior glenoid

humerus

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

deg641216 ed 120308

Anterosuperior Impingement Normal Cuff Biceps Pulley Thickening

No Capsulitis

US

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Coracohumeral Ligament

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Anterosuperior Impingement

Type II acromion

Subacromial spur formation

Inflammation

ndashAnterior peribursal rotator cuff interval coracohumeral ligament

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Rotator Cuff Interval

SSC

SS

Max 10 mm Transverse SS

Interval

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Interval Lesions Supraspinatus Full Thickness Tear Tickening Biceps CL

BIC

Coracohumeral

Cranial GH Lig

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Bicepstendon (sub)luxation

Arthro-CT

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Subluxation Biceps Tendon

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Impingement

bull Internal posterior glenoid

ndash ABduction ExoRotation

bull Glenoid lt-gt Tub Majus

post

bull Undersurface SS post IS

ant

bull Labrum

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Secondary posterosuperior impingement

bull Anatomic landmarks

ndash Posterosuperior humerus

ndash Posterosuperior glenoid

bull Target

ndash Infraspinatus posterior supraspinatus

bull Clinical findings

ndash Late-cocking position (abduction-exorotation)

ndash Instability relatedoverhead sporters le 35 y

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

3 late cocking phase abductionexorotation

posterior RC

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

HW deg701220 ed 111006

Internal impingement with SLAP II labral

dissociation and SS undersurface tear

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

ST deg880712 ed 110314 Javelin Thrower

Internal impingement

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

VV deg800919 ed 120118 Internal Impingement

Posterior Cranial Labral Lesion

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Indirect Arthro Herniation Pit

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Posterosuperior instability

bull Overhead-throwing sports (dominant shoulder)

ndash Repeated abduction and external rotation

ndash Fibrosis of posterior inferior capsule

ndash Contact posteriorsuperior glenoid marginlabrum and

greater tuberosity

ndash Impingement of SS and IS

bull MRI

ndash Cyst formation greater tuberosity

ndash Tear posterosuperior labrum

ndash Underface tear rotator cuff

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Paralabral Cyst

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

ed 060312 Paralabral Cyst

Transverse Infraspinatus View Longitudinal Infraspinatus View

Infraspinatus Muscle

Paralabral Cyst

Spina Scapulae

US

MR

Courtesy FYZZIO

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

ed 111214 Lipomatous Involution IS

Volleyball Player

Transverse Infraspinatus View Longitudinal Infraspinatus View

Teres Minor Muscle Spina Scapulae

Trapezius Muscle Trapezius Muscle

Humeral head

US

MR

Courtesy FYZZIO

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Infraspinatus Denervation MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Supraspinatus Denervation

Nerve Compression Idiopathic DD Parsonage Turner

TSE T2 WI FS

Parsonage Turner Neuritis Brachial Plexus

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Conclusion

bull Conventional radiography ndash Scapular Y view acromion GH-joint

ndash AC-joint

bull Ultrasound ndash Rotator Cuff AC-joint Subdeltoidal bursa

bull Direct arthro-MRI ndash Labral lesions including SLAP 67 accuracy

ndash Capsule

bull Indirect arthro-MRI ndash Most complete evaluation

ndash Labral lesions 100 accuracy

ndash Excluding capsule

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

Conclusion Cuff Lesions

bull Ultrasound

ndash State of the art

ndash Available economical and accurate

ndash Primary examination

bull MRI gadolinium enhanced

ndash Direct or Non-direct

ndash Inconsistency of clinical and ultrasound findings

ndash Preoperatively

bull Massive tears feasibility of primary repair

bull Additional information muscle and musculotendinous

junction

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

References

bull Takayuki S Teruhiko N Masamitsu T Masafumi I Prediction of primary reparability of massive tears of the rotator cuff on preoperative magnetic resonance imaging Journal of Shoulder and Elbow Surgery 200312222-225

bull Seeger LL Gold RH Bassett LW Ellman HShoulder impingement syndrome MR findings in 53 shoulders American Journal Of Roentgenology 1988150343-347

bull Schroder RJ Bostanjoglo M Kaab M Herzog H Hidajat N Rottgen R Maurer J Felix R

bull Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2003175920-928

bull Nakatani T Fujita K Iwasaki Y Sakai H Kurosaka M MRI-negative rotator cuff tears Magn Reson Imaging 20032141-45

bull Schulte-Altedorneburg G Gebhard M Wohlgemuth WA Fischer W Zentner J Wegener R Balzer T Bohndorf K MR arthrography pharmacology efficacy and safety in clinical trials Skeletal Radiol 2003321-12

bull Motamedi AR Urrea LH Hancock RE Hawkins RJ Ho C Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears J Shoulder Elbow Surg 2002 Jan-Feb11(1)6-10 Related Articles Links

bull Chang CY Wang SF Chiou HJ Ma HL Sun YC Wu HD Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness rotator cuff tears Clin Imaging 20022650-54

bull Yamakawa S Hashizume H Ichikawa N Itadera E Inoue H Comparative studies of MRI and operative findings in rotator cuff tear Acta Med Okayama 200155261-268

bull Oh CH Schweitzer ME Spettell CM Internal derangements of the shoulder decision tree and cost-effectiveness analysis of conventional arthrography conventional MRI and MR arthrography Skeletal Radiol 199928670-678

bull Prickett WD Teefey SA Galatz LM Calfee RP Middleton WD Yamaguchi K Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively J Bone Joint Surg Am 200385-A1084-1089

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR

References

bull Magnetic Resonance Imaging in Orthopaedics and

Sports medicine David W Stoller 2nd ed

bull Internal Derangements of Joints Emphasis on MR

Imaging Donald Resnick and Heung Sik Kang

bull MRI Arthroscopy and Surgical Anatomy of the

Joints David W Stoller

US

MR