shoulder mri for rotator cuff tears

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  • Shoulder MRI for Rotator Shoulder MRI for Rotator Cuff TearsCuff Tears

    ConorConor KlewenoKleweno, Harvard Medical School Year III, Harvard Medical School Year IIIGillian Lieberman, MDGillian Lieberman, MD

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    22

    Goals of PresentationGoals of Presentation

    Shoulder anatomyShoulder anatomyFunction of rotator cuffFunction of rotator cuffMRI approach to diagnose cuff tearMRI approach to diagnose cuff tearAnatomy on MRI imagesAnatomy on MRI imagesVisualize Visualize supraspinatussupraspinatus tear on MRItear on MRI

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    33

    Our PatientOur Patient

    78 78 yoyo man with several months of increasing left man with several months of increasing left shoulder pain especially with moving arm across shoulder pain especially with moving arm across front of bodyfront of bodyPhysical exam suggestive of rotator cuff tearPhysical exam suggestive of rotator cuff tear

    Pain limiting range of motionPain limiting range of motion

    Weakness (especially of external rotation)Weakness (especially of external rotation)Menu of radiology tests availableMenu of radiology tests available

    Plain film of shoulder to evaluate for bony anatomy Plain film of shoulder to evaluate for bony anatomy and joint positioningand joint positioning

    MR MR arthrogramarthrogram (if think (if think labrallabral tear is involved)tear is involved)

    MRIMRI

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    44

    Anatomy of ShoulderAnatomy of Shoulder

    Ball and socket jointBall and socket jointGreat range of motionGreat range of motionFour separate articulationsFour separate articulations

    GlenohumeralGlenohumeral, , acromioclavicularacromioclavicular, , sternoclavicularsternoclavicular, and , and scapulothoracicscapulothoracic

    Focus on Focus on glenohumeralglenohumeral joint joint ball and ball and socket between humeral head and socket between humeral head and glenoidglenoid fossafossa of the scapulaof the scapula

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    55

    Shoulder JointShoulder Joint

    www.jointinjury.com

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    66

    Rotator Cuff Rotator Cuff

    Complex of muscles & tendons that arise from the Complex of muscles & tendons that arise from the scapula, and attach to scapula, and attach to humerushumerusSITS muscles/tendonsSITS muscles/tendons

    SSupraspinatusupraspinatus

    IInfraspinatusnfraspinatus

    TTereseres minorminor

    SSubscapularisubscapularisAll these tendons blend with the fibrous capsule to form All these tendons blend with the fibrous capsule to form the the musculotendinousmusculotendinous cuff + cuff + glenohumeralglenohumeral ligamentsligamentsFunctions as the Functions as the dynamicdynamic stabilizer of the jointstabilizer of the jointReinforces joint capsule (superiorly, Reinforces joint capsule (superiorly, anteriorlyanteriorly, , posteriorlyposteriorly))

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    77

    Rotator CuffRotator Cuff

    http://www.nlm.nih.gov/medlineplus http://www.yess.uk.com

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    88

    SagittalSagittal View DiagramView Diagram

    Picture: www.bodybuilding.com

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    99

    SupraspinatusSupraspinatus

    Most often injuredMost often injuredPrimary function is abduct the Primary function is abduct the humerushumerus (but (but also has a role in humeral rotation)also has a role in humeral rotation)Depresses humeral head to counteract the Depresses humeral head to counteract the uplifting force of the deltoid muscle uplifting force of the deltoid muscle Most superior muscle/tendon Most superior muscle/tendon extends over extends over the top of humeral head and inserts on the top of humeral head and inserts on greater greater tuberositytuberosity superiorly superiorly

    Picture: www.abcbodybuilding.com

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    1010

    InfraspinatusInfraspinatus

    Main function is external rotation of Main function is external rotation of humerushumerusAlso functions to depress humeral head and Also functions to depress humeral head and static stabilizer of static stabilizer of glenohumeralglenohumeral jointjointInserts on greater Inserts on greater tuberositytuberosity (inferior and (inferior and posterior to posterior to supraspinatussupraspinatus tendon)tendon)

    Picture: www.abcbodybuilding.com

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    1111

    TeresTeres MinorMinor

    Least commonly injuredLeast commonly injuredPowerful external rotation of Powerful external rotation of humerushumerusPosteroinferiorPosteroinferior to the to the infraspinatusinfraspinatusAlso helps prevent Also helps prevent subluxationsubluxation of humeral headof humeral headInserts inferiorly on greater Inserts inferiorly on greater tuberositytuberosity

    Picture: www.abcbodybuilding.com

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    1212

    SubscapularisSubscapularis

    Largest and most powerful of SITSLargest and most powerful of SITSMain function is internal rotation (also functions to Main function is internal rotation (also functions to adduct, depress adduct, depress humerushumerus))Also reinforces anterior joint capsule and becomes Also reinforces anterior joint capsule and becomes continuous with itcontinuous with itTendon fibers merge with transverse humeral ligament Tendon fibers merge with transverse humeral ligament and fuse with fibers from and fuse with fibers from supraspinatussupraspinatus into sheath that into sheath that encompasses the biceps tendon encompasses the biceps tendon Insertion from anterior scapula to superior aspect of Insertion from anterior scapula to superior aspect of lesser lesser tuberositytuberosity (anterior (anterior humerushumerus))

    Picture: www.abcbodybuilding.com

    Also sends fibers over bicipital groove

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    1313

    Biceps Tendon (long head)Biceps Tendon (long head)Not part of SITS but Not part of SITS but important for shoulder important for shoulder movementmovementStabilizes humeral head Stabilizes humeral head in in glenoidglenoid during during abduction of shoulderabduction of shoulderProximal insertion is Proximal insertion is superior superior glenoidglenoid and and posterosuperiorposterosuperior glenoidglenoid labrum then traverses labrum then traverses across across superomedialsuperomedial aspect of humeral head aspect of humeral head and enters and enters bicipitalbicipital groovegroove

    Picture: www.orthogastonia.com

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    1414

    Rotator Cuff TearsRotator Cuff Tears

    Occurs from: Occurs from:

    End result of chronic End result of chronic subacromialsubacromial impingementimpingement

    Progressive tendon degeneration from traumatic Progressive tendon degeneration from traumatic injuryinjury

    Or a combination of these factorsOr a combination of these factorsInciting injury is often a fall onto an outstretched Inciting injury is often a fall onto an outstretched arm, direct blow to the shoulder, or a rapid arm, direct blow to the shoulder, or a rapid accelerating incident (accelerating incident (egeg, pulling on a starter , pulling on a starter cable) cable) Patients with a history of recurrent rotator cuff Patients with a history of recurrent rotator cuff tendonitis are at increased risk for a tear tendonitis are at increased risk for a tear SupraspinatusSupraspinatus most commonly tornmost commonly torn

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    1515

    MRI MRI Standard ViewsStandard Views

    AxialAxial

    Extending from level of Extending from level of acromionacromion through the through the glenoidglenoid

    Oblique coronalOblique coronal

    Obtained parallel to the scapula and Obtained parallel to the scapula and supraspinatussupraspinatus and extending through and extending through subscapularissubscapularis tendon tendon anteriorlyanteriorly and and infraspinatusinfraspinatus tendon tendon posteriorlyposteriorly

    Oblique Oblique sagittalsagittal

    Level of scapula neck through lateral border of Level of scapula neck through lateral border of greater greater tuberositytuberosity (perpendicular to coronal plane)(perpendicular to coronal plane)

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    1616

    Scout Image & Coil Scout Image & Coil

    MRI shoulder coil to obtain scout image (MRI of the Shoulder, 2003)

    Scout images obtained in coronal plane to serve as localizer for subsequent pulse sequencesCoil improves spatial resolution via higher signal:noise

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    1717

    NL MRI NL MRI Coronal ObliqueCoronal ObliqueSupraspinatus M

    Subscap M

    Deltoid M

    Superior

    Medial

    T1 image, PACS, BIDMC

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    1818

    Normal MRI Normal MRI -- SagittalSagittal

    Subscap T

    Supraspin T, M

    Deltoid

    Infraspin T, M

    Anterior

    Teres minor T,M

    T1, fat saturation, PACS, BIDMC

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    1919

    MRI AnatomyMRI Anatomy

    T2* coronal oblique image. (Musculoskeletal MRI, 2001) Biceps tendon (white arrow head). T2* axial. (Musculoskeletal MRI, 2001)

    Normal infraspinatus T Normal subscap T

    Biceps T

  • Conor Kleweno, HMS IIIGillian Lieberman, MD

    2020

    MRI of FullMRI of Full--Thickness TearsThickness Tears

    Defec

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