shoulder mri for rotator cuff tears

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

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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


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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


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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


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Shoulder JointShoulder Joint

www.jointinjury.com


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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))


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Rotator CuffRotator Cuff

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


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SagittalSagittal View DiagramView Diagram

Picture: www.bodybuilding.com


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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


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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)



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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



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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))


Also sends fibers over bicipital groove


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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


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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


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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)


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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 sequences•Coil improves spatial resolution via higher signal:noise


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NL MRI NL MRI –– Coronal ObliqueCoronal ObliqueSupraspinatus M

Subscap M

Deltoid M

Superior

Medial

T1 image, PACS, BIDMC


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Normal MRI Normal MRI -- SagittalSagittal

Subscap T

Supraspin T, M

Deltoid

Infraspin T, M

Anterior

Teres minor T,M

T1, fat saturation, PACS, BIDMC


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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


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MRI of FullMRI of Full--Thickness TearsThickness Tears

Defects are filled with fluid, granulation Defects are filled with fluid, granulation tissue, or tissue, or synoviumsynoviumThus, defects have fluidThus, defects have fluid--like signal on MRlike signal on MRMight also see tendon retractionMight also see tendon retractionThe spine of the scapula separates the The spine of the scapula separates the supra and supra and infraspinatusinfraspinatus on axial imageson axial images


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Rotator Cuff TearRotator Cuff Tear

http://www.emedx.com

Normal Supraspinatus tear


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Complete Complete SupraspinatusSupraspinatus TearTear

Complete supraspinatus tear. T1 coronal oblique image. Torn end of supraspinatus tendon (white arrow) and medial retraction of the musculotendinous junction (between black arrows). (Musculoskeletal MRI, 2001)


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Partial TearsPartial Tears

Classification of partial tears. A. Articular surface partial. B. bursal surface partial. C. Intrasubstance partial (Figure: MRI of Shoulder, 2003)


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Partial Partial SupraspinatusSupraspinatus TearTear

T1 coronal obliqe image. Partial tear: linear intermediate signal (arrow) between distal supraspinatus tendon and greater tuberosity. (Musculoskeletal MRI, 2001).


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FullFull--thickness, partial width tearthickness, partial width tear

T2, coronal sagittal. PACS, BIDMC


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ImpingementImpingement

Clinically Clinically –– Pain with abduction + external Pain with abduction + external rotation or elevation with internal rotationrotation or elevation with internal rotationCoracoacromialCoracoacromial archarch

Humeral head Humeral head posteriorlyposteriorly

AcromionAcromion superiorlysuperiorly

CoracoidCoracoid process + process + coracoacromialcoracoacromial ligament ligament anteriorlyanteriorly

Conditions that limit space within this arch can Conditions that limit space within this arch can lead to impingement and eventual tears in lead to impingement and eventual tears in supraspinatussupraspinatus tendontendon


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CoracoacromialCoracoacromial ArchArch

www.orthoontheweb.com


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AcromionAcromion ShapesShapes

Sagittal perspective of different acromial shapes. Black circle represents supraspinatus tendon on anterior shoulder. Types III and IV have higher incidence of impingement. (Musculoskeletal MRI 2001, and Bigliani 1991)


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AcromionAcromion OrientationOrientation

Orientation can predispose to impingement and tear. Especially “low-lying” and “Inferolateral.” (Musculoskeletal MRI, 2001)


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MRI of MRI of InferolateralInferolateral AcromionAcromion

T1 coronal image. Acromion (A) tilts inferiorly relative to the horizontal clavical (C). This narrows the space between humeral head and acromion where the supraspinatus tendon and the subacromial/ subdeltoid bursa exist, increasing risk for impingement and tear. (Musculoskeletal MRI, 2001)


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Back to Back to our our

patientpatientComplete supraspinatus tear on T2 image (red arrow). Superior translation of HH. Atrophy of supraspin. Acromion is Type II. (T2, PACS BIDMC)


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Back Back to our to our patientpatient•Torn and retracted subscap T,M. (red arrow)•Displaced biceps T •Axial T2 •PACS, BID


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TreatmentTreatment

NonNon--operative operative –– with most partial tears, or with most partial tears, or if surgery is contraindicatedif surgery is contraindicated

Acute: ice and NSAIDSAcute: ice and NSAIDS

Physical rehabilitationPhysical rehabilitation

Restrict overhead reaching and liftingRestrict overhead reaching and lifting

LidocaineLidocaine/steroid injection/steroid injection


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TreatmentTreatment

Operative ManagementOperative Management

Indicated in young patients with severe tearsIndicated in young patients with severe tears

Delay longer than 6 wks can lead to atrophyDelay longer than 6 wks can lead to atrophy

Young pts who fail nonYoung pts who fail non--op managementop managementOpen repair vs. arthroscopic repairOpen repair vs. arthroscopic repair

Depending on pathologyDepending on pathology


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ReferencesReferences

Magnetic Resonance Imaging in Magnetic Resonance Imaging in OrthopaedicsOrthopaedics and Sports Medicine. and Sports Medicine. StollerStoller DW Ed. 2DW Ed. 2ndnd edition. edition. LippincottLippincott--Raven Publishers. 1997 Raven Publishers. 1997 MRI of the Shoulder. MRI of the Shoulder. ZlatkinZlatkin MB. Editor. 2MB. Editor. 2ndnd

edition. Lippincott Williams and Wilkins. 2003edition. Lippincott Williams and Wilkins. 2003Musculoskeletal MRI. Kaplan et al. W.B. Musculoskeletal MRI. Kaplan et al. W.B. Saunders Company. 2001Saunders Company. 2001BiglianiBigliani et al. The relationship of et al. The relationship of acromialacromial architecture to rotator cuff disease. architecture to rotator cuff disease. ClinClin Sports Sports Med. 1991 Oct;10(4):823Med. 1991 Oct;10(4):823--38. Review. 38. Review.


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AcknowledgementsAcknowledgements

Gillian Lieberman, MDGillian Lieberman, MDPamela Pamela LepkowskiLepkowskiPerry Perry HorwichHorwich, MD, MDLarry Larry BarbarasBarbaras our Webmasterour Webmaster

shoulder mri for rotator cuff tears

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