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MRI  of  the  shoulder  The  rotator  cuff  

Roar  Pedersen  

Gøteborg,  april  2015  

Topics  

•  Anatomy  of  the  cuff  

•  What  is  impingement?  

•  Tendinosis,  partial  rupture,  total  rupture  

•  Calcific  tendinopathy  •  A  few  words  about  the  biceps  tendon  

•  Pitfalls  

•  How  to  report  

Anatomy  

•  Tendons  of  the  rotatorcuff  

•  Footprint  

•  Rotator  cable  

•  Biceps  tendon  

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Impingement  

•  Extrinsic  causes  

•  Intrinsic  factors  

– Tendon  degeneration,  hypovascular  critical  zone.  

•  Subcoracoid  impingement  

Extrinsic  causes  

•  Progressive  process  caused  by  extrinsic  factors  (such  as  acromial  shape  and  slope,  subacromial  entesophyte,  spur  

at  insertion  of  coracohumeral  ligament)  (Neer):  

–  Bursitis  with  subacromial  edema  and  hemorrhage  

–  Tendinosis  of  rotatorcuff  

–  Stress  on  fibers  in  rotator  cuff;    •  Partial  thickness  tear    

•  Progress  to  full  thickness  tear  

Clinical  diagnosis  of  impingement  

•  Pain  over  deltoid  made  worse  by  resisted  

abduction  

•  Neer  and  Hawkins  test,  and  others  

•  Overall  accuracy  for  diagnosis  of  FTT  of  STT  

– Neer:  51.8  %  

– Hawkins:  56.1  %  

Imaging  of  impingement  •  Etiology  or  results  of  impingement:  

– Osteoarthritis  ACJ:  inferior  osteophyte,  acromial  

entesophyte.  

– Coracoacromial  ligament:  spur  formation,  thickening  

– Acromial  morphology:  2  sections  away  from  joint  

–  Subacromial  bursitis  

–  Tendon  pathology:  tendinosis,  tears,  calcification  

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Tendinosis  

•  Most  important  finding:  Thickened  tendon  

with  high  signal!  

•  Do  not  overcall  tendinosis  

•  Can  be  a  result  of  wear/tear,  impingement  

•  Important  to  rule  out  partial  or  total  RC  tear  

Tendinosis  

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Tendinosis  /  tendinopathy  

•  Usually  supraspinatus,  less  often  infraspinatus  or  subscapularis  

•  +/-­‐  subdeltoid  bursitis  

•  High  signal  T2/PD,  but  not  as  high  as  fluid  

•  Pitfalls:  Magic  angle,    partial  tear  Magic  angle  

Tendinosis  

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Rupture  of  the  RC  –  some  facts  

•  SS  is  most  often  affected,  in  the  middle  and  posterior  part  of  the  

tendon  

•  Rupture  of  SS  in  the  anterior  part  more  often  lead  to  muscular  atrophy  

•  It  may  be  difficult  to  decide  if  the  rupture  is  in  IS  or  SS,  or  both  at  the  

transitional  zone    

•  Rupture  of  SSc  is  probably  underdiagnosed  (1/3  of  RC  ruptures).  

Rupture  of  middle  and  lower  parts  may  be  difficult  to  see  by  

arthroscopy.  

•  Discrepancy  between  clinical  symptoms  and  findings!  Large  ruptures  

may  be  asymptomatic.  Bursitis  may  elicit  symptoms.    

Partial  rupture  

•  Articular  side  2-­‐3x  >>  bursal  side  –  Prognosis  worse  with  larger  tears  and  atraumatic  presentation  

–  Rim  rent/PASTA/PAINT  

•  Intratendinous  partial  tear  is  common!  

–  Delamination  of  fibers,  may  lead  to  articular  sided  tears  

–  May  develop  synovial  lining,  inhibits  healing  

•  Bursal  tears  often  associated  with  impingement,  are  more  

often  symptomatic,  often  at  bone-­‐tendon  interface  

Par-al,  ar-cular  sided  rupture  of  supraspinatus  

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Par-al  bursal  sided  rupture  of  supraspinatus  

Bursal  sided  tear…  or    full  thickness  tear?   Look  for:  

•  The  footprint!  

•  The  tendon  signal!  

•  Fluid  signal!  

•  Cystic  collections!  

•  The  surface!  

•  Cysts  of  the    anterior  tuberculum  majus!  

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RIM  RENT  

Full  thickness  rupture  

•  Easier  to  identify  

– Focal  area  of  discontinuity,  from  joint  to  bursa  

– Small  (<1cm),  medium  (3-­‐5),  massive  (>5)  

– Large  tears  extend  into  IS  or  SSc,  may  see  

degeneration  of  long  head  of  biceps  

•  Sensitivity  of  MRI:  84-­‐96%  

Total  rupture  of  Supraspinatus  

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Remember!  

•  Parts  of  the  tendon  may  be  intact!  

•  Describe  retraction,  atrophy  of  the  

muscle,  tendinosis!  

Subscapularis  

•  Subcoracoid  impingement  –  does  it  exist?  

•  Isolated  rupture  is  rare  

•  Usually  tears  are  superior  and  lateral,  articular  

sided  

Subscapular  rupture  a@er  trauma  

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Isolated  total  ruptur  of  subscapular  tendon  –  hanging  from  arm  

after  trauma  

Total  rupture  subscapular  tendon  

Total  subscapular  rupture,  medial  luxation  of  biceps  

Calcific  tendinopathy  

•  Calcification  of  the  tendon  and  soft  tissue  may  be  

difficult  to  identify  on  MRI  

•  May  be  asymptomatic  

•  May  contribute  to  impingement  

•  Usually  SS,  but  may  occur  in  all  tendons  

•  Inflammation,  erosion,  cysts  in  caput  may  be  severe  

and  confusing  

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Calcific  tendinopathy-­‐  severe  calcifica-on  

Unusual  location  

Calcific  tendinopathy  

Calcific  tendinopathy  with  severe  inflammation  

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A  few  words  about  biceps  

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Pitfalls  for  the  more  advanced  

•  Scar  or  granulation  tissue  

•  The  rotator  cable  

 

Scar  tissue  

•  Some  tears  are  relatively  low  signal  on  T2  

•  This  makes  MR  interpretation  difficult  

•  Other  signs  may  give  the  diagnosis:  change  in  signal  or  

contour,  retraction  of  fibers,  fatty  atrophy  

•  Scar  tissue  may  be  impenetrable  for  fluid/contrast,  

and  may  even  appear  as  normal  tendon  at  arthroscopy  

1. Photo  courtesy  of  Thomas  Dovan,  MD.  Elite  Orthopaedics  and  Sports  Medicine,  Nashville,  TN.    By  permission  from  RadSource.  

Scar  tissue  Rotator  cable  

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Rotator  cable  •  Report:  –  Impingement:    

•  AC-­‐joint,  entesophytes,  osteophytes,  os  acromiale,  

calcification,  acromion,  bursa.      

– Partial  tear:    •  articular,  bursal,  intraarticular,  size  of  the  tear,  footprint.  

–  Full  thickness  tear:    •  the  entire  tendon?,  measure  retraction,  tendinosis,  atrophy.  

Summary  

•  Anatomy  

•  Impingement  

•  Tendinopathy  

•  Partial  tear  

•  Full  thickness  tear  

•  Subscapularis  

•  Calcific  tendinopathy  

•  Pitfalls  –  scar  tissue,  rotator  cable  

•  Reporting