Download A Compendium of Rotator Cuff Imaging

Gregory Cvetanovich, MS3
Gillian Lieberman, MD
May 2011
A Compendium of
Rotator Cuff Imaging
Gregory Cvetanovich, Harvard Medical School Yr 3
Gillian Lieberman, MD
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Overview
• Patient presentation
• Rotator cuff
– Anatomy
– Function
– Pathology
• Menu of radiologic tests
• Normal rotator cuff anatomy on MRI
• MRI examples of rotator cuff tears
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Patient Presentation
• 53 year-old woman presents to rheumatology clinic for routine
follow-up six months after diagnosis of likely seronegative
rheumatoid arthritis
– Since beginning treatment with MTX, her bilateral joint pain and
stiffness resolved with the exception of right shoulder pain
– She has experienced right shoulder pain intermittently for a number of
years, worsening with overhead activity and improving with rest and
NSAIDs
– In recent months, the right shoulder pain has worsened and become more
frequent, sometimes awakening her at night.
• Physical Exam: R shoulder exam significant for pain and
weakness with limited ROM presumed secondary to pain
– Clinic note does not document other details of shoulder physical exam,
such as impingement signs or detailed rotator cuff exam
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Shoulder Anatomy
•
•
•
The shoulder has the greatest range of motion of any joint in the body
Three bones: humerus, clavicle, and scapula
Four joints:
– Glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic
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http://www.shoulderdoc.co.uk/
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Glenohumeral Joint
•
Ball (humeral head) and socket (glenoid fossa) joint
– Glenoid fossa is shallow, allowing large ROM at the cost of skeletal instability
– Static stabilizers:
• Glenohumeral ligaments, labrum, bony structures, and capsule
– Dynamic stabilizers:
• Rotator cuff muscles/tendons, long head of the biceps, and scapular stabilizer muscles
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http://www.shoulderdoc.co.uk/
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Rotator Cuff Anatomy and Function
• Four muscles and their tendons
–
–
–
–
–
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Mnemonic “SITS”
• Originate from the scapula
• Form musculotendinous “cuff” that inserts on the proximal
humerus (greater and lesser tuberosities)
• Function: primary dynamic stabilizers of glenohumeral joint
– Muscles actively compress the humeral head in the glenoid fossa
– Counterbalance forces from large muscles acting on humerus
– Contribute to humeral movement: external rotation (infraspinatus, teres
minor), internal rotation (subscapularis), and abduction (supraspinatus)
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Rotator Cuff Anatomy
Anterior
Posterior
Lateral
UpToDate; http://www.shoulderdoc.co.uk/
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Tendon of Long Head of Biceps
• Not part of rotator cuff
• Contributes to glenohumeral
stability
• Intimate anatomic relationship
with rotator cuff and labrum
– Originates at superior glenoid
tubercle
– Travels intraarticularly over the
humeral head
– Travels in bicipital groove between
the greater and lesser tuberosities
• Biceps tendinopathy and tendon
rupture frequently is associated
with rotator cuff pathology
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http://www.shoulderdoc.co.uk/
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Rotator Cuff Pathology
•
Most common reason for seeking treatment among patients with shoulder pain
– 4.5 million office visits and 40,000 surgeries annually in USA
• Subacromial impingement
– Repetitive compression of rotator cuff between greater tuberosity and acromion
– Pain with overhead activities
– Risk factors: repetitive overhead activity (e.g. sports, occupations), narrow
coracoacromial arch (from anatomic variants of acromion or bone spurs)
– Spectrum of disease from subacromial bursitis, to tendinopathy (chronic injury
to rotator cuff), to partial and full thickness rotator cuff tears
• Rotator cuff tears
– Etiology: extrinsic (chronic subacromial impingement) and/or intrinsic (tension
overload such as from overhead throwing; tendon degeneration from aging,
microvascular disease, and comorbidities such as RA)
– Classically, patients have weakness/pain with overhead activities and at night
• In reality, many tears are asymptomatic or produce mild pain
– Supraspinatus is most commonly torn
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Menu of Radiologic Tests for Rotator Cuff
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•
•
•
Shoulder plain films
Musculoskeletal ultrasound
Magnetic resonance imaging
MR Arthrography
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Companion Patient 1: Acromial Bone Spur on
Shoulder Plain Film
Plain films of shoulder
•
•
•
•
Initial imaging modality for shoulder pain of any etiology
Typical views include frontal, lateral, and outlet view
Typically normal in cases of rotator cuff tear
In impingement, outlet view may demonstrate hooked acromion or bone spur
Normal
outlet view
Outlet view
demonstrating
bone spur (red
circle) causing
subacromial
impingement
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http://orthoinfo.aaos.org/topic.cfm?topic=a00032
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Companion Patient 2: High Riding Humeral
Head on Shoulder Plain Film
Plain films of shoulder
•
Humeral head may be high-riding in large or chronic rotator cuff tears
AP view shows high-riding
humerus, decreased
acromiohumeral distance
(black arrows), and
secondary arthropathy with
osteophytes (white arrow)
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Moosikasuwan JB, Miller TT, Burke BJ. Rotator Cuff Tears: Clinical, Radiographic, and US Findings. RadioGraphics 2005; 25:1591.
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Companion Patient 3: Full-Thickness Supraspinatus Tear on
Shoulder Ultrasound
MSK ultrasound
• Advantages:
– Bedside evaluation of rotator cuff
– Visualize moving tendons and compare to contralateral
– No radiation exposure, low cost
• Disadvantages:
– Full rotator cuff may not be well visualized
– Operator dependent
– Limited evaluation of deeper structures such as labrum
• Sensitivity for diagnosing rotator cuff tears is similar to MRI
• Full thickness rotator cuff tear
– Tendon is hypoechoic (fluid replaces the torn tendon)
– Enhanced through transmission results in accentuation of
cartilage, resulting in two hyperechoic lines from
cartilage and cortex (“double cortex sign”)
Hypoechoic supraspinatus
Double cortex sign (black arrows)
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Moosikasuwan JB, Miller TT, Burke BJ. Rotator Cuff Tears: Clinical, Radiographic, and US Findings. RadioGraphics 2005; 25:1591.
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Magnetic Resonance Imaging
Magnetic Resonance Imaging
• Highly sensitive and specific for rotator cuff tears
• Provides information about chronicity, which informs treatment decisions
• Excellent soft tissue visualization, including the labrum and capsule
• Disadvantages: expensive, typical contraindications to MRI and gadolinium contrast (if used), CT is
superior for evaluating fractures
Technical Details
• Patient supine, typically with arm slightly externally rotated
• Usually performed without IV gadolinium (Gd) contrast
• Phased array coil is applied to shoulder for best possible signal/noise ratio and spatial resolution
• Using MR scout localizer images, typical imaging planes are
– Axial sections from the top of the acromioclavicular joint to the inferior glenoid margin
– Coronal oblique images parallel to the plane of the supraspinatus tendon, extending from
subscapularis tendon anteriorly to infraspinatus and teres minor posteriorly
– Sagittal oblique images are perpendicular to the plane of the coronal images, extending from the
lateral aspect of the greater tuberosity to the body of the scapula
• Typical sequences include:
– Proton density or T1-weighted – define anatomy
– Short tau inversion recovery (STIR) or T2-weighted with fat saturation – fluid sensitive 14
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
MR Arthrography
MR arthrography
•
•
•
Inject dilute Gd contrast into glenohumeral joint under fluoroscopic guidance before MRI
Creates joint effusion of Gd contrast that facilitates visualization of small rotator cuff
tears, especially partial tears of the undersurface of the tendon, and tears of the labrum
and capsule
CT arthrography is an option when MRI is contraindicated or unavailable
Injection of gadolinium into
glenohumeral joint via the
rotator interval approach
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BIDMC PACS
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Rotator Cuff Tear: Full vs. Partial Tear on MRI
• Full-thickness tear:
– Tendon is discontinuous on anatomy-defining sequences
– High signal (fluid) fills the tendon defect on fluid-sensitive sequences
– Ancillary findings: fluid in subacromial space, tendon retraction, highriding humeral head, rotator cuff muscle atrophy, narrow
coracoacromial arch (from bone spurs or acromial orientation)
– MR arthrography: contrast traverses the rotator cuff tendon and enters
the subacromial bursa on T1-weighted fat saturation sequences
• Partial-thickness tear:
– Articular surface (most common), bursal surface, or intrasubstance
– Partial-thickness tendon discontinuity on anatomy-defining sequences
– High signal (fluid) fills tendon defect on fluid-sensitive sequences
– MR arthrography: contrast fills the defect in the case of partialthickness tears of the articular surface
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Rotator Cuff Tear: Sensitivity and Specificity
of MRI and MR Arthrography
• Full-thickness tear:
– Conventional MRI: sensitivity 84-96%, specificity 94-98%
– MR arthrography: sensitivity 98%, specificity 100%
• Partial-thickness tear:
– Conventional MRI: sensitivity 35-44%, specificity 85-97%
– MR arthrography: sensitivity 84-95%, specificity 96-100% (data
for articular surface tears only)
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Normal MRI Anatomy
– Coronal Oblique 1
Infraspinatus
Teres minor
Deltoid
MR arthrogram
T1, fat suppression
BIDMC PACS
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Normal MRI Anatomy
– Coronal Oblique 2
Spine of scapula
Head of
humerus
Deltoid
MR arthrogram
T1, fat suppression
BIDMC PACS
Infraspinatus
Contrast in
glenohumeral joint
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Normal MRI Anatomy
– Coronal Oblique 3
Acromion
Supraspinatus
Tendon of
long head
of biceps
Head of
humerus
Superior labrum
Glenoid
Deltoid
Inferior labrum
MR arthrogram
T1, fat suppression
BIDMC PACS
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Normal MRI Anatomy
– Coronal Oblique 4
Distal
clavicle
Supraspinatus
Coracoid process
Head of
humerus
Deltoid
Subscapularis
MR arthrogram
T1, fat suppression
BIDMC PACS
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Normal MRI Anatomy
– Sagittal Oblique
Acromion
Supraspinatus
Tendon of long
head of biceps
Infraspinatus
Head of humerus
Teres minor
Subscapularis
Posterior
MR arthrogram
T1, fat suppression
BIDMC PACS
Anterior
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Normal MRI Anatomy
– Axial
Anterior
Tendon of
long head
of biceps
(in bicipital
groove)
Subscapularis
Head of
humerus
Anterior labrum
Glenoid
Teres minor
Posterior labrum
Infraspinatus
MR arthrogram
T1, fat suppression
BIDMC PACS
Posterior
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Back to Our Patient
• Shoulder plain films normal
• Next step in appropriate workup for suspected
rotator cuff tear would be ultrasound or MRI
• In this case, MRI was performed
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Our Patient: Full-Thickness Supraspinatus Tear on MRI
Coronal oblique T2 with fat saturation
Sagittal oblique T2 with fat saturation
Acromion
Fluid in subacromial space
Supraspinatus tear
Supraspinatus tear
Findings: 1) High signal, full-thickness defect of the supraspinatus on this fluid-sensitive sequence, consistent
with full-thickness supraspinatus tear. The tear is 8mm in width and there is 2cm of tendon retraction.
2) High signal consistent with fluid in subacromial space
3) Laterally sloping acromion with mild narrowing of distance from humeral head to acromion
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BIDMC PACS
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Our Patient: Full-Thickness Supraspinatus Tear on MRI
Coronal oblique proton density
Supraspinatus tear
Findings: Full-thickness discontinuity of supraspinatus tendon on this anatomy-defining sequence, consistent
with full-thickness supraspinatus tear.
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BIDMC PACS
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Companion Patient 4:
Partial-Thickness Supraspinatus Tear
Coronal oblique T2 with fat saturation
Intact supraspinatus
tendon fibers inserting
on greater tuberosity
*
Findings:
- Partial-thickness
disruption of tendons
of articular surface of
supraspinatus with
increased signal on
fluid-sensitive
sequences.
-Consistent with high
grade (>50% of
tendon) articular
surface partialthickness tear of
supraspinatus
-There is a tear of the
superior labrum (*)
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BIDMC PACS
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Companion Patient 5:
Massive Full-Thickness Rotator Cuff Tear of Subscapularis,
Supraspinatus, and Infraspinatus on MRI
Axial proton density
Coronal oblique T2 with fat saturation
Coronal oblique T2 with fat saturation
High-riding
humeral head
Full-thickness tear of
subscapularis, with
retraction and atrophy
Full-thickness tear of
infraspinatus, with
retraction and atrophy
Full-thickness tear of
supraspinatus, with
retraction and atrophy
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BIDMC PACS
Gregory Cvetanovich, MS3
Gillian Lieberman, MD
Treatment of Rotator Cuff Tears
•
•
•
•
Treatment options include:
– Ice
– Activity restriction
– NSAIDs
– Physical therapy
– Glucocorticoid injection
– Surgical repair: typically arthroscopic; open technique in some situations
Choice of treatment depends on specific clinical scenario, including:
– Partial-thickness versus full-thickness tear
– Acute vs. chronic vs. acute-on-chronic tear
– Age, comorbidities, and compliance of patient
Factors that favor non-operative management include:
– Partial-thickness tear, chronic tear, elderly patient, patient with multiple
comorbidities, non-compliant patient, and tear with minimal or no symptoms
Our patient is beginning non-operative treatment with physical therapy
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Student Name, year
Gillian Lieberman, MD
Acknowledgements
•Gillian Lieberman, MD
•Corrie Yablon, MD
•Johannes Roedl, MD
•Mai-Lan Ho, MD
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Gregory Cvetanovich, MS3
Gillian Lieberman, MD
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