Ebook Diagnostic imaging orthopaedics: Part 1

(BQ) Part 1 book Diagnostic imaging orthopaedics presents the following contents: Rotator cuff, biceps tendoni anchor, osseous structures, osseous trauma , distal radioulnar join, triangular fibrocartilage complex, overuse syndromes and muscle trauma, carpal fractures,...

IAGNOSTIC IMAGING

David W Stoller, MD, FACR

Director, California Advanced Imaging and MRI

California Pacific Medical Center Director, National Orthopaedic Imaging Associates

San Francisco, California Director, Musculoskeletal MRI California Pacific Medical Center

Phillip F J Tirman, MD

Director, California Advanced Imaging

California Pacific Medical Center Director, National Orthopaedic Imaging Associates

San Francisco, California Director, Musculoskeletal MRI California Pacific Medical Center

Department of Radiology University of California San Francisco San Francisco, California

Salvador Beltran, MD

Medical Illustrator

Robert M Branstetter Ill, MD

Diversified Radiology of Colorado Denver, Colorado

Simon C P Blease, MD, FRCR

Honorary Senior Clinical Lecturer University of Bristol United Kingdom

AM1 RSYS"

A medical reference publishing company

AM I RSYS"

A medical r e f e r e n c e p u b l i s h i n g company

First Edition

Second Printing -June 2004

Text - Copyright David W S t o l l e r MD 2004

Drawings - Copyright A m i r s y s Inc 2004

Compilation - Copyright Amirsys Inc 2004

A l l rights reserved No part o f this publication may be reproduced, stored in a retrieval system, or transmitted, in any f o r m or media

or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from Amirsys I n c

Composition by Amirsys I n c , Salt Lake City, Utah

Printed by F r i e s e n s , Altona, Manitoba, Canada

ISBN: 0-7216-2920-2

Notice and Disclaimer

The information in this product ("Product") is provided as a reference for use by licensed medical professionals and no others It does not and should not be construed as any form of medical diagnosis or professional medical advice o n any matter Receipt or use of this Product, in whole or in part, does not constitute or create a doctor-patient, therapist-patient, or other healthcare professional relationship between Amirsys Inc ("Amirsys") and any recipient This Product may not reflect the most current medical developments, and Amirsys makes no claims, promises, or guarantees about accuracy, completeness, or adequacy of the information contained in or linked to the Product The Product is not a substitute for or replacement of professional medical judgment Amirsys and its affiliates, authors, contributors, partners, and sponsors disclaim all liability or responsibility for any injury andlor damage to persons or property in respect to actions taken or not taken based o n any and all Product information

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L i b r a r y o f Congress Cataloging-in-Publication Data

S t o l l e r , David W

Diagnostic imaging, orthopaedics / David W Stoller, Phillip F.J

Tirman, Miriam A B r e d e l l a ; S a l v a d o r Beltran, medical illustrator.-

To m y cherished son, GrifFn, and m y lovely wife, Marcia

for their extraordinary love and support

&

to the exceptional team of Phillip F J Tirman, MD,

Branstetter III, MD and Simon C P Blease, MD, FRCR whose cohesive partnership on the production of this book

truly represented a force of nature

D WS

To m y father, the late Robert M Tirman, MD who was

a n inspiration To Collin and Skye, m y children and Linda whose patience and understanding was truly

appreciated

To m y parents, Erika and Lothar, and to Harold, for

their love and encouragement

M.A.B

CONTRIBUTORS

David W Stoller, MD, FACR

Director, California Advanced Imaging and MRI

California Pacific Medical Center

Director, National Orthopaedic Imaging Associates

San Francisco, California

Director, Musculoskeletal MRI

California Pacific Medical Center

Phillip F J Tirman, M D

Director, California Advanced Imaging

California Pacific Medical Center

Director, National Orthopaedic Imaging Associates

San Francisco, California

Director, Musculoskeletal MRI

California Pacific Medical Center

Miriam A Bredella, M D

Department of Radiology

University of California San Francisco

San Francisco, California

Salvador Beltran, M D

Medical Illustrator

Robert M Branstetter Ill, M D

Diversified Radiology of Colorado

Denver, Colorado

Simon C F! Blease, MD, FRCR

Consultant Musculoskeletal Radiologist

Med-Tel International Corporation

Professor Orthopaedic Oncology

University of California, San Francisco

Director Orthopaedic Oncology

Kaiser South San Francisco

vii

DIAGNOSTIC IMAGING: ORTHOPAEDICS

The imaging, orthopedics and sports medicine communities have been waiting a long time for a new "Stoller" We at Amirsys and Elsevier are proud to present a precedent-setting, image- and graphics-packed series that debuts with a brand-new work by David Stoller and colleagues This splendid work represents the textbook of the twenty-first century: Not your old-fashioned, dense prose exposition with comparatively few images The unique bulleted format of the Diagnostic Imaging books allow our authors t o present approximately twice the information and four times the images per diagnosis, compared to the old-fashioned traditional prose textbook

These richly illustrated books will cover all major body areas and follow a similar format The same information is in the same place: Every time! A welcome innovation is the new visual differential diagnosis "thumbnail" that provides at-a-glance looks at entities that can mimic the diagnosis in question "Key Facts" boxes provide a succinct summary for quick, easy review In short, this is a product designed with you, the reader, in mind Today's typical practice settings demand efficiency i n both image interpretation and learning We think you'll find the

Anne G Osborn, MD

Executive Vice-President and Editor-in-Chief, Amirsys

H Ric Harnsberger, MD

Chairman and CEO, Amirsys Inc

David W Stoller, MD, FACR

Editor Diagnostic Imaging Orthopaedics

FOREWORD

Over the last 20 years, MR imaging has become a significant diagnostic test performed in orthopaedic and sports medicine Surgeons have come to depend on this modality to provide crucial information, which assists not only in understanding the underlying pathology, but also

in making the critical decision regarding surgical intervention With the rapid growth and sophistication of MR technology, MR imaging is an indispensable step in the workup of patients with joint disorders and sports injuries It has especially become important in the evaluation and treatment of professional athletes who often depend on quick and accurate diagnosis in order that they can resume their activities

This thousand-page text contains over 550 color illustration plates and over 1000 radiographic images Each radiographic diagnosis is discussed in outline format with thumbnail images of other differential considerations While the unique correlative color illustrations for each

diagnosis allow the reader to better understand anatomy and mechanism of disease, the concise yet complete format of the textbook allows for quick reference in the clinical setting

Dr Stoller has successfully expanded the collaboration between orthopedic surgeons and radiologists with Diagnostic Imaging in Orthopaedics as exemplified by the representative images and correlative discussions of topics including pathophysiology, anatomy, and patient

management Not only does this text focus on orthopaedic diagnosis involving the

appendicular skeleton, but he also covers bone, soft tissue, and marrow tumors Many of the techniques and applications described in this text were either originated or improved by Dr Stoller and his co-authors This comprehensive text is the first of its kind in encompassing an understanding of orthopaedics with correlative color illustrations and therefore will become an invaluable reference and establish a higher standard of imaging for orthopaedists and

radiologists

W Dilworth Cannon Jr., MD

Professor of Clinical Orthopaedic Surgery

UCSF Sports Medicine Center

University of California

San Francisco, California

xii

PREFACE

Joint efforts from the fields of radiology and orthopaedics have continued to define the growing

indications and current issues for the use of MR in orthopaedics and sports medicine Since the mid-

19801s, skeletal radiology has undergone an accelerated transformation with the infusion of MR

technology and applications Credit is acknowledged to my early contemporaries including Jerrold H

Mink, M.D and John V Crues 111, M.D Our collaborative research in 1984-5 helped contribute to the

initial MR applications for the meniscus; and thus, hastened the integration of MR in routine

musculoskeletal imaging

Osborn, M.D and Ric Harnsberger, M.D to further and improve the landscape of education of residents, fellows, academic institutions, and private practice centers of excellence This text reflects the manner in which the authors presently utilize MR in clinical imaging and explains the reliance of MR applications over CT and US in the appendicular joints Each diagnosis consists of a classic color illustration and MR image Differential diagnosis thumbnails are provided as a reference guide to help address related topics without competing or distracting the reader from the image galleries for each diagnosis The outline style

of writing not only provides more information than a comparable prose format, but also allows the reader

to rapidly scan information in selected subsections or within the key facts box

Our team has performed an excellent job in organizing the orthopaedic topics into nine categories:

six chapters concerning the appendicular joints and three chapters addressing marrow, bone and soft

tissue tumors Salvador Beltran, M.D has provided one of the largest correlative collections of superbly illustrated orthopaedic pathology in color found in a single text

need of radiologists, orthopedists, and sports medicine physicians to understand and incorporate new

clinical applications of bone and joint imaging into their practices

David W Stoller, MD

Director, California Advanced Imaging and MRI

California Pacific Medical Center

Director, National Orthopaedic Imaging Associates

San Francisco, California

Director, Musculoskeletal MRI

California Pacific Medical Center

X l l l

Medical Text Editing

Andrew Grainger, MD

John Feller, MD Oliver Cuitanic, MD

Britta Gooding, MD

Production Director

Pattie R Dawson

TABLE OF CONTENTS

ECTiON I: Shoul

Rotator Cuff

Rotator Cuff Tendinopathy

Rotator Cuff Partial Thickness Tear

Internal Impingement, Shoulder

Rotator Cuff Full Thickness Tear

Rotator Interval Tears

Microinstability, Shoulder

Rotator Cuff Post-Operative Repair

Rotator Cuff Calcific Tendinitis

Parsonage-Turner Syndrome

Subscapularis Rupture

Pectoralis Major Tear

Labral Cyst, Shoulder

Anterosuperior Variations, Shoulder

Adhesive Capsulitis, Shoulder

Posterior Labral Tear, Shoulder

Hidden Lesion, Shoulder

Biceps TendonIAnchor

Biceps Tendinosis

Biceps Tendon Tear

SLAP Lesions I-IV

SLAP Lesions V-IX

Biceps Tendon Dislocation

Osteochondral Injuries, Shoulder

Greater Tuberosity Fracture

Arthritis

Osteoarthritis, Shoulder

Rheumatoid Arthritis, Shoulder

Neural Impingement

SECTiON 2: Elbow

Tendinopathy

Lateral Epicondylitis Medial Epicondylitis Biceps Tendon Rupture Triceps Tendon Rupture

Instability

Lateral Collateral Ligament Injury Posterior Dislocation, Elbow MCL Elbow Injury

Little Leaguer's Elbow

Neuropathy

Ulnar Neuropathy Radial Neuropathy Median Neuropathy Anconeus Epitrochlearis

Osseous Trauma

Coronoid Process Fracture Capitellar Osteochondritis Radial Head Fracture Loose Bodies and 0 s Supratrochleare Olecranon Fracture

Lateral Condylar Fracture Capitellum Fracture Supracondylar Fracture Medial Condylar Fracture

Inflammation

Bicipital Radial Bursitis Olecranon Bursitis Synovial Fringe, Elbow

Arthritis

Osteoarthritis, Elbow Rheumatoid Arthritis, Elbow

Infection

Osteomyelitis, Elbow

xviii

I SECTION 3: Wrist and Hand 1

Ligaments

Scapholunate Ligament Tear 3-2

Lunotriquetral Instability 3-6

Carpal Instabilities

Mid Carpal Instability 3-10

Distal Radioulnar Joint

Ulnocarpal Abutment 3-14

Distal Radioulnar Joint Instability 3-18

Triangular Fibrocartilage Complex

Triangular Fibrocartilage Tear 3-22

Fractures, Distal Radius and Ulna

Distal Radius Fractures 3-26

Die Punch Fracture, Distal Radius 3-30

Ulnar Styloid Fracture 3-34

Carpal Tunnel Syndrome 3-54

Guyon's Canal Syndrome

Ulnar Tunnel Syndrome 3-58

Extensor Carpi Ulnaris Tendinitis 3-86

Giant Cell Tumor Tendon Sheath 3-90

Finger

Ulnar Collateral Ligament Tear, Thumb 3-94

Flexor Annular Pulley Tears 3-98

Flexor Digitorum Profundus Avulsions 3-102

Developmental Dysplasia of the Hip

Overuse Syndromes and Muscle Trauma

Muscle Strain, Hip 4-18 Rectus Femoris Muscle Strain 4-22 Gluteus Medius Muscle Strain 4-26 Hamstring Tendinosis 4-30 Piriformis Syndrome 4-34 Iliopsoas Bursitis 4-38 Snapping Hip Syndrome 4-42

Osseous Trauma

Femoral Head Fractures 4-46 Femoral Neck Fractures 4-50 Acetabular Fractures 4-54 Hip Dislocations 4-58 Avulsion Fracture 4-62 Pubic Rami Stress Fractures 4-66 Sacral Insufficiency Fractures 4-70

Loose Bodies, Hip Rheumatoid Arthritis, Hip

Meniscal Longitudinal Tear Meniscal Radial Tear Meniscal Flap Tear Meniscal Bucket-Handle Tear Meniscocapsular Separation Post-Operative Meniscus Change

xix

Anterior Cruciate Ligament Deltoid Ligament Sprain

Syndesmosis Sprain Anterolateral Impingement Anterior Impingement Syndesmotic Impingement Posterior Impingement Sinus Tarsi Syndrome

Anterior Cruciate Ligament (ACL) Tear 5-42

Posterior Cruciate Ligament

Osseous Fractures Medial Collateral Ligament

Ankle Fractures Talus Fractures Calcaneal Fractures Navicular Fractures Metatarsal Fractures Lisfranc Fracture-Dislocation Osteochondral Lesion of the Talus Avascular Necrosis (AVN) of the Talus Freiberg's Infraction

Medial Tibial Stress Syndrome Tarsal Coalition

Medial Collateral Ligament Tear

Medial Bursitis, Knee

Lateral Collateral Ligament Complex

Lateral Collateral Ligament (LCL) Tear 5-62

Osseous/Cartilagenous Structures

Osteochondral Injuries, Knee

Osteochondritis Dissecans, Knee

Bone Infarct, Knee

Spontaneous Osteonecrosis, Knee

Patellar Fracture

Lateral Tibial Plateau Fracture

Overuse Syndromes and Soft Tissue

Injury

0 s Trigonum Syndrome Accessory Navicular Sesamoid Dysfunction Compartment Syndrome, Lower Extremity Gastrocnemius Soleus Strain

Plantaris Rupture Tarsal Tunnel Syndrome Plantar Fasciitis

Plantar Fibromatosis Morton's Neuroma Diabetic Foot

Quadriceps Tendon Tear

Transient Patellar Dislocation

Medial Plica Syndrome

SECTION 2 Bone Marrow

Pigmented Villonodular Synovitis, Knee 5-140

Reflex Sympathetic Dystrophy, Knee 5-146

Round Cell Tumors

Langerhans Cell Histiocytosis Ewing Sarcoma

Leukemia Lymphoma Multiple Myeloma

Achilles Tendon Tear

Tibialis Posterior Tendon Tear

Flexor Hallucis Longus Abnormalities

Tibialis Anterior Tendon Tear

Peroneus Brevis Tendon Tear

Metastases, Bone Marrow Paget Disease

SECTION 8: Bone Tumors

Anterior Talofibular Ligament Tear

Calcaneofibular Ligament Sprain

Unicameral Bone Cyst 8-62

Aneurysmal Bone Cyst 8-66

Malignant Fibrous Histiocytoma

SECTION 9: Soft Tissue Tumors 1

Synovial Tumors

Pigmented Villonodular Synovitis

Synovial Sarcoma

Fatty Tumors

Lipoma, Soft Tissue

Liposarcoma, Soft Tissue

Neural Tumors

Benign Peripheral Nerve Sheath Tumor

Malignant Peripheral Nerve Sheath Tumor

Includes SE and FSE sequences

T2 FSE used to evaluate the rotator cuff (complementing

FS PD FSE images) by differentiating tendinosis and tears

T2 FSE application limited because of hyperintense fat

signal, (FS PD FSE used more commonly for this reason)

FS T2 FSE produces an image with poor SNR (signal-to-

noise) with TE values of greater than 60 msec

May obscure sclerosis or marrow edema due to poor

marrow fat contrast compared to TlWI or FS PD FSE

FS PD FSE

Fat Suppressed Proton Density Weighted Fast Spin Echo

Evaluates marrow edema, articular cartilage, ligaments,

tendons, synovium, and meniscal morphology

Commonly used sequence for all appendicular joint

imaging

- Often referred to as FS T2 FSE although TE values are

typically less than 60 msec

TR values greater than or equal to 3000 msec

TE values of 40-50 msec to optimize image quality

GRE

Gradient Echo

- Reverse gradient polarity to rephrase protons and form

echoes

Usually used to create images with T2* contrast

- T2* contrast used t o evaluate TFC (triangular

fibrocartilage), patellar tendon, intrameniscal signal,

subscapularis tendon and chondrocalcinosis

Also used when fat suppression fails with FSE sequences Sensitive t o magnetic field inhomogeneties, paramagnetics and ferromagnetic micrometallic artifacts compared to SE and FSE (secondary to gradient rephrasing)

ZIP

- Zero-fill Interpolation Processing Reconstruction technique to enhance apparent image resolution without actually creating resolution

STIR (SHORT TI INVERSION RECOVERY)

Inversion Recovery Fat Suppressed Spin Echo Pulse Sequence

- Initial 180 degree inversion pulse prior to 90 degree pulse

STIR has more uniform fat suppression because IR is less sensitive to magnetic field inhomegeneties and off center field-of-view (FOV) effects

Used when FS PD FSE not available or when fat suppression inadequate in FSE images

T1 & T2 contrast additive in STIR however SNR is low secondruy to reduced transverse magnetization

Limited by prolonged scan times

T I C+

Intravenous contrast administration in conjunction with fat suppression to increase the conspicuity of synovium vascularity, inflammation and tumors

Also used to improve visualization of intraarticular structures by delayed enhancement of joint fluid without the benefit of capsular distension

ABER

Abduction External Rotation position of the shoulder to optimize visualization of the inferior glenohumeral ligament labral complex (IGLLC), biceps labral complex (BLC) and articular surface of the rotator cuff

xxiv

-

Rotator Cuff

Rotator Cuff Tendinopathy

Rotator Cuff Partial Thickness Tear

Internal Impingement, Shoulder

Rotator Cuff Full Thickness Tear

Rotator Interval Tears

Microinstability, Shoulder

Rotator Cuff Post-Operative Repair

Rotator Cuff Calcific Tendinitis

Parsonage-Turner Syndrome

Subscapularis Rupture

Pectoralis Major Tear

Labral Cyst, Shoulder

Anterosuperior Variations, Shoulder

Adhesive Capsulitis, Shoulder

Posterior Labral Tear, Shoulder

Hidden Lesion, Shoulder

Biceps TendonIAnchor

Biceps Tendinosis

Biceps Tendon Tear

SLAP Lesions I-IV

SLAP Lesions V-IX

Biceps Tendon Dislocation

Osteochondral Injuries, Shoulder

Greater Tuberosity Fracture

Arthritis

Osteoarthritis, Shoulder

Rheumatoid Arthritis, Shoulder

Neural Impingement

Quadrilateral Space Syndrome

Suprascapular, Spinoglenoid Notch

ROTATOR CUFF TEN1 BPATHY

Coronal graphic shows thickening and degeneration Coronal FS PD FSE MR shows thickening and

of the distal aspect of the supraspinatus tendon, increased signal intensity (arrow) of the distal

consistent with tendinopathy supraspinatus tendon, representing tendinopathy

(tendinosis)

Radiographic Findings - Abbreviations and Synonyms ~ a d i o g r a p h ~

0 Acromial remodeling/sclerosis + acromioclavicular Rotator cuff (RTC) impingement, subacromial (AC) joint hypertrophy

impingement, supraspinatus impingement o Acromial spurs (impingement)

Rotator cuff tendinitis (tendinosis), supraspinatus o Humeral head subchondral sclerosis/cysts

tendinitis, shoulder periarthritis, painful shoulder

syndrome MR Findings

Definitions

Collagenous degeneration of the rotator cuff tendons

most commonly involving the supraspinatus tendon

General Features

Best diagnostic clue: Thickened inhomogeneous

rotator cuff tendon with increased signal intensity on

all pulse sequences

Location: Anterior leading edge of supraspinatus

Size: Tendon thickened but may be thinned by

attrition

Morphology

0 Thickened, inhomogeneous tendon with visible

surface fraying

o Tendon torn or partially torn in advanced cases with

fluid entering defect

T2WI

0 Increased signal intensity of tendon on PD FSE, FS

PD FSE, STIR & T2* GRE Heterogeneous tendon(s) signal

o Hyperintense tendon degeneration on FS PD FSE

FS PD FSE visualizes tendon degeneration as hyperintense while T2 FSE shows degeneration as low to intermediate in signal

o +/- Hyperintense effusion (glenohumeral joint)

0 Hyperintense (fluid signal intensity) bursitis Subacromial/subdeltoid

Subcoracoid - esp with anterior pathology

DDx: Rotator Cuff Tendinopathy

d;

-

Cor FS PD FSE Cor FS PD FSE Cor FS PD FSE ~r FS PD FSE Cor FS PD FSE

-

ROTATOR CUFF TENDINOPATHY

Key Facts

Collagenous degeneration of the rotator cuff tendons ' POSterOsuperior Impingement

most commonly involving the supraspinatus tendon Microinstability

Best diagnostic clue: Thickened inhomogeneous Overuse, degeneration and tearing of the rotator cuff rotator cuff tendon with increased signal intensity on - intrinsic theory

Increased signal intensity of tendon on PD FSE, FS PD

Top Differential Diagnoses Painful even without tendon tear

Partial Thickness Tears

-

o +/- AC arthritis + acromial spurs

Chondromalacia (surface defects, hyperintense

hyaline articular cartilage & marrow edema)

o Prominence of greater tuberosity + subcortical cystic

change

o Post dislocation findings in case of tendinopathy

due to supraspinatus strain

Hyperintense bone marrow edema with +/-

hypointense fractures

Bankart, Hill-Sachs fracture

Type I11 (hooked) acromion

MR arthrography

o No cuff defect identified

Ultrasonographic Findings

Thickened decreased echogenicity/hypoechoic

Tears directly visible

Less sensitive for partial thickness tears

Advantage - allows dynamic evaluation with pain

Tendon thickened and with decreased signal intensity

on all pulse sequences

o Calcium hydroxyapatite within hypointense cuff

tendon@)

o Hypointense calcium deposit

+/- Hyperintense surrounding edema on T2WI

Magic Angle Artifact

Leads to artifactual increased signal at curved portion

of tendon without thickening on short TE sequences

55 degrees to external magnetic field Affects biceps tendon, supraspinatus tendon and labrum

Partial Thickness Tears

Fluid within but not transversing tendon Hyperintense partial defect on T2WI

o Bursal (Bursal Part Tear)

o Interstitial

o Articular

Full Thickness Tears

+/- Impingement Hyperintense defect on T2WI Anterior aspect often involved as in tendinopathy

o Tendinopathy often precursor to tear

Posterosuperior Glenoid Impingement

Internal impingement Posterosuperior cuff, labrum, humeral head

o Triad of findings Overuse

Type 3 (hooked) acromion

Laterallanterior downsloping acromion

0 s acromiale

o Acute but usually in the setting of preexisting

tendinosis

o Eccentric tensile overload of the rotator cuff tendons

o Begins where load is greatest on tendon - on

articular side of anterior insertion of the

o Shoulder pain is 3rd most common cause of

musculoskeletal pain syndrome

After low back pain (LBP) and cervical pain

o 7-25% in Western general population

Gross Pathologic & Surgical Features

Thickened, indurated tendon

Loss of integrity of tendon in partially torn (bursal,

articular or interstitial) and through-and-through torn

' tendons

Partial tear may be on the bursal surface, articular

surface or interstitial

Microscopic Features

Collagen degeneration without influx of inflammatory

cells: "Tendinosis" is preferred term over tendinitis

Increase in collagen type I11

o Protein involved in healing and repair

Increase in glycosaminoglycan and proteoglycan

Tendon cell apoptosis (cell death) within

o Stage I: Reversible edema & hemorrhage typically in

active patient I 25 years

o Stage 11: Fibrosis and tendinitis

o Stage 111: Degeneration & rupture often associated

with osseous changes in patients > 40 years

Burkhart's cable/crescent theory of cuff tears

o Cable = thickened supraspinatus tissue connecting

anterior & posterior tendon edges medially

Most common signs/symptoms

o Progressive onset of shoulder pain Pain, weakness, and loss of shoulder motion common

Pain over anterolateral part of the shoulder worsened by overhead activities in impingement Night pain

Demographics

Age: Peak: > 40 years for impingement, most common

55 years Gender: M:F = 1:l or slight female predominance

Natural History & Prognosis

Insidious onset of pain in adult patient with impingement syndrome

+/- Progression to tear

Treatment

Physical therapy Corticosteroids via injection to decrease inflammation Subacromial decompression for impingement

I DIAGNOSTIC CHECKLIST 1

Image Interpretation Pearls

FS PD FSE may overestimate cuff pathology (tendinosis mistaken for a cuff tear)

T2 FSE (without fat suppression) is used to show the diminished signal in tendinosis as compared to the hyperintensity of a true cuff tear

1 Teefey SA et al: Ultrasonography of the rotator cuff A comparison of ultrasonographic and arthroscopic findings

in one hundred consecutive cases J Bone Joint Surg Am 82(4):498-504, 2000

2 Gartsman GM: Arthroscopic management of rotator cuff disease J Am Acad Orthop Surg 6(4):259-66, 1998

3 Cohen RB et al: Impingement syndrome and rotator cuff disease as repetitive motion disorders Clin Orthop (351):95-101,1998

4 Fritz RC et al: MR imaging of the rotator cuff Magn Reson Imaging Clin N Am 5(4):735-54, 1997

5 Neer CD et al: Cuff-tear arthropathy J Bone Joint Surg 65(9):1232-44, 1983

ROTATOR CUFF TENDINOPATHY

Typical

Typical

Tvsical

(LLfl) Coronal PD FSE MR shows increased signal intensity within the supraspinatus critical zone (arrow), consistent with tendinopathy (Right)

Coronal FS PD FSE MR shows increased signal of the critical zone, consistent with tendinopathy & articular surface fraying This sequence visualizes tendinosis as hyperintense

(LLB) Sagittal FS PD FSE MR shows thickening and increased signal intensity (arrow) within the supraspinatus, consistent with tendinopathy (Right)

Axial PD FSE MR shows increased signal intensity (arrow) within the lateral supraspinatus tendon (crescent area where cuff tears occur) Note the rotator cable (open arrows)

(Lef) Coronal PD FSE MR shows marked thickening (arrow) of the posterior aspect of the supraspinatus tendon, consistent with tendinopathy The patient has PSCl (posterior superior glenoid impingement)

(Right) Sagittal FS PD FSE

MR shows tendinopathy (arrow) predominantly affecting the posterior cuff tendon

1 ROTATOR CUFF PARTIAL THICKNESS TEAR

Coronal graphic shows a partial undersurface tear of Coronal FS PD FSE M R shows an articular surface

the supraspinatus tendon involving the critical zone partial tear (arrow) of the supraspinatus involving

the critical zone

Abbreviations and Synonyms

Partial rotator cuff tear (PRTC Tear)

Definitions

Incomplete (partial) tear of tendon of rotator cuff

o Supraspinatus tendon most common

Acromioclavicular (AC) degenerative changes

MR Findings

TlWI

o Thickening of RTC tendons, of intermediate signal intensity

o Calcifications in the supraspinatus, infraspinatus or

General Features teres minor = calcific tendinitis

o Hypointense bone impaction (Hill-Sachs) - anterior

o Incomplete tear or gap in the RTC tendon filled with Rotator cuff strain associated

joint bursal fluid, +/- granulation tissue o Marrow containing acromial spur (marrow fat)

Location: Supraspinatus (SST) bursal or articular o Fluid signal intensity filling an incomplete gap in

Size: Varies from fraying to large dissecting partial tear FS PD FSE

o Irregularity (fraying) to flap morphology Interstitial, noncommunicating gap

o +/- Fluid within the subacromial bursa

DDx: Rotator Cuff Partial Thickness Tear

Ca++ Tendinitis

EH

Cor FS PD FSE Cor T l Arthro Sag FS PD FSE

ROTATOR CUFF PARTIAL THICKNESS TEAR

Key Facts

Incomplete (partial) tear of tendon of rotator cuff Acute strain

Interstitial (within substance - noncommunicating)

Pain with abduction flexion maneuverslimpingement

Incomplete tear or gap in the RTC tendon filled with Shoulder pain with use of RTC after trauma

joint bursa1 fluid, +I- granulation tissue Partial tears are more painful than full thickness tears

Findings associated with impingement

Diagnostic Checklist Top Differential Diagnoses Partial tear in setting of intramuscular cyst

Full Thickness Tear without Visible Communication communicating with joint or bursa

Calcific Tendinitis (Ca++ Tendinitis) Identify fluid on FS PD FSE, and use the T2 FSE

Adhesive Capsulitis

Increased signal intensity on FS PD FSE

o +/- Fluid within the subcoracoid

Anterior supraspinatus tear, rotator interval tear

Subcoracoid impingement

o Intermediate signal intensity in long head of biceps

tendon, + associated tendinosis

o Hyperintense effusion

o FS PD FSE

Sensitive for evaluating partial tears

o +I- Retraction and degeneration of the tendon edges

Articular or bursal surface partial

o Hypointense bone impaction (Hill-Sachs) - post

anterior dislocation

Rotator cuff strain commonly associated

o Fluid within the substance of the tendon between

layers in interstitial tear

No communication with surface

Not seen at arthroscopy

T1 C+: Enhancement of granulation tissue indicating

partial tear (imbibition)

MR arthrography

o Arthrography: Contrast may fill tear if articular

surface communicates with joint

Ultrasonographic Findings

Decreased echogenicity and thinning of partially torn

region

Lost of convexity of tendonlbursa interface in bursal

surface partial tears

Calcium = hyperechoic foci + shadowing

Associated with partial tears Thickened tendon

Cyst visible on T2WI

0 Hyperintense smoothly marginatedlelongated mass Cyst usually flattened

Full Thickness Tear without Visible Communication

+I- Closed by granulation +/- Closed by fibrosis/adhesions Uncommon

Technique

0 Non fat saturation sequences may be less sensitive

Calcific Tendinitis (Ca++ Tendinitis)

Calcium hydroxyapatite

o Hypointense on all pulse sequences Deposit not visible in following conditions

o Hypointense deposit within hypointense tendon

o Quiescent lesions (silent phase) +I- Surrounding hyperintense edema on T2WI

Rotator Cuff Tendinopathy

Thickened hyperintense (T2WI) tendons +/- Impingement

No tear +/- Chronic repetitive microtrauma/impingement

Adhesive Capsulitis

Thickened hyperintense capsule

o Axillary pouch inferior glenohumeral ligament (IGHL)

o Rotator interval Frozen shoulder

+I- Cuff tear

ROTATOR CUFF PARTIAL THICKNESS TEAR

1 PATHOLOGY

General Features

General path comments

o Three types partial tears of RTC

Articular surface partial tear - most common, associated with ciassical impingement Interstitial - not seen at arthroscopy Bursa1 surface

8 o Partial thickness tears cause muscle contraction pain

similar to other partial tendon injuries (Achilles

tendon, extensor carpi radialis brevis)

o Pain with reflex inhibition of muscle action and loss

of strength

o Partial tear fiber detachment makes muscle less

effective for proprioception function

o Altered cuff function - HH ascends under deltoid

contraction

o Impinging cuff between HH & coracoacromial arch

causative

o Abrasion of cuff occurs with altered humeroscapular

motion = cuff degeneration

o Bankart and Hill-Sachs anterior dislocation

o SLAP tears associated with articular surface partial

tears both anterior (SLAC lesion) and posterior

(posterior peelback lesion) subclassification of type I1

SLAP lesions

Gross Pathologic & Surgical Features

Thickened, indurated tendon edges

Loss of integrity of tendon collagen fibers

Hemorrhage in interstitial tears

Microscopic Features

Collagen degeneration without influx of inflammatory

cells

Inflammatory cells in adjacent bursa = bursitis

Increased levels of smooth muscle actin (SMA)

o SMA-positive cells + glycosaminoglycan and

proteoglycan promote retraction of torn fibers

Staging, Grading or Classification Criteria

Type I - superficial capsular fraying, small local area, <

1 cm

Type I1 - mild fraying, some failure of tendon fibers, <

2 cm

Type I11 - moderate fragmentation and fraying, often

involves entire SST surface, usually < 3 cm

o Partial articular supraspinatus tendon avulsion (PASTA) lesion

Type IV - severe tear with fraying, fragmentation and flap

o Often involves more than one tendon

Presentation

Most common signslsymptoms

o Pain with abduction flexion maneuvers/impingement tests

o Shoulder pain with use of RTC after trauma

o Partial tears are more painful than full thickness tears

Clinical profile: Athlete, patient after 40 years of age with impingement

Demographics

Age

o Younger athlete in case of internal impingement

o Older than 40 years in subacromial impingement Gender: M = F, M > F in throwing athletes and heavy laborers

Natural History & Prognosis

Insidious onset of pain in adult patient with impingement syndrome

Sudden onset of pain in acute traumatic event Most partial tears progress to full thickness tears within 2 years

May heal with cessation of impingement activitieslphysical therapy (PT)

Partial tear in setting of intramuscular cyst Interstitial partial tear with fluid in the tendon not communicating with joint or bursa

Image Interpretation Pearls

Identify fluid on FS PD FSE, and use the T2 FSE sequence to differentiate tendinosis from partial tear

1 SELECTED REFERENCES

1 Kibler WB et al: Clinics in sports medicine current concepts in tendinopathy vol22 W.B Saunders, Philadelphia PA, 791-812, 2003

2 Read JW et al: Shoulder ultrasound: Diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology J Shoulder Elbow Surg 7(3):264-71, 1998

3 Tirman PF et al: Posterosuperior glenoid impingement of the shoulder: Findings at MR imaging and MR

arthrography with arthroscopic correlation Radiology 193(2):431-6, 1994

ROTATOR CUFF PARTIAL THICKNESS TEAR

(Lef) Coronal graphic shows

a bursal surface partial tear with reactive bursal changes

(Right) Coronal FS PD FSE

MR shows a bursal surface partial tear of the supraspinatus tendon distal insertion

(Lef) Coronal graphic shows

an interstitial delamination partial tear (Right) Coronal

FS PD FSE MR shows interstitial delamination partial tear (arrow) There are associated degenerative changes of the humeral head

(Lef) Coronal FS PD FSE MR shows an interstitial delamination partial tear with fluid signal intensity within the substance of the distal tendon (Right)

Coronal FS PD FSE MR shows multiloculated intramuscular hyperintense cyst (arrow) dissecting from myotendinous junction There is associated partial cuff tearing Intramuscular cysts are associated with RTC tears (particularly partial)

INTERNAL IMPINGEMENT, SHOULDER

P

Coronal graphic shows an undersurface partial cuff

lesion and a posterosuperior glenoid labral tear

Abbreviations and Synonyms

Posterosuperior glenoid impingement (PSGI), internal

impingement

Definitions

Impingement of undersurface, posterior supraspinatus

and anterior undersurface infraspinatus by

posterosuperior labrum and humeral head (HH)

Overhead throwing athletes and occupations which

require overhead work (ABER - abduction external

rotation)

Posterior peelback - posterosuperior labral tear

o Subclassification of type I1 SLAP lesion

o Also referred to as internal impingement and

includes associated undersurface tear of cuff at

junction of supraspinatus and infraspinatus

General Features

Best diagnostic clue: Triad of undersurface rotator cuff

(RTC), posterosuperior labrum and HH damage

Location: Posterosuperior aspect of glenoid and rotator

cuff

Coronal FS PD FSE MR shows an undersurface

posterior supraspinatus tendon tear (arrow) +

posterior superior labral fraying and cystic degenerative changes of posterosuperior humeral head

Size: Minimal fraying to full thickness tears of RT(

posterosuperior labrum and osteochondral impacl

of posterosuperior HH Morphology: Thickened irregular tendon, frayed labrum, degenerative change - HH

o +/- Cystic changes, posterosuperior humeral he:

o Posteroinferior calcification in throwing athlete

rn Bennett lesion

CT arthrography

o Posterosuperior labral fraying, +/- tear

o Undersurface posterior supraspinatus/anterior infraspinatus partial tear

Contrast extends into tear

rn Coronal/sagittal reconstructions helpful

- -

INTERNAL IMPINGEMENT, SHOULDER

Key Facts Imaging Findings Degeneration and tearing of the supraspinatus and

ABER (abduction and external rotation) imaging infraspinatus tendon due to sheer forces secondary to demonstrates undersurface tears friction between the posterosuperior RTC, labrum

and HH during overhead throwing activities

Top Differential Diagnoses Epidemiology: Young athletes and adults performing

SLAP Lesions - without RTC Pathology

Microinstability - Affects Anterior Leading Edge RTC Clinical Issues

rotate the arm (occupational)

Pathology

General path comments: Dynamic compression of Diagnostic Checklist

the posterior superior aspect of RTC between Primary impingement, and SLAP lesion

posterosuperior labrum and HH

o Junction of articular surface of supraspinatus and

infraspinatus

o Posterosuperior labral surface irregularity,

hyperintensity = fraying

o +/- Tear of posterosuperior labrum

Increased signal intensity or avulsion

o Posterosuperior humeral head irregularity with

+/- Hypointense sclerosis

+/- Hypointense subchondral cysts

T2WI

o Undersurface tear of posterior supraspinatus and

anterior infraspinatus: Hyperintense

o +/- Visible partial to complete tear - disrupted fibers

Partial articular surface or interstitial tear

+/- Surrounding hyperintense edema

o Full thickness tear in more advanced cases

o Posterosuperior humeral head chondromalacia

Hyperintense (FS PD FSE)

+/- Surface defect

o Normal "bare area" of posterosuperior humeral head

devoid of cartilage may be located adjacent to point

of contract between humeral head and glenoid

o Subchondral cystic changes

+/- Hyperintense

Similar location as Hill-Sachs lesion

o Fraying +/- tearing of the posterosuperior glenoid

labrum

Surface irregularity, hyperintensity

T2 not as sensitive as short TE sequences (TI, T2*

GRE, PD)

o Inferior glenohumeral ligament and anterior inferior

labral injuries associated as IGL is under tension

during abduction and external rotation

STIR

o Less spatial resolution compared to FS PD FSE

o Necessary at low field strength as fat saturation

important for detecting subtle edema

MR arthrography

o Posterosuperior labral fraying, +/- tear demonstrated

by contrast outline

o ABER (abduction and external rotation) imaging

demonstrates undersurface tears

Uncovering posterosuperior labrum with improved visualization

I "Touching" of cuff to labrum on ABER view not correlated with PSGI (seen in asymptomatic shoulders)

I Demonstrates any nondisplaced/healed/partial healed anterior inferior labral tear

ABER places traction on IGHLC (inferior glenohumeral ligament complex)

o Chondromalacia outlined by contrast Surface irregularity

+/- Defect of cartilage

Imaging Recommendations

Best imaging tool: MRI Protocol advice: ABER imaging helps define associated articular sided cuff lesion

I DIFFERENTIAL DIAGNOSIS Subacromial Impingement

History is usually suggestive of internal impingement

o Athlete involved in overhead throwing activities

o Instability may be present

o Subluxation while throwing

SLAP Lesions - without RTC Pathology

Superior labral tear Propagate outside superior labrum

+ Speed's test (bicipital resistance), O'Briens test (anterosuperior pain in labral tear)

+/- Flap component Hyperintense signal abnormality on short TE sequences within biceps anchor

Hyperintensity within substance of biceps anchor specific finding on T2WI

Microinstability - Affects Anterior Leading Edge RTC

Anterior supraspinatus tear

o Undersurface +/- Superior labrum tear

INTERNAL IMPINGEMENT, SHOULDER

Hyperintense tear of cuff on T2WI

+/- Middle glenohumeral (MGHL) tear

o Bankart variation

o +/- Small nondisplaced tear in case of subluxation Presentation

+/- Bankart fracture, Hill-Sachs lesion Most common signs/symptoms: Pain with abduction

Rotator interval

Biceps instability

Superior glenohumeral ligament

(SGHL)/coracohumeral ligament (CHL) abnormality

+/- Subscapularis tear

Calcific Tendinitis

Hypointense calcium deposit (calcium hydroxyapatite)

on all pulse sequences

o Obscured within hypointense cuff tendon(s)

+/- Hyperintense surrounding edema on T2WI

+/- Adjacent bursitis

Supraspinatus Tear

+/- Impingement

Hyperintense defect on T2WI

Anterior aspect often involved as opposed to PSGI

o PSGI extends to involve anterior cuff in advanced

cases

1 PATHOLOGY

General Features

General path comments: Dynamic compression of the

posterior superior aspect of RTC between

posterosuperior labrum and HH

Etiology

o Degeneration and tearing of the supraspinatus and

infraspinatus tendon due to sheer forces secondary

to friction between the posterosuperior RTC, labrum

and HH during overhead throwing activities

o Glenoid rim comes in contact with the deep surface

of the tendon in 120" abduction, retropulsion, and

extreme external rotation

Late cocking phase in throwers External rotation of biceps causes posterior peelback lesion

Epidemiology: Young athletes and adults performing

overhead motion

Associated abnormalities: +/- Anterior instability

Gross Pathologic & Surgical Features

Tendinosis and tearing of supraspinatus, infraspinatus,

labrum

o Humeral head impaction

Cuff tendon is indurated, inflamed, frayed or torn

Degenerative fraying and/or tearing of the

posterosuperior labrum = posterior peelback lesion

- -

and external rotation Clinical profile

o Athletes participating in overhead throwing sports

o Non athletes who frequently abduct and externally rotate the arm (occupational)

0 Varying degrees of RTC disease both and shoulder instability (positive physical examination signs )

Demographics

Age: Adolescent (athlete), adult (occupational) Gender: M > F

Natural History & Prognosis

Typically improves with rest, RTC strengthening

Treatment

Physical therapy Arthroscopic debridement of rotator cuff and labral fraying

Repair of rotator cuff tear Humeral derotational osteotomy

o Absence of instability is required

Consider

Primary impingement, and SLAP lesion

Image Interpretation Pearls

Posterior articular sided RTC pathology in throwing athlete

1 SELECTED REFERENCES

1 Matsen FA 111: Rotator cuff The Shoulder 3rd ed WB

Saunders, Philadelphia PA, 1998

2 Resnick D: Shoulder Internal derangements of joints: Emphasis on MR imaging WB Saunders, Philadelphia PA, 163-333, 1997

3 Hawkins RH et al: Nonoperative treatment of rotator cuff tears Clin Orthop (321):178-88, 1995

4 Tirman PF et al: Posterosuperior glenoid impingement of the shoulder: Findings at MR imaging and MR

arthrography with arthroscopic correlation Radiology 193(2):431-6, 1994

Microscopic Features

Degeneration and varying degrees of inflammation

associated with rotator cuff tendons and

posterosuperior labrum

I INTERNAL I MPINCEMENT, SHOUl

( k p ) Coronal graphic demonstrates tearing of the infraspinatus tendon which can be seen with

posterosuperior impingement This undersurface cuff tear usually involves the anterior articular surface of the infraspinatus (Right) Coronal STIR MR demonstrates a tear (arrow) of the

infraspinatus/pos terior supraspinatus in a patient with posterosuperior glenoid impingement

(Left) Clinical photograph of

a baseball pitcher demonstrates posterior contracture and inability to raise throwing hand - R hand

(arrow) symmetrically with the left hand Note the shoulder asymmetry (Right)

Axial PD FSE MR demonstrates synovitis (arrow) within the posterosuperior aspect of the joint There is associated labral fraying, sclerosis of the posterosuperior glenoid and cystic changes in the posterolateral humeral head

(Lef) Sagittal oblique arthroscopic view demonstrates an undersurface rotator cuff tear (arrow) adjacent to the humeral head (right side)

(Right) T2 FSE ABER shows internal impingement in professional throwing athlete, including posterior peelback subtype SLAP I1 lesion (arrow), undersurface supraspinatus fraying &

humeral head impaction (open arrow)